Behaviour Change - Science and Technology Committee Contents


10 February 2011

Members of the Sub-Committee present were Baroness Neuberger (Chairman), Baroness O'Neill of Bengarve, Lord Patel and the Earl of Selborne. In attendance were Daisy Ricketts (Clerk) and Rachel Newton (Policy analyst).

The speakers were: Professor Thomas Baldwin (Department of Philosophy, University of York); Professor Luc Bovens (Department of Philosophy, Logic and Scientific Method, London School of Economics); Professor Theresa Marteau (Professor of Health Psychology, Kings College London).

Other participants were: Professor Richard Ashcroft (School of Law, Queen Mary, University of London); Dr Bennett Foddy (Institute for Science and Ethics, University of Oxford); Dr Jessica Pykett (Institute of Geography and Earth Sciences Aberystwyth University).

An introduction to ethics in policy making (Professor Thomas Baldwin)

Professor Baldwin argued that it was a core value of liberal societies that citizens should be treated as rational agents, capable of taking responsibility for constructing their own lives. He outlined JS Mill's 'harm principle': the only reason that governments can exercise power against the will of an individual is to prevent harm to others. This principle would however limit the role of Government in public health to health protection and health promotion through the provision of advice (except where others might be harmed, as by smoking or failing to take steps to prevent the transmission of infectious or contagious diseases).

Professor Baldwin suggested that the example of obesity demonstrated that the 'harm principle' would not provide an adequate approach for Government intervention. He noted that obesity was not an infectious disease and that, although there had been much advice about healthy eating and exercise, rates of obesity continued to rise. He argued that the rise in obesity had not been caused by a collapse in personal responsibility but rather by changes in physical and social environment (as claimed in the Foresight report).[348] Tackling obesity was nevertheless a matter for Government because of its implications for the health of the population and the financial burden on public funds. Professor Baldwin suggested therefore that Government had a broad responsibility for the welfare of citizens that went beyond protecting them from harm from others. He further noted that the example of obesity highlighted the significance of equality; child obesity was correlated very closely with social deprivation.

The example of obesity linked three core aims for public policy: protecting personal responsibility, dealing with major challenges to public welfare, and promoting equality (at least equality of opportunity for health). The stewardship model proposed by the Nuffield Council on Bioethics (NCOB) illustrated how these values could work together: the Government's role was to act as 'steward' of the public environment in which individuals can exercise responsibility for their own choices. The NCOB proposed, in the light of this, that public policies should be seen as rungs of a ladder, with the bottom rungs representing minimal and less controversial interventions, and higher rungs representing more intrusive intervention that require stronger justification.[349]

The NCOB recommended that governments should start at the bottom of the ladder and only move to policies higher up the ladder when a lower rung policy was not working; there was reason to think that a higher rung policy would be more effective; and when the goal of the policy was important enough to warrant more intrusive intervention. Professor Baldwin noted that the NCOB ladder had found its way into current Government policy, including the Public Health White Paper Healthy Lives, Healthy People.[350] It was used in this White Paper to justify avoiding the regulation of businesses, although the Nuffield Ladder was only intended to apply to policies directed at individuals.[351]

Intervening to change behaviour: factors influencing acceptability to members of the public (Professor Theresa Marteau)

As a psychologist, Professor Marteau outlined how what was known about human behaviour and evidence for the effectiveness of interventions, might bear on the judgments about the ethical acceptability of behaviour change.

Professor Marteau said that behaviour could be explained by dual process models of human behaviour, which distinguished between the reflective system and the impulsive system. The model represented the reflective system as driven by conscious decisions, taking into account considerations of the future and requiring a high cognitive capacity. It represented the impulsive system as driven by immediate perceptual input, giving no consideration to the future, operating quickly and requiring little or no conscious cognitive capacity. Professor Marteau said it was widely agreed that much behaviour was driven primarily by the automatic system, and was therefore closely linked to our environment, both physical and social. Professor Marteau outlined some experiments which demonstrated the impact of the physical environment on behaviour.

Professor Marteau argued that those who thought that behaviour was as driven primarily by the reflective system often took a negative attitude towards changing the physical environment to produce behaviour change. Conversely, those who thought that behaviour was primarily driven by the automatic system took a positive attitude towards intervening to change the environment, sometimes claiming that such interventions enabled individuals to behave as they really want to behave. Professor Marteau noted that most people mistakenly thought that the reflective system was most influential in causing behaviour. Psychologists referred to this misunderstanding as the 'fundamental misattribution error'.

Professor Marteau then discussed how evidence of effectiveness of interventions could affect public acceptability. She used the example of financial incentives for stopping smoking to demonstrate that though an intervention might initially be conceived negatively, public levels of acceptability might improve with evidence of effectiveness. Professor Marteau offered two examples of current policies to demonstrate that government's trade off the effectiveness of an intervention against other considerations. First, it was estimated that the current Government policy of placing a very low cost price minimum on alcohol would save 27 lives per year, whereas imposing a minimum cost of 40p per unit was estimated to save almost ten times as many lives. Secondly, a voluntary agreement on salt reduction in the United Kingdom achieved a reduction in average daily intake of 1g, saving 6000 lives per year by reducing cardio-vascular diseases, whereas regulation that reduced the average daily intake by 4g would, it was estimated, save 20000 lives per annum. Professor Marteau noted that these examples raised ethical question about the other factors which governments might consider more important than effectiveness, and the extent to which this affected the acceptability of an intervention.

Discussion: when, and how, is it appropriate for the Government to intervene to change people's behaviour?

The discussion began with consideration of whether governments could only restrict choice to prevent harm to others, or whether they could justifiably also intervene to prevent individuals harming themselves. It was noted that it was considered appropriate for government to intervene to restrict children's choices because they weren't considered to have full ability to make rational choices.

The implications of knowledge about the automatic and reflective system of behaviour for measures to restrict choice were discussed. First, it was noted that understanding behaviour demonstrated that people sometimes behave in ways which they do not really want (for example, 77% of smokers wanted to stop smoking and 70% of people who were obese wanted to lose weight). It was suggested that this might explain why some policies which were at first unpopular and considered unacceptably restrictive of choice, became accepted, indeed welcomed when effective. This could justify implementing unpopular policies; though a policy might initially restrict choice, it might then allow individuals to behave in the way they want to behave. Others noted that if governments assumed that they knew what people 'really' wanted better than the individuals themselves, this might be the start of a slippery slope and could be used to justify interventions which were not acceptable.

Secondly, some policies which restricted choice for some enabled choice for others. For example, restricting alcohol consumption through fiscal measures could restrict choice for some by making it more expensive to drink, but might enable choice for others who could walk home safely at night (assuming a reduction in crime and anti-social behaviour as a result of reduced alcohol consumption). Certain restrictions on individual choice limit population harm and could be justified on Millian and many other grounds. Alcohol, smoking and obesity also harm the population by their cost to the NHS and, in the case of alcohol, increased rates of crime. It could therefore be argued that tackling these problems did prevent harm to others, so fell within the meaning of the 'harm principle'.

The role of social norms was then discussed. It was suggested that understanding the impact of social norms entailed understanding automatic and reflective processes which determined behaviour. Science had not been able to explain how and why social norms were produced but they reflected views of what was acceptable. For example, socials norms of alcohol consumption made interventions in this policy area difficult. If it was understood how to create a culture in which nobody would boast of having been "legless" this would support, or provide an alternative to, health promotion measures restricting access to alcohol.

Discussion: what makes a policy intervention coercive and how is this related to the restriction of choice?

A problem found during the course of the inquiry was outlined: those opposed to the use of legislation and fiscal policies to change behaviour had often defended their position by arguing that such measures were coercive. They had moreover cited the Nuffield Ladder in support of this claim. It was noted that in the text of the Nuffield report there was no claim that the top of the ladder represented forms of coercion, only that it represented more powerful or intrusive interventions. They were however characterised as coercive in a box within the report.[352]

It was argued that a distinction should be drawn between policies which were coercive and those which required coercive backing. Even interventions at the bottom of the Nuffield Ladder might require coercive backing if introduced as a matter of public policy, for example if businesses were legally required to provide certain information on food packaging. It was noted that coercion was felt by many to be intrinsically bad but that legislation was not in and of itself coercive. If legislation was seen as coercive, then the rule of law was itself a form of coercion. The link between coercion and financial incentives to change health behaviour was also discussed. It was noted that though the media sometimes described incentives as a form of coercion or bribery, it was very difficult to "pin the coercive tail to the incentive donkey".

The Ladder was intended as a mechanism for thinking about issues of acceptability in the first instance; it was not meant to be the last word on policy justification. It was suggested that the Ladder was being asked to do more than it was capable of doing by policy makers, particularly in the Public Health White Paper Healthy People, Healthy Lives.[353] Though the Ladder was useful, it only had one dimension, and so did not reflect the complexity of policy interventions. For example, providing information was at the bottom of the Ladder but the provision of information could be legally required, and the requirement would have the same coercive backing as other legislation.

Freedom of choice was discussed. It was suggested that the Nuffield Ladder had been used by policy makers because it fitted in with a politically "popular choice agenda". It was noted that there was a wide range of understandings about what sorts of choice should be protected. These included: freedom to make equal choices, freedom to choose as we like, equal freedom to choose as we like, or freedom as non-domination by others. There were problems with all of these understandings of freedom, but the conception of freedom as non-domination by others should be given particular consideration.

Ethics and "Nudge" (Professor Luc Bovens)

Professor Bovens first defined the concept of nudging, citing four criteria that made an intervention a nudge: the intervention must not restrict choice; it must be in the interests of the person being nudged; it should involve a change in the architecture or environment of the choice; it should exploit a mechanism of less than fully deliberative choice. These were relevant to judging what make a nudge permissible.

Professor Bovens noted that most people's immediate reaction to nudging was to think that they were being manipulated. He discussed the differences between subliminal advertising and nudging. He noted that there were two sorts of transparency; transparency could mean that people were told about an intervention or it could mean that people were able to discern for themselves that an intervention had been implemented. In the case of subliminal messaging, the first sort of transparency makes no difference to whether the messaging is manipulative. Similarly, for some interventions, such as placing health food first in a cafeteria, the first sort of transparency might prevent it from working as well. The second sort of transparency, that a perceptive person should be able to discern the intervention, was considered the most important sort.

Professor Bovens highlighted four other facts which should be considered when thinking about the ethics of nudging: the urgency of the problem to be solved; the cost of the intervention for responsible agents (not only financial cost but the cost, for example, of restriction of choice or intrusiveness); the extent to which the nudge is in the interests of the person being nudged; the identity of the organisation doing the nudging.

Discussion: are nudges ethically acceptable?

The extent to which businesses nudge people was considered. It was noted that experiments showed that food adverts influenced people's behaviour in ways that they were not aware of. Adverts exploited the same mechanisms but advertising was not generally considered unethical, unless it was deceptive or inappropriately targeted, for example, at children.

The justifiability of governments intervening to change social norms was discussed. It was suggested that many people would not be happy for government to seek to change the culture of society. Others argued that it was legitimate for the government to look at social norms which were already changing, as in the case of binge drinking.

In conclusion, it was agreed that thinking about choice was very difficult and there was a tendency to fall back on the 'harm principle'. The problem however was that governments would not be able to protect all choices and so they must decide which were most important. Thinking about choice was complicated by different conceptions of autonomy, particularly given the distinction between automatic and reflective choices. The extent to which autonomy should include both automatic and reflective choices was considered. How autonomy was conceived would have a direct impact on the acceptability of nudging, which sought to influence automatic choices. The concepts of informed and fully informed choices were then discussed. It was argued that there was often hypocrisy in public policy, particularly medical ethics, about whether only informed choices should be protected. It was agreed that governments should think very carefully about what they what they meant if they said that an intervention would restrict choice.

348   Tackling obesity: future choices, op. citBack

349   Public health: ethical issues, op. citBack

350   Healthy Lives, Healthy People, op. citBack

351   Public health: ethical issues, op. citBack

352   IbidBack

353   Healthy Lives, Healthy People, op. citBack

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