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Nudge smudge: UK Government misrepresents “nudge”
Comment
Yale University Press
Nudge smudge: UK Government misrepresents “nudge”
Published Online January 17, 2011 DOI:10.1016/S01406736(11)60063-9 See Editorial Lancet 2010; 376: 1959
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The recent public health White Paper, Healthy lives, healthy people: our strategy for public health in England,1 makes several references to the so-called nudge approach to behavioural change popularised in a book of that name by Richard Thaler and Cass Sunstein.2 We argue that the government has misrepresented nudging as being in opposition to their use of regulation and legislation to promote health, and that this misrepresentation serves to obscure the government’s failure to propose realistic actions to address the upstream socioeconomic and environmental determinants of disease. The theory of nudging assumes that people make most decisions unconsciously and non-rationally and are influenced by contextual cues, and thus their behaviour can be manipulated by changing the way that choices are presented to them (see examples below). Nudging is described as libertarian paternalism because, although the nudgers (or choice architects as they are called by Thaler and Sunstein) are trying to encourage individuals to enact beneficial behaviours, no compulsion is involved. The White Paper presents nudging as being in opposition to what is termed “Whitehall diktat”, “nannying”, and “banning”,1 and as working in voluntary partnership with, rather than regulating, business. In his House of Commons speech, Health Secretary Andrew Lansley argued: “Rather than nannying people, we will nudge them by working with industry to make healthier lifestyles easier.”3 The UK Government is already putting this new approach into practice. It is reconsidering the ban on the display of tobacco products that was due to have taken effect in 2011 and is delaying detailed proposals for a ban on below-cost selling of alcohol (having already rejected the strong evidence-based option of minimum pricing).4 The government has established a new public-health advisory body dominated by the food and drink industry, with additional contributions from alcohol producers and operators of private gyms. This is the natural successor of the Public Health Commission that Andrew Lansley created when in opposition, comprising representatives of many of the companies that have been the strongest opponents of public health legislation (including measures that are
entirely consistent with the nudge approach, such as traffic-light warnings on processed food). But the government has misrepresented the nudge approach. Although Thaler and Sunstein argue that nudging does not involve compelling or placing excessive economic pressure on individuals to change their behaviour, they do not pit nudging in opposition to the government using its formal powers to influence the behaviour of business. Their book, Nudge: improving decisions about health, wealth, and happiness,2 presents its case mainly through examples of practical action, including legislation (eg, enacting cap-and-trade systems to limit pollution) and regulation (eg, requiring businesses to inform consumers about harms from cigarettes and pesticides). Reading Nudge,2 it is clear why governments sometimes need to regulate business and why attempts to work with businesses as voluntary partners in public health might be unsuccessful when the interests of the companies concerned conflict with public health goals. Thaler and Sunstein suggest that when “consumers have a less than fully rational belief, firms often have more incentive to cater to that belief than to eradicate it”. Whereas citizens might harm themselves through non-rational decisions, businesses sometimes harm consumers as a result of serving their commercial interests. The previous government commissioned the MINDSPACE report,5 which assessed the potential of nudge-based approaches across the spectrum of public policy. This report did not view nudging and governmental use of formal powers as a dichotomy, nor did it privilege government–business partnerships. Instead, it suggested that nudging “complements and improves conventional policy tools, rather than acting as a replacement for them” and that “sustainable changes in behaviour will come from the successful integration of cultural, regulatory and individual change”, identifying reductions in drink-driving as an example. The misrepresentation of nudging in the White Paper might serve an ideological purpose. Healthy lives, healthy people1 was the government’s response to Michael Marmot’s review6 of health inequalities. Although the White Paper acknowledges that health inequalities exist and are a result of individuals’ social www.thelancet.com Vol 377 June 25, 2011
Comment
and economic circumstances, it makes few realistic proposals about how these inequalities should be addressed, and an independent analysis7 suggests the UK Coalition Government’s broader policies on taxation and welfare are likely to exacerbate economic inequalities, and thus health inequalities too. Reference to nudging might function as a smokescreen for inaction. Superficially, nudging seems to resonate with Marmot’s review in its emphasis on environmental influences. However, whereas Marmot considers upstream factors such as poverty, neighbourhood deprivation, and over-reliance on fossil fuels, nudging focuses on downstream factors such as how individuals absorb information and perceive choices. In fact, Nudge, which is not referenced anywhere by Marmot, largely ignores the socioeconomic determinants of behaviour. Rather than combating poverty and injustice, nudgers can only hope to compensate by nudging people who are poor more vigorously. But how can one nudge away the poor life-chances of children living in poverty,8 the societal harms arising from income inequality,9 or the obesogenic effects of the excessive use of fossil fuels?10 How could nudges have combated cholera from poor hygiene in the 19th century or respiratory disease from pollution in the 20th century? The government even seems to misrepresent the core message of Marmot’s review to legitimise a reduced role for the state in public health. A recent Cabinet Office report on health and behavioural change11 argues: “The lifestyle factors that impact upon people’s health and wellbeing are often deeply entwined in the fabric of our everyday lives. In these areas, passing an Act of Parliament is unlikely to have the desired effect. Strong-armed regulation is not the answer to rebalancing our diets, changing our desire to drink too much alcohol on a Friday night, or making our lives more active.” Unsurprisingly, this argument is not made in Marmot’s review itself, which makes a strong evidence-based case for governmental action to promote public health, including through legislation, regulation, taxation, and welfare. It also highlights the effectiveness of minimum
www.thelancet.com Vol 377 June 25, 2011
pricing for alcohol to reduce health inequalities and calls for regulation to reduce the local concentration of fast-food outlets. This government has apparently welcomed Marmot’s review while using a misrepresentation of nudge theory to muddy debate, obscuring its failure to engage with the upstream socioeconomic determinants of health, for which Marmot provides so much evidence. The Thatcher administration’s attempt to bury the 1980 Black Report12 on health inequalities resulted in it becoming one of the most influential public health reports in history. Politicians might have decided that bland platitudes plus references to fashionable concepts and some misrepresentation of their implications for policy might make for more effective containment than old-fashioned suppression ever could. *Chris Bonell, Martin McKee, Adam Fletcher, Andrew Haines, Paul Wilkinson Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK [email protected] We declare that we have no conflicts of interest. 1
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Department of Health. Healthy lives, healthy people: our strategy for public health in England. Nov 30, 2010. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_121941 (accessed Dec 13, 2010). Thaler R, Sunstein C. Nudge: improving decisions about health, wealth, and happiness. New Haven, CT: Yale University Press, 2009. Channel 4 News. Andrew Lansley publishes public health White Paper. Nov 30, 2010. http://www.channel4.com/news/andrew-lansley-publishespublic-health-white-paper (accessed Dec 16, 2010). Purshouse RC, Meier PS, Brennan A, Taylor KB, Rafia R. Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. Lancet 2010; 375: 1355–64. Dolan P, Hallsworth M, Halpern D, King D, Vlaev I. MINDSPACE: influencing behaviour through public policy. 2010. http://www. instituteforgovernment.org.uk/content/133/mindspace-influencingbehaviour-through-public-policy (accessed Dec 13, 2010). Marmot MG. Fair society, healthy lives. The Marmot review: strategic review of health inequalities in England post-2010. 2010. http://www. marmotreview.org (accessed Dec 13, 2010). Browne J, Levell P. The distributional effect of tax and benefit reforms to be introduced between June 2010 and April 2014: a revised assessment. 2010. http://www.ifs.org.uk/publications/5246 (accessed Jan 4, 2011). Davey-Smith G. Health inequalities: lifecourse approaches. London: Policy Press, 2003. Wilkinson R, Pickett K. The spirit level: why more equal societies almost always do better. London: Allen Lane, 2009. Roberts I, Edwards P. The energy glut. London: Zed Books, 2010. Cabinet Office Behavioural Insight Team. Applying behavioural insight to health. Dec 31, 2010. http://www.cabinetoffice.gov.uk/resource-library/ applying-behavioural-insight-health (accessed Jan 4, 2011). Department of Health and Social Security. Inequalities in heath: report of a research working group. London: HM Stationery Office, 1980.
2159
Yale University Press
Nudge smudge: UK Government misrepresents “nudge”
Published Online January 17, 2011 DOI:10.1016/S01406736(11)60063-9 See Editorial Lancet 2010; 376: 1959
2158
The recent public health White Paper, Healthy lives, healthy people: our strategy for public health in England,1 makes several references to the so-called nudge approach to behavioural change popularised in a book of that name by Richard Thaler and Cass Sunstein.2 We argue that the government has misrepresented nudging as being in opposition to their use of regulation and legislation to promote health, and that this misrepresentation serves to obscure the government’s failure to propose realistic actions to address the upstream socioeconomic and environmental determinants of disease. The theory of nudging assumes that people make most decisions unconsciously and non-rationally and are influenced by contextual cues, and thus their behaviour can be manipulated by changing the way that choices are presented to them (see examples below). Nudging is described as libertarian paternalism because, although the nudgers (or choice architects as they are called by Thaler and Sunstein) are trying to encourage individuals to enact beneficial behaviours, no compulsion is involved. The White Paper presents nudging as being in opposition to what is termed “Whitehall diktat”, “nannying”, and “banning”,1 and as working in voluntary partnership with, rather than regulating, business. In his House of Commons speech, Health Secretary Andrew Lansley argued: “Rather than nannying people, we will nudge them by working with industry to make healthier lifestyles easier.”3 The UK Government is already putting this new approach into practice. It is reconsidering the ban on the display of tobacco products that was due to have taken effect in 2011 and is delaying detailed proposals for a ban on below-cost selling of alcohol (having already rejected the strong evidence-based option of minimum pricing).4 The government has established a new public-health advisory body dominated by the food and drink industry, with additional contributions from alcohol producers and operators of private gyms. This is the natural successor of the Public Health Commission that Andrew Lansley created when in opposition, comprising representatives of many of the companies that have been the strongest opponents of public health legislation (including measures that are
entirely consistent with the nudge approach, such as traffic-light warnings on processed food). But the government has misrepresented the nudge approach. Although Thaler and Sunstein argue that nudging does not involve compelling or placing excessive economic pressure on individuals to change their behaviour, they do not pit nudging in opposition to the government using its formal powers to influence the behaviour of business. Their book, Nudge: improving decisions about health, wealth, and happiness,2 presents its case mainly through examples of practical action, including legislation (eg, enacting cap-and-trade systems to limit pollution) and regulation (eg, requiring businesses to inform consumers about harms from cigarettes and pesticides). Reading Nudge,2 it is clear why governments sometimes need to regulate business and why attempts to work with businesses as voluntary partners in public health might be unsuccessful when the interests of the companies concerned conflict with public health goals. Thaler and Sunstein suggest that when “consumers have a less than fully rational belief, firms often have more incentive to cater to that belief than to eradicate it”. Whereas citizens might harm themselves through non-rational decisions, businesses sometimes harm consumers as a result of serving their commercial interests. The previous government commissioned the MINDSPACE report,5 which assessed the potential of nudge-based approaches across the spectrum of public policy. This report did not view nudging and governmental use of formal powers as a dichotomy, nor did it privilege government–business partnerships. Instead, it suggested that nudging “complements and improves conventional policy tools, rather than acting as a replacement for them” and that “sustainable changes in behaviour will come from the successful integration of cultural, regulatory and individual change”, identifying reductions in drink-driving as an example. The misrepresentation of nudging in the White Paper might serve an ideological purpose. Healthy lives, healthy people1 was the government’s response to Michael Marmot’s review6 of health inequalities. Although the White Paper acknowledges that health inequalities exist and are a result of individuals’ social www.thelancet.com Vol 377 June 25, 2011
Comment
and economic circumstances, it makes few realistic proposals about how these inequalities should be addressed, and an independent analysis7 suggests the UK Coalition Government’s broader policies on taxation and welfare are likely to exacerbate economic inequalities, and thus health inequalities too. Reference to nudging might function as a smokescreen for inaction. Superficially, nudging seems to resonate with Marmot’s review in its emphasis on environmental influences. However, whereas Marmot considers upstream factors such as poverty, neighbourhood deprivation, and over-reliance on fossil fuels, nudging focuses on downstream factors such as how individuals absorb information and perceive choices. In fact, Nudge, which is not referenced anywhere by Marmot, largely ignores the socioeconomic determinants of behaviour. Rather than combating poverty and injustice, nudgers can only hope to compensate by nudging people who are poor more vigorously. But how can one nudge away the poor life-chances of children living in poverty,8 the societal harms arising from income inequality,9 or the obesogenic effects of the excessive use of fossil fuels?10 How could nudges have combated cholera from poor hygiene in the 19th century or respiratory disease from pollution in the 20th century? The government even seems to misrepresent the core message of Marmot’s review to legitimise a reduced role for the state in public health. A recent Cabinet Office report on health and behavioural change11 argues: “The lifestyle factors that impact upon people’s health and wellbeing are often deeply entwined in the fabric of our everyday lives. In these areas, passing an Act of Parliament is unlikely to have the desired effect. Strong-armed regulation is not the answer to rebalancing our diets, changing our desire to drink too much alcohol on a Friday night, or making our lives more active.” Unsurprisingly, this argument is not made in Marmot’s review itself, which makes a strong evidence-based case for governmental action to promote public health, including through legislation, regulation, taxation, and welfare. It also highlights the effectiveness of minimum
www.thelancet.com Vol 377 June 25, 2011
pricing for alcohol to reduce health inequalities and calls for regulation to reduce the local concentration of fast-food outlets. This government has apparently welcomed Marmot’s review while using a misrepresentation of nudge theory to muddy debate, obscuring its failure to engage with the upstream socioeconomic determinants of health, for which Marmot provides so much evidence. The Thatcher administration’s attempt to bury the 1980 Black Report12 on health inequalities resulted in it becoming one of the most influential public health reports in history. Politicians might have decided that bland platitudes plus references to fashionable concepts and some misrepresentation of their implications for policy might make for more effective containment than old-fashioned suppression ever could. *Chris Bonell, Martin McKee, Adam Fletcher, Andrew Haines, Paul Wilkinson Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK [email protected] We declare that we have no conflicts of interest. 1
2 3
4
5
6
7
8 9 10 11
12
Department of Health. Healthy lives, healthy people: our strategy for public health in England. Nov 30, 2010. http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_121941 (accessed Dec 13, 2010). Thaler R, Sunstein C. Nudge: improving decisions about health, wealth, and happiness. New Haven, CT: Yale University Press, 2009. Channel 4 News. Andrew Lansley publishes public health White Paper. Nov 30, 2010. http://www.channel4.com/news/andrew-lansley-publishespublic-health-white-paper (accessed Dec 16, 2010). Purshouse RC, Meier PS, Brennan A, Taylor KB, Rafia R. Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. Lancet 2010; 375: 1355–64. Dolan P, Hallsworth M, Halpern D, King D, Vlaev I. MINDSPACE: influencing behaviour through public policy. 2010. http://www. instituteforgovernment.org.uk/content/133/mindspace-influencingbehaviour-through-public-policy (accessed Dec 13, 2010). Marmot MG. Fair society, healthy lives. The Marmot review: strategic review of health inequalities in England post-2010. 2010. http://www. marmotreview.org (accessed Dec 13, 2010). Browne J, Levell P. The distributional effect of tax and benefit reforms to be introduced between June 2010 and April 2014: a revised assessment. 2010. http://www.ifs.org.uk/publications/5246 (accessed Jan 4, 2011). Davey-Smith G. Health inequalities: lifecourse approaches. London: Policy Press, 2003. Wilkinson R, Pickett K. The spirit level: why more equal societies almost always do better. London: Allen Lane, 2009. Roberts I, Edwards P. The energy glut. London: Zed Books, 2010. Cabinet Office Behavioural Insight Team. Applying behavioural insight to health. Dec 31, 2010. http://www.cabinetoffice.gov.uk/resource-library/ applying-behavioural-insight-health (accessed Jan 4, 2011). Department of Health and Social Security. Inequalities in heath: report of a research working group. London: HM Stationery Office, 1980.
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