Judging nudging: can nudging improve population health?BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d228 (Published 25 January 2011) Cite this as: BMJ 2011;342:d228
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Both this article and the linked editorial make valuable and
interesting reading. I would, however, wish to emphasise a point that is
recognised in each paper, yet is possibly lost in their overall messages.
As a mentor of mine would insist, it's crucial that we keep our eyes
on the prize. The possible oversight in this week's discussion of "nudges"
is of the radical differences in views of what the prize is.
For a libertarian, the prize is not optimal health outcomes: the
prize is achieving political government that does not infringe people's
'basic rights' (widely understood in libertarianism as being to life,
liberty, and property, and not including a right to health; especially a
right to health that can not be waived). In this instance, then, a policy
is judged according to its conforming with a particular understanding of
legitimate governance that values the jealous protection of individual
The authors are right to say, for example: "While nudging relates
more closely to whole population approaches to disease prevention,
indirect harm might arise if an emphasis on nudging resulted in neglect of
population level interventions that were potentially more effective."
But it is wrong to infer from such a point that there is a problem
with nudging. To repeat, the libertarian's concern is the legitimate scope
of government, not the achievement of the highest standard of population
health. Advocates of "nudge" are not speaking on the terms of people who
just want to see improved health. They are speaking on the terms of those
who would wish to see improved health within the confines of particular
limiting political constraints.
So it is important not to criticise Nudge where it is consistent with
its own tenets. You can, of course, oppose the fundamentals of
libertarianism. But you won't embarrass a political position by showing it
does what its advocates argue it is supposed to do on its own terms. The
ends of libertarianism do not entail optimal health outcomes amongst a
population. Efficacy is judged by a different measure.
Debates about the relative health effects of a particular policy are
not the same as those about its political legitimacy or desirability.
NB - for the record, and in the spirit of arguments expressed in this
week's observation piece by McCartney et al (BMJ 2011;342:d269), I
disclose that I am not an advocate of libertarianism (paternalist or
otherwise), and support a brand of welfare liberalism.
Competing interests: No competing interests
I have read with interest the articles promoting public health,
contrasting the anticipated and proven benefits of prescriptive measures,
namely legislation, and non-prescriptive, namely environmental &
Certainly, in the areas of tobacco & alcohol there is good
evidence that legislation to reduce availability & usage are effective
in reducing certain Non Communicable Diseases (NCD)
Legislation to beneficially modify diet and increase physical
activity does not yet exist
Certainly, people are influenced, beneficially or detrimentally, by
"advertising" and "display"
Certainly, increasing awareness of public health problems &
hazards does make the medical profession and public more receptive to life
If the above be so, then the lesson to be learned is that problems
with multi-factorial aetiology require multi-factorial measures to resolve
Does "nudging" have a place amongst those measures? Probably, yes, as
an additional approach to other, more widely employed measures
Now is the time to employ all available measures if we are to reduce
the incidence of NCDs
A project, employing all of the above measures, in conjunction with
diagnosis & treatment of heart disease, cardiac risk-assessment and
prophylactic statins when appropriate, will shortly be commencing in the
city of Ufa, situated in Bashkortostan, Russia
Numerous associated research projects will be undertaken, including
assessment of optimal ways of influencing Russian men, women &
children to adopt life-style modification
Details can be found at www.i-charm.co.uk
1. Framingham Heart Study 2008; Social Networks exert key influences
on decision to quit smoking
2. North Karelia project Diabetes Voice 2008; vol 53 special issue
Competing interests: Executive Director International Cardiac Healthcare & RiskFactor Modification