I think it should be targeted at those who would not normally WALK 10,000 steps per day. This eligibility requirements would discriminate against those those do so currently. If the technology permits, other measures of health-behaviors could be easily added, i think.

Dear Joseph, interesting question. I think we may apply ethics in two situations. The first is purely as you poses: an incentive without apparent reciprocity, that could help people who need to do exercise. Another situation is if the beneficiary should give his/her data as a condition and accept to be monitored by the entity that reports for the public administration. This would entail some ethic problems regarding privacy.

It could be nice to get payment for walking, especially for me, while I am often a lazy bone, and lacking motivation. Dear Joseph Tham, by the way, I agree, all such encouragement for certain useful actions, may be attributed in societal life in general and in particular.

Arvydas Guogis Looking at your professional qualifications and background, i am afraid that if i was in charge of the requirements, you would probably not qualify. There would have to be some kind of income and education threshold. it must be means tested. i am not worried about you i am worried about all the exercise freaks who would be walking anyway, without any motivation. no need to pay them.

As a mid-active person, the incentive would very much motivate me to be active and probably take more than 10,000 steps. Would it be ethically perhaps in a country where diabetes, obesity and other detrimental health issues are more prominent to motivate exercising. The cost of rewarding taking a walk will be less compare to the cost for the health sector to curb the problem so in that sense it is ethical. However as you rightly put it, it will need proper monitoring mechanism, with technology these days, many can cheat. For instance, i can take the steps for my inactive and morbidly obese aunty.

The encouragement to positive healthy behaviours is a thought worth exploring. I present my submission along the following lines:

1. Governments around the world spend a lot on health infrastructure as well as operationalization of the same.

2. A substantial part of this expenditure is on account of the factors that people are not following positive healthy behaviours.

3. If in first place positive healthy behaviours are instilled and encouraged - much of the health expenditure can be saved.

4. Incentivizing the positive health behaviour is an excellent option.

5. Monetary incentivization needs to be carefully thought off.

6. Instead incentivization in terms of privileges, accesses, reward points, appreciation certificates, coverage in media (including social media), etc. - may be considered.

With Kind Regards

Dr. Akshat Mehta

Raksha Shakti University, India

Interesting question - reminds me of parents who paid their kids to get good grades...... once incentive gone - no more interest in reading or studying....In the US many companies have gone the route of incentives for Not Smoking, Increased Walking etc..... but the research indicates if folks are doing it only for the incentive, the behavior tends NOT to last..... My daughter who is a Kinesiology Major has explained many times.. that unless an individual is motivated themselves.... ie need back surgery or knee surgery to decrease pain... then sometimes they will lose the weight because the pain is so unbearable.... So rather than an ethics issue... it really comes down to whether incentives are effective in changing ones behavior...... $$$ wouldn't do it for me..... Has to be when I personally really want to look better, feel better, sleep better and have more energy..... That is usually when I get more serious about exercise.... And use to be a jogger 5 miles/day til had Back Surgery...

Patricia Ann Herlihy Fully agree. The perennial dilemma of intrinsic motivation versus extrinsic motivation. no easy answers. We react and change our behavior according to external incentives but as you say, in the longer term, intrinsic motivation is the key driver. Thank you for your post.

Very sceptical Monetarization is a favourite bandwagon of those who believe they can tap into the increased flow of money so created. Not a good reason at all in my view.

Tony Maine Is it unethical? Immoral? Violates social norms?

Interesting question! Following answers.

Hassan Izzeddin Sarsak Do you agree? Disagree? What are your thoughts? Suggestions?

The problem might be similar to the carrot în front of the donkey: are we able to think and act accordingly or just react for a reward (schooling or circus)? Then, The sustenability of the motivation, as discussed above. Mitigation of cheating behaviour might be a pretext for tehnological control, overwatch (see China). Then, The source of the money makes another topis for discussion.

Overall, I incline to consider it as unethical: it has tendency to destroy the value sistem we try to define since Ancient Greeks (the core of human behaviour would be egoistic,non-virtuous, predictable, submissive, irational, dependent, forced, accidental).

Simona Dracinschi According to economic theory, we tax things that are bad, and provide subsidies for things that are good, from society's point of view. We tax cigarettes and alcohol for instance, and give subsidies for education. Are you in principle opposed to giving monetary incentives in general? For example, are you opposed to giving subsidies to encourage educational performance?

Yes, its ethically acceptable to give monetary rewards for positive health behaviors, such as daily walks.

Yes, it's a good idea.

I tend to believe that money as private incentive perverts our sistem of values. As a macrosystem, society, I didn't go further with analysis. But, We May turn the problem like this: We don't kill People because We are afraid of punishment or because IT îs wrong? Maybe starting giving money for jogging, we'll end up being obliged to paying People not hurting others.

I don't know if it is unethical, but at our house the kids just want to sit and play video games and be on their phones. What we do is give them screen time in exchange for physical activities including stationary bike, eliptical, swimming, and walking the dogs.

So in a way, we are paying them to exercise.

I would like to add that our hope as parents is to instill the value of a balanced healthy life, not to teach them that they should be paid to get off the couch.

I do not think so. This is because it is unrealistic to compensate everyone assuming that they adopted health behaviors. As such, it is not sustainable in the long term. I think the solution is in health education and promotion so that the change to healthy practices may be instigated from the educated/knowledgeable individual.

Financial reward for healthy behaviours sounds rather simplistic. How do you take into account diversity, those that can and those that can't? I think it is a complex issue. So no, I don't think it is particularly ethical as too much to overcome and too much to think about. I think it would be much better to help them to believe that they want to do it and would enjoy doing it. That way it would be personal to them and tailored to their abilities and individual needs. Also, where is the economical value of offering financial reward?

Its a good idea to promote healthy habit of walking . Smart phones / technology can help to verify claims.

Although there may be some debate about the ethics, rewarding healthy behavior is a common practice. In the U.S. it is often done in businesses. There is a literature on the subject. For a paper that focuses on the ethical issue, you might read: Lunze K, Paasche-Orlow MK. Financial Incentives for Healthy Behavior: Ethical Safeguards for Behavioral Economics. Amer J Preventive Med. 2013;44(6):659-665.

With respect to weight loss, though it does not discuss the ethics, per se, there is an interesting article about a study of different approaches to structuring the incentive: https://psmag.com/social-justice/the-weight-loss-incentive-that-works-better-than-cash-54885

Stephen C Schoenbaum Thanks for your support. For a while, i had the feeling that maybe i am the only weirdo who believes in incentives. I am surprised that there is such resistance. What is the global practice? Are the answers here representative? For me it just makes total sense, and it is fine, from an ethical perspective.

I think it makes sense, if done carefully and accompanied by evaluation to determine that it is not discriminatory. I think it is clearly unethical to hold people accountable for things that are entirely outside their control; but presumably we feel that behavior change is important in the management of certain conditions because we also believe that change is possible.

Daily monetary incentives should not be encouraged, it can be done occasionally, we can rather grant privileges as positive reinforcement. Like after the walk, additional 10 or 30 minutes on favourite carroon

Stephen C Schoenbaum As a general principle, do you support taxes on things or activities that society has decided are "bad" such as cigarettes? And promote "good" activities with subsidies?

Generally, yes. In New York City, Michael Bloomberg was elected mayor back in 2001. He chose Thomas Frieden as his Commission of Health. Very early on, they raised taxes greatly on cigarettes and banned smoking in restaurants and bars. The results were dramatic. Although the tax disproportionately affected the young and the poor, many being minorities, it also led to a dramatic reduction of smoking rates in those same groups, They had the highest smoking rates to begin with. Net effect: benefit to those who quit smoking; benefit to their families; benefit to others in the community who might be affected by passive smoke. And, interestingly, the restaurants and bars, which were initially very concerned about loss of business, gained customers.

Stephen C Schoenbaum Okay. Good. so we generally agree. Earlier, you had raised the issue of discrimination and of control. Do we have control on the change in behavior. i guess, since you support the "sin tax" on cigarettes, you think that discrimination was not much of an issue, and people do have control on quitting. Somehow, you do not feel the same about daily walking. If you could kindly explain the difference between taxing bads, and subsidizing good behavior, in this case, daily walks. or do you think there is not necessarily a symmetry in the thinking, and this is fine as well. just trying to figure out on what we can agree to disagree on.

Although it is not easy to quit smoking, it certainly can be done; and it clearly happened in New York City on a large scale. Here is a small piece of a report from 2002: " Significant decreases in prevalence of current smokers in New York City were observed among specific population groups; the frequency of current smokers aged 18-24 years declined from 29.4% in 2001 to 15.2% in 2002 (p=0.01), and, the frequency of smoking among individuals with 4 or more years of college education decreased from 19.7% in 2001 to 12.1% in 2002 (p

Stephen C Schoenbaum Okay. i see your point. it would be discriminatory against people who have trouble walking. That is true. not sure how to solve this problem since i am rewarding walking. We could have some kind of incentive system based on difficulty in walking but this simply raises the costs of implementation and adds to the complexity without any corresponding benefits as far as i can see

Some parts of the city or region would be more friendly for walking. not sure how to address this. it would discriminate against people that do not have ready access to walking facilities.

I have not reviewed the relevant literature on the health benefits of walking but all the anecdotal evidence suggests that it is beneficial. now i may have to look for RCTs. no sure how many RCTs exist. i could argue that this is not a malevolent form of discrimination. i did say that it was voluntary which is a plus point. The tax on cigarettes did not have any exemptions, did it? So it was "compulsory", say we say.

we can discuss eligibility requirements. we could use an array of measures to means-test this scheme. What other issues should i consider to make sure that i satisfy your stringent requirements for careful planning and evaluation? i guess we should put sufficient money for rigorous evaluation. Agree?

This scheme would also DISCRIMINATE against individuals who are not motivated with money. What to do? We could provide other non-monetary incentives but all of this simply complicates the administration, planning and design of a relatively simple idea based on non-rigorous research and no RCTs. i am just surprised that i have not received more support from the answers that have been posted. interesting.

Sorry - I missed your question about walking. I think it is fine to reward daily walking. Rightly or wrongly, since you are offering a reward, I don't see that it is a problem that people who cannot walk are not eligible for the reward. Rewards tend to have eligibility rules. I don't know the ethics behind most of those rules except that when companies offer rewards to customers and potential customers, they generally exclude their own employees and allow the general public (potential customers) to be included, i.e., you don't have to buy something to be eligible.

Interesting! I am following this discussion

Stephen C Schoenbaum The general principle under discussion is whether it is ethical to use monetary incentives to modify behaviors. Many respondents seem to believe that the use of such monetary incentives would only promote extrinsic motivation and not intrinsic motivation, which is superior i guess. but if such monetary incentives are effective, then we should use it, i think. of course, there are lots of people who would NOT respond to such incentives, and we may have to think of non-monetary incentives to reach them.

It is correct that monetary incentives promote extrinsic vs. intrinsic motivation; but I also think that with behavior change programs, such as your walking program, at least some of the people who initially receive monetary incentives and change their behavior like the new behavior well enough that they continue it. I therefore believe that for some people the intrinsic motivation to continue develops and leads to persistent change. I do not have data to support my belief. In fact, the literature tends to support the idea that monetary/extrinsic incentives decrease intrinsic motivation and, accordingly, may be harmful. Despite this, you might be interested in reading what I think is an interesting article on the web: https://review.chicagobooth.edu/behavioral-science/2018/article/short-term-rewards-don-t-sap-long-term-motivation

Stephen C Schoenbaum Thank you for taking the time to write such a thoughtful reply. Greatly appreciated. Let me reflect on your comments and write a response. Thanks for engaging in this conversation.

In order to maintain these behaviors

World is believing in Community Mobilization for Behavioural Change (COMBI), this means after understanding their risk conditions people themselves adjust their life styles. The issue with the cash rewards is two components- as it is not sustainable for long run and people might not best practices through out the day, even though they completed their Walk for cash benefit. Cash as a mechanism was successful in my home country where they targeted to enroll Men for Vasectomy in family planning program. As there is no risk once vasectomy done for the individual intended results achieve for the Public Health program. Therefore it is hard to believe sustainable impact results can be achieved with the cash transfer.

Nalinda Tharanga Wellappuli Thank you very much for your post with practical illustrative examples. i guess local communities would have to be involved in the decision for giving any cash incentives.

Joseph Tham- I agree, good topic to discuss in the era of NCD, my pleasure to contribute.

Joseph Tham

I remember in the 80 several companies were offering this scheme to their employees. The rational was that they will be healthier and the insurance bill will be reduced drastically. Overall the company makes money and have healthier employees. Win win for both.

I dont think it is ethically aceptable. Monetary rewards can seem like a bribe. And positive health behaviours can be rewards in other positive ways. Such as with motivational notes. Healthy food, healthy Shakes. gym passes, massages or even exercise tools or equipment. Monetary rewards can be used to pay for unhealthy habits.

Ethics be damned. Let's do it.

(Fiat money is funny money anyway so whatever is done with such money cannot be deemed ethical or unethical.)

i would count every running step twice, oh my!, i would be so rich!!! i can even imagine New York Step Exchange (NYSE) where people could meet to sell and buy walking and running steps: i would be a da(il)y trader: i would run early in the morning and then i would wait patiently . . . i would sell my steps in tranches during the afternoon rush hour.

Dear Joseph Tham , The principle of reward and punishment exists from ancient times, and must be activated accurately, in order to reward the good and punish the bad, but the most important thing is to set specific controls and standards.

Joseph Tham this is a great question and I applaud your efforts to plumb the ethical dimensions. I wonder if the responses would be equally well-received if it was inverted asking pretty much the same thing. " Would it be ethically acceptable to decline monetary incentives to those not reporting sanctioned health behaviors, such as daily walks?

Interesting as this scheme sounds similar to other health care and insurance company incentives. If I go for yearly check-ups, wellness visits etc., I receive a $500 dollar reduction on my health care premiums. Of course, I engage in this behavior because of the "incentive". But it could be equally be seen as punitive if I don't engage in these behaviors. It is designed so that my behaviors are not private. Sanctioned behavior becomes one of the public (or at least medical) records to be used in whatever fashion is deemed appropriate by whoever has access.

There are many ways these could be decoupled. They could have other parties that monitor the behavior and provide the incentive from stakeholders without telling the stakeholders who is receiving the benefit. Separating the validation from the medical and insurance records would encourage behavior while preserving privacy. But I suspect this, like so many other things, is not about promoting positive behavior as it is about mitigating risk and the affiliated cost of private information. So, while it is a blunt tool, it may be the best one available to all involved.

Joseph Tham, Nice idea indeed for promoting healthy behaviour. The economic and social costs of unhealthy behaviours have more adverse consequences and apparently health behaviours can be significantly influenced by the economic incentives. Various programs in the UK, USA and other countries show promising health and behavioural outcomes. However, it raises the following ethical concerns:

• It may contribute to inequities. It would benefit only those who have access to a mobile phone or digital resources.
• It can be coercive and interfere with therapeutic relationships.
• It undermines personal responsibility for health, and promote dependence.
• It may be a source of stigma or discrimination and can be unfair for those who are already engaged in specific health behaviours or those who cannot fulfil the incentivized behaviours.
• A cash reward may not be a sustainable solution for adapting healthy lifestyle and practices.

Rather linking monetary benefits for healthy behaviours (10000 steps walking, 10 km cycling or exercise, or healthy food intake or avoiding the frequency of junk food or unhealthy food), such behaviours can be encouraged by non-monetary rewards (virtual milestones from newbie to adventurous, ambassador, catalyst, community leader, expert etc.), prizes in terms of a certificate of award, recognition during public programs or profile on a website would provide motivation to sustain healthy practices.

The digital community of Practice platform can be formed for all to discuss, learn and share their experiences, and success stories.

Inviting successful practitioners as a resource person or judge or panellist for various competitions to promote healthy behaviours, for example, marathon, yoga week, group cycling, city trip by walking etc

Motivational merchandise such as cap, t-shirt, key-chain, etc can be given as a reward for achieving certain milestones.

The digital program, Promoting for Healthy Behaviour Change, can be designed and tested for its effectiveness, cost-saving, feasibility and sustainability. Based on the results, it can be recommended for scale-up. Why not we test this idea? Let me know if I can contribute to this initiative.

Best Wishes,

Apurvakumar

Cash incentives can be considered as extrinsic motivators; this will help to a certain extent. But sustaining the behavior may require more efforts on those considered as intrinsic motivators (e.g. education to let them internalize the importance of the desired behavior)