NUDGING AND/OR BOOSTING? AN INQUIRY ON THE ETHICAL JUSTIFICATION OF NORMS FOR MODELING AND IMPLEMENTATION OF EVIDENCE-BASED POLICY AND CLINICAL PRACTICE FOR PATIENT ENGAGEMENT

Purpose: To study the ethical justification of two competing evidence-based policy strategies concerning patient engagement, “nudge” and “boost”, for modeling and implementing interventions both at the clinical and public health levels

Method: Systematic review with concept and ethical analysis of published studies reporting ethical justification for "nudge" and/or "boost" policies and clinical practices.

Result: We mapped 191 publications (PubMed and Google), with a great majority discussing the ethical justification of “nudge” (dominant) and few publications on “boost”, as specifically coded in opposition to “nudge”. The types of ethical justification found for “nudge” derived from the description of liberal paternalism versus its critique on the grounds that it limits the autonomy of the individual and patient engagement, for lack of focus on deliberative processes and commitment to education as a standing-alone empowering value. Boost emerged as ethically justified based on a strong contractualist defense of health education in modeling and implementation at all levels.

Conclusion: It was not clear whether the disagreement on the scientific and epistemic justification in the literature of both related doctrines impacted in any relevant dimension their ethical justification for both evidence-based policies and practices. Further, such disagreement not clearly supported their incompatibility, as the emerging “boost” literature seems to suggest, but at best helps to clarify their distinction. Much of the problem with the ethical justification seem to hinge on the question on how to align both “nudge” and “boost” in the context of justice and social contract theory, as well on the conceptualization of autonomy as it relates to the duties of the clinician and policy-maker to individual patients and populations. The lack of complementary interpretations aligning “nudge” and “boost” is a clear gap in the literature regarding modalities of patient engagement. When interpreted to stand for public health settings - where harm is clearly present for others, "nudge" provides an ethical justification for constraints in patient engagement. "Boost", on the other hand, seem to be more clearly justified in clinical contexts of patient engagement - where the clarification of biases would be justified with the empowerment of the individual patient through education, scientific literacy and overall citizenry.