April 25, 2007

Payment, Compensation and Honoraria

In medical ethics, there are several things concerning which it is problematic to pay people. The two I will deal with here are organ donors and research subjects. Most bioethicists believe one should not pay people for these activities, for a variety of reasons, relating to concerns about exploitation and the confusion created between people and property. I will not address this debate here.

However, most rules concerning payment disallow any money to exchange hands in these cases. I will argue that this rule is too stringent, and does not separate out sufficiently the various ways in which money is used.

In the case of organ donation, there is a difference between payment and compensation. (This is a little tricky, because “compensation” is often used euphemistically to refer to any wage. I will not use the term in this eumphemistic sense). Money can be considered payment when the person expects a net profit from the money and compensation when it directly covers the costs to the person involved. This distinction is important, as to compensate people neither carries with it any concern of exploitation (there is no profit to be made) or of treating body parts as commodities (the organs themselves are never sold).

One can ensure compensation will not become payment in disguise in the same way as one can do so in other contexts. The person would have to present a bill or other paperwork showing that the person indeed lost money as a result of donating the organ. For instance, a plane ticket or a letter from an employer showing lost wages would need to be supplied. This would reduce the costs to organ donors (who are already sacrificing quite a bit) and provide fewer obstacles for poor donors who might otherwise choose not to donate.

In the case of research subjects, some form of money can help prevent what is called the “therapeutic misconception”. This is the misconception patients often have, even after they are told otherwise, that the treatment they receive even in a randomized trial has been specifically created for their own therapy. Some financial reward lessens this misconception, as patients pay doctors rather than vice versa, and a small amount of money will help offset their belief that their doctor is still offering what the doctor believes to be the best treatment.

However, to pay people to become research subjects opens up the possibility of exploitation, and threatens security by making our safety a commodity. This is where the idea of an “honorarium” is useful. An “honorarium” is a small amount of money whose purpose is to thank the person, not to provide a wage for them.

This may seem like hypocrisy, but there is a real distinction to be made here. It is easy to think of money as just one, easily commensurable unit; after all, money is the fungible tool par excellence. However, tools are defined by their functions or powers, and differing amounts of money can do different things. In this sense, different amounts of money can actually be quite different types of tool.

The relevant difference between payment and an honorarium is that payment is something off which we can live, while an honorarium is something that cannot significantly affect our financial security. So, a large amount of money that can pay rent, buy food or provide an automobile is actually a different type of tool than a very small amount of money that can buy a T-shirt or a book. This distinction allows there to be a real difference in function between a payment and a tool.

This type of remuneration is much harder to implement than the compensation for organ donors. After all, it is difficult to gauge how small an amount of money will be a mere honorarium for absolutely everyone. For Bill Gates, almost any reasonable amount of money would be an honorarium; for a poor person in income-geared housing, almost any amount of money would be payment. If that amount of money can serve as payment for even a single person, it will open up the possibility of exploiting that person. Yet, to provide different honoraria for different people may be easily interpreted as discrimination. As such, the honorarium would have to be extremely low relative to the average wage in a society, in no way compensate the person even for the amount of time used, and even then protections would have to be put in place to ensure that the very poor are not put in the position of renting themselves out as research subjects for food. I have doubts that this can be implemented properly in our stratified society, but this possibility is still open in theory.

Paying people for their organs or to risk their health in research subjects is widely considered immoral. However, providing compensation to organ donors or small honoraria to research subjects would not violate this principle. The former is easier to implement than the latter, but, by making the correct distinctions, we can at least partially overcome the financial burdens on organ donors and the therapeutic misconception among patients.

April 17, 2007

On Coercion

I've been away from the Lyceum for a while, but I always thought it was a worthwhile project to which to return. Thank you to everyone for sending me those complementary e-mails. They were largely what convinced me to start writing again.

Oh, and you might have noticed a change in my biography. Kathy and I got married on July 8th, 2006!

What distinguishes a free action from a coerced action? For a long time, I believed that it was that an action was coerced or at least unfree if it was what Aristotle called a non-voluntary decision, that is, a decision that was between a bad thing and a worse thing. His example is someone who needs to throw valuable cargo overboard in a storm to prevent the ship from sinking. In this context, an action should not be considered voluntary, because there is no option actually desired by the agent. What is voluntary is a choice for something one “wishes”, and a decision between two evils doesn’t give us anything we “wish”. So, an action that we make between two options that we wouldn’t want per se would be in some sense not voluntary.

This distinction is useful, but it is not enough. The problem is that it seems to exclude some examples of what we would consider free actions. Having done a lot of medical ethics recently, I noticed that most of the decisions people make in medical contexts are non-voluntary in this sense. One needs to decide between death and losing a limb, for example, or a particularly painful procedure and disability. If these actions are not considered free actions, it would not make sense to say that interfering with patients in these situations would harm their freedom. However, it seems evident that these cases are exactly the sort of cases in which the freedom of patients is most important.

If we do admit that non-voluntary actions are free, however, it would seem to make too many actions free actions. For instance, if a mugger confronts me in an alley with a gun and says, “Your money or your life”, I would be hard pressed to say that I had given my money over freely. This seems paradigmatic of a coerced, rather than a free decision. However, if non-voluntary actions are free, the only actions that would be unfree would be actions (if you can call them that) that actually result from force, such as being pushed off of a cliff. This is also an unacceptable result.

The solution is to consider coercion not in relation only to the type of action, whether voluntary, non-voluntary or involuntary, but with respect to the relationship of the person or people presenting the choice, and how that person manipulates the options. Options are manipulated in cases where the people presenting the choice are also deliberately affecting what choices are available. For instance, the mugger is also the person who is creating the options; he or she will be the one shooting me if I don’t hand over my money. In this case, my choice is manipulated, since the person presenting the choice is also the one fiddling with the possibilities.

This would be too broad if it included all manipulated choices. Someone who offers to sell me coffee is manipulating the options as well; he or she will only give me the coffee if I pay. It would even be too broad if it included all manipulated, non-voluntary choices. Someone offering to sell me a bicycle lock is manipulating my options, and my choice is between the two evils of spending money or having my bicycle stolen. Rather, a coerced choice is one where the person manipulating the choice is also adding a threat. They are adding another evil to one arm of my choice if I do not take the choice they wish me to take. The action is then coerced if three conditions are met: the choice is non-voluntary (I am choosing between two evils), the person presenting the choice is also manipulating the options, and the person manipulating the options is adding another evil (a threat) to one arm of my choices.

In the end, the destinction between a free and a coerced action is not that between a voluntary and an involuntary action. The person throwing goods overboard is acting freely while the mugging victim is coerced. Instead, coercion requires the additional condition that the person presenting the choice is manipulating the options in a particular way. Coercion is not a necessary consequence of the voluntariness of a decision per se, but of the relationship between me, the person presenting the choice, and the type of manipulation of options.