Although manipulation is neither rational persuasion nor coercion, a more precise definition remains elusive. Two main accounts have been offered. One characterizes manipulation as a form of trickery. The other characterizes manipulation as a form of non-coercive pressure. Each account properly identifies only a subset of intuitively clear cases of manipulation. That is, some instances of manipulation apparently involve pressure, while others apparently involve trickery. Yet trickery and pressure seem distinct, so it is puzzling how they could be instances of (...) the same phenomenon. This puzzle can be solved once we recognize that manipulative pressure only works if the target acts akratically. This fact provides the basis for a unified account of manipulation as the attempt to get someone to make a mistake. (shrink)

Although manipulation is neither rational persuasion nor coercion, a more precise definition remains elusive. Two main accounts have been offered. One characterizes manipulation as a form of trickery. The other characterizes manipulation as a form of non-coercive pressure. Each account properly identifies only a subset of intuitively clear cases of manipulation. That is, some instances of manipulation apparently involve pressure, while others apparently involve trickery. Yet trickery and pressure seem distinct, so it is puzzling how they could be instances of (...) the same phenomenon. This puzzle can be solved once we recognize that manipulative pressure only works if the target acts akratically. This fact provides the basis for a unified account of manipulation as the attempt to get someone to make a mistake. (shrink)

This paper focuses on voluntary consent in the context of living organ donation. Arguing against three dominant views, I claim that voluntariness must not be equated with willingness, that voluntariness does not require the exercise of relational moral agency, and that, in cases of third-party pressure, voluntariness critically depends on the role of the surgeon and the medical team, and not just on the pressure from other people. I therefore argue that an adequate account of voluntary consent cannot understand voluntariness (...) as a purely psychological concept, that it has to be consistent with people pursuing various different conceptions of the good and that it needs to make the interaction between the person giving consent and the person receiving consent central to its approach. (shrink)

Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead (...) of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google’s rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most—but not all—nudges in most—but not all—circumstances. (shrink)

In their recently published book Nudge (2008) Richard H. Thaler and Cass R. Sunstein (T&S) defend a position labelled as ‘libertarian paternalism’. Their thinking appeals to both the right and the left of the political spectrum, as evidenced by the bedfellows they keep on either side of the Atlantic. In the US, they have advised Barack Obama, while, in the UK, they were welcomed with open arms by the David Cameron's camp (Chakrabortty 2008). I will consider the following questions. What (...) is Nudge? How is it different from social advertisement? Does Nudge induce genuine preference change? Does Nudge build moral character? Is there a moral difference between the use of Nudge as opposed to subliminal images to reach policy objectives? And what are the moral constraints on Nudge? (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

Too often, we as individuals do things that harm us, that seriously interfere with our being able to live in the way that we want. We eat food that makes us obese, that promotes diabetes, heart failure and other serious illness, while at the same time, we want to live long and healthy lives. Too many of us smoke cigarettes, even while acknowledging we wish we had never begun. We behave in ways that undercut our ability to reach some of (...) our most valued goals, despite education and despite incentives to choose the right thing. What should be done?If I were to try to harm someone else in a way that alters his future seriously and perhaps irrevocably for the worse, I would be stopped. When it comes to hurting myself, though, we have a common belief that it is wrong to interfere, even if I foresee that I will very much regret what I have done, often when it is too late to fix what I have let happen. I think this makes no sense. If it is permissible, even obligatory, to stop me when I do something that seriously interferes with someone else's chances of achieving the life he wants, I think …. (shrink)

The Criminalization series arose from an interdisciplinary investigation into criminalization, focussing on the principles that might guide decisions about what kinds of conduct should be criminalized, and the forms that criminalization should take. Developing a normative theory of criminalization, the series tackles the key questions at the heart of the issue: what principles and goals should guide legislators in deciding what to criminalize? How should criminal wrongs be classified and differentiated? How should law enforcement officials apply the law's specifications of (...) offences? The sixth volume in the series offers a philosophical investigation of the relationship between moral wrongdoing and criminalization. Considering the justification of punishment, the nature of harm, the importance of autonomy, inchoate wrongdoing, the role of consent, and the role of the state, the book provides an account of the nature of moral wrongdoing, the sources of wrongdoing, why wrongdoing is the central target of the criminal law, and the ways in which criminalization of non-wrongful conduct might be permissible. (shrink)

Libertarian paternalism's notion of “nudging” refers to steering individual decision making so as to make choosers better off without breaching their free choice. If successful, this may offer an ideal synthesis between the duty to respect patient autonomy and that of beneficence, which at times favors paternalistic influence. A growing body of literature attempts to assess the merits of nudging in health care. However, this literature deals almost exclusively with health policy, while the question of the potential benefit of nudging (...) for the practice of informed consent has escaped systematic analysis. This article focuses on this question. While it concedes that nudging could amount to improper exploitation of cognitive weaknesses, it defends the practice of nudging in a wide range of other conditions. The conclusion is that, when ethically legitimate, nudging offers an important new paradigm for informed consent, with a special potential to overcome the classical dilemma between paternalistic beneficence and respect for autonomy. (shrink)

In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall into the (...) broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

Manipulative actions come in a bewildering variety of forms: direct and indirect deception, playing on emotions, tempting, inciting, and so on. It is not obvious what feature all these actions share in virtue of which they are all of the same kind and in virtue of which they are all morally wrong. This article argues that all manipulative actions are cases in which the manipulator attempts to lead the victim astray by trying to get her to have emotions, beliefs, or (...) desires that, as the manipulator sees it, are not ideal for the victim. To attempt to lead a person astray in this way is to fail to respect the moral and rational agency of the victim. This analysis captures the fact that actions of many kinds--and with many different psychological effects--can be manipulative, and it tells us what is wrong with acting manipulatively. It also helps distinguish manipulation from non rational persuasion. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

This will be the best way of explaining ‘Paris is the lover of Helen’, that is, ‘Paris loves, and by that very fact [et eo ipso] Helen is loved’. Here, therefore, two propositions have been brought together and abbreviated as one. Or, ‘Paris is a lover, and by that very fact Helen is a loved one’.

Human beings have the unique ability to view the world in a detached way: We can think about the world in terms that transcend our own experience or interest, and consider the world from a vantage point that is, in Nagel's words, "nowhere in particular". At the same time, each of us is a particular person in a particular place, each with his own "personal" view of the world, a view that we can recognize as just one aspect of the (...) whole. How do we reconcile these two standpoints--intellectually, morally, and practically? To what extent are they irreconcilable and to what extent can they be integrated? Thomas Nagel's ambitious and lively book tackles this fundamental issue, arguing that our divided nature is the root of a whole range of philosophical problems, touching, as it does, every aspect of human life. He deals with its manifestations in such fields of philosophy as: the mind-body problem, personal identity, knowledge and skepticism, thought and reality, free will, ethics, the relation between moral and other values, the meaning of life, and death. Excessive objectification has been a malady of recent analytic philosophy, claims Nagel, it has led to implausible forms of reductionism in the philosophy of mind and elsewhere. The solution is not to inhibit the objectifying impulse, but to insist that it learn to live alongside the internal perspectives that cannot be either discarded or objectified. Reconciliation between the two standpoints, in the end, is not always possible. (shrink)

Nudges have been criticized for working ‘in the dark’, influencing people without their full awareness. To assess whether this property renders nudging an illegitimate policy tool in liberal democracies, we argue that in scrutinizing nudge transparency, we should adequately divide our focus between nudging techniques, the nudgers employing them, and the nudgees subjected to them. We develop an account of what it means for nudgees to be ‘watchful’, a disposition that enables them to resist and circumvent nudges. We argue that (...) such ‘watchfulness’ should be cultivated if we want to implement nudges in legitimate, accountable, and democratic ways. (shrink)

Cass Sunstein and Richard Thaler recommend helping people make better decisions by employing ‘nudges’, which they define as noncoercive methods of influencing choice for the better. Not surprisingly, healthcare practitioners and public policy professionals have become interested in whether nudges might be a promising method of improving health-related behaviors without resorting to heavy-handed methods such as coercion, deception, or government regulation. Many nudges seem unobjectionable as they merely improve the quality and quantity available for the decision-maker. However, other nudges influence (...) decision-making in ways that do not involve providing more and better information. Nudges of this sort raise concerns about manipulation. This paper will focus on noninformational nudges that operate by changing the salience of various options. It will survey two approaches to understanding manipulation, one which sees manipulation as a kind of pressure, and one that sees it as a kind of trickery. On the pressure view, salience nudges do not appear to be manipulative. However, on the trickery view, salience nudges will be manipulative if they increase the salience so that it is disproportionate to that fact's true relevance and importance for the decision at hand. By contrast, salience nudges will not be manipulative if they merely highlight some fact that is true and important for the decision at hand. The paper concludes by providing examples of both manipulative and nonmanipulative salience nudges. (shrink)

The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably (...) affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as “nudges.” Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations—for example, the tendency to choose the first option presented even when that option is not the best for them—thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients’ choices, the justification for doing so must appeal to an ethical and professional standard, not to patients’ preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar—the best-interest standard—offers a robust justification for the use of nudges. (shrink)

“Libertarian paternalism” aims to harness cognitive biases in order to improve prudential decision-making. Some critics have objected that libertarian paternalism is wrongly manipulative. I argue that this objection is mostly unsuccessful. First, I point out that some strategies endorsed by libertarian paternalists can help people to better appreciate reasons. Second, I develop an account of manipulation according to which an agent manipulates her target by worsening the target’s deliberative position. The means of influence defended by libertarian paternalists—for instance, the judicious (...) use of default rules—are not manipulative in this way. (shrink)

Shaping the Normative Landscape is an investigation of the value of obligations and of rights, of forgiveness, of consent and refusal, of promise and request. David Owens shows that these are all instruments by which we exercise control over our normative environment.

There is a well-known scene from The Adventures of Tom Sawyer that illustrates what might be considered benign manipulation: Tom has the job of whitewashing a fence but would rather spend the time with friends. By feigning enthusiasm for the job he manages to get his friends to hang around and do it for him. They even pay to do it - with various little items that he later trades for..

Since Mill's seminal work On Liberty, philosophers and political theorists have accepted that we should respect the decisions of individual agents when those decisions affect no one other than themselves. Indeed, to respect autonomy is often understood to be the chief way to bear witness to the intrinsic value of persons. In this book, Sarah Conly rejects the idea of autonomy as inviolable. Drawing on sources from behavioural economics and social psychology, she argues that we are so often irrational in (...) making our decisions that our autonomous choices often undercut the achievement of our own goals. Thus in many cases it would advance our goals more effectively if government were to prevent us from acting in accordance with our decisions. Her argument challenges widely held views of moral agency, democratic values and the public/private distinction, and will interest readers in ethics, political philosophy, political theory and philosophy of law. (shrink)

The ethics of clinical research may be viewed from three different perspectives: the process of acquiring new knowledge, the moral use of the knowledge acquired, and the ethics of the investigator seeking this knowledge.

If citizens’ behavior threatens to harm others or seems not to be in their own interest, it is not uncommon for governments to attempt to change that behavior. Governmental policy makers can apply established tools from the governmental toolbox to this end. Alternatively, they can employ new tools that capitalize on the wealth of knowledge about human behavior and behavior change that has been accumulated in the behavioral sciences. Two contrasting approaches to behavior change are nudge policies and boost policies. (...) These policies rest on fundamentally different research programs on bounded rationality, namely, the heuristics and biases program and the simple heuristics program, respectively. This article examines the policy–theory coherence of each approach. To this end, it identifies the necessary assumptions underlying each policy and analyzes to what extent these assumptions are implied by the theoretical commitments of the respective research program. Two key results of this analysis are that the two policy approaches rest on diverging assumptions and that both suffer from disconnects with the respective theoretical program, but to different degrees: Nudging appears to be more adversely affected than boosting does. The article concludes with a discussion of the limits of the chosen evaluative dimension, policy–theory coherence, and reviews some other benchmarks on which policy programs can be assessed. (shrink)

In recent years, ‘nudge’ theory has gained increasing attention for the design of population-wide health interventions. The concept of nudge puts a label on efficacious influences that preserve freedom of choice without engaging the influencees’ deliberative capacities. Given disagreements over what it takes genuinely to preserve freedom of choice, the question is whether health influences relying on automatic cognitive processes may preserve freedom of choice in a sufficiently robust sense to be serviceable for the moral evaluation of actions and policies. (...) In this article, I offer an argument to this effect, explicating preservation of freedom of choice in terms of choice-set preservation and noncontrol. I also briefly explore the healthcare contexts in which nudges may have priority over more controlling influences. (shrink)

An invalid promise is one whose breach does not wrong the promisee. I describe two different accounts of why duress and deception invalidate promises. According to the fault account duress and deception invalidate a promise just when it was wrong for the promisee to induce the promisor to promise in that way. According to the injury account, duress and deception invalidate a promise just when by inducing the promise in that way the promisee wrongs the promisor. I demonstrate that the (...) injury account is superior. I then argue that in this respect promising is like any exercise of a normative power. I conclude by distinguishing two theories of promissory obligation, a widely held view which I call the information interest theory and an alternative which I call the authority interest theory. I argue that the points established earlier support the authority interest theory over its rival. (shrink)

The nudge approach seeks to improve people’s decisions through small changes in their choice environments. Nudge policies often work through psychological mechanisms that deviate from traditional notions of rationality. Because of that, some critics object that nudging treats people as irrational. Such treatment might be disrespectful in itself and might crowd out more empowering policies. I defend nudging against these objections. By defending a nonstandard, ecological model of rationality, I argue that nudging not only is compatible with rational agency but (...) can even support it. Accordingly, a concern with rationality speaks for more rather than less public policy nudging. (shrink)

In this issue of the Hastings Center Report, Moti Gorin, Steven Joffe, Neal Dickert, and Scott Halpern offer a comprehensive defense of the use of nudging techniques in the clinical context, with the aim of promoting the best interests of patients. Their argument is built on three important claims: Nudging is ubiquitous and inescapable in clinical choice situations, and there is no neutral way of informing patients about their treatment choices; many patients do not have authentic preferences concerning their treatment (...) choices, and those that do can easily resist nudging; and, finally, since many people lack authentic preferences and those that do can still act on their preferences, nudging in the patients’ best interest is justified. I agree with the authors that if these three claims stand up to scrutiny, then they will provide a justification for many types of clinical nudging. I am, however, skeptical as to whether the claims can be sustained, despite the valiant efforts of Gorin and colleagues. (shrink)

Should people be considered organ donors after their death unless they request not to be, or should they not be considered donors unless they request to be? Because people tend to stay with the default in a variety of domains, policymakers’ choice of default has large and often important effects. In the United States, where the organ-donation policy default is ‚Äúnot a donor,‚Ä? about 5,000 people die every year because there are too few donors. Four experiments examined two domains‚Äîbeing an (...) organ donor and saving for retirement‚Äîwhere default effects occur and have important implications. The results indicate that default effects occur in part because policymakers’ attitudes can be revealed through their choice of default, and people perceive the default as indicating the recommended course of action. Policymakers need to be aware of the implicit messages conveyed by their choice of default. (shrink)

Richard Thaler and Cass Sunstein, in Nudge: Improving Decisions About Health, Wealth, and Happiness, assert that rejecting the use nudges is ‘pointless’ because ‘[i]n many cases, some kind of nudge is inevitable’. Schlomo Cohen makes a similar claim. He asserts that in certain situations surgeons cannot avoid nudging patients either toward or away from consenting to surgical interventions. Cohen concludes that in these situations, nudging patients toward consenting to surgical interventions is uncriticizable or morally permissible. I call this argument: The (...) Unavoidability Argument. In this essay, I will respond to Cohen's use of the unavoidability argument in support of using nudges during the process of informed consent. Specifically, I argue that many so-called ‘unavoidable nudges’ are, in fact, avoidable. Although my argument is directed toward Cohen's use of the unavoidability argument, it is applicable to the unavoidability argument more generally. (shrink)

In an analysis of recent work on nudging we distinguish three positions on the relationship between nudging founded in libertarian paternalism and the protection of personal autonomy through informed consent. We argue that all three positions fail to provide adequate protection of personal autonomy in the clinical context. Acknowledging that nudging may be beneficial, we suggest a fourth position according to which nudging and informed consent are valuable in different domains of interaction.

Constitutivists about moral norms are often suspected of providing an overly “self-centered” account of morality which does not take seriously enough morality’s interpersonal nature. This worry see...

Policy makers are understandably interested—for both political and moral reasons—in following Thaler and Sunstein's recommendation to use ‘choice architecture’ , or other ‘nudges’, to promote desirable behaviour in ways that are allegedly compatible with personal freedom.1 Yashar Saghai's intricate analysis shows that simply maintaining the target's choice-set is insufficient to preserve the target's freedom when the nudge bypasses the target's deliberative capacities—as it is specifically designed to do.2 In his friendly amendment to Thaler and Sunstein's project, Saghai advances a more (...) robust account of nudges in which fewer policies would count as nudges, but those that do count as nudges would be less troublesome. In this commentary, I briefly discuss several issues raised by Saghai's project, some of which go beyond the topic of nudges. How important is definitional salvaging? If a ‘substantially controlling’ influence were more efficacious in promoting healthy behaviours, we would have a trade-off between the efficacy of a policy and its compatibility with freedom. Saghai states that an influence can be morally permissible even if it is ‘substantially controlling’ and, therefore, does not qualify as a nudge. So even on Saghai's definitional project it is not clear how much work it does in distinguishing the morally permissible from the morally impermissible. The …. (shrink)

May a doctor treat a patient, despite that patient's refusal, when in his professional opinion treatment is necessary? This is the dilemma which must from time to time confront most physicians. An examination of the validity of such a refusal is provided by the present authors who use the case history of a patient refusing treatment, for cancer as well as for a fractured hip, to evaluate the grounds for intervention in such circumstances. In such a situation the patient is (...) said to have a 'false belief' and it is the doctor's duty to try to change that belief in the patient's interest. The false belief is considered here in terms of the liberty principle, the patient's mental competence and on what is called the 'harm principle' (harm to other individuals or to society). Finally the concept of paternalism is examined. The authors conclude that the doctor must attempt to change a false belief, and if this fails he must examine the patient's mental competence to make the decision to refuse treatment. But in the last analysis the doctor may be under an obligation to respect the patient's refusal. Readers might like to look at (or read again) the papers on 'Liberty' and 'Conscience' published in this Journal under the heading Analysis. (shrink)