By Emily Feng-Gu

Everyone knows that if you’re in an OSCE station the first-line management for a chronic disease is lifestyle modification.

Lifestyle choices contribute to many of the chronic diseases that are topping the list of Australia’s causes of mortality, including cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, and some types of cancer.¹

Behavioural change is difficult, and a lot of how we approach the challenge of motivating patients is rooted in patient education. We lay out the benefits and risks, we set SMART goals, and we hope that information is enough to spur patients into action. That is, we assume people are perfectly rational – but maybe we shouldn’t.

Some say that what separates humans from animals is our rationality, but perhaps it is somewhat under-exercised. One cognitive pitfall particularly detrimental to making healthy lifestyle choices, known as the present bias, is that we attribute more weight to rewards or costs that are immediate rather than those that are distant.² So we eat an extra slice of cake, drink another glass of wine, or spend another evening in front of the TV, even though achieving long-term health is the higher-order goal. It’s not that we fail to understand the consequences of these short-term behaviours, it’s just that we fail, at that moment in time, to care as much as rationality demands.

So how do we overcome the psychological hurdle?

Recently, there has been significant interest in the concept of health incentives – offering financial incentives in the form of cash, vouchers, or discounts contingent on healthy behaviour changes. Common behavioural targets include smoking cessation and weight loss, but could also extend to behaviours such as compliance with medications, vaccination schedules, and screening programs.

Variations of financial incentivisation already exist in the healthcare sphere. For example, in the US, where employers are responsible for worker health insurances, some employers offer discounts on health insurance premiums contingent on participation in the company healthy lifestyle programs. The underlying principle is that by improving employee health and productivity, and decreasing health insurance pay outs, the lifestyle programs reduce company expenditure. Closer to home, GPs can receive financial incentives through the Practice Incentives Program (PIP) for providing services like overdue cervical screening or chronic disease management for Aboriginal and/or Torres Strait Islander patients.

But what about directly and personally incentivising patients? The two questions we need to ask are 1) Does it work? and 2) If it does work, is it ethical?

Does it work?

The study results so far have been mixed and inconclusive. A recent Cochrane review evaluated studies testing the effect of a range of interventions, including vouchers, cash payments, lottery tickets, and deposit refunds, on smoking cessation, with moderately promising results.³ The results were particularly encouraging in pregnant women, who were more likely to have quit by the end of their pregnancy as well as at longest postpartum follow-up.³ However, a 2015 systematic review and meta-analysis tentatively concluded that although personal financial incentives do help change habitual behaviours while the incentives are present, the effects do not persist beyond three months after incentive removal.⁴ Whether incentive-based programs would be a cost-effective method is also still a developing area of research.

There are some theoretical concerns that a monetary reward may, contrary to intuition, bring about a decrease in the desired effect. This phenomenon is known as ‘motivation crowding out’, the classic example being paid versus altruistic blood donation. In his 1970 work The Gift Relationship: From Human Blood to Social Policy, Richard Titmuss argues that payments for blood donations undermine the intrinsic motivation of civic duty and would decrease or eliminate the willingness to give blood.⁵ Although this has been empirically discredited, the broader idea of motivation crowding out persists and has been used as an argument against the implementation of health incentives. Evidence of its effects in the context of health incentive programs is, however, insufficient to be of significant relevance.⁶

Is it ethical?

Let us suppose that health incentivisation does produce cost-effective and sustained behaviour changes on a population-wide scale. There is something rather unpalatable about the idea of paying people to be healthy.

Opponents argue that it represents an intrusion or bribe by the government to forego individual liberties, or that it is wrong to financially reward ‘unhealthy’ lifestyle choices. Perhaps the incentive may even encourage people to start or restart an undesirable behaviour for monetary gain. Furthermore, it would likely disproportionately target, or even coerce, people from low-income earning backgrounds, although it could be argued that this may help correct income-related health outcome disparity in the long run.

One prominent criticism has been put forward by political philosopher Michael Sandel. In his 2012 book, What Money Can’t Buy: The Moral Limits of Markets, Sandel argues that there are some realms of public life where the introduction of market principles corrupts the value of existing moral ones.⁷ In other words, there are some things in life which simply should not be for sale. To place a price tag on these special moral areas of life, Sandel argues, is to irreparably commodify them and erode their value.

One chapter explores this idea in the context of paying children to read, either within the home or at an institutional level. The outcome of improved literacy and its associated far-reaching benefits seems desirable, but Sandel argues that by bringing money into the equation we undermine the moral value of reading and learning. Instead of reading for personal development and the expansion of knowledge, the children are only in it for the money – and isn’t there something amiss in that?

Similarly, Sandel argues that the financial incentivisation of healthy behaviour erodes intrinsically worthwhile respect for our bodies and health. To eat well and exercise for money is to hijack the philosophically ‘higher’ goal of looking after ourselves as an end in and of itself. Even if we could pay our way into a perfectly fit, teetotal, non-smoker society, Sandel suggests that we shouldn’t. It would be doing “the right thing for the wrong reason”.⁷

It seems, however, rather paternalistic to denote ‘right’ and ‘wrong’ reasons for being good to one’s body.⁸ Moreover, even if there are better and worse reasons for adopting healthy behaviours, perhaps it is nonetheless better to do the right thing for the wrong reason than to never do the right thing at all.

Sandel worries that the external motivator of money will ‘crowd out’ the intrinsic motivation to have healthy bodies⁷ but rather than displacing the intrinsic motivations, a financial incentive could very well bolster them. There would be at least some people who find it difficult to make lifestyle modifications despite having the intrinsic motivation, but fall victim to the human tendency to value immediate rewards over future planning. Perhaps financial incentives would fill the motivational gap, so-to-speak.

Health prevention is, sadly, already a difficult political sell, and incentivising healthy lifestyle changes is unlikely to appeal to the public. However, given that financial incentives for healthy behaviours have the potential to improve public health, it is worth examining if our intuitive opposition has a rational basis. Ultimately, it’s an uphill battle for us to make behavioural changes, and maybe the problem warrants a different angle of thinking.

References

1. Australian Institute of Health and Welfare 2016. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4. Canberra: AIHW.
2. O’Donoghue T, Rabin M. Doing It Now or Later. American Economic Review. 1999;89(1):103-124.
3. Cahill K, Hartmann-Boyce J, Perera R. Incentives for smoking cessation. Cochrane Database of Systematic Reviews. 2015.
4. Mantzari E, Vogt F, Shemilt I, Wei Y, Higgins J, Marteau T. Personal financial incentives for changing habitual health-related behaviors: A systematic review and meta-analysis. Preventive Medicine. 2015;75:75-85.
5. Titmuss R. The Gift Relationship: From Human Blood to Social Policy. 1st ed. Allen & Unwin; 1970.
6. Promberger M, Marteau T. When do financial incentives reduce intrinsic motivation? Comparing behaviors studied in psychological and economic literatures. Health Psychology. 2013;32(9):950-957.
7. Sandel M. What Money Can’t Buy: The Moral Limits of Markets. 1st ed. London: Penguin; 2012.
8. Brown R. Social values and the corruption argument against financial incentives for healthy behaviour. Journal of Medical Ethics. 2016;43(3):140-144.
9. Mischel W, Ebbesen E, Raskoff Zeiss A. Cognitive and attentional mechanisms in delay of gratification. Journal of Personality and Social Psychology. 1972;21(2):204-218.
10. Schlam T, Wilson N, Shoda Y, Mischel W, Ayduk O. Preschoolers’ Delay of Gratification Predicts their Body Mass 30 Years Later. The Journal of Pediatrics. 2013;162(1):90-93.

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Feature image by Martin Kingsley at Wikimedia Commons.