Nudging in a clinical context refers to ways that physicians can present information to make patients more likely to choose a certain outcome. Proponents of nudging claim that it is inevitable and that it can help patients make better decisions. Opponents of the practice say that nudging is unethical because it is deceptive and bypasses a patient’s autonomy. In order to determine whether or not nudging is truly ethical, it is important to place the practice in an ethical framework. Principlism is a system for ethical decision-making that is found throughout healthcare. Its four principles are respect for autonomy, beneficence, nonmaleficence, and justice.
Nonmaleficence is not entirely relevant to nudging, as physicians should not be offering options that will harm their patients. The idea of justice and distribution of resources is also less relevant when discussing nudging in terms of individual patient best interest and outcomes. The two principles that are most relevant are respect for autonomy and beneficence. By assessing the value that nudging has on decision making within the principlism framework, it is clear that nudging is ethical.
Respect for autonomy is often cited as the most important of the four ethical principles. Opponents of nudging claim that the practice violates respect for autonomy by affecting the choices that people make. However, the nature of nudging ensures that physicians are still respecting patient autonomy. Nudging affects how information about possible choices is presented. However, nudging does not remove any choices from consideration. For example, a patient could have a lump that may or may not be cancer. His or her options for proceeding are either surgery or watchful waiting. Based on his or her knowledge of the risks and benefits associated with each choice, the physician may nudge the patient to choose watchful waiting. However, the patient is still aware that surgery is an option; the physician does not try to hide this choice from the patient. Therefore, nudging does not violate respect for autonomy, as it does not prohibit patients from making any choices that they would have been able to make without nudging. Opponents of nudging take further issue because they believe that even if all of the options are presented, nudging manipulates patients to make the choice that the physician nudges towards. However, this is not the case. In a review of research on defaults, a type of nudging, surrounding advanced directives, it was found that sixty-nine percent of patients who were nudged to choose life-extending treatment still chose comfort-oriented care. The conclusions were that the power of nudging was not overwhelming, and that the nudging did not push people to make certain choices when they strongly preferred the other option. Another study was conducted on nudging, in which patients chose whether or not to have surgery after being nudged to a particular choice by the physician. Importantly, after being debriefed on the study, and before any surgical intervention occurred, none of the patients changed their minds about the decision they made. They felt that they had made the decision autonomously, and did not think that they were being manipulated. Therefore, despite criticism from opponents, it is clear that nudging does respect patient autonomy and is ethically sound.
The other ethical principle to consider is beneficence. From a patient care standpoint, this means that physicians should do good for their patients and try to maximize the patient’s benefits. Nudging fits well with the principle of beneficence, as nudging can help patients make better decisions. This benefit can take two forms: nudging can help patients make the right choice, or, if there is no one right choice, nudging can help patients make a decision based on their own preferences. The first form, helping patients make the right choice, occurs in situations where there is a consensus of what the right choice is. For example, medical professionals agree that patients should get flu shots, or that women above a certain age should have mammograms to check for breast cancer. Doctors can then present information in a way that will nudge people to make the right choice. Patients are still able to refuse a flu shot or choose not to have a mammogram, but they will be less inclined to do so based on the physician’s nudging. The second way that nudging can help improve decision making is by helping patients make decisions that fit their own preferences. Patients often lack authentic preferences about healthcare decisions, as they often involve novel choices that a patient may not have even known existed. However, patients can have general preferences and values that can be applied to healthcare, such as a value on independence that would be lost if a patient was to become bedridden. Healthcare teams that are working with a patient can seek to understand his values and preferences that he holds generally. Physicians can then nudge the patient to make the decision that fits his own preferences, so that a patient who places the highest value on independence becomes less likely to choose a treatment that will leave him unable to function on his own. By nudging, physicians are helping maximize the benefits for their patients, thus fulfilling the ethical principle of beneficence.