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#BELHP2014 Panel 1, The Ethics of Nudges in Health Care

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[Ed. Note: On Friday, May 2 and Saturday, May 3, 2014, the Petrie-Flom Center hosted its 2014 annual conference: “Behavioral Economics, Law, and Health Policy.”  This is the first installment in our series of live blog posts from the event; video will be available later in the summer on our website.]

The panel on the Ethics of Nudges in Health Care was comprised of:

  • Yashar Saghai, Post-Doctoral Fellow and Director of Global Food Ethics, John Hopkins University
  • Jennifer Blumenthal-Barby, Assistant Professor, Baylor College of Medicine, presenting with Zainab Shipchandler and Julika Kaplan, Rice University
  • Nir Eyal, Associate Professor at Harvard Medical School
  • Jonathan Gingerich, Ph.D. student, Department of Philosophy, UCLA

Yashar Saghai’s presentation, titled Public Health Nudges and the Principle of the Least Restrictive Alternative, argued against the notion that policies or interventions that impose fewer restrictions on individual choice should always be preferred over more restrictive options. More on this topic in Saghai’s 2012 BMJ article “Salvaging the Concept of Nudge.”

Jennifer Blumenthal-Barby and student collaborators Zainab Shipchandler and Julika Kaplan asked whether incentives in global health studies should be viewed as nudges and what are the potential ethical implications. In their presentation, titled Incentives as Nudges for Childhood Vaccination in Rural India, they showed evidence that suggests food incentives to participate in vaccine programs could function as nudges that influence individual’s behavior in a wider range of healthcare related ways, beyond simply increasing participation in the vaccine program.

Nir Eyal explored potential arguments for When nudging is just fine, and why? Eyal started with the observation that nudges can cause large modifications in individual behavior despite being very easily resistible, and canvassed several related ideas about the appeal of nudges, finding problematic counterarguments to most of these prima facie claims. He concluded by suggesting that nudges could be viewed as morally acceptable ways of manipulating people into behaving in ways that are better for them without transgressing on any fundamental liberties.

Jonathan Gingerich argued that the ethical acceptability of nudges should be put into question when they prevent democratic deliberation on important issues. In his presentation, The Political Morality of Nudges, Gingerich presented several examples of how interventions that claim to improve social welfare through nudges could in fact prevent broader substantive deliberation over important political issues for which we generally require democratic decision making.

How should we label these “cognitive errors” that are particularly common among MDs?

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Behavioral economists are really into giving the cognitive errors they study, and the corrective policy interventions they favor, labels. “Status quo bias,” “availability bias,” “recall bias,” etc., can all be fixed through “nudges” that involve “asymmetric paternalism” and the like.

Here’s an interesting “cognitive error” that I’m trying to crowd-source a label for: When America’s joint surgeons were challenged to come up with a list of unnecessary procedures in their field, their selections shared one thing: none significantly impacted their incomes.

And here’s another odd cognitive anomaly that seems to be especially limited to ophthalmologists: forgetting there’s a $50 dollar alternative that works just as well as the $2,000 injection they get 6% commission on. 

I’ve thought of my own labels (or rather, euphemisms) for the policy interventions I would suggest in response: “continuing medical education”  for the first of these neat little errors, and “resocialization” for the second.

You can’t put a price tag on Sovaldi (unless it’s over $84K)

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Gilead Sciences has developed a new drug (Sovaldi) that cures hepatitis C.

This is a huge deal: about 150 million people world wide are chronically infected with the hepatitis C virus (HCV); according to the CDC 60-70% of people with chronic HCV will go on to develop chronic liver disease, 5-20% will develop cirrhosis over 20-30 years, and 1-5% will eventually die from the direct consequences of chronic infection (liver cancer or cirrhosis).

Sovaldi, which cures patients about 90% of the time with minimal side effects, could change all of this. John Castellani, President of Pharmaceutical Research and Manufacturers of America says that this breakthrough is so valuable, that “you just can’t put a price tag on it.”

But of course, a price tag has been put on it: $84,000 for the 12-week course of treatment (or $1,000) per day.

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Awkward Company

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I am often surprised when I discover the folk who are on the same side of an issue as me. I must say, it’s not always a pleasant surprise. In fact, I just as often regret having to share company with many people who are on “my side” of a cause.

I expect this is exactly what many of those who oppose abortion in this country would feel if they learned who the main champion of their cause is in Colombia: Inspector General Alejandro Ordoñez, who recently gained international notoriety after he deposed the left-leaning Mayor of Bogotá, Gustavo Petro and barred him from holding public office for 18 years. The official reason is related to his administration’s handling of waste management in Bogotá. However, many believe that the harshness of the sanctions were motivated due to Ordoñez’s repudiations of Petro’s positions regarding abortion and the rights of the LGBT community.

I very much believe that most opponents of abortion in the US would also strongly oppose most of the stringently misogynistic, homophobic and anti-Semitic views that are fundamental to Ordoñez’s political conception, which he defends in his writings, including: “Towards the Free Development of our Animalness” or “Gender Ideology: Tragic Utopia or Cultural Revolution.”

In case you’re curious, below are some translated excerpts from his Law School thesis, which he presented to the University of Saint Thomas in Bucaramanga, Colombia, in 1979.

“Fundamental Presuppositions of the Catholic State“

Dedication: To our lady the VIRGIN MARY, Mother of God and Mother of ours, co-redeemer of the human lineage… supplicating from her the restoration of the Christian order and the crushing of atheistic communism so that catholic faith my shine allover since without her there is no hope for societies or for men.”

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Snotty Hand-Washing

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Hand-washing is one of the mainstays of public health and of good clinical practice. Images of surgeons with their hands raised in the air, as they enter the OR to have a nurse help them don sterile latex gloves after having meticulously washing their hands, have been immortalized by pop-culture representations of medicine. Indeed, learning the “surgical hand-wash” is one of the glorified coming-of-age rituals for med students. It quite literally initiates aspiring physicians into being legally and morally allowed to cut people open for their own benefit.

Proper hand-washing is crucial for non-surgical clinical practice as well. At my hospital, clinicians are supposed to wash or sanitize their hands as soon as they enter a patient’s room, and after they have made any contact with a patient. And although the procedure for “clinical hand-washing” is much less thorough than its surgical counterpart, there’s still an evidence-based, 11 step process that WHO officially recommends in its annual “SAVE LIVES: Clean Your Hands Campaign.“

The rationale for all this rigor in medical practice is pretty obvious, and any hospital-based physician who doesn’t have overly dry skin without moisturizing is probably shirking an important responsibility. However, the clinical obsession over asepticism has spilled over to mainstream culture, but not without some controversy.

Relax: I’m not going to get into the debate over the hygiene hypothesis. I’m also not even going get back on the bacterial-resistance soapbox (except for one quick point–although asepticism in clinical settings certainly does help prevent resistance, it might be counterproductive beyond the clinical setting as wiping out benign bacteria might simply open more ecological space for nastier bugs).

I just want to point out that simple repugnance is probably a better explanation  for the hygiene-neurosis of current times than any legitimate public health concern. Normal people today would probably have seemed like obsessed germophobes fifty years ago. What’s interesting is there’s lots of neat evidence that even the most visceral types of disgust are socially constructed. For example, Norbert Elias’ treatise on snot in “The History of Manners” (1982) describes dinner-table behavior that was deemed perfectly polite by in the most sophisticated European social circles of previous centuries, but which would probably make even the coarsest sailor of today vomit in disgust. I’ll leave you with some highlights, taken from pages 143-148 of this wonderful (yet long, two volume) work by Elias.

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How Coke might help cure obesity

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Coca-Cola has an interesting symbolic presence the world of public health.

Its delivery system is the envy of vaccine programs: the committed global health workers who’ve trekked for days through harsh and inhospitable lands to reach even the most distant communities are likely to find a refreshing, cold Coke already waiting for them at the village store.

For those who focus on non-communicable chronic diseases (NCD), (regular) Coke is the scourge that is providing the extra calories that fuels the obesity epidemic. Many experts believe that eliminating the calories contained in a single, 16oz serving of regular Coke from daily diet would be more than enough to revert the trend towards rising obesity and return average weight in the population back to where it was 30 years ago. 

But the symbolic presence of Coca-Cola in US culture and politics is perhaps even more interesting, and the resulting dynamics could have some unexpected consequences in terms of population health.

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The bright side of antibiotic resistance

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My parent’s generation grew up in fear of a nuclear apocalypse: the cold war was raging, team USA and team USSR were competing in a frightening arms race, and people were building bomb shelters in preparation for a nuclear end to the world. That’s like so 1950’s though; what’s hot now is the environmental apocalypse. We all know about rising water levels, and some doomsayers are even warning that enough methane is about to be released from the icecaps to cause the greatest mass extinction since the dinosaurs.

Me? I’m not too concerned about either of these scenarios, but it’s not because I’m much of an optimist. It’s because I’m convinced that bugs will kill most of us before we kill ourselves.

In 1928, Alexander Fleming discovered penicillin, and it was being mass produced by World War II. This means it has effectively been around for at least 70 years, and it still works against a broad range of bacteria. Superb; 70 years is a hefty amount of time–enough for billions of doses to have been administered–and we’re still going strong.

But bacteria don’t care. They’re (still) here, they’re (always) evolving, get used to it.

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Aging, Fertility, and Evolution

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The world’s population is aging (mostly excluding sub-Saharan Africa however). Perhaps the most alarming example of the challenge this demographic trend creates for policy-makers is the “one-two-four” problem it could cause for China and it’s one child policy: in the face of an aging population, one child might have to care for two parents and four grandparents.

There are other, more quotidian, examples of the challenges an aging population represents for different societies, and how this trend will affect any given people depends on a myriad of other factors. Nevertheless, aging will undoubtedly be one of the biggest challenges facing our generation.

Perhaps ironically, the medical world also sees aging as one of the primary challenges of the time, but in a whole difference sense. Not only is it a fact that we are getting older, we are trying as hard as we can to make sure we can live to even older.

All of this has certainly generated a great deal of activity and exciting advances in how societies cope with aging, in both aspects. And although we’re starting to understand it at even a molecular level (something about telomeres and such), the phenomenon of aging is really still a bit of a mystery. One of its more mysterious aspects, in my opinion, is the evolutionary side. Why do organisms age, and how does evolution shape average life-spans? (How much is selection? How does it operate? How much is drift? Etc?)

These questions might be a bit up-stream from the main interest of this blog, but here’s an interesting piece on the evolutionary biology of aging.

Healthy questions about health insurance

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By Julián Urrutia

I recently attended a presentation by Bernard Black about a study he is working on where he evaluates the effect of health insurance on overall mortality and health among the near-elderly through an observational study using the Health Retirement Survey. He found that health insurance, in general, was not associated with differences in health outcomes, except for public insurance, which he found to be associated with higher mortality.

Black concluded that we would be better off without health insurance because it has either no effect, or perhaps even a negative effect, on population health. I’m not sure the observational study design he relies on supports such a strong causal inference, despite the sophisticated econometrics he employs.  But I’ll leave the discussion about the internal and external validity of Black’s findings to the statisticians. I want to focus on his research question itself.

I find the question “what is the effect of health insurance on the health status of the near elderly” somewhat puzzling. In my view, health insurance is not a public health intervention or a healthcare service that is primarily meant to improve the health of any recipient; it’s really just a financial tool. Unlike iodizing salt or health education campaigns, we have no reason to expect that health insurance itself will improve the health of the average person.

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A disenfranchising effect of the right to health?

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By Julian Urrutia

Human rights embody the humanist egalitarian principle that all human beings are morally important, and that they are morally important simply because of their humanity. Princes and paupers, bankers and bums, women and men . . . we’re all subjects of human rights that are not contingent on anything other than our humanity.

There is widespread agreement that the rise of humanism is one of the most important milestones in the history of moral progress. However, it also clear that the rise of humanism did not, by itself, bring us all the way down the path of progress to where we are today: throughout colonial history, for example, humanism failed to deliver us from outrageous discrimination when the boundaries of humanity were delineated too narrowly.

Humanists are just as prone to inhumane conduct when they fail to recognize other’s humanity. When we determine what is human (and must therefore be treated with respect), we tacitly also determine what is un-human (and can therefore be exploited). As Carl Schmitt put it “Given the coherence of this two-sided aspect of humanity, it should be remembered that Bacon opposed the axiom homo homini deus to that of homo homini lupus.” (The nomos of the earth, 1950)

That’s why contemporary, liberal constitutions that recognize human rights are so great. All people are recognized as being equally human, and therefore equally subjects of human rights. This is certainly a form of moral progress. However, narrow human rights-based approaches to politics, legislation and policy-making can have similarly perverse consequences as narrow forms of humanism. Instead of delivering us from outrageous discrimination, marginalization and exploitation, a narrow focus on rights might confine us to them. For example, there is growing evidence that human-rights-based legislation and litigation often fails to achieve an effective enjoyment of the right to health to among those who need it most. Even more troubling is the possibility that, sometimes, rights-based approaches not only have little positive effects, but might in fact lead to further marginalization and disenfranchising of the poor.

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