Top

Published in:

Open Access 21-07-2023 | Original Article

Why Health-enhancing Nudges Fail

Author: Thomas Schramme

Published in: Health Care Analysis | Issue 1/2024

Abstract

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.

I agree with Andreas Schmidt and Bart Engelen, who conclude in their recent overview that “there is an increasing understanding that ethical concerns differ radically from practice to practice and from nudge to nudge” and that hence “ethical analysis should proceed case by case” (Schmidt & Engelen, [2019], 9).

I avoid the commonly used term choice architecture, because other people might represent mechanisms of nudging—say, when role models are intentionally introduced—and they are hardly part of what would normally be called an architecture, though they are part of the environment of a chooser. Some scholars define nudges as mechanisms that intentionally use the same psychological imperfections (biases etc.) that seem to make nudges necessary in the first place (White, [2016], 21). I do not think nudges necessarily work on non-rational psychological mechanisms.

It is true that Thaler and Sunstein, in one of their first publications on the topic, were mainly preoccupied with paternalistic nudges. Yet in their book Nudge, first published in 2008, they more generally consider nudges as “any factor that significantly alters the behavior in a predictable way without forbidding any options or significantly changing their economic incentives” (Thaler & Sunstein, [2008], 9). This allows for paternalistic and non-paternalistic goals. Some of their examples accordingly target externalities, for instance a proposed “civility check” to avoid impolite emails or the programme “dollar a day” to reduce teenage pregnancy. The latter is advised because “taxpayers end up paying a significant amount for many children born to teenagers” (ibid. 232 f.). Gigerenzer (2015, 363) recommends a more restrictive conceptualisation, which only allows for paternalistic nudges.

Sunstein goes on to call the use of a GPS device a form of so-called means paternalism (Sunstein, [2020], 44), which aims at making the choice of the best means for a set end more likely. However, such a perspective additionally makes the notion of paternalism far too broad. In an earlier study, Sunstein even claimed that “[n]ature itself nudges; so does the weather” (Sunstein, 2016a, 21). This, for him, is then evidence that it is “pointless to object to choice architecture or nudging as such” (ibid.). He calls this his “first central argument” in favour of governmental nudges (ibid., 23).

In an elaborate analysis of nudges, Christopher McCrudden and Jeff King deem unhealthy or risky lifestyles harmful to others instead of merely self-regarding. For them, “pensions, cigarettes and obesity” are related to forms of “risk-taking [that] is in reality free-riding on the generosity of those who pick up the pieces after the gamble is lost” (McCrudden & King, [2016], 102). I do not take a stance towards such an interpretation of imperfect health-related behaviour as harmful to others.

Personal nudges are not my main concern. Intuitively, they seem reasonable, because they are a form of self-binding or externally reinforced commitment.

In a recent publication, Sunstein refers to what choosers themselves value in the sense of an ideal, modelled chooser (Sunstein, [2020], 60). Similarly, he believes that planners need to make assumptions about the “best understanding of welfare” (ibid., 38).

Sunstein and Thaler call real individuals that are subject to psychological mechanisms, such as biases, “Humans” and idealised choosers “Econs” (Thaler & Sunstein, [2008], 7 ff.). Econs are based on the traditional homo economicus model, as developed by neoclassical economics. Behavioral economists reject that model and aim at a psychologically more realistic analysis. Given their own idealisations, I believe Sugden is right when he says that Sunstein and Thaler actually do not discuss real humans but faulty Econs (Sugden, [2017], 117; see also Rizzo, [2020], 46 ff.).

The debate on the concept of health in philosophy of medicine is fairly advanced. Helpful introductions are Nordenfelt, [2017] and Schramme, [2019], 17ff.

One recent survey found that the most effective nudges reduced daily calorie intake by 209 kcal (Cadario et al. 2018, 29). Whether there was any long-term effect on calorie-intake over a period of time was not tested. For comparison, the National Health Service of the UK recommends a daily calorie intake of 2,000 kcal a day for women and 2,500 kcal for men (https://www.nhs.uk/common-health-questions/food-and-diet/what-should-my-daily-intake-of-calories-be/). There are numerous other reviews of effectiveness, which seem to support a more optimistic outlook. Yet, these usually measure the impact of nudges on consumption choices, which is obviously different from impact on health (see, e.g., Adam and Jensen, 2016; Mertens et al., 2022). In fairness, there are studies that explicitly acknowledge the need for outcome measures (Bucher et al., 2016).

It is interesting to see that a recent trend in behavioral economics indeed pushes against individual nudges and for system-oriented interventions, such as traditional legal frameworks, tackling discrimination and economic destitution, as well as education (Chater & Loewenstein, 2022).

Self-induced (personal) health-enhancing nudges might fare better, but they also cannot solve the epistemic problems surrounding the task of identifying holistically effective choices.

Engelen and Nys [2020] use the term “autocracy” for this interpretation of autonomy, thereby following Paul Guyer’s formulation.

Sunstein claims that philosophers’ understanding of autonomy is somewhat limited anyway: “[I]n speaking of autonomy, philosophers could learn a great deal from economists, who know that the real question is usually not whether people are going to be allowed to make choices, but whether someone (such as government) will or should impose costs on people who make choices” (Sunstein, 2016b, 63).

In contrast to philosophers who discuss the manipulative nature of nudges and see them perhaps as a kind of “usurpation of will” (Dworkin, [1983], 107), I am more interested in the second part of Shiffrin’s description, the relevant insult that comes with assuming better agency than the nudged person.

This is an empirical claim, mainly based on anecdotal evidence. I do not think, though, that it is a far-fetched assumption. For some empirical evidence supporting my claim see, e.g., Thunström, [2019]. The negative effects of nudges are here fleshed out in terms of an emotional tax.

It is true, of course, that such kind of insult is not specific to nudges, but other interferences as well. Still, it applies here.

Surely there are limits to this freedom. Importantly, the potential impact of a choice, for instance if it is life-threatening, makes a difference. But these are not the cases we discuss in this paper, of course.

Admittedly, I am not an expert regarding the medical impact of negative emotions, but there is empirical evidence supporting my assumption (Smith et al. 2006; Novaco 2010).

I ignore the issue of nudges being usually covert—undisclosed to nudged individuals—and hence more difficult to control democratically. One study suggests that transparency about nudges does not alter their effects, at least as tested in a particular scenario regarding default options about hypothetical advance directives (Loewenstein et al., 2015). Interestingly, Sunstein himself claims that all nudges should be transparent (Sunstein, [2020], 55 f.). By that, he seems to mean that they should be democratically controlled—“[n]udges should be visible, scrutinized, and monitored” (ibid., 55)—not that they should be made conscious to individual choosers.

Adam, A., & Jensen, J. D. (2016). What is the effectiveness of obesity related interventions at retail grocery stores and supermarkets?—A systematic review. Bmc Public Health, 16(1247), 1–18.

Barton, A., & Grüne-Yanoff, T. (2015). From Libertarian Paternalism to nudging—and Beyond. The Review of Philosophy and Psychology, 6(3), 341–359.CrossRef

Bovens, L. (2009). The Ethics of Nudge. In T. Grüne-Yanoff, & S. O. Hansson (Eds.), Preference change: Approaches from Philosophy, Economics and psychology (pp. 207–219). Heidelberg u.a.: Springer.CrossRef

Bucher, T., Collins, C., Rollo, M. E., McCaffrey, T. A., & De Vlieger, N. (2016). Van der Bend, Daphne; Truby, Helen and Perez-Cueto, Federico JA. Nudging consumers towards healthier choices: A systematic review of positional influences on food choice. British Journal of Nutrition, 115, 2252–2263.PubMedCrossRef

Cadario, R., & Chandon, P., (2018). Which healthy eating nudges work best? A meta-analysis of field experiments (working paper). Available at SSRN: https://ssrn.com/abstract=3090829.

Chater, N., & Loewenstein, G. (2022). The i-frame and the s-frame: How focusing on individual-level solutions has led behavioral public policy astray. Behavioral and Brain Sciences. https://doi.org/10.1017/S0140525X22002023CrossRefPubMed

Coupland, R. (2007). Security, insecurity and health. Bulletin of the World Health Organization, 85(3), 181–184.PubMedPubMedCentralCrossRef

Desroches, C., & Tyler (2020). Value Commitment, Resolute Choice, and the normative foundations of behavioural Welfare Economics. Journal of Applied Philosophy, 37(4), 562–577.CrossRef

Dworkin, G. (1983). Paternalism: Some second thoughts. In R. Sartorius (Ed.), Paternalism (pp. 105–111). Minneapolis: University of Minnesota Press.

Engelen, B., & Nys, T. (2020). Nudging and Autonomy: Analyzing and alleviating the worries. Review of Philosophy and Psychology, 11, 137–156.CrossRef

Eyal, N. (2016). Nudging and Benign Manipulation for Health. In Glenn I. Cohen, Holly Fernandez-Lynch, Christopher T. Robertson (Eds.), Nudging Health: Health Law and Behavioral Economics Baltimore: Johns Hopkins University Press, London.

Freeman, A. (2016). Behavioral Economics and Food Policy: The limits of nudging. In I. Glenn, Cohen, & C. T. Robertson (Eds.), Nudging Health: Health Law and behavioral economics (pp. 124–139). Baltimore: Johns Hopkins University Press.

Gigerenzer, G. (2015). On the supposed evidence for Libertarian Paternalism. The Review of Philosophy and Psychology, 6(3), 361–383.PubMedCrossRef

Gingerich, J. (2016). The political morality of Nudges in Healthcare. In I. Glenn, Cohen, & C. T. Robertson (Eds.), Nudging Health: Health Law and behavioral economics (pp. 97–106). Baltimore: Johns Hopkins University Press.

Glod, W. (2015). How nudges often fail to treat people according to their own preferences. Social Theory and Practice, 41(4), 599–617.CrossRef

Grüne-Yanoff, T. (2012). Old wine in new casks: Libertarian paternalism still violates liberal principles. Social Choice and Welfare, 38, 635–645.MathSciNetCrossRef

Hallsworth, M. (2017). Seven Ways of applying behavioral science to Health Policy. In I. Glenn, Cohen, & C. T. Robertson (Eds.), Nudging Health: Health Law and behavioral economics (pp. 40–51). Baltimore: Johns Hopkins University Press.

Hanna, J. (2015). Libertarian Paternalism, Manipulation, and the Shaping of Preferences. Social Theory and Practice, 41(4), 618–643.CrossRef

Hausman, D. M., & Welch, B. (2010). Debate: To nudge or not to nudge. Journal of Political Philosophy, 18, 123–136.CrossRef

Kickbusch, I. (2009). Health literacy: Engaging in a political debate. International Journal of Public Health, 3, 131–132.CrossRef

Loewenstein, G., Bryce, C., Hagmann, D., & Rajpal, S. (2015). Warning: You are about to be nudged. Behavioral Science & Policy, 1(1), 35–42.CrossRef

Marlow, M. (2016). Weight-loss nudges: Market test or government guess? In A. Sherzod (Ed.), Nudge theory in action: Behavioral design in Policy and Markets. Palgrave Macmillan.

McCrudden, C., & King, J. (2016). The Dark side of nudging: The Ethics, Political Economy, and Law of Libertarian Paternalism. In A. Kemmerer, C. Möllers, M. Steinbeis, & G. Wagner (Eds.), Choice Architecture in Democracies: Exploring the legitimacy of nudging (pp. 75–139). Baden-Baden: Nomos.

Mertens, S., Herberz, M., Hahnel, Ulf, J. J., & Brosch, T. (2022). The effectiveness of nudging: A meta-analysis of choice architecture interventions across behavioral domains. Pnas, 119(1), 1–10.CrossRef

Mills, C. (2015). The heteronomy of Choice Architecture. The Review of Philosophy and Psychology, 6(3), 495–509.CrossRef

Noggle, R. (2018). Manipulation, salience, and nudges. Bioethics, 32(3), 164–170.PubMedCrossRef

Nordenfelt, L. (2017). On concepts of positive health. In Schramme, Thomas & Edwards, Steve (Eds.), Handbook of the philosophy of Medicine. Springer.

Novaco, R. W., et al. (2010). Anger and Psychopathology. In M. Potegal (Ed.), International Handbook of Anger. Heidelberg: Springer. New York NY.

Qizilbash, M. (2012). Informed desire and the ambitions of libertarian paternalism. Social Choice and Welfare, 38, 647–658.MathSciNetCrossRef

Rebonato, R. (2012). Taking Liberties: A critical examination of Libertarian Paternalism. Basingstoke: Palgrave Macmillan.

Rizzo, M. J. (2020). Escaping paternalism: Rationality, behavioral Economics, and Public Policy. Cambridge: Cambridge University Press.

Rizzo, M. J., Douglas Glen, W. (2009). The knowledge problem of new paternalism. Brigham Young University Law Review, 2009(4), 905–968.

Schmidt, A. T., & Engelen, B. (2019). The ethics of nudging: An overview. Philosophy Compass, 15, e.

Schramme, T. (2019). Theories of Health Justice: Just Enough Health. London: Rowman & Littlefield Int.

Schwartz, P. H. (2008). Risk and disease. Perspectives in Biology and Medicine, 51(3), 320–334.PubMedCrossRef

Scoccia, D. (2019). Paternalisms and nudges. Economics and Philosophy, 35, 79–102.CrossRef

Shiffrin, S. V. (2000). Paternalism, Unconscionability Doctrine, and accommodation. Philosophy and Public Affairs, 29(3), 205–250.CrossRef

Smith, T. W., MacKenzie, J. (2006). Personality and risk of physical illness. Annual Review of Clinical Psychology, 2, 435–67.PubMedCrossRef

Sugden, R. (2008). Why incoherent preferences do not justify paternalism. Constitutional Political Economy, 19(3), 226–248.CrossRef

Sugden, R. (2017). Do people really want to be nudged towards healthy lifestyles? International Review ofEconomics, 64(2), 113–123.

Sunstein, C. R. (2014). Why nudge? The politics of Libertarian Paternalism. New Haven and London: Yale University Press.

Sunstein, C. R. (2016a). The Ethics of Choice Architecture. In A. Kemmerer, C. Möllers, M. Steinbeis, & G. Wagner (Eds.), Choice Architecture in Democracies: Exploring the legitimacy of nudging (pp. 21–74). Baden-Baden: Nomos.

Sunstein, C. R. (2016b). The Ethics of Influence: Government in the age of behavioral science. Cambridge: Cambridge University Press.CrossRef

Sunstein, C. R. (2018). Better off as judged by themselves: a comment on evaluating nudges. International Review of Economics, 65, 1–8.CrossRef

Sunstein, C. R. (2020). Behavioral Science and Public Policy. Cambridge: Cambridge University Press.CrossRef

Sunstein, C. R., Richard, H., & Thaler (2003). Libertarian paternalism is not an Oxymoron. The University of Chicago Law Review, 70(4), 1159–1202.CrossRef

Thaler, R., & Sunstein, C. (2008). Nudge: Improving decisions about Health, Wealth and Happiness. London: Penguin.

Thunström, L. (2019). Welfare effects of nudges: The emotional tax of calorie menu labeling. Judgment and Decision Making, 14(1), 11–25.CrossRef

Waldron, J. (2014). It’s all for your own good. New York Review of Books, 9, 21–23.

White, M. D. (2013). The manipulation of choice: Ethics and Libertarian Paternalism. Basingstoke: Palgrave Macmillan.CrossRef

White, M. D. (2016). Bad Medicine: Does the Unique Nature of Healthcare decisions justify Nudges? In I. Glenn, Cohen, & C. T. Robertson (Eds.), Nudging Health: Health Law and behavioral economics (pp. 72–82). Baltimore: Johns Hopkins University Press.

Wilkinson, T. M. (2013). Nudging and manipulation. Political Studies, 61, 341–355.CrossRef

Title: Why Health-enhancing Nudges Fail
Author: Thomas Schramme
Publication date: 21-07-2023
Publisher: Springer US
Published in: Health Care Analysis / Issue 1/2024
Print ISSN: 1065-3058
Electronic ISSN: 1573-3394
DOI: https://doi.org/10.1007/s10728-023-00459-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Why Health-enhancing Nudges Fail

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 1/2024

Gendering the Pandemic: Women’s Health Disparities From a Human Rights Perspective

Moral Distress and Nursing Education: Curricular and Pedagogical Strategies for a Complex Phenomenon

The Ethics of Population Policy for the Two Worlds of Population Conditions

Consent for Medical Treatment: What is ‘Reasonable’?