Unduly induce us, please

The Austrian philosopher Ludwig Wittgenstein famously claimed that many traditional philosophical problems are ultimately rooted in conceptual confusions. Once these confusions are carefully exposed and analyzed, he believed, the problems are not just answered: they forfeit their original status as genuine problems, and simply vanish into thin air.

In this week’s Lancet, Ezekiel Emanuel et. al. make a noble attempt to make the problem of undue inducements disappear. Undue inducement is commonly regarded a standard research ethics problem and is viewed as particularly acute in international biomedical research. On the one hand, researchers are instructed not to provide excessively attractive incentives to prospective research participants, because this ‘offer you can hardly refuse’ could undermine the voluntary element of consent. On the other hand, much of international research takes place in impoverished countries where simply having blood pressure taken for free by a medical practitioner could be wildly seductive. Many an international researcher has agonized over how to recruit participants in low-income countries without violating their autonomy in the process.

According to Emanuel et. al., worries over undue inducements in international research are misplaced. Properly understood, undue inducements involve (1) the offer of a highly attractive good where (2) the offer undermines the persons judgment and (3) has them agreeing to take serious risks that threaten his/her fundamental interests. But in fact (3) is doing all the ethical work here. Inducements in research are only unethical according to Emanuel et. al. if they entice the participant to enter a study with a highly unfavorable risk-benefit ratio. Inducement itself, in other words, is not the problem: inducement into unduly risky research is the problem. As long as a research study fulfills basic ethical requirements – including the minimization of risk – then the problem of ‘undue inducement’ vanishes.

The argument seems to have an interesting implication. There appears to be nothing in principle stopping researchers from pulling out all the stops in terms of benefits, for as long as the research study is in ethically good shape, even awesome inducement is not undue inducement. In moderate and low-risk studies, why not just offer research subjects whopping big sums of cash to join?
Given the current state of health research budgets, and the general reluctance to substantially reduce global inequalities, the lavishing of benefits on developing world research participants is unlikely to happen. But it is nice to hear that there is nothing ethically against it.