measures to push us to make healthier decisions

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On May 13, 2021, the mayor of New York, Bill de Blasio, announced at an online press conference a curious agreement between the New York City Council and the Shake Shack hamburger chain. The idea was to encourage the population of the Big Apple to get vaccinated. Each vaccinated individual would receive a coupon to get a free hamburger or sandwich at any of the New York chain’s establishments. In behavioral sciences, this type of incentive falls into the nudge category. Richard H. Thaler (2017 Nobel Prize in Economics) and Cass R. Sunstein popularized the term in 2008 after publishing the bestseller A Little Nudge: The Boost You Need to Make the Best Decisions in Health, Money, and Happiness. In essence, it is about any manipulation of the decision environment that alters people’s behavior in a direction that is beneficial to them, but without restricting their options, respecting their freedom of choice at all times. One of the most popular examples is found in the Google dining rooms. Its managers came up with an idea to improve the habits of their workers: modify the product dispensing machines so that soft drinks and other ultra-caloric beverages remain in a less visible position than water bottles. And it worked. With this simple measure, they managed to increase water consumption among employees by 47%. Another measure along these lines is to install interactive stairs, with lights on the steps or mechanisms that produce piano sounds when stepped on. These types of stairs have been effective in encouraging their use even when they are right next to the elevators. I push you but you decide Nudges interfere with people’s behavior, ignoring, to a certain extent, their autonomy. Thaler and Sunstein call it libertarian paternalism. Is it legitimate to influence people’s decisions if their well-being is increased? Those who support libertarian paternalism argue that it is. In particular when it is used to help prevent or solve public health problems such as obesity, dependencies, a sedentary lifestyle, undertreatment or overtreatment. For example, to encourage healthy eating, various campaigns have been created, such as the one in Connecticut, where free apples were offered in school canteens to encourage fruit consumption or, in Argentina, systematically removing salt shakers from coffee tables. the restaurants. As we see in the previous examples, these “pushes” do not impose a direction on the person. Google workers are free to choose hypercaloric drinks and not bottles of water. And we can use the elevators and ignore the playful effect of the musical stairs. The libertarian component demands that the influence in the election does not prevent the preservation of the freedom of decision, which means, according to Thaler and Sunstein: 1. That no option can be prohibited. 2. That the use of economic incentives cannot be such that it undermines freedom (for example, a free hamburger, yes, but a check for more than one hundred euros, no). 3. That in the same way that the alternative towards which it is pushed is easy, accessible and cheap, its alternatives (in case you want to avoid it) should also be. Clinical nudges and health nudges In the context of health, nudges can be classified into clinical nudges and health nudges. The first are those that occur in the clinical relationship making use of how the information of a certain treatment is presented to encourage the patient to consent for himself. For example, mention the success rate of a procedure, instead of expressing the same information from the failure rate. A clinical nudge focuses on the best interest of the patient. Health nudges, for their part, promote individual actions that improve individual health and, by extension, community health. For example, making the menus of public schools by default meat and fish with salad, but the diner can ask for chips if he wants. In both cases these are non-coercive interventions. However, the obligation to confine oneself to one’s home to prevent the transmission of a disease is a health measure, but not a clinical nudge. And the same applies to involuntary commitment in the case of a sick person with suicidal ideation. From here on we are going to focus mainly on health nudges. A little push for our good and that of others The arguments against libertarian paternalism consider that implementing these little pushes in the health field violates the principle of autonomy. It is worth asking whether in the context of public health, where the bioethical principle of autonomy is usually subordinated to collectively oriented normative considerations such as justice, equity or utility, this criticism has the same weight. In public health, nudges serve as a smooth means of driving citizens without having to resort to more drastic and restrictive measures of individual freedom (for example, mobility restrictions). The recent pandemic provides a few examples that could be considered nudges. For example, almost any closed space (restaurants, supermarkets…) could find hydroalcoholic gel at the entrance or at various accessible points. Reminders to go to vaccination appointments or vaccination campaigns with mobile points in the vicinity of many universities where you could go without an appointment and, after identifying yourself, get vaccinated from the first or second dose, are also considered nudges. Other actions aimed at avoiding contagion did compromise people’s freedom, they were not health nudges. This is the case of the mandatory use of a mask indoors and, at times, even outdoors. Or the decision to take the temperature at the entrance to certain spaces, preventing access to people with fever. Or the obligation to take a PCR/antigen test to be able to make international trips or enter certain places. Therefore, health nudges become a valuable tool to achieve public health objectives without compromising the individual freedom of people. Only in case they are not effective does it make sense to continue moving towards more restrictive policies. As long as the use of nudges meets the public health objective pursued, their use seems reasonable before resorting to other measures that curtail freedom. Authors Ramón Ortega Lozano Professor of Bioethics, Health Anthropology and Human Communication at the San Rafael-Nebrija University Center, Nebrija University Aníbal M. Astobiza Postdoctoral Researcher, specialized in cognitive sciences and applied ethics, University of Granada David Rodríguez-Arias Professor of Bioethics, University of Granada

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