UNDER THE INFLUENCE OF GIFTS, COUPONS AND CASH

IF money changes everything, why not use it on people?

It is the cash the women want, says Barbara Harris of Anaheim, Calif.,
founder of Children Require a Caring Kommunity, known by its acronym
Crack, which since 1997 has paid drug users $200 to be sterilized or
to use contraception.

Not only cash but discount coupons, gifts and vouchers have become
incentives in programs to encourage healthy behavior, whether the
issue involves reproduction, drug treatment or even organ donation.
Yet some experts question whether such methods actually work in the
long term.

At least 246 women have taken up the offer, according to Crack's Web
site: www.cracksterilization.com. Ms. Harris hopes a new $50 referral
bonus will bring in additional clients.

Crack's promotional slogan -- "Don't Let a Pregnancy Interfere With
Your Drug Habit" -- bluntly conveys why cash can be such a powerful
motivator for drug addicts, many of whom become pregnant repeatedly
and whose babies are underweight and at risk for birth defects.
Although Ms. Harris does not track how the women spend the money, she
said, "Sure, some use it to buy more drugs."

A few years before Crack began its program, a dollar-a-day program was
established in Colorado to persuade young women to delay pregnancy.
The cash is part of a program that includes weekly support-group meetings.

But criticism has dogged international population-planning efforts.
Widespread condemnation followed revelations in 1998 that Peruvian
women were being sterilized in exchange for dresses, T-shirts and food
in cases where informed consent was doubtful and post-operative care
inadequate. In March, members of Congress questioned whether aid to
Peru was violating prohibitions against the use of federal funds for
forced family planning abroad.

Incentives have also encouraged women to have children. In Scotland,
the Catholic Church undertook an initiative in 1997 to pay women not
to terminate their pregnancies, in one case paying the family of a
12-year-old girl. Elsewhere, moral objections over abortion are not
the issue; low birthrates are. In Japan, private companies are
offering cash bonuses to employees who have more than one child.

Whether cash is an undue inducement depends on the circumstances.
"Cash is a very effective incentive that we use all the time," said
Bonnie Steinbock, chairwoman of the philosophy department at the State
University of New York at Albany, who has studied incentives in
reproductive decision-making. "It isn't necessarily coercive."

Offers of cash to do good are nothing new. And paying donors for
plasma, for example, has caused officials at blood banks to worry
about needy participants lying about their health histories.

But do incentives involving reproductive decisions really work?
Sometimes, say Cheri Pies and Sarah Samuels, researchers with the
Incentives Project, a two-year program of the School of Public Health
at the University of California at Berkeley. They found only 11
rigorous studies of such inducements, which varied from cash and small
gifts to coupons for infant formula combined with education, support
and counseling. The cash incentives could not be linked to the success
or failure of the programs in the studies, said Dr. Pies and Dr.
Samuels, who advocate using money for achievable short-term outcomes.

Cash has also been dangled to keep teenagers off drugs. In Florida,
Arkansas and Pennsylvania programs, participants get discounts at
local shops and exemptions from curfew rules when they pass a
voluntary urine test and agree to future random tests.

Charles Schlichter, a financial adviser and member of the Chamber of
Commerce in Chambersburg, Pa., lobbied to bring the Arkansas antidrug
program Truce, the acronym for Teens Resisting Unhealthy Choices
Everyday, to his rural community. About 20 percent of the students in
grades 8 through 12 have been voluntarily tested. "It was the first
program we heard about that involved a carrot and not a stick," Mr.
Schlichter said.

Although federal law prohibits commerce in human organs and tissues
(with an exemption for replenishable material like blood, plasma,
sperm or eggs), Pennsylvania health officials attracted attention last
year with a proposal that circumvented the 1984 statute. They designed
an experimental program in which families of organ donors would
receive a $300 reimbursement for funeral expenses. Fearful of
violating the law, they recently scaled back and now propose paying
some hotel and travel costs for donor families directly to the lodging
and transportation providers.

Critics argue that the introduction of cash incentives could result in
fewer people donating their organs. Money has the potential for
dirtying the process, said Bob Spieldenner, a spokesman for the United
Network for Organ Sharing. "Paying might very well drive out
altruism," Mr. Spieldenner said.

One aspect of the debate about money versus altruism might be
gullibility as far as organ donation is concerned. The Department of
Health and Human Services recently began to investigate certain
practices in harvesting tissues, including skin, tendons, bones and
foreskins. Many people may be unaware that their freely given
donations may end up fattening lips or enlarging penises in what has
now become the vast, lucrative enterprise of cosmetic surgery. Federal
rules limit reimbursement for tissue to reasonable administrative and
processing costs, although some interpret those rules
expansively.

Although the examples of cold, hard cash enlisted to encourage health
and good works is growing, one particular program has failed to catch
on. The Frederick Christian Fellowship in Frederick, Md., gave $10
bills to first-time visitors in 1994, which succeeded in almost
doubling attendance. Few churches, though, have followed suit.