Purpose: To articulate and defend normative guidelines for the responsible deployment of behavioral economics and behavioral psychology principles to change health decisions and behaviors.  

Method: Systematic review of the literature to identify studies recently done and policies recently developed that use principles from behavioral economics and behavioral psychology to change health decisions and behaviors, followed by conceptual analysis to develop and defend normative guidelines.  

Result: Motivated in part by the NIH’s designation of The Science of Behavior Change as a Roadmap Initiative, policy makers, researchers, and clinicians are turning increasingly to behavioral economics and behavioral psychology for tools to change individual and group health-related behaviors and decisions. Examples include exploiting the principle of loss aversion through incentives to get people to lose weight and engage in regular cancer screenings, exploiting the principle of the status quo to set defaults to increase HIV screening (CDC policy) and Sickle Cell Trait screening (NCAA policy), exploiting the principle of availability bias to paint vivid images in people’s minds to discourage smoking (FDA policy) and full code status for certain patients, and exploiting the power of subconscious cues to prime people to pick healthy foods in restaurants and grocery stores. No corresponding guidelines have been developed to guide the use of these methods to ensure that they are used in an ethically responsible way.   

Conclusion: The use of behavioral economics and behavioral psychology principles to change health decisions and behaviors fall into the following main categories: incentives, defaults, salience and affect, norms, and subconscious priming. Incentives must be guided by considerations of amount, kind, and whether they will damage the physician-patient relationship. Default settings and subconscious priming must be guided by considerations of whether it is fairly easy for people to opt-out or avoid and go their own way, and whether the default represents what is in most people’s interests from an evidence-based point of view. The use of salience and affect, and also norms, must be guided by considerations of whether what is being presented is true and accurate, and whether there is a justification for appealing to emotion instead of rational argument.

Purpose: Two of the approved screening tests for colorectal cancer (CRC) are colonoscopy performed every ten years and fecal occult blood testing (FOBT) done annually. While FOBT is easier to perform for many patients, it is also less sensitive and specific than colonoscopy for identifying polyps or CRC. As part of a research study that is currently underway, patients view a computer-based presentation about approved CRC screening tests. Half also view a “nudge” to encourage them to undergo stool testing if they are unsure about which test to choose or are unwilling to have a colonoscopy. The justification for the nudge, consistent with behavioral economics, is to reduce procrastination due to indecision and increase the percentage of patients who get at least some screening. Pilot testing has suggested that the nudge may be effective at increasing interest in FOBT. Critics have raised the following ethical concern: The nudge may lead some patients who would have had screening colonoscopy to get FOBT instead, and some of them will be harmed if FOBT fails to identify a polyp or cancer that would have been detected by colonoscopy.  

Method: Conceptual analysis of ethical issues raised by the use of a nudge towards FOBT, and consideration of relevant research on patient decision-making about CRC screening and in behavioral economics.  

Result: The possibility that a nudge towards stool testing will harm some patients does not make the nudge unethical, according to widely accepted moral theories. From a Utilitarian perspective, the benefits can be expected to outweigh the harms if the nudge increases uptake of screening. From a Kantian perspective, some patients being harmed does not imply that the nudge is unethical, as long as it does not coerce or mislead individuals. At the same time, justifying the use of a nudge towards FOBT requires demonstrating improvement in outcomes or decision-making. In research studies of the impact of a nudge, the existence of possible harm should be disclosed to potential participants, even if the risk is minimal.  

Conclusion: A nudge towards FOBT for CRC screening may be ethically acceptable even if it can be expected to harm some patients. More generally, it can be ethical to utilize nudges towards screening tests or preventive treatments that have lower effectiveness than other approaches.

Background: The insufficient success of conventional strategies to promote healthy behaviors suggests the need for novel approaches.  Two broad motivations exist for such innovation.  First, considerable reductions in productivity and increases in avoidable healthcare costs represent substantial externalities attributable to the unhealthy choices people make for themselves.  At least as important are what have been called internalities – in this case, peoples’ tendencies to make decisions that are easiest or most gratifying for in the present (e.g., to eat chocolate cake) despite the substantial costs these decisions carry for their future selves.  The externalities of present choices provide a rationale for intervention based on social justice; the internalities of present choices provide a rationale for intervention based on beneficence.  

Approach: This presentation will analyze the role of health incentives for promoting healthier behaviors – specifically, the use of money to reward (or penalize) individuals or groups for adopting (or failing to adopt) healthier behaviors. I will focus on the theme of comparative ethics – the idea that although all approaches to using or not using incentives for health promotion have ethical pros and cons, on balance some strategies have greater propriety than others. 

Conclusions:  The presentation will defend three key conclusions.  First, incentive programs are not created equally, no more so in their ethics than in their effectiveness, and so judgments of propriety require both specificity and comparative thinking.  Second, considering the concerns with incentive programs requires thinking broadly, comparing these concerns with those we might levy against either not intervening, or intervening in different, non-incentive-based ways.  Third, a comparative ethics approach suggests the need for empiricism – a view that the most compelling concerns we might levy against incentive programs rest on empirically testable, but as yet untested, assumptions about such programs’ unintended consequences.

Discussion/response to the foregoing three presentations.