Nudges and hard choices

Nudges are small changes in the presentation of options that make a predictable impact on people's decisions. Proponents of nudges often claim that they are justified as paternalistic interventions that respect autonomy: they lead people to make better choices, while still letting them choose for themselves. However, existing work on nudges ignores the possibility of “hard choices”: cases where a person prefers one option in some respects, and another in other respects, but has no all-things-considered preference between the two. In this paper, I argue that many significant medical decisions are hard choices that provide patients with an opportunity to exercise a distinctive sort of “formative autonomy” by settling their preferences and committing themselves to weigh their values in a particular way. Since nudges risk infringing formative autonomy by depriving patients of this opportunity, their use in medical contexts should be sensitive to this risk

When Not to Ask: A Defense of Choice-Masking Nudges in Medical Research

In this article, we examine the legality and ethics of a controversial but widespread practice in clinical research: choice-masking nudges. A choicemasking nudge (CMN) exists when a research team explicitly obscures a meaningful choice from participants by presenting a default decision as the standard way forward. Even though an easy-to-use opt-out mechanism is available for participants who independently express concerns with the standard default, the fact that a default has been pre-selected is not made obvious to research participants. To opt out of the nudge, a participant must overtly request non-standard treatment. We argue that use of such nudges in medical research can be justified by their individual, collective, and social benefits, provided that they respect autonomy and satisfy four additional acceptability conditions. In Part II of this Article, we describe three controversial cases of CMNs in medical research. In Part III, we provide background on nudging and explain how our proposed CMNs fit into the existing literature on nudging and libertarian paternalism. In Part IV, we explain how the reasonable person standard as employed by United States research regulations can be used to support CMNs. In Part V, we anticipate some of the strongest objections to CMNs by explaining how CMNs are compatible with a wide range of plausible accounts of autonomy. Finally, in Part VI, we discuss four additional core considerations an acceptable CMN must meet: legitimate policy goals; benefits outweighing harms; burdens distributed fairly; and absence of ethically superior feasible alternatives. We also revisit and analyze the three existing controversies previously explored in Part II and show how each would benefit from the conceptual clarity offered by our analytic framework. Medical research is complicated and can be difficult for participants to understand. Thoughtfully designed CMNs can play an important role in gently guiding large numbers of research participants toward decision outcomes that really are best for them and their communities

Transparency in Metaethics

Many of us pride ourselves on our moral credentials. But, while we may be confident in our views about what is right or wrong, when we take a step back to consider our moral views more generally or abstractly, we recognize that there are many features of our moral thought and talk that moral competence does not shed light on. Being able to answer questions about what kind of person we ought to strive to be, or what actions we are forbidden from performing does not mean that we are able to answer metaethical questions about the metaphysical, epistemological, semantic, and psychological views, assumptions, and commitments that underlie these practices. Moral competence does not guarantee true beliefs about metaethical issues, or competence to engage with such issues at the level of abstraction this kind of engagement actually requires. Answers to metaethical questions are often opaque to us rather than transparent: we can participate competently in our moral practice without having true beliefs about its metaethical underpinnings; indeed, we can participate without having any such beliefs at all. Metaethicists have lots of beliefs about the metaethical underpinnings of our moral practices. But for all their successes, metaethicists often fail to pay attention to the ways that failures of transparency matter to metaethical theorizing. Often, in the course of defending or arguing against a particular metaethical theory, metaethicists assume that the claims made by that theory would have to be transparent to competent moral speakers if they were true: that if the theory is right that something is true of our moral thought and talk, then the theory is also committed to those who are competent with moral thought and talk believing that that something is true. I call this mistake “the transparency fallacy.” In the first paper of my dissertation, I provide a clear, general formulation of the transparency fallacy, which is assuming, without further argument, that if p, then competent moral speakers and thinkers believe that p, where p is some putative metaethical fact. In the second paper of my dissertation, I consider a particular commission of the transparency fallacy made by Jack Woods in his recent argument against expressivism. And in the third paper of my dissertation, I consider a case where a failure of transparency leads to a dialectical impasse between cognitivists and expressivists. My dissertation represents only a first attempt to tackle some very large questions in metaethics and metametaethics (to borrow Jamie Dreier’s unfortunate but apt term). I gesture at how these questions might be answered but leave the details to be worked out in later research

Ethical veganism and free riding

The animal agriculture industry causes animals a tremendous amount of pain and suffering. Many ethical vegans argue that we therefore have an obligation to abstain from animal products in order to reduce this suffering. But this argument faces a challenge: thanks to the size and structure of the animal agriculture industry, any individual’s dietary choices are overwhelmingly unlikely to make a difference. In this paper, we criticize common replies to this challenge and develop an alternative argument for ethical veganism. Specifically, we argue that individuals should abstain from animal products because vegans, as a group, successfully reduce animal suffering, and individuals are obligated to participate in rather than free ride on this collective endeavor. Or, at the very least, individuals have strong reasons to purchase fewer inhumanely-raised animal products—even if they are not obligated to go vegan per se

When not to ask: a defense of choice-masking nudges in medical research

In this article, we examine the legality and ethics of a controversial but widespread practice in clinical research: choice-masking nudges. A choicemasking nudge (CMN) exists when a research team explicitly obscures a meaningful choice from participants by presenting a default decision as the standard way forward. Even though an easy-to-use opt-out mechanism is available for participants who independently express concerns with the standard default, the fact that a default has been pre-selected is not made obvious to research participants. To opt out of the nudge, a participant must overtly request non-standard treatment. We argue that use of such nudges in medical research can be justified by their individual, collective, and social benefits, provided that they respect autonomy and satisfy four additional acceptability conditions. In Part II of this Article, we describe three controversial cases of CMNs in medical research. In Part III, we provide background on nudging and explain how our proposed CMNs fit into the existing literature on nudging and libertarian paternalism. In Part IV, we explain how the reasonable person standard as employed by United States research regulations can be used to support CMNs. In Part V, we anticipate some of the strongest objections to CMNs by explaining how CMNs are compatible with a wide range of plausible accounts of autonomy. Finally, in Part VI, we discuss four additional core considerations an acceptable CMN must meet: legitimate policy goals; benefits outweighing harms; burdens distributed fairly; and absence of ethically superior feasible alternatives. We also revisit and analyze the three existing controversies previously explored in Part II and show how each would benefit from the conceptual clarity offered by our analytic framework. Medical research is complicated and can be difficult for participants to understand. Thoughtfully designed CMNs can play an important role in gently guiding large numbers of research participants toward decision outcomes that really are best for them and their communities

Pain research and children and adolescents with severe intellectual disability: ethical challenges and imperatives

Children with severe intellectual disabilities encounter inequities in pain-related care, yet little pain research involves this population. A considerable issue with pain research in this population is its ethical complexity. This Viewpoint delineates the ethical challenges of pain research involving children (aged 2–12 years) and adolescents (aged 13–21 years) with severe intellectual disabilities. There are two main issues. First, some of the standard methods for assessing pain and pain sensitivity are not suitable for individuals with severe intellectual disability, who are often non-verbal and unable to understand or follow instructions. Second, children and adolescents with severe intellectual disability cannot provide informed consent or assent to participate in pain research, and their dissent is not always recognised. The existing ethical guidelines for pain research by the International Association for the Study of Pain provide helpful, but general, guidance. This Viewpoint supplements these guidelines and uses a well established framework for assessing the ethics of clinical research to highlight points relevant to designing, doing, reviewing, and evaluating research involving children and adolescents with severe intellectual disability, focusing on issues that are unaddressed in existing guidance