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July 14, 2021

Beyond Voluntariness—Ethics and Incentives for Contraception

Author Affiliations
  • 1Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill
  • 2Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill
JAMA Psychiatry. Published online July 14, 2021. doi:10.1001/jamapsychiatry.2021.1284

In this issue of JAMA Psychiatry, Heil et al1 report a randomized clinical trial to evaluate the efficacy and cost benefits of interventions to increase prescription contraceptive use among women with opioid use disorder (OUD) at risk for unintended pregnancy. The study found that verified contraception use was highest and unintended pregnancy rates were lowest among women randomized to receive 2 interventions: onsite contraceptive services plus a financial incentive to return for follow-up visits.

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    1 Comment for this article
    Reply from Heil et al.
    Sarah Heil, PhD | University of Vermont
    My co-authors and I appreciate the thoughtful editorial written by Dr. Lyerly that appeared with our article. We agree with the concerns she lays out about the ethics of incentivizing contraception and as she notes early in her editorial, we did not make the incentives in the contraceptive services plus financial incentives (CS+) condition contingent on contraceptive use, but rather on attending follow-up visits at the clinic. One effort to make this distinction clear for participants which was described in the main text of our article involved having those randomized to the CS+ condition complete an IRB-approved true/false consent “quiz” after randomization that included the item “In order to earn incentives, you must use one of the six methods of birth control offered in the study,” to ensure they knew that the answer was FALSE. Data from the trial suggests participants assigned to the CS+ condition understood the difference given that they did not report any contraceptive use at one-third of all the follow-up visits when a financial incentive was paid out.
    We also heartily concur with Dr. Lyerly that women with opioid use disorder are “already struggling with myriad life challenges.” This is why we believe it is important to develop interventions like the ones we tested to make it easier for them to exercise their reproductive rights. Related to this, one CS+ participant told us the clinic was “a genious [sic] asset to have so close to M.A.T. women.” Many CS+ participants also reported that the clinic staff was helpful and caring despite participants’ life challenges, with one saying, “even when I couldn’t make my appointments they were understanding and kind.” Dr. Lyerly also notes that women with opioid use disorder have often experienced deep prejudice, but many CS+ participants reported that clinic staff were respectful and compassionate, with one saying, “they really listened to me” and another stating, “I definitely felt supported the whole way.”
    Overall, we believe women with OUD have the same right to decide whether and when to have children as other women, but their persistently high rate of unintended pregnancy suggests that the way contraceptive services are typically provided does not work for most of them. The two interventions we tested provide women with OUD who do not want to become pregnant with contraceptive services that better meet their needs and do so in an ethical manner.