Yashar Saghai

This paper presents a literature review on the ethics of self-tracking technologies which are utilized by users to monitor parameters related to their activity and bodily parameters. By examining a total of 65 works extracted through a systematic database search and backwards snowballing, the authors of this review discuss three categories of opportunities and ten categories of concerns currently associated with self-tracking. The former include empowerment and well-being, contribution to health goals, and solidarity. The latter are social harms, privacy and surveillance, ownership control and commodification of data, autonomy, data-facilitated harm, datafication and interpretability of data, negative impact on relation to self and others, shortcomings of design, negative impact on health perception, and regulation and enforcement of rules. The review concludes with a critical analysis of the existing literature and an overview of a future research agenda that could complement the current work on ethics of self-tracking.

I warmly thank Richard Ashcroft, Luc Bovens, Gerald Dworkin, Brynn Welch, and Alan Wertheimer for their insightful comments on my article.1 As I do not have the space to discuss all the questions they raise, I will focus on four concerns that run through my commentators’ responses. Wertheimer argues that my Choice-Set Preservation Condition is objectionable because it wrongly implies that any reduction of the choice-set is incompatible with the preservation of freedom of choice.2 He notes that removing unimportant options may enhance the influencee's ‘deliberative capacities and, perhaps, her freedom’. I agree with Wertheimer's substantive claim, although I do not think it is incompatible with my view. As Joel Feinberg argued, freedom of choice is undermined when fecund options are eliminated.3 Fecund options are options that lead to another array of options. For instance, the choice between several universities opens up different career prospects. Restricting those upstream choices has consequences on an unspecifiable number of branching downstream choices. However, restricting ‘limited’ options (eg, multiple toothpaste brands) that are not gateways to other options may actually facilitate decision-making and ultimately increase freedom. Cluttering our minds with trivialities would undermine the exercise of practical reason. Welch's objections focus on my definition of easy resistibility.4 He claims that my definitions of easy resistibility and of the ability to resist an influence easily are inconsistent. Dworkin argues that the language of the ‘ability to easily resist’ overlooks the critical distinction between having a capacity and exercising it.5 While I stand by my understanding of nudges, I would like to rephrase my view in order to consolidate some of the definitions I offer, taking into account the comments of Dworkin and Welch. I defend the thesis that an influence preserves freedom of choice if and only if it is …

The distinction between clinical research and clinical practice directs how we partition medicine and biomedical science. Reasons for a sharp distinction date historically to the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, especially to its analysis of the “boundaries” between research and practice in the Belmont Report (1978).Belmont presents a segregation model of the research-practice distinction, according to which research and practice form conceptually exclusive sets of activities and interventions. This model is still the standard in federal regulations today. However, the Commission’s deliberations and conclusions about the boundaries are more complicated, nuanced, and instructive than has generally been appreciated. The National Commission did not conclude that practice needs no oversight comparable to the regulation of research. It debated the matter and inclined to the view that the oversight of practice needed to be upgraded, though the Commission stopped short of proposing new regulations for its oversight, largely for prudential political reasons.

The distinction between clinical research and clinical practice directs how we partition medicine and biomedical science. Reasons for a sharp distinction date historically to the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, especially to its analysis of the “boundaries” between research and practice in the Belmont Report (1978). Belmont presents a segregation model of the research-practice distinction, according to which research and practice form conceptually exclusive sets of activities and interventions. This model is still the standard in federal regulations today. However, the Commission’s deliberations and conclusions about the boundaries are more complicated, nuanced, and instructive than has generally been appreciated. The National Commission did not conclude that practice needs no oversight comparable to the regulation of research. It debated the matter and inclined to the view that the oversight of practice needed to be upgraded, though the Commission stopped short of proposing new regulations for its oversight, largely for prudential political reasons.

There is growing interest in using non-coercive interventions to promote and protect public health, in particular "health nudges." Behavioral economist Richard Thaler and law scholar Cass Sunstein coined the term nudge to designate influences that steer individuals in a predetermined direction by activating their automatic cognitive processes, while preserving their freedom of choice. Proponents of nudges argue that public and private institutions are entitled to use health-promoting nudges because nudges do not close off any options. Opponents reply that the nudgee has no opportunity to deliberate over her choice. The nudger controls the nudgee, who has no real freedom of choice. In my dissertation, I salvage the concept of nudge from the charge that it merely pays lip service to freedom of choice, offer an alternative account of the moral import of nudges for the evaluation of public health policies, and provide an ethical framework for their justified use. My argument proceeds in four steps. First, I argue that nudging mechanisms often involve some form of incomplete deliberation, and do not always bypass deliberation. Second, I maintain that nudges preserve freedom of choice because they preserve the choice-set and are substantially noncontrolling. I show that the debate over nudges is plagued by confusion between real nudges, which are easily resistible and therefore substantially noncontrolling, and influences that are not easily resistible yet activate the same cognitive mechanisms as nudges. Third, I reject the view that nudges are systematically preferable to more controlling influences, even when they interfere with non-consequential liberties. I show that the principle of the least restrictive alternative often invoked in public health ethics is applied with too wide a scope. Fourth, I argue that paternalism is not central to the ethics of public health nudges. Rather, the substantive problem with nudges is that their overall cumulative effect might weaken our decisional capacities or undermine their proper exercise. This is a reason to limit recourse to certain nudges. I finally show, contra certain Kantians and Millians, that we have no perfect duty to engage or enhance decisional capacities.

In her target article “Shared health governance” (AJOB 11(7): 32-45, 2011) and in her book Health and Social Justice (2009), Jennifer Prah Ruger defends an original model of governance dubbed “Shared Health Governance” (SHG). This model borrows elements from many other models of governance, and one may wonder what is the secret sauce that holds together these diverse ingredients. In response, Ruger would perhaps ultimately turn to public moral norms. My comment raises some concerns about the function and content of these norms in her model and their connection to her claims about shared sovereignty within SHG.

In recent years, ‘nudge’ theory has gained increasing attention for the design of population-wide health interventions. The concept of nudge puts a label on efficacious influences that preserve freedom of choice without engaging the influencees’ deliberative capacities. Given disagreements over what it takes genuinely to preserve freedom of choice, the question is whether health influences relying on automatic cognitive processes may preserve freedom of choice in a sufficiently robust sense to be serviceable for the moral evaluation of actions and policies. In this article, I offer an argument to this effect, explicating preservation of freedom of choice in terms of choice-set preservation and noncontrol. I also briefly explore the healthcare contexts in which nudges may have priority over more controlling influences.