Background: Conditional cash transfers (CCTs) are complex social interventions that provide cash to selected recipients if they change their health behavior. The aim is to nudge recipients, for example, to stop smoking; start exercising; reduce weight; avoid unwanted pregnancies; give birth at hospitals; send children to health checkups and to school. Consequently, CCTs might save lives. Seen as an investment in human capital, CCTs might indirectly reduce poverty. A Cochrane Review on the effect of CCTs in low- and middle-income countries “strongly suggest[s] that CCT schemes may result in a number of benefits to health and access to health services…”, but does not address many of the moral concerns related to the intervention. Although CCTs have been described as 'magic bullets', they can also be seen as paternalistic; coercive; unfair; racist; damaging to intrinsic motivation; an assault on freedom and human dignity; a challenge to gender equality, and even counterproductive.
Objectives: To present and discuss ethical issues and moral concerns related to CCTs.
Methods: We used the Socratic approach developed for Health Technology Assessment reports. We systematically searched the literature for papers related to CCTs. We extracted ethical issues including theories, values, viewpoints and arguments according to the list of morally relevant questions embedded in the Socratic approach. We deemed any moral concern raised in the literature as legitimate and informative.
Results: We found 286 papers related to paying people to change their health behavior. We present any moral concern or argument both in favor of and against CCTs, including possibly helpful or harmful unintended consequences.
Conclusions: Despite positive effects and underlying good intentions, CCTs raise a number of ethical issues and moral concerns. A review of ethical issues related to the intervention would complement the Cochrane Review on CCTs.