Nudge can make us healthier even if it’s a bit 1984

Power of suggestion. Summer Kitchen, CC BY-NC-SA

In George Orwell’s futuristic dystopia Nineteen Eighty-Four, O’Brien, an apparatchik of the Thought Police come sadistic torturer, famously boasts to the book’s protagonist Winston Smith, “We create human nature. Men are infinitely malleable.”

Similar sentiments to those of O’Brien are being echoed, not by the world’s Ingsoc-aping totalitarian states, but by longstanding democratic governments. The UK is a notable case in point. Recent UK governments of all ideological hues have come to recognise the intractability of certain social “problems”. In health this includes smoking rates, obesity and low sign-up to organ donation.

Increasingly, governments have come to favour cognitive approaches that seek to shape people’s lifestyle choices through positive reinforcement, indirect suggestion and incentives, alongside more legislative approaches. This new “educative state” is growing rapidly and its techniques becoming more prominent. In mind-altering circles, it’s simply known as “nudge”.

The individual is not rational

Behavioural economics is the intellectual cornerstone of nudge and one of its most celebrated cheerleaders, Nobel Laureate Daniel Kahneman, attacked head-on the most cherished and prized dogma of modern economics: the unshakable belief in the individual as a rational, utility maximising homo economicus. But it was the Chicago economist, Richard Thaler, a friend and colleague of Kahneman, who popularised behavioural economics in the form of “nudge theory”, especially among heads of state and within government departments.

In the book Nudge: Improving Decisions about Health, Wealth and Happiness, which Thaler co-authored with legal scholar Cass Sunstein, the world is divided into “Econs” and “Humans”, which essentially represent reflective and automatic systems of thinking. The Humans display clueless behaviour, unable to make the best decisions for themselves, and irrational forms of behaviour dominate their decision-making because the Humans are, in part, dominated more by instinctive, automatic thinking than rational calculation.

This is where behavioural economics and public policy can make something of a “utopian-like” intervention: a third party – a government or a private agency – can manipulate and filter signals so that individuals make informed choices in terms of their own welfare or the collective good of society.

A question of incentives

A natural terrain for nudgery is health and physical wellbeing, and in the UK the Nudge Unit (as the Behavioural Insights Team is known colloquially in Whitehall), which spearheads this approach for the government, has turned its mind to a number of health challenges including smoking, alcohol abuse, obesity, diabetes, physical activity and teen pregnancy.

One recurrent nudge strategy used by the unit is the use of incentives, either monetary or psychological, to encourage healthier lifestyles, so paying people not to smoke. A discussion document published by the Nudge Unit on health cites Bayer’s Nintendo Didget device to make blood testing for diabetes more rewarding for children.

Local government is trying it too. Earlier this year, Stoke-on-Trent City Council began a ten-week pilot to send obese people “motivational” weight loss texts such as “use the stairs more”, “eat fruit and veg” and “keep a check on snacks and drinks” to encourage them to lose weight. The council’s aim is to cut the number of 70,000 obese adults in the city and the £50m NHS bill for tackling weight-related illnesses.

Many health professionals are keen too. John Strang, director of the National Addiction Centre in London, contends that treatment programmes for hardened drug addicts can be improved by about 50% by offering incentives like shopping vouchers (Strang also chaired a watchdog committee which recommended the use of vouchers). For Strang, the use of incentives in curing addiction is both powerful and highly cost-effective.

According to the Nudge Unit paper “evidence on incentives is very mixed” and tend to be more effective in maintaining behaviour if people are rewarded intermittently. There are also shortcomings as far as translating initiatives from one cultural context to another so what improves health in the US may not work in the UK. An article in the BMJ also suggested that nudge doesn’t have a consistent track record when it comes to improving health, or as the title put it: “One nudge forward, two steps back.”

A third way

Western politicians have been the most willing adherents of nudge and nudge appeals to both the left and the right of the political spectrum, from Obama to Osborne. For Tory leader David Cameron, who showed interest before the coalition government was formed, nudge theory provided something of a third way between overbearing state intervention and unrestrained free market capitalism.

There are clear implications for a democratic state, for liberal governance and civil society. The emergence of a “ministry of the mind” centres not so much on “libertarian paternalism” – as Thaler and Sunstein call it – but on paternalistic (or behavioural) panopticon. One of the key intellectual godfathers of behavioural economics, Burrhus Frederic Skinner, was aware that the modification of human behaviour through the surreptitious use of choice architecture, or as he would put it, “operant conditioning”, raises significant political questions. Not only about freedom of choice for individuals but also who decides ultimately what is worthwhile or good behaviour, or what happens when others – again some third party – decides what is “healthy” behaviour.