Lawyers as sharks?

Front Hum Neurosci. 2014 Dec 2;8:973. doi: 10.3389/fnhum.2014.00973. eCollection 2014.

The importance of being apt: metaphor comprehension in Alzheimer's disease.

Roncero C1, de Almeida RG1.

Author information

• 1Department of Psychology, Concordia University Montreal, QC, Canada.

Abstract

We investigated the effect of aptness in the comprehension of copular metaphors (e.g., Lawyers are sharks) by Alzheimer's Disease (AD) patients. Aptness is the extent to which the vehicle (e.g., shark) captures salient properties of the topic (e.g., lawyers). A group of AD patients provided interpretations for metaphors that varied both in aptness and familiarity. Compared to healthy controls, AD patients produced worse interpretations, but interpretation ability was related to a metaphor's aptness rather than to its familiarity level, and patients with superior abstraction ability produced better interpretations. Therefore, the ability to construct figurative interpretations for metaphors is not always diminished in AD patients nor is it dependent only on the novelty level of the expression. We show that Alzheimer's patients' capacity to build figurative interpretations for metaphors is related to both item variables, such as aptness, and participant variables, such as abstraction ability.

From UNC: The fiduciary relationship model for managing clinical genomic "incidental" findings

J Law Med Ethics. 2014 Dec;42(4):576-89. doi: 10.1111/jlme.12177.

The fiduciary relationship model for managing clinical genomic "incidental" findings.

Lázaro-Muñoz G1.

Author information

• 1Postdoctoral Research Fellow at the Center for Genomics and Society at the University of North Carolina School of Medicine.

Abstract

This paper examines how the application of legal fiduciary principles (e.g., physicians' duty of loyalty and care, duty to inform, and duty act within the scope of authority), can serve as a framework to promote management of clinical genomic "incidental" or secondary target findings that is patient-centered and consistent with recognized patient autonomy rights. The application of fiduciary principles to the clinical genomic testing context gives rise to at least four physician fiduciary duties in conflict with recent recommendations by the American College of Medical Genetics and Genomics (ACMG). These recommendations have generated much debate among lawyers, clinicians, and bioethicists hence I believe this publication will be of value and interest to your readership.

Am J Respir Crit Care Med. 2015 Jan 15;191(2):219-227.

An Official American Thoracic Society Policy Statement: Managing Conscientious Objections in Intensive Care Medicine.

Lewis-Newby M, Wicclair M, Pope T, Rushton C, Curlin F, Diekema D, Durrer D, Ehlenbach W, Gibson-Scipio W, Glavan B, Langer RL, Manthous C, Rose C,Scardella A, Shanawani H, Siegel MD, Halpern SD, Truog RD, White DB; on behalf of the ATS Ethics and Conflict of Interest Committee.

Abstract

Rationale: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. 

Objectives: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. 

Methods: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. 

Main Results: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. 

Conclusions: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

No Physical Activity is twice as deadly as Obesity

Written by Tanya Campbell on 16 Jan 2015

Professor Ulf Ekelund from the Medical Research Council (MRC) Epidemiology Unit at the University of Cambridge said, "Although we found that just 20 minutes would make a difference, we should really be looking to do more than this - physical activity has many proven health benefits and should be an important part of our daily life".

"After a peak in 2009-2010, the clinical research sector in India appears to be experiencing a contraction."

J Clin Res Bioeth. 2014 Nov 1;5(6):1-8.

Clinical Research Environment in India: Challenges and Proposed Solutions.

Burt T1, Sharma P2, Dhillon S3, Manchanda M2, Mittal S2, Trehan N2.

Author information

• 1Duke Clinical Research Unit and Duke Clinical Research Institute, Durham, NC, USA.
• 2Novartis, Singapore.
• 3Medanta the Medicity, Gurgaon, Haryana, India.

Abstract

India has compelling need and keen aspirations for indigenous clinical research. Notwithstanding this need and previously reported growth the expected expansion of Indian clinical research has not materialized. We reviewed the scientific literature, lay press reports, and ClinicalTrials.gov data for information and commentary on projections, progress, and impediments associated with clinical trials in India. We also propose targeted solutions to identified challenges. The Indian clinical trial sector grew by (+) 20.3% CAGR (compound annual growth rate) between 2005 and 2010 and contracted by (-) 14.6% CAGR between 2010 and 2013. Phase-1 trials grew by (+) 43.5% CAGR from 2005-2013, phase-2 trials grew by (+) 19.8% CAGR from 2005-2009 and contracted by (-) 12.6% CAGR from 2009-2013, and phase-3 trials grew by (+) 13.0% CAGR from 2005-2010 and contracted by (-) 28.8% CAGR from 2010-2013. This was associated with a slowing of the regulatory approval process, increased media coverage and activist engagement, and accelerated development of regulatory guidelines and recuperative initiatives. We propose the following as potential targets for restorative interventions: Regulatory overhaul (leadership and enforcement of regulations, resolution of ambiguity in regulations, staffing, training, guidelines, and ethical principles [e.g., compensation]).Education and training of research professionals, clinicians, and regulators.Public awareness and empowerment. After a peak in 2009-2010, the clinical research sector in India appears to be experiencing a contraction. There are indications of challenges in regulatory enforcement of guidelines; training of clinical research professionals; and awareness, participation, partnership, and the general image amongst the non-professional media and public. Preventative and corrective principles and interventions are outlined with the goal of realizing the clinical research potential in India.

Sociol Health Illn. 2015 Jan 8. doi: 10.1111/1467-9566.12213. [Epub ahead of print]

The politics of healthcare informatics: knowledge management using an electronic medical record system.

Bar-Lev S1.

Author information

• 1Ruppin Academic Centre, School of Engineering, Israel.

Abstract

The design and implementation of an electronic medical record system pose significant epistemological and practical complexities. Despite optimistic assessments of their potential contribution to the quality of care, their implementation has been problematic, and their actual employment in various clinical settings remains controversial. Little is known about how their use actually mediates knowing. Employing a variety of qualitative research methods, this article attempts an answer by illustrating how omitting, editing and excessive reporting were employed as part of nurses' and physicians' political efforts to shape knowledge production and knowledge sharing in a technologically mediated healthcare setting.

Is patient empowerment by health coaching the key to controlling health care costs?

Med Care. 2015 Feb;53(2):133-140.

How Effective is Health Coaching in Reducing Health Services Expenditures?

Jonk Y1, Lawson K, O'Connor H, Riise KS, Eisenberg D, Dowd B, Kreitzer MJ.

Author information

• 1*Center for Rural Health, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND †Center for Spirituality and Healing, School of Nursing ‡Division of Health Policy and Management, School of Public Health §Department of Biobehavioral Health and Population Sciences, University of Minnesota, Minneapolis, MN ∥Samueli Institute, Alexandria, VA ¶Harvard School of Public Health, Boston, MA.

Abstract

BACKGROUND::

Health coaching interventions aim to identify high-risk enrollees and encourage them to play a more proactive role in improving their health, improve their ability to navigate the health care system, and reduce costs.

OBJECTIVES::

Evaluate the effect of health coaching on inpatient, emergency room, outpatient, and prescription drug expenditures.

RESEARCH DESIGN::

Quasiexperimental pre-post design. Health coaching participants were identified over the 2-year time period 2009-2010. Propensity scores facilitated matching eligible participants and nonparticipating controls on a one-to-one basis using nearest kernel techniques. Difference in differences logistic and generalized linear models addressed the impact of health coaching on the probability of incurring costs and levels of inpatient, emergency room, outpatient, and prescription drug expenditures, respectively.

MEASURES::

Administrative claims data were used to analyze health services expenditures preparticipation and post health coaching participation time periods.

RESULTS::

Of the 6940 health coaching participants, 1161 participated for at least 4 weeks and had a minimum of 6 months of claims data preparticipation and postparticipation. Although the probability of incurring costs and expenditure levels for emergency room services were not affected, the probability of incurring inpatient expenditures and levels of outpatient and total costs for health coaching participants fell significantly from preparticipation to postparticipation relative to controls. Estimated outpatient and total cost savings were $286 and $412 per person per month, respectively.

CONCLUSIONS::

Health coaching led to significant reductions in outpatient and total expenditures for high-risk plan enrollees. Future studies analyzing both health outcomes and claims data are needed to assess the cost-effectiveness of health coaching in specific populations.

South Med J. 2015 Jan;108(1):1-4. doi: 10.14423/SMJ.0000000000000221.

Cross-cultural barriers to health care.

Vidaeff AC1, Kerrigan AJ1, Monga M1.

Author information

• 1From the Department of Obstetrics and Gynecology and the Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.

Abstract

Culturally sensitive health care represents a real ethical and practical need in a Western healthcare system increasingly serving a multiethnic society. This review focuses on cross-cultural barriers to health care and incongruent aspects from a cultural perspective in the provision of health care. To overcome difficulties in culturally dissimilar interactions and eventually remove cross-cultural barriers to health care, a culturally sensitive physician considers his or her own identity, values, and beliefs; recognizes the similarities and differences among cultures; understands what those similarities and differences mean; and is able to bridge the differences to accomplish clear and effective communication.

Pediatric ethics: "...on some issues, the ethical debate now looks remarkably similar to that of 40-50 years ago."

J Paediatr Child Health. 2015 Jan;51(1):8-11. doi: 10.1111/jpc.12793.

Fifty years of paediatric ethics.

Gillam L1.

Author information

• 1Children's Bioethics Centre, Royal Children's Hospital, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.

Abstract

In 1965, when the first issue of Journal of Paediatrics and Child Health appeared, medical ethics was just becoming established as a discipline. The sub-speciality of paediatric ethics did not make an appearance until the late 1980s, with the first key texts appearing in the 1990s. Professional concern to practice ethically in paediatrics obviously goes much further back than that, even if not named as such. In clinical areas of paediatrics, the story of the last 50 years is essentially a story of progress - better understanding of disease, better diagnosis, more effective treatment, better outcomes. In paediatric ethics, the story of the last 50 years is a bit more complicated. In ethics, the idea of progress, rather than just change, is not so straightforward and is sometimes hotly contested. There has certainly been change, including some quite radical shifts in attitudes and practices, but on some issues, the ethical debate now looks remarkably similar to that of 40-50 years ago. This is the story of some things that have changed in paediatric ethics, some things that have stayed the same and the key ethical ideas lying beneath the surface.

J Med Ethics. 2015 Jan 13. pii: medethics-2013-101981. doi: 10.1136/medethics-2013-101981. [Epub ahead of print]

Paternalistic breaches of confidentiality in prison: mental health professionals' attitudes and justifications.

Elger BS1, Handtke V2, Wangmo T2.

Author information

• 1Institute for Biomedical Ethics, University of Basel, Basel, Switzerland Center for Legal Medicine, University of Geneva, Geneva, Switzerland.
• 2Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.

Abstract

AIM:

This manuscript presents mental health practitioners' (MHPs) practice, attitudes and justifications for breaching confidentiality when imprisoned patients disclose suicidal thoughts or abuse by others.

METHODS:

24 MHPs working in Swiss prisons shared their experiences regarding confidentiality practices. The data were analysed qualitatively and MHPs' attitudes and course of action were identified.

RESULTS:

Analysis revealed paternalistic breaches of confidentiality. When patients reported suicidal thoughts and abuse, MHPs believed that forgoing confidentiality is necessary to protect patients, providing several justifications for it. Patients were informed that such information will be transmitted without their consent to medical and non-medical prison personnel. With reference to suicidal attempts, MHPs resorted to methods that may reduce suicidal attempts such as transfer to hospital or internal changes in living arrangements, which would require provision of certain information to prison guards. In cases of abuse, some MHPs convinced patients to accept intervention or sometimes overrode competent patients' refusals to report. Also in the case of abuse, provision of limited information to other prison personnel was seen as an acceptable method to protect patients from further harm.

DISCUSSION:

Breaches of confidentiality, whether limited or full, remain unethical, when used for competent patients based solely on paternalistic justifications. Institutionalising ethical and legal procedures to address suicidal and abuse situations would be helpful. Education and training to help both medical and prison personnel to respond to such situations in an appropriate manner that ensures confidentiality and protects patients from suicide and abuse are necessary.

Pers Soc Psychol Rev. 2015 Jan 13. pii: 1088868314566683. [Epub ahead of print]

A Constructionist Review of Morality and Emotions: No Evidence for Specific Links Between Moral Content and Discrete Emotions.

Cameron CD1, Lindquist KA2, Gray K2.

Author information

• 1University of Iowa, Iowa City, USA daryl-cameron@uiowa.edu.
• 2University of North Carolina at Chapel Hill, USA.

Abstract

Morality and emotions are linked, but what is the nature of their correspondence? Many "whole number" accounts posit specific correspondences between moral content and discrete emotions, such that harm is linked to anger, and purity is linked to disgust. A review of the literature provides little support for these specific morality-emotion links. Moreover, any apparent specificity may arise from global features shared between moralityand emotion, such as affect and conceptual content. These findings are consistent with a constructionist perspective of the mind, which argues against a whole number of discrete and domain-specific mental mechanisms underlying morality and emotion. Instead, constructionism emphasizes the flexible combination of basic and domain-general ingredients such as core affect and conceptualization in creating the experience of moral judgments and discrete emotions. The implications of constructionism in moral psychology are discussed, and we propose an experimental framework for rigorously testing morality-emotion links.

Curr Opin Support Palliat Care. 2015 Jan 9. [Epub ahead of print]

Desire for hastened death: exploring the emotions and the ethics.

Branigan M1.

Author information

• 1Temmy Latner Centre for Palliative Care, Toronto, Ontario, Canada.

Abstract

PURPOSE OF REVIEW:

As we approach the end of our lives, many of us will have a desire for hastened death (DHD). Fortunately, our ability to respond to suffering at the end of life is improving. At the same time, in many jurisdictions, changes are underway to legislate physician-assisted death. This compels us as clinicians to explore DHD in a compassionate way - to reduce suffering and reduce premature death. This challenge is becoming more compelling as a large cohort of individuals, who value autonomy and control, age and experience illness.

RECENT FINDINGS:

Studies confirm that DHD is not always a request to die. Clarifying the intention behind the desire and exploring the individual factors and underlying reasons behind the wish have been described. Another theme questions our basic assumptions about these statements - a normal part of a human experience or an indicator of disease. This tension is also manifested in the appropriate balance between patient autonomy and preventing harm.

SUMMARY:

We have a professional responsibility to mindfully explore with the patient the suffering that can be relieved and the suffering that remains.

Poll shows public support for lowering sales tax on ‘healthy’ foods

Poll shows public support for lowering sales tax on ‘healthy’ foods 

By Jim McLean

KHI News Service

Public support and potential health benefits aside, the state’s growing budget problems likely will make any sales tax exemption a tough sell. State income tax cuts enacted at Gov. Sam Brownback’s urging have slowed revenue collections and created a $280 million hole in the current year’s budget. 

- See more at: http://www.kckansan.com/2015/01/poll-shows-public-support-for-lowering.html#sthash.YsTry52m.dpuf

Indian J Occup Environ Med. 2014 May;18(2):82-8. doi: 10.4103/0019-5278.146897.

Global mesothelioma epidemic: Trend and features.

Bianchi C1, Bianchi T1.

Author information

• 1Center for the Study of Environmental Cancer, Italian League Against Cancer, Monfalcone, Italy.

Abstract

BACKGROUND:

Mesothelioma incidence has taken epidemic proportions in various countries. The trend of the epidemic remains undefined.

OBJECTIVE:

To collect the most recent available data on mesothelioma incidence in order to determine the present trend of the epidemic.

MATERIALS AND METHODS:

Data of the Cancer and Mesothelioma Registries have been reviewed. In addition, numerous researchers were contacted to obtain supplementary information.

RESULTS:

The highest incidence rates are reported from some countries in Europe (United Kingdom, The Netherlands, Malta, Belgium), and in Oceania (Australia, New Zealand). Relatively low incidence/mortality rates are reported from Japan and from Central Europe. In many countries a trend to increase continues to be observed. Data are not available for the mostly populous countries.

CONCLUSION:

Mesothelioma epidemic does not show signs of attenuation. The lack of data for a large majority of the world does not allow that the consciousness of the risks related to asbestos exposure is reached.

From Harvard U: Promoting Equity in Health: What Role for Courts?

Health Hum Rights. 2014 Dec 11;16(2):E1-E9.

Editorial: Promoting Equity in Health: What Role for Courts?

Yamin AE1.

Author information

• 1Guest Editor, Lecturer on Global Health and Policy Director at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University.

Abstract

One of the most significant transformations to occur in the landscape of struggles for health justice since this journal was originally launched relates to the increasing judicialization of health-related rights, and economic, social, and cultural rights (ESC rights) more broadly. Indeed, the articles in this issue go far toward debunking outdated conceptions about health rights as merely "programmatic rights," which are not justiciable. Over the last 20 years, and increasingly in the last decade, we have seen that health and related rights are in fact being enforced by courts around the world, from South America to South Asia, Eastern Europe to East Africa. And increasingly, even in low-income countries, important demands for health-related entitlements are being framed in terms of legally enforceable claims.

J Pers Med. 2014 Mar 27;4(2):137-46. doi: 10.3390/jpm4020137.

Ethics, evidence and economics in the pursuit of "personalized medicine".

Lewis J1, Lipworth W2, Kerridge I3.

Author information

• 1Centre for Values Ethics and Law in Medicine, University of Sydney Medical Foundation Building (K25), University of Sydney, Sydney, NSW 2006, Australia. jlewis@med.usyd.edu.au.
• 2Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW 2052, Australia. wendylipworth@gmail.com.
• 3Centre for Values, Ethics and Law in Medicine, University of Sydney Medical Foundation Building (K25), University of Sydney, Sydney, NSW 2006, Australia. ian.kerridge@sydney.edu.au.

Abstract

Despite enthusiastic advocacy for what personalized medicine might be able to deliver and major investments into the development of this, there remain disappointingly few examples of personalized medicine in routine clinical practice today, particularly in high areas of unmet need such as cancer. We believe that this is because personalized medicine challenges the moral, economic and epistemological foundations of medicine. In this article, we briefly describe the scientific premises underpinning personalized medicine, contrast these with traditional paradigms of drug development, and then consider the ethical, economic and epistemological implications of this approach to medicine.

Acad Med. 2015 Jan 6. [Epub ahead of print]

Should Medical Students Track Former Patients in the Electronic Health Record? An Emerging Ethical Conflict.

Brisson GE1, Neely KJ, Tyler PD, Barnard C.

Author information

• 1Dr. Brisson is assistant professor in clinical medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Dr. Neely is assistant professor in medicine, Feinberg School of Medicine, Northwestern University, and chair, Medical Ethics Committee, Northwestern Memorial Hospital, Chicago, Illinois. Dr. Tyler was a final-year medical student, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, at the time this article was written. He is now a first-year resident, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Ms. Barnard is director of quality strategies, Northwestern Memorial Hospital, and research associate professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Abstract

Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

Our challenge in the 21st century: "The majority (97.7%) had never heard of the Pap smear test."

Int J Womens Health. 2014 Dec 24;7:31-9. doi: 10.2147/IJWH.S71797. eCollection 2015.

Knowledge, practice, and barriers toward cervical cancer screening in Elmina, Southern Ghana.

Ebu NI1, Mupepi SC2, Siakwa MP1, Sampselle CM3.

Author information

• 1University of Cape Coast, School of Nursing, Cape Coast, Ghana.
• 2Kirkhof College of Nursing, Grand Valley Sta University, Grand Rapids, MI, USA.
• 3School of Nursing, University of Michigan, Ann Arbor, MI, USA.

Abstract

AIMS:

The aims of this study were: 1) to assess the level of knowledge of women about Pap smear tests, 2) to determine the practices of women regarding Pap smear tests, and 3) to determine the barriers to Pap smear tests in Elmina, Ghana.

METHODS:

A cross-sectional study was conducted with 392 randomly selected sexually active females aged 10-74 years using structured interview questions. The Institutional Review Board of the University of Cape Coast gave ethical approval for the study and informed consent was obtained from participants. Data were analyzed with SPSS software (v19.0) using frequencies, chi-square test, and exploratory factor analysis.

RESULTS:

The results revealed that 68.4% had never heard about cervical cancer, 93.6% had no knowledge on the risk factors, nine (2.3%) reported multiple sexual partners and being sexually active as risk factors, and 92% did not know about the prevention and treatment of cervical cancer. The majority (97.7%) had never heard of the Pap smear test. Only three (0.8%) women out of 392 had had a Pap smear test. Reasons for seeking a Pap smear test included referral, fear of cervical cancer, and radio campaigns. A significant association was found between institutional and personal barriers and having a Pap smear test.

CONCLUSION:

Comprehensive education on cervical cancer screening and removal of access barriers are critical in reducing risk associated with the disease and promoting women's health.

Front Public Health Serv Syst Res. 2013;2(1). pii: 2.

Carrots, Sticks and False Carrots: How high should weight control wellness incentives be? Findings from a population-level experiment.

Schmidt H1.

Author information

• 1Lecturer, Department of Medical Ethics and Health Policy, Research Associate, Center for Health Incentives and Behavioral Economics, School of Medicine, University of Pennsylvania, schmidth@exchange.upenn.edu.

Abstract

Employers are increasingly using wellness incentives, including penalties for unhealthy behavior. Survey data suggests that people are willing to accept the principle of penalizing those perceived to take health risks, but the equally relevant question of the magnitude of acceptable penalties is unclear. While the principle of penalizing overweight and obese people has some support, findings from a population-level experiment (n=1,000) suggest that the acceptable size of penalties is comparatively small, around $50: more than 10-fold below levels favored by advocates. Reward-based incentives are favored over penalty-based ones by a factor of 4. Of two different ways of framing penalty programs, poorer and higher weight groups appear to find the one that is more overtly penalizing less acceptable. Levels of incentives matter on effectiveness as well as on ethical grounds, as it cannot be assumed that it is equally easy for all to meet health targets to secure a benefit or avoid a penalty. Programs should be designed to engage, not to frustrate those most in need of health improvement. Employee involvement in determining incentive types and levels, and explicit justification for program design can help both employees and employers to reap benefits.