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Queen Elizabeth Psychiatric Hospital, Edgbaston, Birmingham B15 2QX, email: giles.berrisford{at}bsmht.nhs.uk

Claassen et al state that financial incentives to increase adherence to depot medication should be considered further and welcome a debate upon the ethical implications of this management strategy. They identify autonomy, as defined by Beauchamp’s four-principles approach, as a specific area of concern (Beauchamp, 2003). The key issue here therefore is whether the payment is coercive or not. If it is coercive, the individual’s ability to act autonomously has been reduced. Claassen et al use Wertheimer’s definition that ‘threats coerce but offers do not’, with a threat being an action that makes the individual worse off than a baseline whereas an offer does not (Wertheimer, 1993). They argue that the offer is not coercive and is therefore ethically neutral. It can be argued, however, that routine payment for receiving a depot will become the new baseline, rendering the removal of payment a threat. Removal of payment therefore becomes coercive, reducing autonomy.

The loss of money is minimised by Claassen et al because they consider its small value to mean that its removal is seen as non-threatening. However, this contradicts the hypothesis that it is the money that encourages the individual to accept the depot. Inevitably the use of payment will be coercive for some groups, reducing their autonomy. At the same time payment promotes access to essential treatment, in keeping with Beauchamp’s principle of justice. A tension clearly exists between the principles of autonomy and justice; this is brought into sharper focus for disenfranchised, economically deprived groups.

References

BEAUCHAMP, T. L. (2003) Methods and principles in biomedical ethics. Journal of Medical Ethics, 29, 269 -274.[Abstract/Free Full Text]

WERTHEIMER, A. (1993) A philosophical examination of coercion for mental health issues. Behavioural Sciences and the Law, 11, 239 -258.

This Article Full Text (PDF) Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Berrisford, G. Search for Related Content PubMed Articles by Berrisford, G.