Justifying Clinical Nudges

Abstract

The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as "nudges." Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations-for example, the tendency to choose the first option presented even when that option is not the best for them-thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients' choices, the justification for doing so must appeal to an ethical and professional standard, not to patients' preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar-the best-interest standard-offers a robust justification for the use of nudges.

Vaccine Hesitancy: Where We Are and Where We Are Going

“…Some have argued that nudges are a gentle subversion of patient autonomy, whereas others emphasize that nudges are acceptable as long as they adhere to the principle of promoting the best interest of the patient. 77 In the context of vaccination, using nudges to present vaccination as a default choice may be preferable to and more effective than establishing mandatory requirements. 78 Choice architecture and nudges are examples of how the fields of psychology and behavioral economics may improve our response to vaccine hesitancy.…”

The ethics of behavioural public policy

“…At the same time, distinct topical discussions about the ethics of nudging have emerged independently from within fields in which nudges have been applied. Examples include debates in sub-fields such as public health (Ménard 2010) and bioethics (e.g., in clinical contexts when discussing nudging by physicians, see Cohen 2013;Gorin et al 2017), ethics of artificial intelligence and big data (Helbing et al 2017;Yeung 2017), environmental nudges (Schubert 2017b ), and charitable giving (Hobbs 2017) and development (Berndt 2015). Here, debates are specific to the field of application and rarely discuss the ethics of nudging across fields in general terms.…”

Ethical Issues in the Use of Nudges to Obtain Informed Consent for Biomedical Research

“…Even if a nudge does not fall into the category of undue influence (and most are unlikely to do so), there may still be concerns that nudges are unfairly manipulative. Some proponents of nudging assert that nudging should not be considered manipulative because it does not cause people to make choices that are inconsistent with their strong preferences . There is no support for this assertion, however.…”