What's Your Pain Worth?
The Ethics of Paying Research Subjects

In hospital corridors across the country and in online posts, volunteers are recruited for clinical studies. Some seek healthy people willing to track their sleep or follow a special diet. Others seek patients with specific diseases, sometimes asking them to undergo painful procedures or experimental treatments with uncertain outcomes. Almost all offer some form of compensation.

Incentives are usually fine, but context matters enormously.

Clinical medical research depends on human participants. Volunteers alone cannot meet the demand, so incentives — cash payments, free medical care, gift cards — have become standard recruiting tools. Used appropriately, participants serve a genuine public good, helping researchers answer questions that ultimately save lives. There is nothing inherently wrong with compensating someone for their time and inconvenience.

The ethical trouble begins when an incentive stops being a simple thank-you and instead becomes "coercive," corrupting a person's decision-making.

Consider two recruiting scenarios. In the first, a hospital offers a healthy adult $50 to complete a week-long diary about their eating and exercise habits — a minor inconvenience, fair compensation, no meaningful risk. In the second, researchers offer a desperately poor patient $5,000 to undergo repeated, painful biopsies for a study with uncertain safety outcomes. The second person may say yes — but are they agreeing because the research sounds worthwhile, or because they simply cannot afford to say no?

Some conditions make incentives ethically suspect. When the doctor conducting the research also provides the patient's care, that's a conflict of interest. It raises questions about whether the researcher is acting in the patient's best interest or their own. And conflicts aren't only financial. There is enormous pressure on researchers to "publish or perish," advancing their own careers through publications, grants, and citations. This can also create an incentive to recruit subjects too aggressively.

Hospitals and universities are not neutral either — more grant money coming in means more income and greater prestige. It is easy for formal protections for patients to be enforced less strictly.

A useful rule of thumb: if researchers cannot recruit without offering unusually large incentives – say, over $1000- that is itself a warning sign. It likely means people might have strong reasons to avoid the study, for instance, taking a medicine that has a large risk or one that requires a large time commitment. If you're ever approached to participate in research, take your time to decide. Ask a clinician who has nothing to do with the study for their opinions.

Medical progress is a moral imperative. But, so is treating research participants as people, not resources. Getting incentives right is how we honor both obligations.

— Dr. Michael Wilkes with a Second Opinion

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