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The Government should conduct an “ethical analysis… as a matter of routine” if it introduces health policies that involve so-called ‘nudge’, the National Advisory Committee on Bioethics (NACB) has recommended to the Minister for Health.
Nudge is the application of behavioural science to subtly guide (ie, ‘nudge’) choice in certain directions in order to influence people’s behaviour and it can be used to encourage the adoption of healthier lifestyle choices. For example, placing fruit rather than chocolate bars near a supermarket cash register.
The NACB says such an ethical analysis is vital because “it will embed ethical principles such as justice, equity and proportionality into these public health initiatives and assure their integrity. Also, nudging programmes will be more effective if such an analysis is undertaken”.
A Department of Health spokesperson did not confirm to the Medical Independent (MI) whether the conducting of “an ethical analysis” is now Department policy. However, the Department admitted that under the NACB’s definition, many public health policies could now be described as deploying aspects of nudge.
“As outlined in the NACB’s opinion document, while the exact definition can vary, nudging from a policy perspective can encompass any actions that include defaults (eg, opt-out systems), warnings of various kinds (eg, on alcohol containers), changing the layouts and features of different environments (eg, sweets no longer being placed in front of checkouts), reminding people about their choices, drawing attention to social norms and using framing in order to change behaviour,” a Department spokesperson told MI.
“As such, a broad range of public health policies could potentially be deemed to be using some aspects of ‘nudge’.”
The NACB’s opinion document Nudging in Public Health — An Ethical Framework was completed and delivered to then Minister for Health Leo Varadkar’s office at the end of last year.
However, the document was only published on the Department’s website in April, without any formal launch, despite the interesting observations contained in the report.
While highlighting international examples of where nudge has been used with a positive health effect (see panel on p12), the NACB concludes that nudge “might impact on personal autonomy”. Therefore the NACB says it raises some “ethical concerns” of which the Government should be aware.
In 2008, Richard Thaler and Cass Sunstein published the highly influential book Nudge: Improving Decisions About Health, Wealth, and Happiness. Arising from the field of behavioural science, nudge is about changing the “choice architecture” in people’s lives, thus altering the context in which we make decisions. One often-citied example of nudge is asking someone to become an organ donor after they register for their driving license online. The use of behavioural science is an increasing part of health policy in many OECD countries, and experts in Ireland say the health service needs to keep up with these trends.
Behavioural economics expert Mr Pete Lunn, a Senior Research Officer at the ERSI with a PhD in neuroscience and an MSc in economics and author of the book Basic Instincts: Human Nature and the New Economics (Marshall Cavendish), told MI last summer that the Irish Government needed to utilise behavioural science if it is not to be left behind other countries.
Mr Peter Lunn, ESRI
“Ireland can learn lessons from watching the pioneers in this area, but we also risk being left behind if we don’t wake up to the opportunities of applying behavioural science to policy,” he warned in June 2015.
Speaking to MI this month, Mr Lunn again raised concerns that Ireland may not be deploying behavioural science techniques to the best of our abilities.
“Much more could be done to exploit the findings of behavioural economics in areas such as health and in other areas too,” he tells MI.
“One sensible way to do this would be to conduct a behavioural analysis of how people engage with our health system, then plan a series of trials to test ways to improve the system to help patients, parents and carers to make better decisions.
“The process could also make people’s interactions with the system less stressful and time consuming.”
While Mr Lunn acknowledged that there have been some concrete moves recently to introduce more behavioural thinking into policy formation, partly driven by the Department of Public Expenditure and Reform, and also in some other departments and agencies, “we are only beginning to scratch the surface though”.
The UK is generally regarded as at the forefront in the application of nudge policies. In 2010, the then coalition government led by former UK Prime Minister David Cameron introduced the British Behavioural Insights (BIT) Team (often called the ‘Nudge Unit’). It was established within the British Cabinet Office, although it has since become a private company.
Does Mr Lunn think a similar body could work at the heart of government and policy-making in Ireland?
“I am not sure,” he says. “Certainly the BIT has been successful in the UK, but it is a much larger country with much larger resources and a much larger pool of behavioural scientists to draw upon.
“It might be hard to set up an equivalent here. A more dispersed network of behavioural scientists might work better, but I’m really not sure.”
Where next for the NACB?
More than six months since the NACB completed its opinion document on nudge, there is still no word on what its next project will be.
“No decision has been made regarding the next topic on the work programme for the NACB,” a Department of Health spokesperson told MI.
The process behind the nudge document was cost free.
“There was no direct cost associated with producing the NACB opinion document entitled Nudging in Public Health — An Ethical Framework. There were no design or printing costs associated with the publication of this document, as this work was conducted by the Committee’s secretariat, which is provided by the Department of Health,” the spokesperson told MI.
“The Committee members give of their time and expertise voluntarily, though they may claim for reasonable expenses incurred in relation to attending Committee meetings, for example, travel costs.
“In addition, all of the Committee’s meetings are held in Hawkins House so there are no meeting venue costs relating to the work of the Committee.”
The NACB, which was established in March 2012, has previously provided advice on issues such as informed consent on blood transfusion and the detention of voluntary and involuntary patients in mental health facilities.
Nudge has certainly been occupying the minds of some of the top Department of Health officials in recent times. Along with the publication of the NACB document, the Department also held a symposium last year titled ‘Influencing Healthy Lifestyles: Nudging or Shoving? The Ethical Debate’. Hawkins House welcomed worldwide experts and some high-ranking medical officials from home — including the Chief Medical Officer.
However, despite this upsurge in focus on the role of nudge in public policy, there is no intention to create an office exclusively focused on the use of behavioural science in the Department.
“There are no plans within the Department of Health to establish a permanent Behavioural Insights Team or Nudge Unit,” a spokesperson confirmed to MI.
The NACB’s most recent opinion document, Nudging in Public Health — An Ethical Framework, delves into some of the possible “ethical concerns” raised by any government policy using nudge.
“It is important to be cognisant of the reality that while nudging does not involve compulsion, it is a powerful tool of persuasion that might impact on personal autonomy and consequently raises a number of ethical concerns,” the NACB concludes.
While the document outlines some very positive international results in health with the deployment of nudge, the NACB warns that its use is not without some ethical dimension.
“Is it up to individuals to make choices such as eating and drinking less, or should Government do more to tackle the binge-drinking and obesity crises? These responsibilities need not be mutually exclusive but it is important to note that the positive impact of achieving public health objectives must be balanced against the means by which they are realised,” according to the NACB.
“Making lifestyle a moral issue is problematic on a number of levels.”
The NACB says the ethical dimension should look at areas such as personal autonomy, proportionality, justice, equality, non-discrimination, protection of vulnerable populations, respect for culture diversity and pluralism, solidarity and trust.
“The dilemma facing public health officials is how to implement behavioural change policies in a manner that is equitable, reasonable, proportionate, in compliance with national and international legislation and which does not discriminate against particular groups or individuals,” the NACB states.
Prof Bovens from the LSE said that “everyone always seems so concerned about the ethics of nudging”.
“I think that what worries people the most is that they will be manipulated by authoritarian governments against their will in sinister ways,” Prof Bovens tells MI.
“It’s interesting that Thaler and Sunstein actually have a discussion of why nudge is different from subliminal images. Imagine that the government would like to promote healthy eating by slicing pictures of happy carrots in your favourite TV programme. You can’t see them with the naked eye, but unconsciously you will be drawn to the carrots in your fridge rather than the buttery popcorn. Nobody would give the government a licence to do that, even if it would make obesity rates drop significantly.
“Thaler and Sunstein respond that nudge is different because there is transparency. Now, it’s not that easy. There are cases of nudge in which there is considerably transparency, but that’s not always the case. In their cafeteria example, we don’t put up a sign saying that the donuts are at the end of the line to encourage healthy eating. So transparency as such is not the answer.
“I argued in my ‘Ethics of Nudge’* that for a nudge to be permissible, it should be in principle possible for a citizen to discern that they are being nudged at the time that the nudge is occurring. That is what is absent in the case of the subliminal images case. I called it ‘in principle, token transparency’.”
Prof Bovens points to the significant differences between the use of so-called subliminal advertising and nudge. The differences make the ethical concerns very different as well.
“But now, let’s first notice that there has always been lots of talk about subliminal images, but I have seen very little evidence in the scientific literature that any of this works,” he said.
“It simply doesn’t work to increase the consumption of a particular product in the movie theatre by slicing a picture of the product that is shown at a speed that the naked eye can’t observe. If you can’t see it in the ordinary sense of ‘seeing’, then it won’t change your behaviour.
“What nudgers suggest is that by making changes to the environment in which we make our choices, we can try to make it easier for people to choose what they, upon reflection, would like to do. And that is the sort of thing that does work. If you can make it easy for people to do what is in their own as well as the public interest, then you may get them to co-operate.”
- Bovens, L, ‘The Ethics of Nudge’ in Preference Change: Approaches from Philosophy, Economics, and Psychology, ed. by Till Gruene-Yanoff and Sven Ove Hansson, Springer, 207-20 (2008). www.bovens.org/assets/docs/TheEthicsofNudge.pdf.
But even if Ireland is not large enough to sustain a specific organisation such as BIT, Mr Lunn (who addressed the Department’s nudge symposium last year) still believes there is much that the Department of Health and others can do to better utilise behavioural science.
“Either way, behavioural science in Ireland needs more resources directed to it, because the evidence is that it can generate a high return on investment.”
If nudge continues to be on the agenda in public health circles in Ireland, the NACB document will make for useful reading.
“I read the report Nudging in Public Health— an Ethical Framework. It’s very nicely done and sums up the debate surrounding the ethics of nudge nicely,” Prof Luc Bovens, Professor of Philosophy and Head of Department at the London School of Economics (LSE), told MI. Prof Bovens is also author of Why Couldn’t I be Nudged to Dislike a Big Mac? (2013) and was one of the speakers at last year’s nudge symposium in Hawkins House.
With his international experience, Prof Bovens is in a good position to judge whether interest in nudge is expected to increase or fall off in the coming years.
“I think that the very idea of helping people make choices that are in their own interest or the public interest will stay with us,” says Prof Bovens.
“We also see it in other areas, where we study how people interact with technology and improve the design, making it easier for people to do what they want to do. We certainly did some of this before the publication of Thaler and Sunstein’s Nudge, without calling it ‘nudge’.
“The nudge agenda has put emphasis on it and has brought out some creativity in the area. And my guess is that the talk about nudge may fade but the very question of whether we can make changes to the environment to make people act in their own interest or in the public interest will stay with us.”
NACB looks at practical examples
The NACB opinion document itself provides a number of practical examples of situations where nudging has been used as part of public health policy in the UK. For example, a randomised, controlled trial on variants of an NHS appointment reminder text message.
This trial tested the effectiveness of the reminder message sent to outpatients. Results showed if the message included the specific cost to the NHS of not attending, then the patient was more likely to attend or rearrange the appointments.
In another NHS nudge trial highlighted in the report, a prompt to consider joining the NHS Organ Donor Register appeared on a web page once individuals completed renewing their vehicle tax or registering for a driving licence online. This led to an increase in the numbers of organ donor registrations.
A further UK example relates to a letter that was sent out to the 20 per cent of GPs with the highest antibiotic prescription rates, in an effort to reduce antibiotic resistance. The letters were personally addressed and among other things included a so-called ‘social norm’ message (ie, “the great majority (80 per cent) of practices… prescribe fewer antibiotics per head than yours”). This led to a decrease in antibiotic prescriptions.
The HSE had not responded to MI queries at the time of going to press, asking whether the Executive planned any trials of nudge policies, like those that the NHS has undertaken in recent years.
Prof Bovens cautions that there may be some limitations to the use of controlled trials of applications of nudge in health.
“That’s its own can of worms. I am not that convinced that we are making real progress by doing randomised, controlled trials to find out what the phrasing or the pictures in the letters should look like that we use to, say, increase tax compliance or increase organ donor sign up. This may be a bit of a fad and I doubt that, say, 10 years from now, this is what we will be doing in the field of policy worldwide.”
‘I think that what worries people the most is that they will be manipulated by authoritarian governments against their will in sinister ways’
However, Prof Bovens says that contrasting and comparing the environments in which people make health choices in different countries could well be an effective way of understanding which examples of ‘nudge’ work.
Prof Luc Bovens, LSE
“Personally, I think that more could be gained from comparing the choice environment in different regions or countries that have better and worse health outcomes, educational outcomes, etc,” he says.
“How are the environments different? Is there anything in these differences that explain the better and worse outcomes? This is what I have called ‘real nudge’ — can we learn anything about how to structure choice environments by comparing real environments that yield different outcomes?”
Nudge is celebrated by supporters as an inexpensive way of changing behaviour, but it is sometimes critiqued by left-wing critics as policy done ‘on the cheap’, lacking due regard for factors such as economic inequality.
The NACB opinion document warns that policy-makers cannot use nudge as a quick way of overcoming structural economic differences.
“Policy-makers must be mindful that social and economic inequalities lead to inequality in health. In fact, almost half of people living in consistent poverty in Ireland report having some form of chronic illness,” reads the NACB document.
“Therefore, it is important, from a social justice perspective, that consideration be given to the appropriateness of harnessing nudging to influence the behaviour of people living in consistent poverty, as opposed to using resources to improve the environment, health and wellbeing of those living in economically-disadvantaged communities.
“Some commentators have argued that social inequalities constitute a strong argument against nudging in favour of targeting the industries that profit from selling certain products (eg, foods containing trans fats or tobacco), rather than merely placing them on a different shelf in shops and cafes.”