#BELHP2014 Panel 2, Potential Problems and Limits of Nudges in Health Care

[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 an installment in our series of live blog posts from the event; video will be available later in the summer on our website.]

By Matthew L Baum

In this next installment of today’s live-blogging of the conference (and with all of the caveats of live-blogging mentioned by my colleagues and my apologies for any errors or misrepresentations) we have Professors David Hyman (DH), Mark White (MW) and Andrea Freeman (AF) in a panel moderated by Glenn Cohen (GC) on the “Potential Problems and Limits of Nudges in Health Care”.

The panel began with DH, H. Ross & Helen Workman Chair in Law and Director of the Epstein Program in Health Law and Policy, University of Illinois College of Law, and a talk entitled, “what can PPACA teach us about behavioral law and economics” (Patient Protection and Affordable Care Act). DH began with the observation that nudges often work quite well… “unless they don’t”. While many nudges are “sticky”, i.e. they influence behavior in the way they were intended, others are “slippery”, i.e. they fail to influence behavior in the way they were intended. His talk set out to illustrate the phenomenon, and to pose two questions. The first was an empirical question: what makes a nudge sticky vs slippery? The second was philosophical: is it meaningful to talk about a “failed nudge” or when we do, do we really just mean failed marketing? He focused on an analysis of PPACA as a case study.

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#BELHP2014 Plenary 1, Provost Alan Garber

Provost Garber at the Conf
Provost Garber at the Conf

By Christopher Robertson

[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.]

Alan M. Garber is Harvard’s provost, and both an economist and a physician by training.  He holds appointments in the medical school, the faculty of arts and sciences, the school of government, and the school of public health.   [Perhaps I should have just listed the colleges that haven’t yet given him an appointment?]  I’ll mostly just paraphrase Garber’s talk, and sparsely add my own comments in brackets [as I just did].

Garber’s talk is focused on the Affordable Care Act, and says that it has two purposes:  expand access to care, and reduce the costs of care.  The latter is particularly important, given the way healthcare is impinging on the larger United States economy.

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

[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.

#BELHP2014 Behavioral Economics, Law, and Health Policy Conference: Keynote, Cass Sunstein

[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.]

Today’s sessions opened with a keynote address from Cass Sunstein, Robert Walmsley University Professor at Harvard. Sunstein is also the founder and director of the Program on Behavioral Economics and Public Policy at Harvard Law School.

Sunstein addressed a wide variety of in-depth issues in his talk on “Choosing Not to Choose.”

In the beginning of the talk, he provided three objections to the argument that active choice-making is a muscle and should not be interfered with. First, people often choose not to choose, and forcing them to do active choice-making is “part of the family” instead of an alternative to default rules. It is also a form of libertarian paternalism. Second, in thinking about active choosing and default rules, we should bear in mind a basic evaluation framework that helps to minimize sum of decision costs and error costs. Third, sometimes it is best to choose not to choose. In many case we should honor people’s choice not to choose when it minimizes decision costs and reduces the magnitude and number of errors (especially when people are forced to choose, they may go in the direction that is wrong or not in their best interest).

Sunstein went on to three examples on the ground to orient the audience:

  • Case 1: A private company is deciding among three options: (1) automatic enrollment in insurance unless opt out, (2) opt in to insurance, or (3) as condition for starting work, forced choice of whether to be insured and which insurance plan (active choosing).
  • Case 2: A utility company is deciding between a green default, a grey default for its consumers, or to force them to decide which source they prefer (no service until you decide).
  • Case 3: A doctor is dealing with patient facing difficult medical situations, and could decide among: (1) present array of options, (2) default (“if it were me I would/most patients do”) with opt out.

All three cases have an institution considering requiring active choice instead of default rules. Sunstein played with the meaning of “requiring” in order to unsettle the opposition and to suggest that it is often illusory. He briefly reviewed claims such as that doctors and policymakers are prone to error as well (behavioral biases), that governments lack knowledge as well, that behavioral findings can compound the problem, or that even when people are likely to err, their autonomy to choose should be respected. He argued that the distinction between active choosing and default is rather illusory because people often want to choose not to choose (for reasons like limited bandwidth, find choosing unpleasant, don’t want to take responsibility or regret, or know they are biased). When people don’t want to choose and are forced to do active choosing, we forbid their choice not to choose. “Choice requiring paternalism is not an oxymoron.”

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FRIDAY & SATURDAY: Petrie-Flom Center Annual Conference, “Behavioral Economics, Law, & Health Policy”

Petrie-Flom Center 2014 Annual Conference: Behavioral Economics, Law, and Health Policy

May 2-3, 2014

Wasserstein Hall, Milstein East ABC, Harvard Law School, 1585 Massachusetts Ave.

Richard H. Thaler and Cass R. Sunstein’s book  Nudge: Improving Decisions About Health, Wealth, and Happiness brought behavioral economics to the masses, beginning a discussion of libertarian paternalism and the many ways that “choice architects” can help nudge people to make better choices for themselves without forcing certain outcomes on anyone. Some of their examples fall in the realm of health policy, as is also the case of Daniel Kahneman’s recent book, Thinking, Fast and Slow, which examines various cognitive errors people make in their judgments, choices, and conclusions, as well as how we might correct them.  But the conversation has only just begun.

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5/2-3: Petrie-Flom Center Annual Conference, “Behavioral Economics, Law, and Health Policy”

Petrie-Flom Center 2014 Annual Conference: Behavioral Economics, Law, and Health Policy

May 2-3, 2014

Wasserstein Hall, Milstein East ABC, Harvard Law School, 1585 Massachusetts Ave.

Richard H. Thaler and Cass R. Sunstein’s book  Nudge: Improving Decisions About Health, Wealth, and Happiness brought behavioral economics to the masses, beginning a discussion of libertarian paternalism and the many ways that “choice architects” can help nudge people to make better choices for themselves without forcing certain outcomes on anyone. Some of their examples fall in the realm of health policy, as is also the case of Daniel Kahneman’s recent book, Thinking, Fast and Slow, which examines various cognitive errors people make in their judgments, choices, and conclusions, as well as how we might correct them.  But the conversation has only just begun.

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