The debate surrounding clinical trial inducements has been relevant since the late 1700s when clinical trials first began (Pearn, Shields). The term inducement can be defined as something that influences a person to do something. In this particular context, "inducement" refers to some form of monetary payment. Today, the majority of inducements given to patients are based on risk factors, discomfort, time spent, and restriction (Blandizzi, Gori, Guiseppe, Tacca). If an inducement is given at all, the same monetary amount is given to healthy and ill patients alike. The biggest disagreement within the clinical trial debate is whether or not healthy volunteers should be given inducements for their participation. Healthy patients should be paid based on risk factors for participating in clinical trials because unlike their ill counterparts, they do not receive direct medical benefits from the trial; It will increase the chances for the healthy people to participate which will encourage the ill to do the same and will result in an improvement in the well-being for the ailing individuals; and inducements can be cost-effective.  

When a healthy person participates in a clinical trial, they do not have any obligation to do so. Many people chose to participate because someone close to them, whether it be a relative or a good friend, has a condition that could be helped or cured by the specific trial. Nevertheless, it is highly unlikely that the results of the trial will have an immediate effect on the disease or condition. Therefore, it is altruistic for a healthy person to voluntarily take part in an activity that could potentially put their health at risk. Healthy participants are some of the most noble members of society. This kind of volunteerism is inconsistent with other volunteerism methods of today. There is no debate over whether or not people should be paid for feeding the homeless, donating their old coats to Goodwill, or running in a 5k dedicated to curing cancer. The reason that healthy clinical trial patients should be paid for their volunteerism is because they are putting their individual well-being at risk in order to improve the well-being of society. The Journal of the American Medical Association outlines seven major requirements for ethical research. The fourth requirement reads, "There must be a favorable risk-benefit ratio -- within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks" (Ezekiel, Wendler, Grady). Inducements simply contribute to the favorable risk-benefit ratio. While an ill person may receive direct benefits from the trial, a healthy person will not. Because of this, it is only ethical to pay a healthy person for participating in medical research. 

When healthy clinical trial participants are given an inducement, it encourages the ill to participate, improving the well-being of the ill. Many people who are in need of treatment are hesitant to take part in clinical trials. Some people are afraid that the resulting side effects may be more harmful than their current condition. Others are simply afraid of getting their hopes up only to discover that the treatment did not work. A lot of ill people are hesitant to participate because they are not willing to dedicate much of their time and focus to the trial. For example, the trial may require that the patient travel to the study sight or stay in the hospital overnight for long periods of time. However, the most common reason that ill patients hesitate to take part in trials is because if the trial is a success and the treatment works for the patient, the treatment may not be available to them immediately (Salleh). It is frustrating when a patient knows that something exists that is capable of improving their current state if the patient does not have access to the cure. One study examined eleven randomized trails with quantitative data concerning the effect of financial incentives in the forms of cash, vouchers, lottery tickets, and gifts. Ten of the eleven trials found that financial incentives improved patient compliance (the extent to which a patient's behavior coincides with medical advice) in both the ill and the healthy. For example, the primary doctor, Dr. Shepard, in trial 6 explained that one of his pro bono patients is a homeless man with tuberculosis. Shepard stated that despite an ample amount of peer support, the man had refused to participate in the clinical trial multiple times. However, when a five-dollar inducement was offered to the man, he gladly agreed to participate in the tuberculosis trial. Trial 6 ended up being far more beneficial to the man than the five dollars he received for his participation. The treatment tested on the man was able to relieve his chest pain, calm his chills, and reduce his sweating. Although this trial did not fully cure the disease, the man's well being has greatly improved since his participation in the trial. If an inducement was never offered for this trial, the homeless man in trial 6 would still be unnecessarily suffering from painful symptoms. The study's most compelling find is that when hospitals offered inducements, 9 of the 11 trials had healthy participants volunteer before ill participants. For each healthy participant registered to participate, the doctors would contact an ill patient and say, "Good Morning Mr./Ms./Miss/Mrs. ______. We are under the impression that you are suffering from (insert condition) and are eligible for (insert trial). We wanted to make you aware that we have healthy people signed up to participate in this trial because they are dedicated to finding a cure for your condition. Would you like to join them?"  With 76.2 percent of ill patients agreeing to participate after learning a healthy person volunteered, the healthy individuals deserve the basic right to receive inducements (Giuffrida, Togerson). 

Offering inducements for clinical trials is oftentimes cost-effective. Financial incentives are able to achieve greater compliance at a lower cost than alternative interventions. It is important to note that the kind of inducement that would be most cost-effective is cash. In a recent study of an AIDS Prevention Program, statistics show that participation significantly deteriorated when monetary payments were changed to gift or food vouchers. It is also important to note that financial inducements are only cost-effective when the treatment benefits accrue not only to the individual patient, but to society as a whole. However, the goal of clinical trials is always to eventually benefit society at large. Consider treating tuberculosis, for example. If patients infected with tuberculosis are not offered inducements for participating in a trial concerning the disease, they are unlikely to volunteer. Ill patients already have enough on their plate; it is oftentimes more than overwhelming to sign up for a trial where the risks are unknown. Because of this, treatments will be made more expensive for individual tuberculosis patients later in the cycle of their disease. Small amounts of volunteers will also lead to "the possibility of the drug resistant strains the disease and the infection of other people". However, when inducements are offered, the possibility of rejection is majorly reduced. The reduction of rejections within clinical trials saves a plethora of resources that would otherwise be needed for re-transplantation. Financial inducements also improve equity, the quality of being fair and impartial. Because all of the inducements would be based on risk factor and remain the same dollar amount, the inducement would have a greater effect on the low-income population, therefore improving equity. If equity is improved financially, it can be assumed that the action that improved equity was cost effective as well (Jones, Liddell, Saunders). 

People who do not believe in providing inducements to healthy clinical trial participants based on risk believe that inducements take advantage of less fortunate people's "lack of options". These people claim that inducements make it so that impoverished people hardly have any other choice than to risk their health for money. They believe that clinical trials exploit the vulnerable by taking advantage of their situation. People who are against inducements claim that people of low socioeconomic status are forced to undergo trials containing risks that better-off people would not agree to. This belief argues that the option to take part in a trial, with a promised monetary inducement, will make a person "better off" regardless of the possible risks associated with the trial. The majority of people with this belief reference the four elements of undue inducement: 

A good is offered in order to do something 

The offered good is excessive so that it is irresistible

This leads to poor judgment on the part of the person who offered the inducement 

That poor judgment leads to a high probability of a serious risk of harm

 Joan McGregor tells the story of a mother who risked her child's health because he believes that she had no other choice than to do so. A millionaire proposes to the mother that he will pay for the treatment that her ill child needs if she becomes his mistress. "From the perspective of her child's welfare, it is in her interest to accept the offer; on the other hand, from the perspective of avoiding unwanted sexual interactions it is not," McGregor explains. The mother's decision to accept the millionaire's offer is rational because it provides her with hope for her child's well-being. However, it will cause serious emotional and physical harm to the mother. McGregor explains that for extremely impoverished people without any medical alternatives, the offer of a clinical trial where they have a 50% chance of receiving no treatment at all is better than no medical treatment, "making going along with the trial their only choice. They are coerced to accept the offer given their miserable circumstances." Inducements that are offered to impoverished people with little or no alternatives force them to only picture the promised reward, with no regard to the conditions associated with receiving it. Another reason why some people oppose the idea of inducements within clinical trials is because they believe that inducements transform an altruistic act into something of commercial business. Traditionally, health professions are built on a platform of altruism. The Journal of Clinical Nursing explains that, "despite any salary or payment for service, there is a fundamental ethos of the primacy of alleviating suffering, of promoting dignity and the fulfilment of palliative care; of the prevention of disease and injury, and of curing disease." People who do not support inducements believe that inducements have the potential to degrade scientific integrity. When inducements are offered to healthy clinical trial participants, there will be a reduction in the component of altruism in medical research (McGregor). 

The belief that inducements are taking advantage of impoverished peoples' "lack of options" is simply ignorant. While there will always be some sort of risk associated with clinical trial research, there are drastic measures taken by doctors, hospitals, and scientists to ensure that research is performed as safely as possible. There are many ways in which a patient is protected when undergoing a clinical trial: the informed consent process, the careful review and approval of the clinical trial protocol, and the ongoing monitoring of the trial. The trial is constantly being watched by an institutional review board, a data board, a safety board, the organization sponsoring the trial and the research team composed of scientists and doctors. The moment in which a trial becomes truly unsafe, (containing life-altering risks), the trial will be terminated. Therefore, impoverished people are not being forced to risk their health for money because their well-being is protected under a clinical trial (Gavin, King, McNichols, Mohan, Roche). Another reason why this belief is fallacious is because the monetary amount given to patients is not enough to significantly enhance a person's wealth. If an impoverished person turned down a clinical trial, it is not as if they would be missing out on a large sum of money. A week's worth at a fast food restaurant could easily equal the amount a patient would receive in an inducement. Another reason why this belief can be proven wrong is that there are so many opportunities for impoverished people to seek help other than turning to a clinical trial inducement to help their financial situation. Everywhere in the United States has programs available to help impoverished people whether it be in the form of a soup kitchen, group home, etc. The belief that inducements transform an altruistic act to something of commercial business is also false. As previously stated, inducements do not make a significant difference in a person's wealth or income, they simply help raise participation rates and level the playing field for healthy volunteers. It is still a commonly held belief that healthy clinical trial participants are some of the most noble humans in society. A small inducement does not change the fact that healthy clinical trial participants are taking a large chunk of time out of their schedules to undergo treatments that will not have any direct benefits to their well-being whatsoever. An inducement is simply a reward for doing something altruistic. A small amount of money given to an individual for a noble act of volunteerism does not take away from the fact that the individual is promoting the common good. 

Healthy patients should be paid monetarily based on risk factors for participating in clinical trials because they do not receive direct medical benefits from the trial, unlike ill patients do. While an ill person may directly benefit from a trial, a healthy person will not. Because of this, healthy participants should be paid for their nobleness. When inducements are offered, healthy people will be more likely to participate. In turn, the ill will be encouraged to participate, resulting in improving the well-being of the ill and eventually society as a whole. Incentives can also be cost-effective. More often than not, providing inducements for clinical trial participation is more cost-effective in the long run. Without clinical trial inducements, treatment options become more expensive for the ill individual. Clinical trial inducements are beneficial to society at large.   

