La ética de los impulsos ('nudges') que promueven la salud

AutorPolychronis Voultsos
CargoSchool of Medicine, Aristotle University of Thessaloniki-Thessaloniki-Greece E-mail:
Nudging / nudge(s);
health decision(s);
automatic reasoning;
intuition(s); emotional
Palabras clave:
decisión(es) de
salud; razonamiento
intuición(es); impulsos
emocionales, incitar
en salud.
Recibido: 12/06/2021
Aceptado: 16/08/2021
School of Medicine, Aristotle University of Thessaloniki-Thessaloniki-Greece
El objetivo del documento es proporcionar una descripción general del conocimiento actual relaciona-
do con la ética de los impulsos (literalmente empujar suavemente, (“nudges”, en inglés) que promueven
la salud. Se realiza un análisis narrativo completo de las publicaciones sobre este tema con el objetivo de
contribuir a su debate actual. Es difícil determinar si la autonomía de quien decide puede verse afectada
por la incitaciónes particulares (nudges) o no, ya que la línea de distinción entre las formas cognitivas del
razonamiento humano y las formas automáticas de este —es decir, las emociones— permanece borrosa
y los diversos tipos de “impulsos” recaen sobre una combinación de dos continuos: uno que va de trans-
parente a no transparente y el otro que va de reflectante a automático. Por lo tanto, es probable que la
mayoría de los “empujones” funcionen como influencias no argumentativas que eluden la razón y modifi-
can, así, la autonomía de quien decide. Hay que aceptar que estos “impulsos o incitaciones” producen una
alteración de la autonomía (individualista) en un grado proporcional al beneficio incontestable previsto
para el paciente. Es posible que el interés del paciente no sea claro o que la incitación promueva más
el interés de un tercero (no el de quien decide) o, incluso, el bien común. La ética del impulso no siempre
está más allá de toda duda razonable. En tales casos, la parcialidad debe ser lo más mínima posible (es
decir, limitarse a empujones o incitaciones transparentes o casi transparentes y que funcionen de manera
reflexiva o casi reflexiva). Estas incitaciones o “empujoncitos” pueden usarse por ejemplo contra la pande-
mia de la COVID-19.
The paper aims to provide an overview of current knowledge related to the ethicality of health-pro-
moting nudges and a further elaboration, particularly in terms of linking the interpretation of the findings
of the study and the conclusions adopted. A comprehensive narrative review of literature on the topic of
interest was undertaken, aiming to contribute to the current debate on the topic of interest. It is practically
hard to determine whether or not the nudgee’s agency will be eroded by the particular nudge because
the line of distinction between emotions or automatic ways of human reasoning and cognitive ways of hu-
man reasoning remains blurry, and the various types of nudges fall on a combination of two continuums:
the one ranging from transparent to non-transparent and the other ranging from reflective to automatic.
Therefore, the majority of nudges are most likely to work as reason-bypassing nonargumentative influ-
ences, thus eroding the nudgee’s agency. It is time to accept a deviation from the strict commitment to the
principle of (individualistic) autonomy in degrees proportional to the incontestably anticipated patient’s
Cuadernos de Bioética. 2021; 32(106): 301-320
DOI: 10.30444/CB.104
Copyright Cuadernos de Bioética
Este trabajo se publica bajo una licencia de
Creative Commons Reconocimiento-NoComercial-SinObraDerivada 4.0 Internacional
CUADERNOS DE BIOÉTICA. 2021; 32(106): 301-320
benefit. In case that patient’s best interest is less than clear or the nudging promotes another individual’s
best interest (not the decider’s one), or even the common good, the ethicality of nudging is not always be-
yond reasonable doubt. In such cases the deviation should be as minimal as possible (i.e. limited to nudges
that are transparent or almost transparent and work reflectively or almost reflectively). Nudging may be
used against the COVID-19 pandemic.
1. Introduction
1.1. The definition of nudges
“Nudges are subtle changes to the design of the
environment or the framing of information that can
influence our behavior”1. “Libertarian paternalism des-
cribes the idea of nudging-that is, steering individual
decision-making while preserving freedom of choice”,
namely, appropriately balancing “autonomy and pater-
nalistic beneficence”2. It has been well observed by Ubel
and Rosenthal that “in recent years, health care lea-
ders have increasingly turned to “nudges” to influence
health-related behaviors”3. For instance, “nudges can
improve chronic disease self-management”4. There may
be “potential value of nudges for helping individuals
receiving services from behavioral health programs”5.
Nudges incentivize vaccinations without violating the
individual’s right to refuse unwanted treatment6.
According to the older and most influential definition
provided by Thaler and Sunstein ‘a nudge… is any aspect
of the choice architecture that alters people’s behavior
1 Harrison JD, Patel MS. Designing Nudges for Success in
Health Care. AMA J Ethics. 2020;22(9):E796-801.
2 Soled D. Public health nudges: weighing individual liberty
and population health benefits. J Med Ethics. 2020 Oct 30:medeth-
ics-2020-106077. doi: 10.1136/medethics-2020-106077. Epub ahead
of print. PMID: 33127665.
3 Ubel PA, Rosenthal MB. Beyond Nudges - When Improv-
ing Health Calls for Greater Assertiveness. N Engl J Med. 2019 Jan
4 Möllenkamp M, Zeppernick M, Schreyögg J. The effective-
ness of nudges in improving the self-management of patients with
chronic diseases: A systematic literature review. Health Policy. 2019
Dec;123(12):1199-1209. doi: 10.1016/j.healthpol.2019.09.008. Epub
2019 Oct 2. PMID: 31676042.
5 Nemec PB, Swarbrick M, Spagnolo A, Brandow CL. Nudges
to Support Health and Wellness for Individuals Served by Behav-
ioral Health Programs. J Psychosoc Nurs Ment Health Serv. 2021 Jan
1;59(1):21-28. doi: 10.3928/02793695-20201015-03. Epub 2020 Oct
23. PMID: 33095264.
6 Dubov A, Phung C. Nudges or mandates? The ethics of
mandatory flu vaccination. Vaccine. 2015 May 21;33(22):2530-5. doi:
10.1016/j.vaccine.2015.03.048. Epub 2015 Apr 11. PMID: 25869886.
in a predictable way without forbidding any options or
significantly changing their economic incentives. To cou-
nt as a mere nudge, the intervention must be easy and
cheap to avoid’7. Nudges do not change the outcomes of
available options or restrict individual’s ability to choose8.
Niker et al., in line with the definition of Thaler and
Sunstein, write that nudges are ‘small changes to the en-
vironment or ‘choice architecture’, designed to promote
particular welfare-promoting choices without coercively
limiting the range of options’9. Simkulet writes that a
nudge is any influence that is designed and expected to
predictably alter a person’s behavior without (substan-
tively) limiting their options or giving them reasons to
decide otherwise10.
Hansen et al. write that by the definition provided by
Thaler and Sunstein nudges are operationally indepen-
dent from regulation (i.e. bans), namely, from ‘liberta-
rian paternalism’11. While this independence is a formal
condition of the definition, it is simply an implication
of a later definition provided by Hansen (2016)12. This
is noticed by Hansen et al. who characterize this defini-
tion as more ‘precise’, ‘consistent’, and ‘fundamental’13.
By this definition ‘a nudge is a function of (condition I)
any attempt at influencing people’s judgment, choice
7 Thaler R.H., Sunstein C.R. Nudge: Improving Decisions about
Health, Wealth, and Happiness. Revised and Expanded Edition. New
York: Penguin Books. 2008. p: 6.
8 Thaler R.H., Sunstein C.R. Nudge: Improving Decisions...
9 Niker F, Reiner PB, Felsen G. Perceptions of Undue Influence
Shed Light on the Folk Conception of Autonomy. Front Psychol.
2018; 9: 1400.
10 Simkulet W. Informed consent and nudging. Bioethics 2019;
11 Hansen PG, Skov LR, Skov KL. Making Healthy Choices Eas-
ier: Regulation versus Nudging. Annu Rev Public Health. 2016; 37:
12 Hansen P. The Definition of Nudge and Libertarian Paternal-
ism: Does the Hand Fit the Glove? European Journal of Risk Regula-
tion 2016; 7(1): 155-74.
13 Hansen PG, Skov LR, Skov KL. Making Healthy Choices Easi-

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