Personal financial incentives in health promotion: where do they fit in an ethic of autonomy?

Aim This paper reviews the ethical controversy concerning the use of monetary incentives in health promotion, focussing specifically on the arguments relating to the impact on personal autonomy of such incentives. Background Offering people small amounts of money in the context of health promotion and medical care has been attempted in a number of settings in recent years. This use of personal financial incentives has attracted a degree of ethical controversy. One form of criticism is that such schemes interfere with the autonomy of the patient or citizen in an illegitimate way. Methods This paper presents a thematic analysis of the main arguments concerning personal autonomy and the use of monetary incentives in behaviour change. Results The main moral objections to the uses of incentives are that they may be in general or in specific instances paternalistic, coercive, involve bribery, or undermine the agency of the person. Conclusion While incentive schemes may engage these problems on occasion, there is no good reason to think that they do so inherently and of necessity. We need better behavioural science evidence to understand how incentives work, in order to evaluate their moral effects in practice.