Given my former line of business working on digital wellness programs for employees and health plan members, I’ve tended to have a positive spin on the trend of including these types of programs in the benefits package. While I am not a big fan of financial incentives for health behaviors because they might re-wire motivation, I didn’t necessarily see them as morally ambiguous. That is, I didn’t necessarily see them as morally ambiguous until I read an article that helped me draw a parallel between rewarding wellness programs and research ethics.
The article, in Bloomberg, reviews recent court cases in which employees have sued over being told to participate in workplace wellness programs (most or all of which have been decided in the employer’s favor). The article focuses on privacy issues, but what caught my eye was this:
Under the new guidelines, the maximum penalty an employer can impose on non-participating workers is 30 percent of the total cost of employee-only coverage.
That . . . is a lot. Health care is expensive, and a 30% surcharge could make a huge difference for some people depending on their overall financial situation. Even though participation is technically voluntary, when the rewards and punishment become so significant, it’s not really an option to opt-out.
This situation is echoed in human subjects research protocols. Part of the ethical commitment that human subjects researchers makes is to avoid coercion of research participants. The natural interpretation of “coercion” is the use of force or threat to compel someone to participate in research, but most Institutional Review Boards make it clear that it can also include over-compensating participation such that people do not feel they have the ability to decline. This can be especially problematic with vulnerable populations such as the homeless, ill, or elderly, or with anyone at an economic disadvantage where even a small reward seems worth great risk.
Thinking about wellness programs in parallel with coercive human subjects recruitment, I suddenly wonder if it is ethical to reward or punish participation in these programs. After all, one of the hallmarks of a vulnerable population is being unduly influenced by another group, and in this particular situation, the employer holds both real and imagined power over the employee. What is framed as a choice may not be if a person’s autonomy has been diminished by the situation. I’m not sure how to fix this issue–we know participation in wellness programs is often poor in the absence of an incentive, and that wellness programs don’t work when people don’t take them, but the current reward system brings its own problems.
How could we better motivate people to participate in wellness programs that could help them? Can we?