On Considering (What I Might Do for) Money

Like Christine Grady, I have looked at advertisements. It was in the early 1980's by the Science Building elevators—a place seen by students, staff, and faculty—when I saw the flyer that left me believing that Institutional Review Boards (IRBs) should review advertising. It read, "Research Study: Great Pay—No Risks, Call. . . ." I recalled the IRB had extensive discussion about the rare but serious harms of the study. Shortly thereafter I was asked to write a term paper in my MBA ethics class. I wrote on "Money, Coercion, and Undue Influence." I concluded, as did Grady, that money offered to subjects was rarely coercive, but that it had the potential for seriously unduly influencing a person. Grady picks up where my work ended by asking how we can determine when an amount of money might be undue. Although she and other commentators make elegant and persuasive arguments, I (the pragmatist) remain unsure how to evaluate whether to pay Ms. or Mr. Doe $15 or $1500 for the use of her or his body.

Money can never be considered in isolation. Money is handled differently by strong- and/or weak-willed people, by rich and poor people, by those with options and those with no options, by those with knowledge and those with no knowledge, and by those consenting on their own and those consenting on another's behalf. In fact, the issue of payments to investigators is receiving much the same examination. What level of inducement might alter a researcher's motivation enough so that he or she might act in a manner not in the best interests of his or her subjects or of the study? Most of Grady's arguments also apply to this arena.

The key to the evaluation of conflict of interest for subjects and for investigators is to evaluate the point at which due becomes undue, and to seek to reduce the ill effects of undue inducements. In effect, this evaluation becomes a combination of minimizing risks and requiring respect for persons.

Mark Wartofsky (1976) argues that subjects are, in effect, selling their bodies for money and that this is akin to prostitution. This strikes me as a memorable proposition. Each of us has a personal line in the sand. Each line is different and most lines are never articulated. How can we—as researchers or reviewers—evaluate what we should offer to others for participation in research studies?

Jerry Menikoff (2001) discusses payment in relation to assumption of risk. Although he acknowledges that we do pay people for assuming risks, his analysis stops short of comparing apples to apples (Fujis to Macintoshes). Most steelworkers are paid more than most teachers. If we were to account for relative levels of risk within the same profession, though, we might pay inner-city teachers more than those in suburban private schools. Should all subjects doing the same thing be paid the same amount?

Unlike local IRBs, which examine only the compensation offered in their local area, a central IRB such as the one I run must review multiple sites. The question of appropriate compensation is very difficult. In one study in which I was involved, women in a very wealthy area were asked to agree to extended discomfort and intervention prior to a desired therapeutic surgery. The IRB agreed that $300 compensation would not be unduly coercive in this setting.

Soon thereafter, an investigator from a poor, under-served, inner-city area applied to the IRB for permission to conduct the same study. The IRB was very concerned that $300 might be undue inducement in this situation. After the IRB administrator made multiple calls to research colleagues in the area, the IRB determined that $300, although at the upper end of what could be considered noncoercive for the inner-city area, was within local standards. When informed of this, the investigator responded "Thank God! Some of these women can't have surgery without this assistance."

The investigator's exclamation is unnerving. It implies...