Promoting population health through manipulation: Behavioral economics, public health and social justice

Acts of health promotion range from value-free information provision to sanctions and coercion. I evaluate emerging findings from behavioral economics (BE) in advancing our understanding of ethical practices in health promotion. Fusing psychology and economics, BE has demonstrated that people are often motivated by preferences that are frequently not in their best interests. BE research makes two potential contributions to understanding some of the normative dimensions of health policymaking: (1) it provides an analysis of cognitive distortions, including loss aversion and preference inconsistencies that lead people to form irrational preferences, and (2) it suggests the existence of an adaptive capacity to maintain happiness despite adverse health that could de-prioritize efforts to maintain health. The findings of BE have informed libertarian and asymmetric paternalist approaches to program design and policymaking. Broadly, these approaches favor non-coercive policy interventions (commitment mechanisms, opt-in or opt-out defaults, framing and labeling) that manipulate the “choice architecture” in ways that guide individuals to make welfare-promoting choices. As these approaches become more prevalent in health promotion and disease surveillance contexts (e.g., opt-out A1C registry in NYC), they compel us to reevaluate: (1) the ethical justifiability of manipulation and coercion in the design and implementation of public health interventions, and (2) our understanding of individual and social responsibility for health. BE-based interventions are a unique breed, favoring individual liberties while altering certain features of the social and lifestyle environment. Here, I explore the extent to which such approaches are consonant with a social justice orientation to public health.