Institute for the Health Sciences, Norwegian University of Science and Technology, Gjovik, Norway; Centre of Medical Ethics, University of Oslo, Oslo, Norway.
Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria; Faculty of Philosophy and Education, University of Vienna, Vienna, Austria.
Patient Educ Couns. 2018 Sep;101(9):1561-1569. doi: 10.1016/j.pec.2018.03.021. Epub 2018 Mar 27.
Nudging is the purposeful alteration of choices presented to people that aims to make them choose in predicted ways. While nudging has been used to assure high uptake and good outcome of screening programs, it has been criticized for being paternalistic, undermining free choice, and shared decision making. Accordingly, the objective of this study is to explore a) nudging strategies identified in screening, b) arguments for and against nudging; and on basis of this, to c) suggest a tentative conclusion on how to handle nudging in screening.
Literature searches in Ovid MEDLINE and PsycINFO for combinations of screening and nudging. Screening based on content analysis of titles, abstracts, and articles.
239 references were identified and 109 were included. Several forms of nudging were identified: framed information, default bias, or authority bias. Uptake and public health outcome were the most important goals. Arguments for nudging were bounded rationality, unavoidability, and beneficence, while lack of transparency, crowding out of intrinsic values, and paternalism were arguments against it. The analysis indicates that nudging can be acceptable for screenings with (high quality) evidence for high benefit-harm ratio (beneficence), where nudging does not infringe other ethical principles, such as justice and non-maleficence. In particular, nudging should not only focus on attendance rates, but also on making people "better choosers."
Four specific recommendations follow from the review and the analysis: 1) Nudging should be addressed in an explicit and transparent manner. 2) The means of nudging have to be in proportion to the benefit-harm ratio. 3) Disagreement on the evidence for either benefits or harms warrants special care. 4) Assessing and assuring the intended outcome of nudging appears to be crucial, as it can be context dependent.
推动是有目的地改变呈现给人们的选择，旨在使他们以预测的方式做出选择。虽然推动已被用于确保筛查计划的高参与率和良好结果，但它因具有家长式作风、破坏自由选择和共同决策而受到批评。因此，本研究的目的是探讨：a）筛查中确定的推动策略；b）支持和反对推动的论点；并在此基础上，c）提出关于如何处理筛查中推动的初步结论。
在 Ovid MEDLINE 和 PsycINFO 中搜索与筛查和推动相结合的文献。基于标题、摘要和文章的内容分析进行筛查。
确定了 239 篇参考文献，其中 109 篇被纳入。确定了几种形式的推动：框架信息、默认偏差或权威偏差。参与率和公共卫生结果是最重要的目标。支持推动的论点是有限理性、不可避免性和善行，而缺乏透明度、内在价值观的排挤和家长式作风则是反对的论点。分析表明，对于具有高获益-风险比（善行）的证据的筛查，推动是可以接受的，并且推动不会侵犯其他伦理原则，如正义和不伤害。特别是，推动不应仅关注出席率，还应使人们成为“更好的决策者”。
从审查和分析中得出了四项具体建议：1）应明确和透明地处理推动问题。2）推动的手段必须与获益-风险比成比例。3）对证据的益处或危害存在分歧需要特别关注。4）评估和保证推动的预期结果至关重要，因为它可能取决于具体情况。
