Ethical discussion

An ACT team specializes in the care and treatment of young adult aged 18-24 with serious and persistent mental illness (SPMI). The teams are composed of social workers from the county health department, the mental health center, and the state; nurses from the mental health center; a psychiatrist; and an advanced practice registered nurse. The teams are funded from the Department of Human Services and do not have adequate funds for supplies or patient needs. The primary goal of the team is to assist patients in goals related to rehabilitation of their mental illness in order to avoid hospitalization and keep them living in the community. Specific goals include maintaining stable housing, learning to stick to a budget, medication and treatment adherence, effective parenting, sobriety, socialization, better physical health, staying out of jail, and staying out of the hospital. The ACT team has found that money can be effective in getting patients to complete tasks. For example, they sometimes pay non-compliant patients $2/day to take their medications in front of the staff, or the patients are given gift cards to Subway or Target after a week of medication compliance. The team also has given money ($10-$20) for patients to get necessary lab work they would not otherwise do and also have given a patient with extreme hand contractures $20 for each visit to the physical therapist. Birth control options are discussed with all female patients. Many already have children and have declined birth control options in the past for various reasons. A young woman with schizophrenia came into the office and said she had run out of money. She asked to borrow $50 from the team’s flex fund. She had borrowed money in the past and not paid it back. The case managers and the nurse decided not to loan the money to the patient, but instead offered her a $50 to get a Depo Provera injection that day plus an additional incentive of $50 every three months for subsequent injections. She agreed to get the injection in exchange for the money even though she had refused birth control in the past. Is it ethical to pay a patient to receive birth control? For any reason? Do these scenarios describe inducement or coercion? What is the difference? Informed consent?