How ethical is the use of financial incentives to promote medication adherence among patients with serious mental illness? - a scoping review of the literature

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Poor adherence to medication treatment in those with serious mental illness is common. Typical solutions and consequences in Western, formal psychiatric care settings often involve coercive measures such as involuntary hospital admissions and treatment, and out-patient commitments, with serious infringements on civil liberty. We examine the relatively unfamiliar, controversial and under-explored area of using financial incentive (FI) to enhance medication adherence in this population through a comprehensive scoping literature review, focusing on the ethical aspects of this practice. From nineteen qualified papers, we identified seven key themes of ethical “concerns,” and opposing arguments on whether FI is: (1) itself a form of coercion affecting autonomy; (2) leading to erosion of a proper consent process; (3) causing indirect and unintended harm; (4) worsening multiple levels of stigma related to mental illness; (5) associated with loss of intrinsic motivation of treatment; (6) associated with misuse of the fund itself; and (7) potentially leading to negative impact on therapeutic relationships. The ethics review shows a moderate receptivity to the use of FI in some specific and individualized circumstances; exceptions for those with poor insight and lacking treatment capacity are particularly relevant in order to avoid other forms of coercion. Additional highlights of the review include the optimal amount, duration, scope, and target population of the FI, and need for rigorous attention to psychoeducation, process, therapeutic relationships, stigma, and not lose sight of ultimately aiming to improve on patients’ insight, autonomy, quality of life and intrinsic motivation in this controversial approach.