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Policymakers, employers, insurance companies, researchers, and health care providers have developed an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or health care, and we identify the ethically relevant dimensions that should be considered for the utilization of each principle.
2018
Each of us is made up of the decisions that we make. The rich tapestry of our lives is constructed from the hundreds of thousands of decisions that have led us to this very moment. If each of us were endowed with perfect rationality, our optimal decision-making qualities might lead us down similar paths. But here we are, instead each of us on unique and sometime bumpy rides accentuated by our perfectly irrational choices. The goal of my research is to make sense of our faulty decision making in areas related to personal health by applying insights from the field of behavioral economics. I am not the only one searching for answers. It's an exciting time to be a behavioral economist in light of the relatively recent birth of the subfield, as a splinter off of the traditional economics cutting block. It is a moment of prolific research in a thriving field of economists seeking to understand how exactly we err in the decision-making process, and what precisely can be done to help us...
Physicians frequently encounter patients who make decisions that contravene their long-term goals. Behavioral economists have shown that irrationalities and self-thwarting tendencies pervade human decision making, and they have identifi ed a number of specifi c heuristics (rules of thumb) and biases that help explain why patients sometimes make such counterproductive decisions. In this essay, we use clinical examples to describe the many ways in which these heuristics and biases infl uence patients’ decisions. We argue that physicians should develop their understanding of these potentially counterproductive decisional biases and, in many cases, use this knowledge to rebias their patients in ways that promote patients’ health or other values. Using knowledge of decision-making psychology to persuade patients to engage in healthy behaviors or to make treatment decisions that foster their long-term goals is ethically justifi ed by physicians’ duties to promote their patients’ interests and will often enhance, rather than limit, their patients’ autonomy. We describe techniques that physicians may use to frame health decisions to patients in ways that are more likely to motivate patients to make choices that are less biased and more conducive to their long-term goals. Marketers have been using these methods for decades to get patients to engage in unhealthy behaviors; employers and policy makers are beginning to consider the use of similar approaches to infl uence healthy choices. It is time for clinicians also to make use of behavioral psychology in their interactions with patients.
Doctoral Dissertation (Philosophy Department and Kennedy Institute of Bioethics, Georgetown University), 2012
There is growing interest in using non-coercive interventions to promote and protect public health, in particular "health nudges." Behavioral economist Richard Thaler and law scholar Cass Sunstein coined the term nudge to designate influences that steer individuals in a predetermined direction by activating their automatic cognitive processes, while preserving their freedom of choice. Proponents of nudges argue that public and private institutions are entitled to use health-promoting nudges because nudges do not close off any options. Opponents reply that the nudgee has no opportunity to deliberate over her choice. The nudger controls the nudgee, who has no real freedom of choice. In my dissertation, I salvage the concept of nudge from the charge that it merely pays lip service to freedom of choice, offer an alternative account of the moral import of nudges for the evaluation of public health policies, and provide an ethical framework for their justified use. My argument proceeds in four steps. First, I argue that nudging mechanisms often involve some form of incomplete deliberation, and do not always bypass deliberation. Second, I maintain that nudges preserve freedom of choice because they preserve the choice-set and are substantially noncontrolling. I show that the debate over nudges is plagued by confusion between real nudges, which are easily resistible and therefore substantially noncontrolling, and influences that are not easily resistible yet activate the same cognitive mechanisms as nudges. Third, I reject the view that nudges are systematically preferable to more controlling influences, even when they interfere with non-consequential liberties. I show that the principle of the least restrictive alternative often invoked in public health ethics is applied with too wide a scope. Fourth, I argue that paternalism is not central to the ethics of public health nudges. Rather, the substantive problem with nudges is that their overall cumulative effect might weaken our decisional capacities or undermine their proper exercise. This is a reason to limit recourse to certain nudges. I finally show, contra certain Kantians and Millians, that we have no perfect duty to engage or enhance decisional capacities.
The American Journal of Bioethics
Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google's rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most-but not all-nudges in most-but not all-circumstances.
The American Journal of Bioethics
We review selected literature that examines how biases in decision making can be utilized to encourage individual health behavior, such as vaccination, and promote policy decisions, such as resource allocation. These studies use simple interventions to nudge people towards more optimal health decisions without restricting decision-makers' freedom of choice. Examples include framing effects, defaults, implementation intentions, position effects, social norm, incentives, and emotions. We suggest that nudges are an effective way to promote healthy behavior.
Health Care Analysis
Nudges are means to influence the will formation of people to make specific choices more likely. My focus is on nudges that are supposed to improve the health condition of individuals and populations over and above the direct prevention of disease. I point out epistemic and moral problems with these types of nudges, which lead to my conclusion that health-enhancing nudges fail. They fail because we cannot know which choices enhance individual health—properly understood in a holistic way—and because health-enhancing nudges are often themselves bad for our health. They can be bad for our health because they assume inferior agency in their targets and accordingly regularly lead to appropriate resentment and anger—strong emotions which go along with an increased risk of health impairments. Briefly, health-enhancing nudges fail because they are based on persistent ignorance and on a presumptuous attitude.
8th International Symposium on Social Sciences, EJSER, 2021
While trying to compensate for the devastating effects of the Covid-19 epidemic in the world, the supply chain from energy to agriculture and food, the supply chain extending from the health sector to the economy is also protected. Although the epidemic process has created many psychological and sociological difficulties, it has also created awareness in the health sector about individual interaction and behavior patterns or individual-society relationship. These behavioral approaches, which form the main lines of human and social sciences, are also widely used in multidisciplinary fields such as public policy and economics. As a result of the studies, it has been determined that people exhibit attitudes far from rationality and fall into cognitive misconceptions. However, these behaviors can be brought under control by consciously triggering instructions to individuals within certain limits. This approach, which is considered as "nudging" in the economic literature, can keep people away from acting irrationally and is frequently used in public policy practices. For this purpose, in this study, decision-making behaviors against some problems observed in the health sector were examined using the survey method in the light of "nudge". It is expected that the results obtained will contribute to the policies and decision mechanisms in the relevant sector.
The aim of this piece is to clarify three key matters: (a) the extent to which, as citizens, our volition is impacted as a result of the implementation of nudges in the health domain; (b) the efficacy of educational campaigns as a means of behavioral change relative to other nudges as well as typical regulatory instruments; and (c) the empirical, theoretical, and practical details that ethical debates concerning nudges might want to consider.
Behavioral policy to improve health and health care often relies on interventions, such as nudges, which target individual behaviors. But the most promising applications of behavioral insights in this area involve more far-reaching and systemic interventions. In this article, we propose a series of policies inspired by behavioral research that we believe offer the greatest potential for success. These include interventions to improve health-related behaviors, health insurance access, decisions about insurance plans, end-of-life care, and rates of medical (for example, organ and blood) donation. We conclude with a discussion of new technologies, such as electronic medical records and web- or mobile-based decision apps, which can enhance doctor and patient adherence to best medical practices. These technologies, however, also pose new challenges that can undermine the effectiveness of medical care delivery.
Social and Personality Psychology Compass, 2013
We review selected literature that examines how biases in decision making can be utilized to encourage individual health behavior, such as vaccination, and promote policy decisions, such as resource allocation. These studies use simple interventions to nudge people towards more optimal health decisions without restricting decision-makers' freedom of choice. Examples include framing effects, defaults, implementation intentions, position effects, social norm, incentives, and emotions. We suggest that nudges are an effective way to promote healthy behavior.
Californian Journal of Health Promotion, 2006
Despite documented short-term success, dieting has a very low success rates, most dieters regain their weight back within three to five years (IOM, 2003). Relapse, temporary loss of control, and return to old behavior is common in dieting. This paper presents some insights from a behavioral economics perspective to explain why people fail to stick to their goal for eating healthy diet in order to lose weight. Knowing why people fail to maintain a desired healthy behavior over time will go some way towards avoiding relapse. Know the why makes it much easier to handle the how when we need to. A better understanding of changing preferences could also shed light on the proper role of health promotion policy. Behavioral economics identifies a number of circumstances in which people seem to behave inconsistently. Identifying these conditions provide an understanding of what factors make it harder for dieters to resist attractive food, and will help dieters to resist temptation. A recent r...
The Journal of Applied Christian Leadership, 2010
Preventive medicine, 2016
Health-related behaviors such as tobacco, alcohol and other substance use, poor diet and physical inactivity, and risky sexual practices are important targets for research and intervention. Health-related behaviors are especially pertinent targets in the United States, which lags behind most other developed nations on common markers of population health. In this essay we examine the application of behavioral economics, a scientific discipline that represents the intersection of economics and psychology, to the study and promotion of health-related behavior change. More specifically, we review what we consider to be some core dimensions of this discipline when applied to the study health-related behavior change. Behavioral economics (1) provides novel conceptual systems to inform scientific understanding of health behaviors, (2) translates scientific understanding into practical and effective behavior-change interventions, (3) leverages varied aspects of behavior change beyond increa...
BMJ, 2011
If people didn't smoke, drank less, ate healthier diets and were more active, the huge burden of chronic diseases such as cancer, heart disease, and type 2 diabetes would be much reduced. 1 The prospect of being able to nudge populations into changing their behaviour has generated great interest among policymakers worldwide, including the UK government. 2 We explore what nudging is and assess the prospect of nudging our way to a healthier population.
Patient Preference and Adherence, 2014
Clinicians are committed to effectively educating patients and helping them to make sound decisions concerning their own health care. However, how do clinicians determine what is effective education? How do they present information clearly and in a manner that patients understand and can use to make informed decisions? Behavioral economics (BE) is a subfield of economics that can assist clinicians to better understand how individuals actually make decisions. BE research can help guide interactions with patients so that information is presented and discussed in a more deliberate and impactful way. We can be more effective providers of care when we understand the factors that influence how our patients make decisions, factors of which we may have been largely unaware. BE research that focuses on health care and medical decision making is becoming more widely known, and what has been reported suggests that BE interventions can be effective in the medical realm. The purpose of this article is to provide clinicians with an overview of BE decision science and derived practice strategies to promote more effective behavior change in patients.
Psychological Bulletin, 1997
Health-relevant communications can be framed in terms of the benefits (gains) or costs (losses) associated with a particular behavior, and the framing of such persuasive messages influences health decision making. Although to ask people to consider a health issue in terms of associated costs is considered an effective way to motivate behavior, empirical findings are inconsistent. In evaluating the effectiveness of framed health messages, investigators must appreciate the context in which healthrelated decisions are made. The influence of framed information on decision making is contingent on people, first, internalizing the advocated frame and, then, on the degree to which performing a health behavior is perceived as risky. The relative effectiveness of gain-framed or loss-framed appeals depends, in part, on whether a behavior serves an illness-detecting or a health-affirming function. Finally, the authors discuss the cognitive and affective processes that may mediate the influence of framed information on judgment and behavior. To the extent that people are motivated to seek health and avoid illness, healthy behaviors should be easy to promote. The opportunity to obtain a prostate examination, for instance, should be embraced with little hesitation when the costs of missed early detection are made salient. In fact, the impact of appeals that emphasize personal vulnerability is predicated on the assumption that people will adopt an available, effective behavior to reduce the likelihood of experiencing an unwanted outcome (e.g.,
2019
Nudging is widely portrayed as a purely inductive approach to influencing human behavior using insights from the behavioral sciences to learn what works. However, as this paper argues, to understand ‘what works’, requires not only scientists, but also policy-makers as well as practitioners to understand what cognitive mechanisms brings behavior change about as well as under what conditions. This is argued by explicating how the concept of nudge itself identifies the main condition for the efficacy of nudging as well as calls for considering what specific mechanisms mediate a nudge and its behavioral effects. The practical implications are illustrated relative to the intuitively appealing policy application of nudging people into becoming organ donors by changing the default from an opt-in to an opt-out system; and in turn reveals why prominent scientists in the field believe this policy application to be a bad idea.
2015
Presenting a default option is known to influence important decisions. That includes decisions regarding advance medical directives, documents people prepare to convey which medical treatments they favor in the event that they are too ill to make their wishes clear. Some observers have argued that defaults are unethical because people are typically unaware that they are being nudged toward a decision. We informed people of the presence of default options before they completed a hypothetical advance directive, or after, then gave them the opportunity to revise their decisions. The effect of the defaults persisted, despite the disclosure, suggesting that their effectiveness may not depend on deceit. These findings may help address concerns that behavioral interventions are necessarily duplicitous or manipulative.
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