Cross Post: Re: Nudges in a Post-truth World 

In a recent article in the Journal of Medical Ethics, Neil Levy has developed a concept of “nudges to reason,” offering a new tool for those trying to reconcile medical ethics with the application of behavioural psychological research – a practice known as nudging. Very roughly, nudging means adjusting the way choices are presented to the public in order to promote certain decisions.

As Levy notes, some people are concerned that nudges present a threat to autonomy. Attempts at reconciling nudges with ethics, then, are important because nudging in healthcare is here to stay but we need to ensure it is used in ways that respect autonomy (and other moral principles).

The term “nudge” is perhaps a misnomer. To fill out the concept a bit, it commonly denotes the use of behavioural economics and behavioural psychology to the construction of choice architecture through carefully designed trials. But every choice we face, in any context, already comes with a choice architecture: there are endless contextual factors that impact the decisions we make.

When we ask whether nudging is acceptable we are asking whether an arbitrary or random choice architecture is more acceptable than a deliberate choice architecture, or whether an uninformed choice architecture is better than one informed by research.

In fact the permissibility of a nudge derives from whether it is being used in an ethically acceptable way, something that can only be explored on an individual basis. Thaler and Sunstein locate ethical acceptability in promoting the health of the person being nudged (and call this Libertarian Paternalism — i.e. sensible choices are promoted but no option is foreclosed). An alternative approach was proposed by Mitchell: nudges are justified if they maximise future liberty. Either way the nudging itself is not inherently problematic.

Detailing the relevant psychological research, Levy outlines how our responses to new information are influenced by our understanding of the source. Does the source stand to benefit from persuading us? Does the source wish us good or ill? These are classified as Messenger factors in the Behavioural Insights Team’s¹ MINDSPACE classification.

Levy goes on to show how sensitivity to these factors makes evolutionary sense and as such constitutes part of our subconscious reasoning. Nudges that promote appropriate sensitivity to the factors, then, do not subvert our rationality; they apply or appeal directly to it.

There is huge scope within Levy’s grouping of nudges for interventions that do not threaten autonomy. For example the “N” in MINDSPACE stands for “norms.” An attuned sensitivity to group norms is adaptive in the same way as are messenger factors. But there is another group of nudges that actively promote autonomy.

The challenges to healthcare and wider society in this purportedly post-truth era demand improved quality of public debate and individual deliberation, and nudges can help. Building on Mitchell’s notion that nudges can be good if they increase future liberty and taking a rich conception of autonomy maximised through reflection and rationality, we could conceive of nudge-based policies which maximise current autonomy. 

1. Mandated Choice for Organ Donation

Defaults allow us to make decisions without thinking. A policy of mandatory choice would force people to consider or discuss their organ donor status, and avoid wrongly using (or unnecessarily wasting) the organs of unmotivated potential donors.

The best way to implement this in the UK would be to utilise the QOF system. One function of QOF is incentivising GP surgeries to record whether patients smoke or not. Payments depend upon the proportion of the surgery’s patient register whose status is recorded. Similarly GPs could be paid to record the organ donor status of all their patients, either joining the Organ Donor Register or a Non-Donor Register.

In essence GPs would be incentivised to have this conversation and reach a conclusion, thus encouraging people to make autonomous decisions rather than slide into defaults. It is not that this neutralizes the nudge; many people would be influenced by their GP but not unduly, not against their interests, and not without their own deliberation.

2. School Entry and Vaccinations

Children in Italy are denied state primary education until they are up to date with their vaccinations. How about a less restrictive policy where any parent who doesn’t arrange vaccination has to request special exemption from the school nurse? This process would provide the impetus for a discussion and for the school nurse to respond with evidence. Levy draws attention to the importance of facilitating autonomy by directing people towards good evidence, but this policy would go even further by forcing deliberation – albeit only among those who are acting against the interests of their dependents and society.

Fundamentally, the choice architecture is adjusted such that the hassle of arranging vaccinations is rebalanced by the hassle of having to justify the decision. It is not likely to compel hardcore anti-vaccine activists to change their minds, but it would be a reasonable way to nudge the uncertain or the poorly-informed.

3. Commitment to Discuss Wishes with Lasting Power of Attorney

Not all nudges towards autonomy require the involvement of a professional. The paperwork conferring Lasting Power of Attorney (LPA) for Health and Wellbeing could include an agreement between parties to discuss pertinent issues on specific dates. This utilises the power of commitments (the “C” in MINDSPACE). Research shows that people are more likely to follow through on intentions once they have formed specific plans. The LPA would not become void should the conversation not take place, but through the application of research in behavioural psychology we would be able to better match healthcare decisions to patients’ wishes.

All of these approaches use principles of behavioural psychology to promote careful consideration and reasoning and help us escape from our lazy reflexes and instincts. They may or may not be, all thing considered, the best ethical option but they show that choice architectures can be designed to operate in autonomy-promoting ways.

Levy is right to show that in many ways nudges do not impair autonomy – but let’s not stop there. The behavioural economics cat is out of the bag so rather than discuss the relative merits of evidence-based choice architecture against arbitrary choice architecture, we might more fruitfully seek to apply nudge theory in ways that actively maximise autonomy.

Footnote

1. The Behavioural Insights Team, known colloquially as the ‘nudge unit’ was set up in 2010 by David Cameron’s coalition government as a subsidiary of the cabinet office designing large scale RCTs and providing policy advice for government departments. Since being spun off in 2014 it has become technically Behavioural Insights Ltd and charges departments for its analysis and advice.