Bonuses as incentives and rewards for health responsibility: A good thing

Bonuses, as incentives or rewards for health-related behavior, fea-ture 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 re-sponsibility in German health-care policy is described, and a frame-work 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; attribut-ability and opportunity of choice; evidence, rationale, and feasibil-ity; 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 identifi cation of the key ethical issues by particular poli-cies, which are illustrated by applying the framework to particular bonus polices