The popular notion of “nudging” is based on the idea we can push people gently towards doing what’s best for their health.
But what’s best? And who gets to decide? Is it your mum, your doctor, the health department or you?
When could nudging help?
The philosophy behind nudging is that a benevolent “choice architect” can rearrange information and the environment to make it easier for us to do the “right thing”, while preserving our freedom of choice.
The choice architect could be an organisation like the federal health department or the New South Wales Behavioural Insights Unit. But it could also be an individual person in control of your environment, like a shop owner, a school principal or your boss.
The right thing is often defined as something that improves public well-being with minimal cost to individual well-being.
Examples of how nudging is being used to influence our health choices in Australia include:
campaigns to reduce the unnecessary use of antibiotics, such as getting doctors and patients to sign a pledge. This aims to increase your commitment to doing something you agree with
introducing plain packaging and graphic images for cigarettes. This reduces the influence of marketing and reminds people of the consequences of smoking without restricting availability or choice of cigarettes brands
changing the national personal electronic health record from an “opt in” system to an “opt out” system. This idea has improved rates of organ donation registration in other countries, where it is still easy to opt out if you have objections to joining.
When is nudging controversial?
Nudging can be controversial. Many health situations involve a trade-off between benefits and side-effects, length of life and quality of life, or individual freedom and public cost.
Deciding what’s best gets complicated when people value different things, and this can vary by culture and the specific nudge.
For example, guidelines to prevent heart disease and stroke recommend assessing who could benefit from medication to reduce their risk, even if they are healthy.
Is it OK to nudge healthy people into taking medication if we know it will reduce their risk?
Some people might agree it’s worth the cost, inconvenience and potential side-effects of cholesterol-lowering medication to reduce their risk of a heart attack or stroke in the next five years from 10% to 8%.
But others may prefer instead to change their diet and exercise more to reduce their risk. Older people may decide it’s not worth the increased risk of a fall or fracture if they add blood pressure-lowering medication to their existing medications.
And some people may be comfortable with this level of risk and decide to do nothing at all.
If we nudge people in a way they are not aware of, these different values and preferences can’t be included when deciding which option to take.
Research across many countries suggests people prefer to know when they are being nudged, and why the choice architect has chosen a particular course of action.
What options are there?
Even when we think about the same sort of health decision (for instance, how we use antibiotics), choice architects could use different approaches. Some are more obvious, or offer more choice, than others:
shared decision making is increasingly recognised as the “gold standard”. This process allows doctors and patients to talk through the options, and the evidence for their benefits and harms. One example is to use a decision aid to explain how a sore throat is likely to disappear in a few days whether or not you take antibiotics
explicit nudge moves people towards the “right” choice when they want to help themselves make a change or hadn’t realised they are an outlier compared with their peers. This could encourage GPs who prescribe the most antibiotics to commit to not using them unnecessarily for cold and flu over winter
implicit nudge moves people towards the “right” choice without stating this directly. This may be appropriate when everyone agrees on what should be done (or would agree if they were asked) but habit, time limitations or effort prevents them from following through. An example of this might be setting the “right” default in software hospital doctors use when prescribing medicines to encourage them to use antibiotics appropriately
regulation may be considered more paternalistic but this can be acceptable to restrict options that have serious adverse consequences for the public or individuals. This option might be appropriate to make it difficult for doctors to prescribe the strongest antibiotics and so reserve them for serious antibiotic-resistant infections.
What can you do?
If you need to make a decision about your health, and are concerned about the direction in which you might be being nudged, here are five questions to ask your doctor or other health professional:
- do I really need this test, treatment or procedure?
- what are the risks?
- are there simpler, safer options?
- what happens if I don’t do anything?
- what are the costs?
You could also look for resources to help you make choices about your health; these help you better understand the benefits and harms of all options for a range of common health conditions.
Carissa Bonner receives funding from the National Health and Medical Research Council, the National Heart Foundation of Australia, The Royal Australian College of General Practitioners, and Therapeutic Guidelines Ltd.
Ben Newell receives funding from the Australian Research Council.
Authors: Carissa Bonner, Research Fellow, University of Sydney