This paper rejects an argument defending the view that the boundary between deception and manipulation is such that some manipulations intended to cause false beliefs count as non-deceptive. On the strongest version of this argument, if a specific behaviour involves compromising the victim’s reasoning, then the behaviour is manipulative but not deceptive, and if it involves exposing the victim to misleading evidence that justifies her false belief, then it is deceptive but not manipulative. This argument has been consistently used as (...) a reason to reject the traditional analysis of human deception, according to which intentionally causing someone to acquire a false belief is sufficient for deception. And because the traditional analysis is also consistent with our most basic intuitions about deception, it does matter whether this argument succeeds. (shrink)

Pregnant adolescents have a higher risk of poor maternal and fetal outcomes, particularly in the setting of concomitant maternal alcohol and other drug (AOD) use. Despite numerous programmes aimed at reducing overall teen pregnancy rates and the recognition of AOD use as a risk factor for unintended pregnancy in adolescents, interventions targeting this specific group have been sparse. In adult drug-using women, financial incentives for contraception have been provided but are ethically controversial. This article explores whether a trial could ethically (...) employ monetary incentives in adolescents with AOD use to promote the use of long-acting reversible contraception (LARC), with special attention to the relevant distinctions between adults and adolescents. We conclude that a trial of incentives to promote LARC in this patient population is ethically permissible if the incentives are small, are tied to completion of an educational activity to minimise the quick fix temptation and potential for non-attendance to the risks and benefits of LARC and are provided only to the adolescent after an assessment of her reasoning to rule out coercion (eg, by guardians) as motivation. Information about treatment for AOD use and follow-up care in case of problems with the contraceptive or desire for removal should also be provided. Before implementing such a trial, qualitative research with input from providers, potential patients and their parents should be conducted to inform the programme's specific structure. (shrink)

This essay explores three issues in respect for autonomy that pose unfinished business for the concept. By this, I mean that the dialogue over them is ongoing and essentially unresolved. These are: whether we ought to respect persons or their autonomous choices; the role of relational autonomy; and whether nonhuman animals can be autonomous. In attending to this particular set of unfinished business, I highlight some critical moral work left aside by the concept of respect for autonomy as understood in (...) Beauchamp and Childress’ Principles of Biomedical Ethics. Specifically, while significant pragmatic traction is gained by the authors’ focus on autonomous choice, carving such a focus out from the broader questions of moral respect and the autonomy of the person leaves aside a number of questions that we might have thought a view about respect for autonomy in biomedicine ought to answer. These include: How should physicians respond when autonomous patients make decisions that appear nonautonomous? What is the impact of the view that autonomy is “relational” for cross-cultural differences in how autonomy is respected? If chimpanzees can be autonomous, what does that mean for how they should be treated? (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 16-17, February 2012.

The American Journal of Bioethics, Volume 12, Issue 2, Page 28-30, February 2012.

Libertarian paternalism describes the idea of nudging—that is, steering individual decision-making while preserving freedom of choice. In medicine, libertarian paternalism has gained widespread attention, specifically with respect to interventions designed to promote healthy behaviours. Some scholars argue that nudges appropriately balance autonomy and paternalistic beneficence, while others argue that nudges inherently exploit cognitive weaknesses. This paper further explores the ethics of libertarian paternalism in public health. The use of nudges may infringe on an individual’s voluntary choice, autonomy and informed consent, (...) but they are ethically justified when there is a clear public health benefit to the manipulation of choice. (shrink)

This article articulates a framework for normatively assessing influence operations, undertaken by national security institutions. Section I categorizes the vast field of possible types of influence operations according to the communication’s content, its attribution, the rights of the target audience, the communication’s purpose, and its secondary effects. Section II populates these categories with historical examples and section III evaluates these cases with a moral framework. I argue that deceptive or manipulative communications directed at non-liable audiences are presumptively immoral and illegitimate (...) for liberal states, as are deceptive operations aimed at an unjust end, or even operations aimed at a just end where secondary effects are forecast to be disproportionate to the proximate end. (shrink)

Some philosophers have argued that during the process of obtaining informed consent, physicians should try to nudge their patients towards consenting to the option the physician believes best, where a nudge is any influence that is expected to predictably alter a person’s behaviour without restricting her options. Some proponents of nudging even argue that it is a necessary and unavoidable part of securing informed consent. Here I argue that nudging is incompatible with obtaining informed consent. I assume informed consent requires (...) that a physician tells her patient the truth about her options and argue that nudging is incompatible with truth-telling. Instead, nudging satisfies Harry Frankfurt’s account of bullshit. (shrink)

> The bullshitter may not deceive us, or even intend to do so, either about the facts or about what he takes the facts to be. What he does necessarily attempt to deceive us about is his enterprise. His only indispensably distinctive characteristic is that in a certain way he misrepresents what he is up to. 1 - Harry Frankfurt In both lying and truth-telling, the speaker intends the audience to believe what she says is true; that her enterprise is (...) to inform her audience. In contrast, the speaker who bullshits doesn’t care whether the audience believes what she says, rather she intends her audience to believe or do something else—to think highly of her, to buy what she is selling, or the like. I argue that nudging is incompatible with securing genuine informed consent.2 I assume, but do not argue, that informed consent requires truth-telling during adequate disclosure. When a physician nudges, her intention is to irrationally influence her patient’s choice, not inform. Because of this, nudging cannot be understood as truth-telling ; rather it is essentially bullshit.1 In " Truth be told," Jennifer Blumenthal-Barby and Peter A Ubel argue that not all nudging is incompatible with truth-telling, contending that ‘nudges can be bullshit,’ but that ‘nudging does not require bullshitting.’3 They ask us to consider the following: Vaccination: Consider a physician who wants her patient to get a vaccine. She tells him why the vaccine is important, by providing factually correct information about the vaccine. In other words, she engages in informed disclosure aimed at enhancing the patient’s understanding. At the same time, she also tells the patient that the majority of people his age get the vaccine. In other words, she engages in nudging the patient by …. (shrink)

Powers and Faden argue that social justice ‘is concerned with securing and maintaining the social conditions necessary for a sufficient level of well-being in all of its essential dimensions for everyone’ (2006: 50). Moreover, social justice is concerned with the ‘achievement of well-being, not the freedom or capability to achieve well-being’ (p. 40). Although Powers and Faden note that an agent alone cannot achieve well-being without the necessary social conditions of life (e.g. equal civil liberties and basic material resources, such (...) as food and shelter), it seems that achievement requires that an agent actually pursue the six dimensions of well-being. In this article, I question the extent to which an individual has an obligation to achieve well-being, even if he or she would choose to do otherwise. For example, can an agent choose to forgo being healthy even if all the social conditions are met in her life, thereby choosing to not achieve well-being? It remains unclear how the dimension of self-determination coheres with the remaining five dimensions of well-being and the extent of society’s obligations toward an individual’s achievement of well-being, even in those instances when society’s actions may go against an individual’s right to self-determination. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 11-12, February 2012.

Is it a stronger interference with people's freedom to withdraw options they currently have than to withhold similar options they do not have? Drawing on recent theorizing about sociopolitical freedom, this article identifies considerations that often make this the case for public policy. However, when applied to tobacco control, these considerations are shown to give us at best only very weak freedom-based reason to prioritize the status quo. This supports a popular argument for so-called “endgame” tobacco control measures: If we (...) believe that cigarettes would and should be withheld from entering markets in hypothetical scenarios in which they do not yet exist, then we also have reason to seek their abolition in situations, such as ours, in which cigarettes do exist—if necessary by banning their sale. The same considerations are then used to disarm objections that have recently been raised to using nudges in public policy. (shrink)

So‐called nudge policies utilize insights from behavioral science to achieve policy outcomes. Nudge policies try to improve people's decisions by changing the ways options are presented to them, rather than changing the options themselves or incentivizing or coercing people. Nudging has been met with great enthusiasm but also fierce criticism. This paper provides an overview of the debate on the ethics of nudging to date. After outlining arguments in favor of nudging, we first discuss different objections that all revolve around (...) the worry that nudging vitiates personal autonomy. We split up this worry into different dimensions of autonomy, such as freedom of choice, volitional autonomy, rational agency, and freedom as nondomination. We next discuss worries that nudging is manipulative, violates human dignity, and prevents more important structural reform. Throughout, we will present responses that proponents of nudging can muster. On the whole, we conclude that the objections fail to establish that the nudge program as a whole should be rejected. At the same time, they give us important guidance when moving towards an ethical assessment of nudges on a case‐by‐case basis. Towards the end, we provide some possible ways forward in debates around the ethics of nudging. (shrink)

The novel coronavirus (SARS-CoV-2) pandemic has refocused attention on the issue of mandatory vaccination. Some have suggested that vaccines ought to be mandatory, while others propose more moderate alternatives, such as incentives. This piece surveys a range of possible interventions, ranging from mandates through to education. All may have their place, depending on circumstances. However, it is worth clarifying the options available to policymakers, since there is sometimes confusion over whether a particular policy constitutes a mandate or not. Further, I (...) illustrate a different kind of alternative to mandatory vaccination. Rather than seeking less coercive alternatives to a mandate, we might instead employ an alternative mandate, which requires people to do something less than get vaccinated. For instance, we might merely require people to attend an appointment at a vaccine clinic. Whether this mandatory attendance policy is justified will depend on specific circumstances, but it represents another way to promote vaccination, without mandating it. In some cases, this may represent an appropriate balance between promoting public health goals and respecting individual liberty. (shrink)

In recent years, ‘nudge’ theory has gained increasing attention for the design of population-wide health interventions. The concept of nudge puts a label on efficacious influences that preserve freedom of choice without engaging the influencees’ deliberative capacities. Given disagreements over what it takes genuinely to preserve freedom of choice, the question is whether health influences relying on automatic cognitive processes may preserve freedom of choice in a sufficiently robust sense to be serviceable for the moral evaluation of actions and policies. (...) In this article, I offer an argument to this effect, explicating preservation of freedom of choice in terms of choice-set preservation and noncontrol. I also briefly explore the healthcare contexts in which nudges may have priority over more controlling influences. (shrink)

In “Nudging and Informed Consent,” ShlomoCohen (2013) attempts to address the common objection against nudges that they are autonomy-thwarting because they foster irrationality. He explicitly focuses on informed consent, which he contrasts with the policy context in which health nudges are usually discussed. I think Cohen’s rich article is a significant contribution to the nudge literature. However, I have some concerns with the way he frames and motivates his inquiry...

BackgroundHealth decisions occur in a context with omnipresent social influences. Information concerning what other patients decide may present certain interventions as more desirable than others.ObjectivesTo explore how physicians refer to what other people decide in conversations about the relevancy of cardio-pulmonary resuscitation or do-not-attempt-resuscitation orders.MethodsWe recorded forty-three physician–patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR is discussed. Data was analysed with conversation analysis.ResultsReference to what other people decide in regards to CPR is used five (...) times, through reported speech. The reference is generic, and employed as a resource to deal with trouble encountered with the patient’s preference, either because it is absent or potentially incompatible with the medical recommendation. In our data, it is a way for physicians to present decisional paths and to steer towards the relevancy of DNAR orders. By calling out to a sense of membership, it builds towards the patient embracing norms that are associated with a desirable or relevant social group.ConclusionsIntroducing DNAR decisions in terms of what other people opt for is a way for physicians to bring up the eventuality of allowing natural death in a less overt way. Formulating treatment choices in terms of what other people do has implications in terms of supporting autonomous and informed decision making, since it nudges patients towards conformity with what is presented as the most preferable choice on the basis of social norms. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 20-22, February 2012.

Is implementing the beneficent nudge program morally permissible in worlds like ours? I argue that there is reason for serious doubt. I acknowledge that beneficent nudging is highly various, that nudges are in some circumstances morally permissible and even called for, and that nudges may exhibit respect for genuine autonomy. Nonetheless, given the risk of epistemic injustice that nudges typically pose, neither the moral permissibility of beneficent nudging in the abstract, nor its case-by-case vindication, appears sufficient to justify implementing a (...) nudge program in worlds like ours. Drawing on Miranda Fricker’s account of epistemic injustice, I argue that the cogent defense of any nudge program, relative to worlds like ours, stands in need of serious attention to its potential for fostering or sustaining epistemic injustice. A more specific point hinges on recognizing a form of epistemic injustice not enough attended to in the literature to date, which I call reflective incapacitational injustice. This includes relative disadvantages in the attaining of the capacity to engage in critical reason, such as the capacity to go in for potentially critical reasoned deliberation and discursive exchange concerning ends. Since Cass Sunstein’s First Law of behaviorally informed regulation would be taken, in worlds like ours, to justify indeterminately many nudges leading to such epistemic injustice we have general grounds for doubting the moral permissibility of this nudge program. We should hence oppose the implementation of any such program until it is shown not to violate the demands of epistemic justice. (shrink)

The idea that it is acceptable to ‘nudge’ people to opt for the ‘healthy choice’ is gaining currency in health care policy circles. This article investigates whether researchers evaluating Abdominal Aortic Aneurysm Screening Programmes (AAASP) attempt to influence decision makers in ways that are similar to popular ‘nudging’ techniques. Comparing two papers on the health economics of AAASP both published in the BMJ within the last 3 years, it is shown that the values chosen for the health economics modelling are (...) not representative of the literature and consistently favour the conclusions of the articles. It is argued (1) that this and other features of these articles may be justified within a Libertarian Paternalist framework as ‘nudging’ like ways of influencing decision makers, but also (2) that these ways of influencing decision makers raise significant ethical issues in the context of democratic decision making. (shrink)

In an analysis of recent work on nudging we distinguish three positions on the relationship between nudging founded in libertarian paternalism and the protection of personal autonomy through informed consent. We argue that all three positions fail to provide adequate protection of personal autonomy in the clinical context. Acknowledging that nudging may be beneficial, we suggest a fourth position according to which nudging and informed consent are valuable in different domains of interaction.

Policymakers and institutions have developed an increasing interest in applying principles from cognitive science to encourage individuals to adopt behaviors, attitudes and perspectives that enable them to reach higher levels of personal and collective well-being. We focused on the value of nudging people to adopt a broader farsighted view when making their day-to-day decisions, overcoming the temporal discounting bias which leads them to prefer smaller immediate gains to larger future rewards. Following recent advances in the literature, we tried to mitigate (...) this myopia promoting the connection that individuals feel between their present and future selves through a nudge which capitalizes on their natural tendency to illusory superiority. We defined and tested a paradigm to exploit persuasively this optimistic bias to mitigate temporal discounting through the mediation of an increased future self-continuity. Implications for well-being and public policies are discussed. (shrink)

Nudging works through dispositions to decide with specific heuristics, and has three component parts. A nudge is a feature of an environment that enables such a disposition; a person is nudged when such a disposition is triggered; and a person performs a nudged action when such a disposition manifests in action. This analysis clarifies an autonomy-based worry about nudging as used in public policy or for private profit: that a person’s ability to reason well is undermined when she is nudged. (...) Reasoning well is a component of self-guidance, which is an aspect of autonomy and so something there is reason to promote, preserve, or respect. However, a person can reason well when she is nudged: Many of these heuristics are good rules to reason with, and she can be flexible with respect to them when she takes there to be a better way to reason. Along the way, this paper uncovers several design specifications for responsible nudging, and discusses open empirical questions. However, nudging’s being compatible with reasoning well crystallizes a distinct worry about manipulation: that nudge designers can rely on nudged people guiding themselves toward the designers’ own ends. Manipulation of this sort exploits one aspect of autonomy (namely, self-guidance) to undermine autonomy in other respects. (shrink)

Techniques from behavioral economics—nudges—may help physicians increase pediatric vaccine compliance, but critics have objected that nudges can undermine autonomy. Since autonomy is a centrally important value in healthcare decision-making contexts, it counts against pediatric vaccination nudges if they undermine parental autonomy. Advocates for healthcare nudges have resisted the charge that nudges undermine autonomy, and the recent bioethics literature illustrates the current intractability of this debate. This article rejects a principle to which parties on both sides of this debate sometimes seem (...) committed: that nudges are morally permissible only if they are consistent with autonomy. Instead, I argue that, at least in the case of pediatric vaccination, some autonomy-undermining nudges may be morally justified. This is because parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and because the interests of both the vaccinated child and other members of the community can sometimes be weighty enough to justify autonomy-infringing pediatric vaccination nudges. This article concludes with a set of worries about the effect of pediatric vaccination nudges on parent-physician relationships, and it calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges. (shrink)

The realm of non-rational influence, which includes nudging, is home to many other morally interesting phenomena. In this paper, I introduce the term bumping, to discuss the category of unintentional non-rational influence. Bumping happens constantly, wherever people make choices in environments where they are affected by other people. For instance, doctors will often bump their patients as patients make choices about what treatments to pursue. In some cases, these bumps will systematically tend to make patients’ decisions worse. Put another way: (...) doctors will sometimes harm their patients by bumping them in systematic ways. I use the case of medical overuse, the provision of medical services where the likely harm outweighs the likely benefit to the patient, as a touchstone for arguing that doctors who systematically bump their patients towards harm can be blameworthy for their unwitting influence. (shrink)

BackgroundHealth behavior change is among the top recommendations for improving health of patients with lifestyle-related chronic diseases. An array of behavior change techniques have been developed to support behavior change initiation and maintenance. These BCTs often show limited success when they are not informed by theory, leading to a mismatch between the intention of the BCT and patients’ needs or expectations. Previous studies have identified a number of resources which patients may require to initiate and maintain health behavior change. Indeed, (...) not yet well established is how BCTs address these resources, i.e., the functional mechanisms of BCTs.PurposeProvide a theoretical framework of the functional mechanisms of BCTs for developing and implementing successful interventions for health behavior change.MethodsConceptual review, including literature analysis and synthesis as well as conceptualization of a new model based on the synthesis.ResultsThrough the integration of dual-process models as well as reward and motivation proceeding, i.e., affective, emotional, or intuitive neurobiological cues, into the rational framework of rather linear cognitive or task-related decision progress, we categorize previously identified resources into three distinct sets: external, internal reflective, and internal affective resources. Based on this triad, we classify BCTs according to their functional mechanisms into facilitating, boosting, and nudging. Consequently, we present a simplified Behavior Change Resource Model that is centered on patients’ resources.ConclusionThe model can be applied to develop health behavior change interventions, which promote engagement and empowerment. Future studies should aim at testing the applicability and practicality of the BCRM. (shrink)

The most discussed puzzle about weakness of will (WoW) is how it is possible: how can a person freely and intentionally perform actions that she judges she ought not perform, or that she has resolved not to perform? In this paper, we are concerned with a much less discussed puzzle about WoW?how is overcoming it possible? We explain some of the ways in which previously weak-willed agents manage to overcome their weakness. Some of these are relatively straightforward?as agents learn of (...) the real costs of weakness, or as those costs mount dramatically, they can become strongly motivated to do what they already judged best. But other cases are more difficult to explain: sometimes, agents with a long history of forming and then weakly abandoning resolutions manage to stick to their guns. We argue that these cases can be explained by combining George Ainslie's model of agents as multiple preference orderings competing in game theoretic interactions along with the insights of evolutionary game theory. This can explain the puzzling cases where agents suddenly adopt successful strategies for avoiding weak-willed behavior, especially where agents gain no new information about themselves or the consequences of their actions. (shrink)

A few years ago, the New York City Department of Health introduced a public health campaign entitled “Cut Your Portions, Cut Your Risk”, a series of posters in which images of food in increasingly large portion sizes appear. In one example, three packets of french fries are featured; in another, cheeseburgers are shown. In a red box in each, the text, in large, all-capital letters in English and Spanish, reads “Portions have grown,” and, below this, in all capitals, “so has (...) obesity, which can lead to many health problems” or “so has type 2 diabetes, which can lead to amputations.” Beneath the food, the posters admonish, again in all-capital... (shrink)

Can Artificial Intelligence be more effective than human instruction for the moral enhancement of people? The author argues that it only would be if the use of this technology were aimed at increasing the individual's capacity to reflectively decide for themselves, rather than at directly influencing behaviour. To support this, it is shown how a disregard for personal autonomy, in particular, invalidates the main proposals for applying new technologies, both biomedical and AI-based, to moral enhancement. As an alternative to these (...) proposals, this article proposes a virtual assistant that, through dialogue, neutrality and virtual reality technologies, can teach users to make better moral decisions on their own. The author concludes that, as long as certain precautions are taken in its design, such an assistant could do this better than a human instructor adopting the same educational methodology. (shrink)

Many of our daily activities are now made more convenient and efficient by virtual assistants, and the day when they can be designed to instruct us in certain skills, such as those needed to make moral judgements, is not far off. In this paper we ask to what extent it would be ethically acceptable for these so-called virtual assistants for moral enhancement to use subtle strategies, known as “nudges”, to influence our decisions. To achieve our goal, we will first characterise (...) nudges in their standard use and discuss the debate they have generated around their possible manipulative character, establishing three conditions of manipulation. Secondly, we ask whether nudges can occur in moral virtual assistants that are not manipulative. After critically analysing some proposed virtual assistants, we argue in favour of one of them, given that by pursuing an open and neutral moral enhancement, it promotes and respects the autonomy of the person as much as possible. Thirdly, we analyse how nudges could enhance the functioning of such an assistant, and evaluate them in terms of their degree of threat to the subject’s autonomy and their level of transparency. Finally, we consider the possibility of using motivational nudges, which not only help us in the formation of moral judgements but also in our moral behaviour. (shrink)

Many high-risk medical devices earn US marketing approval based on limited premarket clinical evaluation that leaves important questions unanswered. Rigorous postmarket surveillance includes registries that actively collect and maintain information defined by individual patient exposures to particular devices. Several prominent registries for cardiovascular devices require enrolment as a condition of reimbursement for the implant procedure, without informed consent. In this article, we focus on whether these registries, separate from their legal requirements, have an ethical obligation to obtain informed consent from (...) enrolees, what is lost in not doing so, and the ways in which seeking and obtaining consent might strengthen postmarket surveillance in the USA. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 26-27, February 2012.

Advice-giving is an important means of supporting others to act well. It inspires gratitude, indifference and resentment in equal measure. Although we can often predict a resentful reception for advice, its normative implications may be unclear. Should advice that is likely to be resented be withheld or modified because of its resentability, or delivered despite it? The norms that underwrite advice-giving, and which inform justified resentment, have thus far evaded systematic philosophical analysis. Using a case proposed by Edward Hinchman, the (...) first part of this paper develops three lines of reasoning that explain why advice might be resented. The second part explores three norms of advice suggested by the case. Together they cast light upon the role of advice in our moral and social lives, and offer a starting point for practical reasoning about when to give resentable advice, and how to be a good advisor. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 22-24, February 2012.

Nudging is a tool of libertarian paternalism. It involves making use of certain psychological tendencies in order to help people make better decisions without restricting their freedom. However, some have argued that nudging is objectionable because it interferes with, or undermines, the rational decision-making of the nudged agents. Opinions differ on why this is objectionable, but the underlying concerns appear to begin with nudging’s threat to rational decision-making. Those who discuss this issue do not make it clear to what this (...) threat to rationality amounts. In this paper I evaluate what effect nudging has on our decision-making and I argue that it does not typically interfere with our rationality in a problematic way. Perhaps nudging is objectionable for other reasons, but we should not argue that nudging is objectionable based on concerns about rational decision-making. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 18-20, February 2012.

Many parents are hesitant about, or face motivational barriers to, vaccinating their children. In this paper, we propose a type of vaccination policy that could be implemented either in addition to coercive vaccination or as an alternative to it in order to increase paediatric vaccination uptake in a non-coercive way. We propose the use of vaccination nudges that exploit the very same decision biases that often undermine vaccination uptake. In particular, we propose a policy under which children would be vaccinated (...) at school or day-care by default, without requiring parental authorization, but with parents retaining the right to opt their children out of vaccination. We show that such a policy is likely to be effective, at least in cases in which non-vaccination is due to practical obstacles, rather than to strong beliefs about vaccines, ethically acceptable and less controversial than some alternatives because it is not coercive and affects individual autonomy only in a morally unproblematic way, and likely to receive support from the UK public, on the basis of original empirical research we have conducted on the lay public. (shrink)

Background There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade." Methods The main objective of this qualitative case study was to document the experiences (...) of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes. Results Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional. Conclusions We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges. (shrink)

In the course of a project on European policy on media and alcohol, a series of structured deliberative discussion sessions with young people (aged 13–25 years) in Sweden were arranged, where young people could communicate and exchange ideas about risks and policy issues connected to alcohol consumption and drinking, as presented in fictional media. The objective was to understand how risks and knowledge about alcohol consumption is acquired by young people and ‘uploaded’ to peers. The discussion sessions applied adapted variants (...) of the Youth Jury approach developed to facilitate the communication of ideas for guidelines and policies stemming from young people’s own perceptions about alcohol and media consumption. When ordinary ‘matters of fact’ information about drinking and alcohol fail to engage young people of today (even if it is understood), using humor, horror and shock seems a justified way in Sweden to get the desired reaction. Many of the jury participants themselves thought so. Social network has become an important way of communication also for temperance nongovernmental organizations and public initiatives, in particular with regard to nudging through emotional engagement and attempting to inspire further ‘peer-to-peer’ communication of this type, as young people ‘click-to-connect’. (shrink)

Toleration is one of the fundamental principles that inform the design of a democratic and liberal society. Unfortunately, its adoption seems inconsistent with the adoption of paternalistically benevolent policies, which represent a valuable mechanism to improve individuals’ well-being. In this paper, I refer to this tension as the dilemma of toleration. The dilemma is not new. It arises when an agent A would like to be tolerant and respectful towards another agent B’s choices but, at the same time, A is (...) altruistically concerned that a particular course of action would harm, or at least not improve, B’s well-being, so A would also like to be helpful and seeks to ensure that B does not pursue such course of action, for B’s sake and even against B’s consent. In the article, I clarify the specific nature of the dilemma and show that several forms of paternalism, including those based on ethics by design and structural nudging, may not be suitable to resolve it. I then argue that one form of paternalism, based on pro-ethical design, can be compatible with toleration and hence with the respect for B’s choices, by operating only at the informational and not at the structural level of a choice architecture. This provides a successful resolution of the dilemma, showing that tolerant paternalism is not an oxymoron but a viable approach to the design of a democratic and liberal society. (shrink)

One of the most pervasive criticisms of nudges has been the claim that they violate, undermine or decrease people’s autonomy. This claim, however, is seldom backed up by an explicit and detailed conception of autonomy. In this paper, we aim to do three things. First, we want to clear up some conceptual confusion by distinguishing the different conceptions used by Cass Sunstein and his critics in order to get clear on how they conceive of autonomy. Second, we want to add (...) to the existing discussion by distinguishing between ‘autonomy’ as the ability to set your own ends and ‘autocracy’ as the ability to actually realize those ends. This will allow for a more careful ethical evaluation of specific nudge interventions. Third, we will introduce the idea of ‘perimeters of autonomy’ in an attempt to provide a realistic account of personal autonomy and we will argue that it can alleviate most of the worries about nudging being autonomy-undermining. (shrink)

Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead (...) of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google’s rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most—but not all—nudges in most—but not all—circumstances. (shrink)

We examined the relationship between political affiliation, perceptual estimates, and subjective judgements of disease prevalence and mortality across three chart types. An online survey exposed separate groups of participants to charts displaying COVID-19 data or COVID-19 data labeled ‘Influenza ’. Block 1 examined responses to cross-sectional mortality data ; results revealed that perceptual estimates comparing mortality in two countries were similar across political affiliations and chart types, while subjective judgements revealed a disease x political party interaction. Although Democrats and Republicans (...) provided similar proportion estimates, Democrats interpreted mortality to be higher than Republicans; Democrats also interpreted mortality to be higher for COVID-19 than Influenza. Block 2 examined responses to time series ; Democrats and Republicans estimated greater slopes for COVID-19 trend lines than Influenza lines ; subjective judgements revealed a disease x political party interaction. Democrats and Republicans indicated similar subjective rates of change for COVID-19 trends, and Democrats indicated lower subjective rates of change for Influenza than in any other condition. Thus, while Democrats and Republicans saw the graphs similarly in terms of percentages and line slopes, their subjective interpretations diverged. While we may see graphs of infectious disease data similarly from a purely mathematical or geometric perspective, our political affiliations may moderate how we subjectively interpret the data. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 14-15, February 2012.