Introduction
In everyday life, there are different degrees by which one might try to influence the behavior of someone else. For example, you might try to convince your friend to go to the movies with you by telling them all of the good things that would happen if they came. This process also occurs on a larger scale, using data from behavior psychology to create policies and marketing that influence peoples behavior. For example, grocery stores might position certain foods in places that will catch your eye, in hopes that you will buy it. In what ways it is permissible to use this power over other people’s decision making?
In bioethics, we call this ability to influence others’ behaviors nudging. In our grocery store example, the customer is “nudged” towards purchasing whatever the store is highlighting. The store organizing things such that our choices are presented to us in a very specific way. Yashar Sagahi’s defines a nudge as follows, “A nudges B when A makes it more likely that B will ϕ, primarily by triggering B’s shallow cognitive processes, while A’s influence preserves B’s choice-set and is substantially noncontrolling (ie, preserves B’s freedom of choice)” (2013). So how does one influence someone else’s choice while still allowing them to decide autonomously? Is someone who is being nudged able to exercise their autonomy?
These questions are prevalent in many different areas of bioethics, including physician authority and paternalism, genetic data banking, research ethics, and more. Theorists aim to identify what kind of nudging (if any) is permissible, whether nudges infringe upon agential autonomy, and how nudges can be permissibly used in policy making.
Assigned Readings
Seminar participants were asked to read the following papers prior to meeting for discussion.
Blumenthal-Barby J. S. (2012). Between reason and coercion: ethically permissible influence in health care and health policy contexts. Kennedy Institute of Ethics journal, 22(4), 345–366.
- Thesis: Blumenthal-Barby addresses the conceptual space between rational persuasion and coercion, which she argues should be called nonargumentative influence. Blumenthal-Barby believes that instances of influence should be evaluated independently based on the type of influence and the relationship of the influencer to the influenced. She then applies her analysis to two examples in health care and health policy.
Sunstein, C. R. (2015). Nudging and Choice Architecture: Ethical Considerations. Yale Journal on Regulation. https://ssrn.com/abstract=2551264
- Thesis: Sunstein defends the concepts of nudging and choice architecture, saying that the concepts in general are not objectionable though token instances of each might be. He argues that nudging can promote welfare and autonomy, and choice architecture need not compromise dignity. That said, both can be objectionable, either when they are used to meet illicit ends or are impermissibly manipulative. Manipulation, both the concept and the practice, thus deserves careful attention.
Moles, A. (2015). Nudging for Liberals. Social Theory and Practice, 41(4), 644–667. http://www.jstor.org/stable/24575753
- Thesis: Moles argues that nudging in itself is not problematic for anti-perfectionist liberals. Anti-perfectionist liberals reject the idea that governments can permissibly encourage certain things given their intrinsic value because it fails to treat people as free and equal. Moles argues that nudging can be permissible under anti-perfectionist liberal frameworks when it increases peoples compliance with certain duties. Nudging is appropriate only to secure that people discharge their duties, or to secure that the interest they have in exercising their fundamental moral powers is fulfilled.
Discussion Questions
Seminar participants were asked to consider the following questions prior to meeting for discussion.
- What is a nudge exactly, and how does it differ from paternalism?
- What is “non-argumentative influence” and why does Blumenthal-Barby jettison the term “manipulation” in favor of “non-argumentative influence”?
- What do you think about the reasoning behind defending nudges to get people to perform their duties and promote social good, and how could this reasoning apply to issues such as research participation or going through proper channels for procedures such as drug approval and access?
Reflection Points
In discussion, seminar participants reflected on the following points.
- There seems to be space in the literature for case studies where different cases are applied to different definitions of nudging to see their various conclusions.
- The aim of nudging is to enhance the well-being of the nudged in some way. But how do we judge “better off” for another person? Whose perspective should we be using in these considerations?
- Autonomy preservation requires transparency. But to meet the transparency requirement undermines the very idea of nudging. What should or can be done about that?
- It seems that nudges in medical encounters are criticized as being unethical because they can be coercive, exploitative, lack transparency, etc. At the same time, nudges are ubiquitous in medicine and most may seem beneficial. Are there circumstances where doctors have an ethical duty to use nudges in interactions with patients?
Nudging in Action Exercise
It can be helpful to consider different examples to see how frameworks of nudging and choice architecture might differ in different contexts. Below are five cases that are examples of nudging. As an exercise, go through each case and determine what sort of influence is being applied and whether or not you think that influence is permissible. Identify in what respects the cases are different.
Additional Resources
There are many papers in the philosophical literature about the ethics of nudging and how nudges interact with agential autonomy and liberties. Below are several books and high impact papers on nudging that serve as a good introduction to the topic.
Blumenthal-Barby, J. S. (2021). Good ethics and bad choices : the relevance of behavioral economics for medical ethics. Cambridge, Massachusetts: The MIT Press.
Thaler, R. H., & Sunstein, C. R. (2009). Nudge: Improving decisions about health, wealth, and happiness.
Hausman, D.M. and Welch, B. (2010), Debate: To Nudge or Not to Nudge. Journal of Political Philosophy, 18, 123-136. https://doi.org/10.1111/j.1467-9760.2009.00351.x
Grüne-Yanoff, T. & Hertwig, R. (2016). Nudge Versus Boost: How Coherent are Policy and Theory?. Minds & Machines 26, 149–183. https://doi.org/10.1007/s11023-015-9367-9
Saghai, Y. (2013). Salvaging the concept of nudge. Journal of Medical Ethics. 39, 487-493.
Sunstein, C. R. (2014). Nudging: A Very Short Guide. 37 J. Consumer Pol’y 583 Available at SSRN: https://ssrn.com/abstract=2499658 or http://dx.doi.org/10.2139/ssrn.2499658