Nudging Healthcare in the Right Direction: Libertarian Paternalism and Better Health
Thursday, February 11th, 2010What is a Nudge?
Many people have at some point wanted to lose weight, exercise more or work harder but have struggled with finding the motivation to do so. Nudges are ways in which we can structure choices so that we find it easier to overcome short term factors which prevent us achieving these goals. Indeed, political opinion is in accordance, with President Obama and David Cameron embracing this concept, appointing pioneers of the concept Cass Sunstein and Richard Thaler as advisors. Nudges have a variety of applications in healthcare.
Behavioural economics gives us an understanding of why such problems occur. Economists and psychologists have shown through various studies that we have a preference for immediate gratification over long-term benefits (1) and a tendency to underestimate the costs associated with our behaviour (2).
Although those politically to the left believe the state should intervene and prevent behaviours that adversely affect us, libertarians argue that any intervention would curtail individual freedom. Nudges aim to bridge this divide by altering the way that choices are presented such that beneficial decisions are more likely, while maintaining freedom of choice (3). This is politically attractive because in addition to avoiding accusations of paternalism, governments can often enact such changes at minimal cost.
Who to Nudge
I will be discussing how three groups of people can be nudged to improve healthcare outcomes. Firstly, individuals who make adverse lifestyle choices can be encouraged to improve their habits in order to prevent disease. Secondly, individuals can be encouraged to act in a way which benefits others in the population. Finally, healthcare professionals can be encouraged to optimise their performance.
How to Nudge
There are several ways in which choices can be tailored to optimise benefit (3). The first way to influence choice is to change the default option. The default option is selected automatically unless an alternative is specified, so with organ donation the default option is not to donate your organs. Many people will go with the default, either through inertia, or because it is the path of least resistance; however, those that feel strongly enough are free to choose options other than the default. The second way is to anticipate the mistakes that people will make, and to take steps to correct those errors. For example, on NHS wards, there are sometimes observers present to make sure staff are washing their hands! Giving people feedback allows them to adjust their behaviour according to the results they see: losing weight on an exercise programme could provide further motivation to continue with the programme. Indeed, it is generally a good idea to highlight the importance of incentives behind an action. Tied together with this is helping people understand the consequences of their choice to their welfare. This should be explained simply and clearly. Finally, it is advisable to structure complex choices. Having lots of choices can be overwhelming, so simplifying choices could facilitate the choosing of healthy options.
Nudging People
The aim is to encourage people to live a better lifestyle, with calorie control and exercise, and to discourage smoking and excessive drinking. As well as bettering the health of the individual, there are also population benefits, for example, passive smoking is a risk factor for lung cancer. A recent study found a 23% increased risk of lung cancer in those with spouses that smoked (4). In a socialised healthcare system such as the NHS, there is also an incentive to maximise health benefits from taxpayer money input into the system: encouraging a healthier lifestyle is cheaper than dealing with the problems of a poor lifestyle (5).
An obvious way to intervene is to make people aware of the consequences of their choices is through educational campaigns with clear and memorable messages. The “5 a day” advertising campaign encouraged people to achieve a simple target for fruit and vegetable consumption, facilitating healthy dietary choices (6). Labelling of food has also been simplified under a traffic light system (7), so that it is easy to compare the relative merits of different choices in a supermarket environment.
Nudging can help people make a commitment to their goals. A savings programme has been initiated by the Green Bank of Caraga in the Phillipines (8), where someone who wants to quit smoking will regularly deposit money into an account. After six months they have a urine test and can only keep the money if the result is negative. This is an excellent way of anticipating that people may be tempted to resume smoking despite wanting to quit.
A third way of improving health would be to create barriers to consumption. Julian Le Grand, an adviser to Tony Blair, has previously suggested the introduction of a smoker’s permit in order to discourage people from smoking (9). Smoking would still be legal, but smokers would face an additional administrative burden to be permitted to smoke.
Organ Donations
One way in which individuals can benefit others in the population is through organ donations. Britain faces a chronic lack of supply of donors for organ transplants: at the end of March 2009, 7877 patients were listed as actively waiting for a transplant (10). This lack of supply is thought to be due to inertia arising from the opt-in system, whereby people must express a desire to donate. A survey conducted in the USA showed that while 97% of respondents supported the idea of transplantation, only 43% had signed up as donors, suggesting people are not acting on their opinions (11). This undersupply could be addressed through changing the default option by switching to an opt-out system. When an opt-out system was introduced in Spain, the number of donors rose from 14.3 per million population in 1989 to 25 per million in 1994 (12).
One potential problem with this system is the implication that the state has ownership of a body after death; it is controversial whether there is sufficient justification for appropriation in terms of an individual’s obligation to the state. An alternative with proven success in France is an opt-out system where the family of a potential donor are able to refuse permission for donation (13).
Nudging Organisations
As well as encouraging individuals to make decisions to benefit themselves and the general population, nudges can encourage healthcare professionals to optimise their performance. Performance tables in the NHS can allow for comparisons between different doctors, hospitals and trusts. They are thought to encourage competition, which drives improvement. Furthermore, identification of the best performing hospitals could allow the examination of best practice, and identification of the worst performing hospitals could allow a focus on their improvement. The Institute of Healthcare in the USA has attempted to start this process in the field of cystic fibrosis (14). The Cystic Fibrosis Foundation compiled data tables using quantitative parameters to judge the quality of care given at different hospitals. The rankings for Cincinnati Children’s Hospital were low, so they made their rankings available to their patients and examined best practice at better ranked hospitals under the guidance of the institute. This has resulted in a marked improvement in outcome measurements.
There are solutions to a number of the imperfections of NHS performance tables. Apparent differences in hospital death rates and other parameters can be explained by and adjusted for the variability of illnesses in different regions (15). There is a need to take into account statistical considerations that mean smaller hospitals are more likely to come near the top or bottom of performance tables (16). There is also a role of chance in determining rank which can be mitigated by using control charts (17).
As medicine incorporates ever more complex procedures with multidisciplinary teams taking care of patients, it can be hard to keep track whether procedures have been followed without mistakes or missing steps. An Israeli study found that 178 actions per day were carried out for the average patient in an Intensive Care Unit (ICU) and that there was an error rate of about 1% (18). This may seem small, but can have can have dramatic consequences. To take central line infections as an example, there are 80,000 line infections in the USA per year, a 4% infection rate. Despite the small percentage, the result is an increase in the patient’s time in the ICU and on the fatality rate. Professor Peter Pronovost, of Johns Hopkins University, advocates structuring these complex choices by using a checklist. He obtained authorisation for nurses in his department to stop doctors skipping steps on the checklist. As a result, there were only two line infections over a 15 month period. It is estimated that 43 infections and 8 deaths were prevented, and over $2,000,000 was saved (19).
Technological advances can be used to improve outcomes within health systems. The number of avoidable cardiac arrests in intensive care units has previously been highlighted as a clinical problem (20). Early detection of patients at risk is possible through monitoring of vital signs (21); however, deterioration is often missed because patient monitors generate a high number of false alerts so are ignored. Visensia® is a software system that uses data fusion technology to remove these false positives, so alerts are no longer ignored. Clinical trials in the UK and USA have yielded positive results and the product has been awarded FDA approval (22).
Conclusion
There are critics of libertarian paternalism, who believe that the state cannot decide what impacts on an individual’s happiness, yet in the healthcare arena, there are clear indications that people have a desire to perform certain actions which they find difficult to carry out, or that they do not fully appreciate the magnitude of their actions. From helping people make the best choices for themselves and for others to helping healthcare professionals deliver quality care, nudges have already shown the potential to be an effective means of improving our health.
Sanjay Budhdeo is a fourth year medical student at New College, Oxford University in the UK
sanjay.budhdeo(at)new.ox.ac.uk
References
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