Download PDFPDF

Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care
Compose Response

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g.
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests


  • Responses are moderated before posting and publication is at the absolute discretion of BMJ, however they are not peer-reviewed
  • Once published, you will not have the right to remove or edit your response. Removal or editing of responses is at BMJ's absolute discretion
  • If patients could recognise themselves, or anyone else could recognise a patient from your description, please obtain the patient's written consent to publication and send them to the editorial office before submitting your response [Patient consent forms]
  • By submitting this response you are agreeing to our full [Response terms and requirements]

Vertical Tabs

Other responses

  • Published on:
    Pause before you nudge: ethical implications of behavioral economics and choice architecture in the health care setting
    • Jonathan Kantor, Adjunct Assistant Professor of Dermatology University of Pennsylvania School of Medicine

    The authors should be commended for highlighting some of the groundbreaking work on behavioral economics and touching on the potential for nudging in the clinical setting.1 Recently, others have advocated for the broad incorporation or nudge units within health systems.2 While the authors focus on physician-oriented nudges, for patient-directed nudges in particular, reflecting on the ethical implications of the nudge, and deciding to what degree patient autonomy is compromised, may be particularly important for physicians embarking on incorporating choice architecture into practice.

    There is an important distinction between engaging in what the original proponents of nudging termed “libertarian paternalism” (e.g., encouraging smoking cessation),3 and self-serving nudging (e.g., encouraging patients to choose a particular procedure or treatment, which may also benefit the physician or health care system).4 Indeed, concerns abound regarding the ethics of nudging the informed consent process, and pharmaceutical companies’ reliance on similar heuristics to improve sales is well established.5,6

    It is also worth highlighting that nudges are often experimental; as such, it is not always clear that they will have the desired effect, further stressing the need for an ethical pause. While these concerns are implicitly acknowledged by the authors, given the potential impact of nudges, and the lack of patient-facing transparency in developing choice architecture—a defini...

    Show More
    Conflict of Interest:
    None declared.