Head to head
Plans to give drug misusers shopping vouchers to attend treatment programmes and stay clean have been unveiled by the UK National Institute for Health and Clinical Excellence. Joanne Shaw believes that payment creates perverse incentives, whereas Tom Burns says rewarding patients for cooperation is consistent with good medical practice
YES. How can it be considered perfectly ethical to lock up a patient with psychosis and force them to take drugs against their wishes and yet be “unacceptable” and “unethical”1 to offer them money to take the same drugs to stay well? Claassen and colleagues offered five assertive outreach patients, with whom they had failed to establish effective maintenance medication, £5-£15 (€7.5-€22; $10-$30) for each injection of depot antipsychotic.1 Four accepted the offer and have done well; three have stayed out of hospital for two years of follow-up; and one improved so much he demanded a pay rise. It doesn't need a health economist to calculate that two years of such payment costs less than a day or two in hospital.
Rewarding patients to cooperate is not new. In a study of over 1000 public mental health patients in the United States, half reported an offer of either coercion (compulsory