Research Participation and Financial Inducements

Payments are different things to different people. To a homeless person, a guarantee of shelter and food is payment; to someone fighting a disease, treatment that might result in alleviation or a cure constitutes payment; to the impoverished student, maybe money is all that counts. What is important to understand is that motivation to participate in research can be varied and multifaceted and cannot be reduced to a single framework of monetary "payment."

Christine Grady (2001) sets out to examine whether payment for research participation can either be coercive or act as an undue influence, thus affecting informed consent. She decides that payment is not coercive according to her literal and potentially limited interpretation of the definition of coercion, "since the offer of money is not a threat of punishment or harm, but rather an offer." Similarly, undue influence, she argues, only occurs on rare occasions with offers of money. As long as the offers remain temperate and in line with payment for other forms of unskilled work, payment should not constitute an excessive influence.

The difference between coercion and undue inducement is, as Grady points out, subtle, which has led to the terms being used synonymously. She deals with this by discarding coercion altogether as being extraneous to her argument and instead focuses on "undue inducements." The difference between coercion and undue inducement for the purpose of the present argument is analagous to that which in contract law identifies two major obstacles to achieving autonomous choice: "the law of duress" and "the law of undue inducements" (Macklin 1981). Duress influences free choice through compelling, threatening pressure, whereby other options are invalidated or portrayed as comparatively worse, but undue influence entices people to participate in research with promises and rewards "against their better judgment."¹

Although Grady does acknowledge that payment need not only include money, she argues throughout her paper with a one-dimensional approach towards coercion. According to her reasoning, if money itself cannot coerce (by virtue of the fact that it does not present a direct threat), then it cannot be deemed coercive. However, prior to the offer of money, the stage has often been set for a situation rife with all the necessary elements of coercion. If the perceived harm of not accepting the money is deemed to be greater than that of doing so, then the situation underlying the potential "solution" of money is coercive. Therefore, money or good healthcare or whatever it is that the subject is lacking become potentially coercive instruments in the hands of the researchers by providing the "only" choice or alternative. What makes something coercive is not just the perceived way out of the situation but the situation prior to the offer of a way out.

A broader definition of coercion is "to deprive a man of freedom" (Berlin 1969, 121). Coercion is often phrased in terms of a lack of choice, a dearth of alternatives, but even where choices exist, not all choices are equally free (130). As Grady rightly observes, people "attracted to research by money . . . do have the freedom to refuse" (2001). However, what circumstances in these people's lives would tip the balance in favor of taking money for something they would not normally do? What motivates a person in India to sell a kidney for money? Surely it is the perceived paucity of other choices, combined with a sense of desperation or even a societal or familial expectation of how a situation should be resolved (precisely because the possibility exists), that transforms a potentially free choice into a coerced act.² If the harm of not participating in research is perceived as greater than any potential harms of taking part, for example of having no other money-earning options or a lack of access to good medical care outside the program, a person's "free" decision becomes seriously compromised, and a situation exists whereby a person may feel coerced due to the overt (even if unspoken) threat of a greater harm.

Paternalism and Autonomy

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