Monday, October 24, 2011: 1:45 PM
Columbus Hall AB (Hyatt Regency Chicago)
(BEC) Behavioral Economics

Peter H. Schwartz, MD, PhD, Indiana University School of Medicine, Indianapolis, IN
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.