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Nudge or Grudge? Choice Architecture and Parental Decision-Making

Richard Thaler and Cass Sunstein define a nudge as “any aspect of the choice architec­ture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives.” Much has been writ­ten about the ethics of nudging com­petent adult patients. Less has been written about the ethics of nudging surrogates’ decision-making and how the ethical considerations and argu­ments in that context might differ. Even less has been written about nudging surrogate decision-making in the context of pediatrics, despite fundamental differences that exist between the pediatric and adult con­texts. Yet, as the field of behavioral economics matures and its insights become more established and well-known, nudges will become more crafted, sophisticated, intentional, and targeted. Thus, the time is now for reflection and ethical analysis re­garding the appropriateness of nudg­es in pediatrics.

We argue that there is an even stronger ethical justification for nudg­ing in parental decision-making than with competent adult patients de­ciding for themselves. We give three main reasons in support of this: (1) child patients do not have autonomy that can be violated (a concern with some nudges), and nudging need not violate parental decision-making au­thority; (2) nudging can help fulfill pediatric clinicians’ obligations to ensure parental decisions are in the child’s interests, particularly in con­texts where there is high certainty that a recommended intervention is low risk and of high benefit; and (3) nudging can relieve parents’ deci­sional burden regarding what is best for their child, particularly with deci­sions that have implications for pub­lic health.

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