Bonuses as incentives and rewards for health responsibility: a good thing?

Bonuses, as incentives or rewards for health-related behavior, feature prominently in German social health insurance. Their goal is centered around promoting personal responsibility, but reducing overall health-care expenditure and enabling competition between sickness funds also play a role. The central position of personal responsibility in German health-care policy is described, and a framework is offered for an analysis of the ethical issues raised by policies seeking to promote responsibility. The framework entails seven tests relating to: solidarity; equality and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence. It is contended that a focus on tests, in particular from within contractualism, is the most appropriate way of addressing the question of health responsibility in pluralistic societies. However, taken by themselves, the tests also allow an identification of the key ethical issues by particular policies, which are illustrated by applying the framework to particular bonus polices.