Pay for performance: is it ethical?

Since the advent of pay for performance in medicine, there has been an intense debate about its efficacy and enforceability. This article examines some philosophical and psychological aspects of pay for performance. The very concept of pay for performance is inimical to the Hippocratic oath; it operates in direct conflict with powerful ideals such as altruism and concern for community. These ideals traditionally serve as powerful motivators for physicians. Physicians have just begun to incorporate and enhance the autonomy model. This is designed to help patients and physicians make decisions leading to positive outcomes. Pay for performance threatens to reintroduce an incurable power imbalance between patients and clinicians. Research from the corporate world suggests that hardwiring the thought processes of pay for performance into health-care delivery may lead to a culture of hyper-productivity. This can lead to addictive behavior and ethical abuse.