“Nudge” in the clinical consultation – an acceptable form of medical paternalism?

Abstract

BackgroundLibertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities.DiscussionEvidence has shown that decision making is prone to bias and not necessarily rational or logical, particularly during ill health. Clinicians will usually have an opinion about what course of action represents the patient’s best interests and thus may “frame” information in a way which “nudges” patients into making choices which are considered likely to maximise their welfare. This may be viewed as interfering with patient autonomy and constitute medical paternalism and appear in direct opposition to the tenets of modern practice. However, we argue that clinicians have a responsibility to try and correct “reasoning failure” in patients. Some compromise between patient autonomy and medical paternalism is justified on these grounds and transparency of how these techniques may be used should be promoted.SummaryOverall the extremes of autonomy and paternalism are not compatible in a responsive, responsible and moral health care environment, and thus some compromise of these values is unavoidable. Nudge techniques are widely used in policy making and we demonstrate how they can be applied in shared medical decision making. Whether or not this is ethically sound is a matter of continued debate but health care professionals cannot avoid the fact they are likely to be using nudge within clinical consultations. Acknowledgment of this will lead to greater self-awareness, reflection and provide further avenues for debate on the art and science of clinical communication.

How acceptable is paternalism? A survey-based study of clinician and nonclinician opinions on paternalistic decision making

“…It has been shown previously that patients and their surrogate decision makers are more likely to doubt prognostication when presented as certainly poor or futile (Zier et al 2009). Surrogate decision makers are also known to interpret prognostic information with an optimistic bias (Aggarwal Davies and Sullivan 2014). If nonclinician respondents did not believe the doctor’s prognostication in scenarios where a poor prognosis was presented as certain but did believe the prognostication in scenarios where the prognosis was presented as uncertain, it could explain the observed differences.…”

Concepts of personhood and autonomy as they apply to end-of-life decisions in intensive care

“…There should be an awareness of different ways of ''framing'' information presented (Aggarwal et al 2014). Time is a necessary constraint upon the decision-making process.…”

Public health for paediatricians:How can behavioural economics help to make paediatric practice more effective?

“…Children and families in paediatric care are likely to be in a state of stress, affecting their ability to process information. Aggarwal et al 17 have argued that understanding how this works and using that knowledge to help patients make the right decisions is a justifiable way of restoring their autonomy, not a way of taking it away. It is also possible to argue that the population is being constantly manipulated by the ‘nudge’ techniques of advertising and sales and so using these techniques transparently within healthcare is a way to redress the balance in favour of positive health outcomes.…”