A sidewalk chalk drawing that reads, “Healthy People, Healthy Planet are the future” below a drawing of wind mills in a field with a sunset.
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A popular area of applied behavioral science, nudges are frequently deployed within public health and healthcare systems to influence people’s choices. But can people be nudged into better health? And are nudges, which often take the form of guided choices, aligned with the principles of ethical and equitable health practices?

Nudge theory, one of the most influential frameworks to come out of behavioral economics, is deployed within the healthcare system to promote healthy behaviors. Nudges are meant to be noncoercive ways of reframing choices to help people make better decisions. In public health, nudges have been used to reframe food and drink options to encourage lower-sugar or lower-calorie foods, promote physical activity and water consumption, and discourage unhealthy activities like drinking alcohol and smoking.

When people are unaware of…their purposes and effects, nudges can be interpreted as manipulation or experimentation.

In their seminal book, Nudge: Improving Decisions about Health, Wealth, and Happiness, Richard Thaler and Cass Sunstein situate nudge theory within the larger context of libertarian paternalism, asserting that nudging is libertarian in that it preserves the right of the individual to choose a course of action for themselves, free of interference from governments or corporations, but is paternalistic in that it aims to influence choices in a way that will make choosers better off. Though it sounds obtuse, Thaler asserts that the term combines helping people (paternalism) and preserving individual choice (libertarianism).

While the very idea of paternalism, especially when enacted by government agencies, can be viewed as a limit on one’s free choice, libertarian paternalism remains a strong framework for thinking through the utility and appropriateness of nudge theory within public health and medicine as well as its limitations for improving health among marginalized groups.

While well-intentioned, nudge campaigns have sometimes stripped people of their autonomy, created solutions that failed to address root causes, or exacerbated the initial issue. For instance, people who are nudged into doing more physical activity may also begin increasing their calorie intake. Another inherent problem with nudging is that when people are unaware of them, or merely unaware of their purposes and effects, nudges can be interpreted as manipulation or experimentation. For people who have historically been violated, manipulated, or exploited by healthcare systems, these feelings can be heightened.

But despite the complexities and shortcomings of nudges, and though more testing is needed to fully understand the costs and benefits of nudging in different contexts and among diverse sets of people, there is evidence that this approach can be effective.

When Nudging Works

In public health and medicine, nudges have been effective in encouraging healthy lifestyle choices, improving the way patients navigate the healthcare system, and enhancing how healthcare systems function and patients are treated. Two examples of this are:

  • General Health and Fitness Nudges

Making small tweaks to physical environments can nudge people toward healthier habits. As simple as it may seem, the placement of certain foods, like swapping cake with fruit in the impulse basket next to the cash register, has been found to lead people to buy more fruit and less cake; and decreasing the size of food packaging and tableware has helped with portion control. Small changes have also made an impact on physical activity. A San Diego State University study found that stair use increased when signs nudging people to take the stairs were placed at the base of a staircase or escalator. These environmental cues are a relatively simple and cost-effective approach to nudging.

Another similar form of nudging, which centers on the images and text of warning labels, is effective in discouraging unhealthy behaviors like alcohol and tobacco consumption. However, these nudges work best when integrated into comprehensive prevention policy frameworks rather than being deployed on their own.

How patients interact with the healthcare system—especially the extent to which people access preventative care—presents another area of promise for health-related nudging. Nudges have been shown to promote medication adherence which is typically low and difficult to address through traditional interventions, decrease the amount of missed healthcare appointments, and bolster influenza vaccination.

  • Sludge adheres only to capitalist market forces while nudging for good draws on other values systems.Nudges for Healthcare Professionals

Though many health nudges are aimed at healthcare consumers, physicians, nurses, and other health professionals can also be nudged. Since healthcare delivery affects patient outcomes, nudging healthcare professionals is critical for improving people’s health and wellbeing. Some of the systemic problems that have been addressed using nudges include reducing medical errors, promoting good hand hygiene among clinicians, combatting the unnecessary prescription of antibiotics (which contributes to the prevalence of antibiotic-resistant bacteria), and other equitable prescribing behaviors. 

Examining the Ethics of Nudging

Behavioral science—specifically behavioral economics—first found a home in industry to manipulate consumer behavior. Behavioral economics is behind strategies to increase impulse buying: placing snacks close to the checkout aisle in supermarkets, when consumers are most likely to grab them, or designing menus to encourage people to buy more food. Thaler has labeled these strategies that use nudges against people’s best interest as “sludge.”

The Nudging for Good movement emerged as part of an effort to utilize behavioral science tools for social impact and infuse behavioral science practitioners in nonprofits and other mission-driven organizations. The movement can also be viewed as a countermovement to sludge; sludge adheres only to capitalist market forces while nudging for good draws on other value systems, such as advancing health initiatives or making it easier for people to access resources. Nudging has also been used to encourage giving to social causes and to increase support for social good campaigns.

Though the nudge/sludge distinction is important, many of the ethical issues involved in nudging lie in another crucial distinction: nudges versus pushes. Nudges are supposed to reimagine choice environments without coercion, while pushes rely more heavily on arm-twisting to elevate some choices over others. In a podcast for the American Medical Association Journal of Ethics, Dr. Mitesh Patel, director of the Penn Medicine Nudge Unit and Associate Professor of Medicine and Health Care Management at the University of Pennsylvania, made the case that one of the key differences between a nudge and a push is transparency. Essentially, people feel pushed when they can sense that they’re being steered toward certain options or behaviors without their knowledge or consent.

In contrast to the status quo of an invisible hand doing the nudging—according to Dr. Patel—the evidence shows that transparent nudging tends to be more effective. When there is more transparency, nudging helps people understand why they’re receiving certain information or why the options are framed a certain way, allowing for goal alignment at the patient level. Rather than a top-down strategy that may feel like an imposition, making nudges transparent also allows people to have input into how nudges are deployed, making people more likely to accept them. This approach also helps people maintain their agency and be actively involved in making decisions about their health.

Nudges have been scrutinized for the way they veil larger, systemic public health problems.

When Nudging Isn’t Enough

Even when nudging is transparent and collaborative, the larger environmental, political, and economic contexts in which nudges are deployed create other concerns. For instance, nudges that discourage people from buying highly processed or high-sugar foods are inherently ineffective for people who live in food deserts. And nudges that encourage exercise are of limited utility for communities that aren’t safe to walk or jog in, have few sidewalks, limited green spaces, or lack bike lanes.

Indeed, nudges have been scrutinized for the way they veil larger, systemic public health problems that disproportionately affect people of color and other marginalized groups. Scholars and thought leaders who are critical of behavioral science argue that nudging has too often led to incremental individual gains that overshadow the need for solutions at the population level. Therefore, one of the most pressing limitations of behavioral public health policy is it places a disproportionate amount of emphasis on personal responsibility rather than addressing the root causes of health inequities, which can create a smokescreen for governmental inaction.

Another emerging concern regarding nudges, especially within clinical settings, is the lack of rigorous research on their effectiveness. Some of the central issues with research on nudging is that there simply isn’t always enough robust empirical evidence to support research findings. Nudging studies are often conducted over a short timescale that contributes to concerns about sustainability and the long-term effects of interventions within complex and dynamic real-world settings. Such research-related shortcomings have called into question the place of nudging within evidence-based policy.

Perhaps of even greater concern, nudge interventions are rarely tested on vulnerable or disadvantaged groups, resulting in an important evidence gap related to how these groups respond to nudging in different contexts. Therefore, despite the hype around behavioral science techniques, the lack of understanding for the people already underserved by public health and healthcare systems means that behavioral science-inspired policy may not work in practice when transplanted to different populations.

Nudging can be useful if the nudges are properly and thoughtfully designed from a human-centered perspective that includes transparency and shared goal setting. However, until behavioral science becomes more fully integrated with the social determinants of health and health equity by realizing the larger contextual factors that influence decision-making, its potential impact—especially for those most in need of new solutions to solve persistent healthcare problems—will remain largely unrealized.