Is It Justifiable to Make Self-Determination Illusory to Motivate a Specific Health Outcome?

Abstract

A nudge is an intervention designed to prompt people to "voluntarily" make the choice intended by those who altered the choice environment or situation, and therefore using nudges is thought to undermine selfdetermination. Evidence for this assumption is weak, however, and sets aside much of what we know about human conduct sociologically. This paper argues that the practical consciousness that people have about their own actions and reasons for executing those actions can inform our thinking about motivating compliance with treatments in clinical settings and the ethical issues involved. Case Mr H is a 58-year-old man with insulin-dependent diabetes, hypertension, and class II obesity (with a BMI of 35 kg/m 2). Mr H sees Dr K today after a 6-month trial of lifestyle changes to lose weight because he wasn't interested in taking anti-obesity medications. As Mr H has told Dr K in the past, "I am already on too many medications for my sugar and blood pressure." Evaluation reveals that Mr H's BMI has increased since the last visit, and Dr K is increasingly concerned, given Mr H's strong family history of coronary artery disease. Recalling that Mr H is afraid of bariatric surgery, Dr K considers reiterating the risk of death and a drawn-out recovery period as Mr H's most feared drawbacks of surgery in order to prompt Mr H to agree to taking anti-obesity medication. 1,2,3