Nudging by shaming, shaming by nudging.

Nudging In both developing and developed countries, health ministries closely examine use of so-called nudges to promote population health and welfare. Cass Sunstein and Richard Thaler, who developed the concept, define a nudge as “any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates” (1). Two examples may illustrate this notion. Placing healthier food items at the cafeteria entrance and at eye level so that clients make healthier food choices is a nudge, according to Sunstein and Thaler. So are opt-out arrangements for cadaveric organ donation, so that more organs would be volunteered. Nudges affect choice using neither rational persuasion nor restrictive means like mandates and substantial fines. Any pressure they apply is soft (2). In the cafeteria food choice example, the only ‘cost’ to customers who insist on unhealthy food choice is having to take a few steps to the other end of the cafeteria, where unhealthy food items are found. Nor do any nudges that Sunstein and Thaler would support include lies, deceit, subliminal advertising, or other powerful manipulation. Strong material incentives are also ruled out. The hope is that although the pressure that nudges exert is soft, nudges could affect choice considerably and improve health and welfare a lot. For instance, predictably, many customers will choose food placed at the entrance and at their eye level. Sunstein and Thaler explain that nudges are able to do so by exploiting our merely bounded rationality, as delineated by behavioral psychology in recent decades. Nudges allegedly make us healthier or happier without jeopardizing our freedom of choice. It is an interesting philosophical question whether, so understood, nudges are possible at all. If so many of us predictably pick healthy food when it is placed in front of us, does not that mean or indicate that we are somehow forced to choose it, or are subtly but irresistibly manipulated? How can something tend so reliably to elicit a determinate choice without having forced that choice? Elsewhere I plan to explore how nudges may have this ‘magical’ effect. Our focus here is one account. It explains that while in nudges, nothing is objectively forcing the healthy choice, subjectively a strong desire issues or the nudge undercuts rational calculations, Correspondence to: Nir Eyal, Email: [email protected] Copyright: © 2014 by Kerman University of Medical Sciences Citation: Eyal N. Nudging by shaming, shaming by nudging. Int J Health Policy Manag 2014; 3: 53–56. doi: 10.15171/ijhpm.2014.68 Received: 10 July 2014, Accepted: 24 July 2014, ePublished: 25 July 2014 culminating in widespread response. In the cafeteria example, exceeding laziness or hyperbolic discounting makes most of us disproportionately averse to taking a few steps to the back of the cafeteria, or our appetite concentrates only around what we see first and blocks appetite for alternatives. This is not a rational response on our parts but the result is that we pick the first item we see. This editorial does not question or defend this understanding of some nudges’ mechanism of action. Instead it advances two hypotheses regarding the connection between nudging so characterized and shame, understood broadly to include embarrassment, stigma effects, and any compunction in general. One hypothesis I advance is that shame can serve in nudging. Another hypothesis is more critical. It states that nudging can instigate shame, which more restrictive measures to improve health would not. These two hypotheses bear on the possibility and on the advisability of using nudges to promote personal and population health. They also bear on the cogency of the so-called least restrictive alternative principle in public health policy.