Jennifer S. Blumenthal-Barby. Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics. Cambridge: MIT Press, 2021. 264 pp. (e-book), ISBN 978-0-262-36529-1; $45.00 (paper), ISBN 978-0-262-54248-7.
Reviewed by Mira Vale (University of Michigan)
Published on H-Sci-Med-Tech (August, 2022)
Commissioned by Penelope K. Hardy (University of Wisconsin-La Crosse)
Jennifer S. Blumenthal-Barby’s book Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics presents an argument in two parts. First, the author asserts that conditions understood by contemporary bioethics as necessary for patient decision-making are often not met. Studies of judgement and decision-making find people often rely on biases and heuristics to make decisions, strategies that sometimes lead them to act against their own interests. Second, Blumenthal-Barby contends that techniques of “nudging,” the art of influencing behavior in predictable ways, can be adapted from behavioral economics to support—and indeed, improve—patient decision-making. Written by a philosopher and bioethicist, the book weaves concepts from multiple disciplines together with empirical findings from behavioral economics and a decade of the author’s own research.
Chapter 1 marshals evidence from behavioral economics that people rely on heuristics to make decisions. These strategies are what Daniel Kahneman describes as “System 1” decision-making: mental shortcuts that speed thinking in ways subject to patterned biases. Much of the chapter is devoted to definitions and examples of heuristics and biases common in medical decision-making, which, while less engaging to read, builds the reader’s vocabulary for the rest of the book.
In chapter 2, Blumenthal-Barby argues first that evidence from chapter 1 demonstrate flaws in fundamental assumptions from medical ethics around autonomy. To be autonomous, patients must have “liberty (independence from controlling influences) and agency (capacity for intentional action)” (p. 27). The author asserts that given the nature of biases and heuristics, this definition is rarely met. Patients often lack intentionality and freedom from controlling influences and typically do not have full understanding of their situation. The argument then takes a normative turn, suggesting the same factors that lead patients to make decisions against their goals and values can be reappropriated to achieve the opposite effect.
The third chapter introduces a key term, the “nudge,” and proposes a “moral and philosophical rationale for nudging in medicine” (p. 63). Adapting from Richard H. Thaler and Cass R. Sunstein’s work, the author defines a nudge as something that changes people’s behavior in a predictable way without foreclosing any options and in such a way that is easy to ignore. This leads to the core argument of the book: Blumenthal-Barby asserts that nudging should be used for patient decision-making when it (1) is easy to do and can prevent an undesirable outcome; (2) furthers the principle of beneficence (the obligation to prevent harm and promote patients’ welfare); (3) prevents people from acting non-autonomously; and (4) is a strategy endorsed by patients themselves. The chapter then reviews arguments about when nudging should not be used: (1) when a patient’s decision is “well thought out and/or in line with her values and goals”; (2) when little can be gained from nudging, including in situations where the best choice is unclear; and (3) when the patient would object to being nudged (p. 110).
Chapter 4 extends the previous chapter’s argument with an ethical analysis of the use of nudging. The author reviews different types of nudging and weighs whether some are more or less ethically permissible. This chapter also works to distinguish what nudging is not, systematically raising and contesting plausible critiques.
In the book’s final chapter, Blumenthal-Barby evaluates empirical data from her own research, an assemblage of studies that examine nudging in different clinical settings. A brief conclusion follows to reiterate the book’s main points.
The book is clearly written and meticulously organized. Blumenthal-Barby is skilled at explaining concepts and defining terms for a non-expert audience. Even the book’s densest content is laid out logically and accessibly.
In the introduction, the author suggests the book may be of interest to medical practitioners and healthcare institutional leadership, philosophers and ethicists, and behavioral economists and psychologists. The first set of suggestions seems most apt. This book is useful for practitioners interested in integrating nudging into their clinical repertoire. Its main points are helpfully summarized in tables found in each chapter. For those more interested in philosophical argumentation, a careful read allows for deeper engagement with debates around the ethics of nudging.
Still, social scientists outside of psychology and behavioral economics may be unconvinced by some of the book’s assumptions. The case for nudging frames decision-making as an individual choice. To believe this, we would have to ignore the many structural constraints on human freedom that organize social life. People are not equally free to choose, yet the limits on that freedom do not figure into a behaviorist’s model of decision-making. Nudging also presumes that decision-making is informed by discrete and knowable factors in a causal chain. Nudging acknowledges social forces like cultural norms, but it operationalizes them as variables with a fixed set of values. The assumption that decision-making is a complex but finite set of causes and effects presumes that these factors can be enumerated and that their effects can be definitively known.
Using the author’s own qualified defense of nudging, we may find that the ethical use case for nudging is diminishingly difficult to realize: clinicians must know what their patient’s values and goals are, know all the possible outcomes of a clinical action and their respective likelihood, know that their patient wants to be nudged, and perhaps most implausibly, know that their own clinical opinion is not under the influence of bias.
That said, the book’s most compelling argument in favor of nudging is a pragmatic observation: clinicians already nudge all the time. To borrow one more term from behavioral economics, doctors are inevitably choice architects, people who choose how a decision-maker is presented with options. The task is not to decide whether to nudge, but to figure out how to do so more effectively and more ethically.
. Kahneman, Thinking, Fast and Slow (New York: Farrar, Straus and Giroux, 2011).
. Thaler and Sunstein, Nudge: Improving Decisions about Health, Wealth, and Happiness (New Haven, CT: Yale University Press, 2008).
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Mira Vale. Review of Blumenthal-Barby, Jennifer S., Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.
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