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A nuanced ‘nudge’ or a paternalistic push for health?

By Dermot - 10th Jun 2015

It is about situating healthy food in more prominent positions in canteens, or making plates smaller so portion sizes drop. It could also involve a public-hire bike scheme to encourage cycling, or more controversially, price regulation and tax incentives.

Arguably, a recent high-profile example would be the Minister for Health Leo Varadkar urging over-35s to take out private health insurance to avoid extra charges in the future.

‘Nudge’ has become a buzz concept in public health in recent years, generating disciples, dissidents and controversy in its wake.

Arising out of behavioural science, nudge is about changing the ‘choice architecture’ in people’s lives, thus altering the context in which we make decisions. So maybe we are asked to become an organ donor when we register for our driving licence, or colourful fruit rather than chocolate bars greet us when we finally reach the cash register in the supermarket.

Nudge is applied in several countries. In Britain, the concept established itself through the formation of the Behavioural Insights Team (often called the ‘Nudge Unit’) in the British Cabinet Office. This initiative is now a ‘social purpose company’ part-owned by the UK government.

Nudge is celebrated by supporters as a versatile, inexpensive and nuanced way of changing behaviour. But it is disparaged by left-wing critics as policy done ‘on the cheap’, lacking due regard for factors such as economic inequality. Critics on the political right say it’s the ‘nanny state’ undermining the freedom of the individual. So the debate around nudge continues to rage.

Many movements begin with a book, and nudge is no different. In 2008, Richard Thaler and Cass Sunstein published the highly influential <em>Nudge: Improving Decisions About Health, Wealth and Happiness</em>. However, as with many causes spawned by a book, there is some disagreement over what it all means.


“It is worth noting that there are a lot of misconceptions about what a nudge is,” Dr Pete Lunn, a Senior Research Officer at the ESRI, tells the <em><strong>Medical Independent (MI)</strong></em>.

“Thaler and Sunstein’s idea is that you don’t deny people options; instead, you use behavioural economics to design the contexts in which people make decisions, in order to help them make better ones,” he says.

<img src=”../attachments/a6dd270f-3d9a-4e26-ae6e-11566d5dff1d.JPG” alt=”” /><br /><strong>Dr Pete Lunn, ESRI</strong>

“What this means is that you don’t ban stuff or hit unhealthy choices with punitive taxes, but instead make it easier for people to make good decisions. In public health terms, this means things like laying-out food options and changing plate sizes to make it more likely that people eat healthily, or designing buildings to make it more likely that people take the stairs, or changing glass sizes to help people drink sensibly, and so on. In the jargon, this is called designing the ‘choice architecture’.

“In each case, you can carry on eating cheeseburgers, taking the lift and binge-drinking if you want to, but the behavioural science shows that you will be less likely to when the choice architecture has these ‘nudges’ built in.”

Not all policy-makers agree, and some do see an important role for price restrictions and taxation policy in nudge.

Quite aside from definitions, it is clear that Irish health authorities are beginning to take the use of nudge seriously. The recent Department of Health symposium, ‘<em>Influencing Healthy Lifestyles: Nudging or Shoving? The Ethical Debate</em>’, welcomed worldwide experts and high-ranking medical officials from home, including the Chief Medical Officer Dr Tony Holohan.

More significantly, this newspaper has learned that the Government’s National Advisory Committee on Bioethics is presently working on an opinion document on the application of nudge in public health.

Founded in 2012, the Committee has produced two previous opinion documents, both on controversial issues (informed consent in blood transfusion; and detention in mental health facilities). It is clear that the ethical debates around nudge are being taken seriously in the Department.

The Committee is “currently tasked with preparing advice on the ethics of using nudging for public health purposes,” a department spokesperson tells <em><strong>MI</strong></em>.

“Work on this topic has just commenced. The Committee is due to meet in late September in order to further progress this work.”

The Committee’s role involves “providing advice in the form of expert reports on priority issues of national significance as requested by the Minister”.

But one may wonder, why the fuss? You do not have to be an avid fan of the recently-concluded Mad Men series to understand that the private sector has long been involved in variations of nudge. Whether it is enticing us with advertisements to drink alcohol, crave fast food, or (decades ago) promoting smoking as ‘cool’, the private sector has been moving the ‘choice architecture’ around us for many years, with obvious health consequences. So why can’t public health get involved?

In truth, public health policies have been affecting our choices, but traditionally this has involved the more obvious form of legislation. But this, some experts argue, has its limitations.


“In practical terms, this involves using a mix of regulation and more traditional public health interventions such as education and information campaigns,” Dr Siobhán O’Sullivan, Chief Bioethics Officer, said at the Department’s recent symposium.

“It is true that traditional public health approaches have mostly concentrated on restricting choice or even the outright banning of certain behaviours. However, legislation in isolation is unlikely to be the solution, which is why governments are looking beyond such orthodox approaches and adopting innovative ways of promoting and protecting health and wellbeing.”


‘Nudge’ has become a buzz concept in public health in recent years, generating disciples, dissidents and controversy in its wake


With the Government currently shepherding its Public Health Alcohol Bill through the Houses of the Oireachtas, one of its more hotly debated aspects is minimum unit pricing (MUP). This is, for some, a tool of nudge. Simply put, if alcohol is more expensive then people will buy less, and the resulting health consequences will not be so destructive.

“There is a lot of talk about pricing,” Prof Luc Bovens tells <em><strong>MI</strong></em>.

Prof Bovens works at the London School of Economics and Political Science (LSE) and is author of <em>Why Couldn’t I be Nudged to Dislike a Big Mac?</em> (2013). He was one of the speakers at the recent Department symposium.

“The Cabinet in Ireland in February 2015 has followed Scotland (2012) in adopting MUP. This follows the recommendations of the Sheffield study on the impact that MUP is projected to have on alcohol-related morbidity and mortality,” says Prof Bovens. “We have very good evidence that pricing works. It will take very cheap alcohol off the shelves, which carries huge responsibility for heavy drinking.”

But is nudge all about pricing? And if it is, are legislated price reductions not a very blunt instrument in impacting on people’s choices? In other words, more a paternalistic push than nuanced nudge?

“When people talk about nudge, they often want to hear whether anything else can be done than pricing,” says Prof Bovens. “Business obviously does not like pricing policies…there is a concern that responsible drinkers who are not well off will have their budgets affected by pricing policies.”

Resistance from business to nudge is not something confined to Europe. In 2013, one of the more interesting recent battles between government and the private sector took place in the beating heart of global capitalism.

Former New York Mayor Michael Bloomberg could hardly be described as left wing or ‘anti-capitalist’. A billionaire and leading public businessman, he proposed regulation to limit a soft-drink size in New York’s cinemas, delis, sports stadiums, etc. The ban would have seen the end of sugar-sweetened drinks in cups larger than 16 ounces (0.5 litres).

He wanted to make some of the citizens of the Big Apple just that little less big.

However, an alliance of business figures and angry conservative and libertarian politicians raised itself against the law. Many of the conservatives rejected the initiative as government ‘nannying’ or ‘paternalism’. The law died in court.

“When Bloomberg was mayor of New York, he proposed a maximum drink size on sugar-sweetened drinks,” recounts Prof Bovens.

“This did not stand up to challenges in court, which cited unfair competition from supermarkets, who were not so constrained. It is indeed very difficult to get businesses on-board with public health initiatives.”

However, he adds: “Nannying is about constraining business; nudging is about developing a partnership with business, inviting them to come up with creative solutions, and setting targets to measure the success of implementation.”


There is a deeper debate over how far public health campaigns should go.

“Making lifestyles a moral issue is problematic on a number of levels,” said Chief Bioethics Officer, Dr O’Sullivan at the recent symposium.

“Why focus on those who eat or drink or smoke too much? What about the workaholics amongst us, the mountaineers, the non-compliant patient? If people are to be made responsible for their own adverse state of health, should that somehow reduce their moral claim to healthcare?”

<img src=”../attachments/81efa5b0-e063-4461-9bff-b699125b8063.JPG” alt=”” /><br /><strong>Dr Siobhan O’Sullivan</strong>

Echoing this cautionary note, Prof Bovens warns that campaigns must be careful not to stigmatise.

“We have seen many creative social advertisement campaigns that target binge-drinking,” the LSE academic tells <em><strong>MI</strong></em>. “It paints an image that makes it distinctively uncool, or even outright disgusting. One needs to be careful about stigmatisation of a group who often ended up in a bad spot due to life’s misfortunes, rather than due to conscious choices of their own. I think that this worry is most acute when fighting obesity. I remember a poster from Western Australia with an eminently ‘grabbable’ gut juxtaposed next to an interior shot of layers of fat.”

But Prof Bovens feels that some shaming of binge-drinking is “not beyond the pale,” just as “few people object to raising the disgust factor concerning smoking”.

He adds: “We also do find such advertisements more permissible considering that the enemy is the drinks industry, which is very clever at making booze nights looks like good times, never mind the ‘Drink Responsibly’ disclaimer in small print.”

Prof Harald Schmidt is Assistant Professor at the Department of Medical Ethics and Health Policy in the University of Pennsylvania. He feels that there remain some core ethical questions at the heart of nudge.

“A central ethical question is whether all those who are offered incentives have a reasonably equal chance of completing the incentivised behaviour, whether this is weight control, smoking cessation, medication adherence or other activities people often find challenging,” Prof Schmidt informs <em><strong>MI</strong></em>.

“Incentives can be helpful and empowering, but there is also the risk of victim-blaming in cases where people are held responsible for factors that are beyond their control.”

<em>Healthy Ireland (HI) </em>is the main document relating to Irish public health policy. While nudge strategies are not overtly mentioned in HI, possible nudge-like initiatives have been raised at <em>Healthy Ireland </em>Council meetings, minutes of which have been seen by this newspaper following a Freedom of Information request.

But <em>HI</em> also emphasises the more structural aspects of health inequality in Ireland and the need for a ‘whole-of-Government’ approach to rectify this. Nudge, it is argued by some, can only go so far.

Ms Kate O’Flaherty, Director of the Health and Wellbeing Programme, Department of Health, spoke at the recent symposium, where she laid-out the broader issues that negatively impact on health, such as education and employment.

“As well as recognising that creating a healthier Ireland is about changing individual ‘choices’ and ‘behaviours’ on modifiable lifestyle issues, we also need to address the wider social determinants of health and wellbeing such as education, employment, the living environments of citizens,” said Ms O’Flaherty.

However, she added: “It’s obviously attractive to us as a society and a Government that up to 80 per cent of this chronic disease burden is preventable through modifying behaviour, so naturally it should be a focus for us to see how we encourage, support, influence and facilitate our population to make healthier lifestyle choices.”


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<h3>A nudge is as good as a drink</h3>

Alcohol legislation is one of the areas where nudge is discussed most often.

The Government’s Public Health Alcohol Bill would be the “most far-reaching proposed by any Irish government, with alcohol being addressed for the first time as a public health measure,” the Minister for Health recently claimed.

The Bill is expected to be introduced in the Oireachtas in the autumn, and a core aspect is minimum unit pricing.

“I am all in favour of alternatives to pricing, but at the same time, why not work on an integrated policy?” says Prof Luc Bovens, an expert in the use of nudge in alcohol policy.

<img src=”../attachments/99af38d0-31a9-48fc-b3da-3205829c37ee.JPG” alt=”” /><br /><strong>Prof Luc Bovens, LSE</strong>

“The choice architecture is the context of off- and on-licence sales. Let’s think about beer sales in supermarkets and pubs.

“As to supermarkets, it’s often mentioned that the alcohol should not be placed between, say, the milk and the Coke. You need to signal somehow that this is a drink that carries risks. We don’t place the cigarettes between the cookies and the crisps.

“It would also be good to have a broader choice of decent no-alcohol and low-alcohol beers (2.8 per cent) in the UK/Ireland. Now, granted, they are not easy to brew,” he says.

Prof Bovens has a very innovative idea about how to improve the taste and quality of low-alcohol beers.

“I propose that we have a contest in the UK and Ireland for brewing decent no- and low-alcohol beers that would appeal to the Irish and UK palate. In addition, there should be a proper media campaign to popularise the product. Jupiler Blue did an excellent job in Belgium.


Make the no-alcohol and low-alcohol beers available on tap and serve them in regular glasses


“As to on-licence, here are a few ideas. Make the no-alcohol and low-alcohol beers available on tap and serve them in regular glasses.” This would avoid the embarrassment of joining friends with a bottle of alcohol-free beer, he reasons. “This seems like a very simple intervention and I am hopeful that could make a real difference.”

Prof Bovens says it’s important to have “cool new ideas”. He comments: “I think that it is important to study popular culture and to assess how one can steer it in the right direction when it comes to alcohol consumption.

“There is a fringe of teetotallers in their 20s. What drives them? Can one capitalise on this movement? Another trend we see is the rise of coffee shops and pubs losing business as coffee shops pop-up like mushrooms.

“Lunch in the pub during working hours is losing popularity. Again, we are fighting one drug (alcohol) with another drug (caffeine) and this raises questions about legitimate Government involvement.”

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<h3>Nudge effectiveness and the international context</h3>

Beyond the debate about whether it is ethical, there is the important matter of whether nudge actually works. “It is almost impossible to generalise about the effectiveness of nudges,” Prof Harald Schmidt, a US-based ethics expert, tells <em><strong>MI</strong></em>.

“They comprise an extremely wide range of interventions. But in specific contexts, they have had a powerful impact. The importance of nudges in policy and ethical terms lies in the recognition that people often make irrational choices, typically centered on maximising tangible benefits in the here-and-now.

“What is common to all nudge approaches is that they try to help people make choices that are also in their longer-term interest, without coercing people into doing so. In being sensitive to personal autonomy, the charge of paternalism that makes many more intrusive public health measures controversial can often be averted.”

<img src=”../attachments/0c299ca0-a03d-43b5-b4f0-26a0ea2f0d55.JPG” alt=”” /><br /><strong>Prof Harald Schmidt</strong>

So while Prof Schmidt is broadly optimistic about the possible benefits of nudge as a public health tool, he too mentions that wider factors such as class and education need to be factored in.

“Nudges are very plausible, but this does not mean that they do not require robust evaluation,” he says.

“Aside from the effectiveness in terms of improving health, attention also needs to be paid to the distribution of benefits across different groups in terms of income, educational or health status.”

ESRI Senior Research Officer Dr Pete Lunn believes it is still a little too early to make judgments on the overall benefit. “On the effectiveness of nudges, the jury remains out,” says Dr Lunn.

“In some areas of policy, nudges have been shown to be very powerful, eg, changing the default option on pension enrolment has dramatically increased pension coverage in some countries.”

However, he says many nudges have quite small effects. “Furthermore, especially in public health, the effectiveness of nudges can be hard to measure. For instance, it is easy to measure whether the calories people eat at lunch are reduced by giving them smaller plates, but harder to test whether they are then more likely to have a chocolate bar with their tea in the afternoon.


They compromise an extremely wide range of interventions


“Nevertheless, nudges can be effective and, importantly, offer the possibility of significant returns for what are relatively cheap and easy interventions. The application of behavioural science to policy is spreading very rapidly,” he says.

But as the behavioural economics becomes more important, Dr Lunn feels Ireland needs to remain focused if it is not to be nudged behind, so to speak.

“The UK is the world leader in this area and the government there now has more than 200 behavioural scientists working in state agencies and government departments.

“Obviously, only a proportion of these people are working on health-related issues, but the growth in recent years is remarkable.

“Behavioural teams of different sorts now work in the governments of the UK, US, Australia, Denmark, Finland, Germany, France and some others. 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.”