Nudging for Health: a Genuine Push or the Pinnacle of the Nanny State?

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Title:

Nudging for Health:

a Genuine Push or the Pinnacle of the Nanny State?

Author: Daan Warmerdam

Student number: S1537504

Supervisor: Wouter Kalf

Leiden University, Faculty of Humanities

Abstract:

The debate on state interference to promote citizen’s health is broad and controversial. In this thesis, my aim is to provide a philosophical argument in favour of nudging for health, which is an effective tool to create more health. Liberals in general are afraid that nudging for health is too paternalistic and coercive and hence deprive our freedom. I will argue that some liberals and specifically “Humean liberals” can accept this far-reaching and invasive interference in the personal sphere. This argument is based on the idea that we should follow our ‘higher’ desire to be healthy.

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Health is a necessity for a good human life, because it enables us to fulfil our life plans. The Netherlands is seen as one of the healthiest countries of the world with an excellent healthcare system.1_{However, like all societies, also the Netherlands faces serious health challenges. If the} trend scenarios would become a reality, we can legitimately claim that we are heading towards a health crisis. In 2040, 54% of the Dutch population would have a chronic disease, 1.5 million people will suffer from diabetes type-2 and 63% of the people would be overweight.2_{So isn’t} there any good news? Yes, our life expectancy will increase from 81.5 to 86. However, men will get their first chronic disease when they are 46 years old and women at the age of 41.4 years. So we are close to living the majority of our lives in illness. Moreover, our healthcare expenditure will increase from 87 billion to 174 billion euros in 2040. That is an increase of 200%, which is an immense burden on our society.

So what is the culprit of these alarming trends? It is our lifestyle. The choices we make on a daily basis are making us sick. These choices are strongly influenced by cognitive biases and our set of choices. A fundamental question that arises is if we could blame individuals for their illness when the set of choices are mostly unhealthy and steer us towards an unhealthy choice. According to behavioural psychologists and economists, human beings are imperfect decision makers (Simon, 1957; Dawes, 1988; Kahneman & Tversky, 1979; Katz & Kahn, 1966). This notion strengthens the idea that we are not always capable of making rational choices. If we want to create more health, which is in everyone’s interest, then it might be a solution to influence the set of choices that are presented to us.

In policy-making, there is a recent trend and attention to behavioural research in an attempt to reach policy goals, such as health promotion. Policy-makers mostly focus on the approaches that are seen as 'nudges'. By changing the contexts of decisions, it is possible to eliminate a person’s cognitive biases and heuristics and steer someone in a specific direction without directly interfering in their personal sphere. This is called 'choice architecture' and describes how the design of choices impacts our decisions. Nudging focuses on the way information is presented to us and influences the probability that we will choose in one direction over another. However, critics (Caloia, 2015; Hausman & Welch, 2010) are concerned about these influences. They claim that nudges are manipulative, coercive, deceptive, lacks transparency and undermine the liberty and autonomy of an individual. Liberal political theorists in particular have difficulties with nudging because the state interferes in the private sphere. They claim that freedom of choice is more critical than preventing us from making mistakes, even if nudges create more health for us all. Here is a tension. We all want to live in a liberal state and improve our health in an effective way, but we do not want to reach this goal via a paternalistic way. It

1_{Measuring performance on the Healthcare Access and Quality Index for 195 countries: a systematic analysis} from the Global Burden of Disease Study. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext#seccestitle310. August 6, 2019.

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is proven that health nudges are effective but they are considered to be paternalistic. Can nudging for health and liberalism go together?

The main question in this thesis is whether nudging for health is consistent with “Humean liberalism”.3_{I want to find out if a Humean liberal can, in principle accept a form of paternalism} in the form of nudging to improve the health status of individuals. This form of liberalism matches with the notion of positive freedom. According to “Humean liberalism”, one is truly free when he or she can follow their 'higher' desires and hence realize their 'true' self. Consequently, people act rationally if they act following their 'true' self. The Humean aspect of this kind of liberalism is rooted in procedural practical rationality and tells us how we should act in accordance with our ‘true’ self.4

Over three different chapters, I will formulate an answer to the main question of whether nudging for health is consistent with "Humean liberalism". In the first chapter, I formulate a clearly demarcated definition of nudging for health. First, I will clarify the concept of health. Second, I focus on underlying reason why we are unhealthy, which is about the fact that we are imperfect decisionmakers. Section III shows how nudging is an effective tool to make us healthier. Thereafter, in Section IV, I highlight the critique on nudging. Critics claim that nudging is coercive, paternalistic, lack transparency and undermines our liberty and autonomy. I will opt for a far-reaching and invasive definition of nudging for health and argue that this strong form of nudging is required for the maximum promotion of our health. Moreover, the argument is way more compelling if it is possible to show that a strong definition of nudging is compatible with “Humean liberalism”.

In the second chapter, I will focus on liberalism. What is the core idea of liberalism? What kinds of freedom do liberals want to protect and why? In the first section I explain the core idea of liberalism in general and its origin. Section II offers two conceptions of liberty: negative and positive. I argue that we should not only be concerned with negative freedom, but also with positive freedom if want to be truly free. Thereafter, in Section III, I examine whether these two rival and incompatible conceptions of liberty have any common ground and discuss a possible third conception of freedom. Finally, Section IV discusses if these conceptions of freedom are compatible with my far-reaching definition of nudging for health.

After it is being made clear that liberals, who support the idea of positive freedom, can accept nudging when people follow their 'true' self, we need to know how we act in accordance with our 'true' self. The focus in the last chapter is, therefore, on practical rationality. In Section I, I will make a distinction between Humean and Kantian rationality. I claim that the Kantian view of practical rationality does not make sense. In Section II, I define “Humean liberalism” and argue using Hume’s proceduralism that everyone has the desire to be healthy. Section III shows how nudging for health induces this desire internally through a process of rational deliberation.

3_{What this form says, exactly, will be discussed in Chapter 3, Section II.}

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In the last section, I will return to the sceptical liberals and argue that their fear for nudging for health is groundless.

I will conclude that nudging for health is consistent with “Humean liberalism”. Nudging is an essential tool to tackle the severe health challenges we face today and it is compelling that there is a form of liberalism that accepts far-reaching and invasive health nudges to support the realization of people's desire to be healthy. It is a reassuring idea that this tool does not restrict the freedom of individuals, but enables them to realize even more desires that they seek.

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Chapter 1. Nudging for Health.

The goal of this chapter is to get a better understanding of nudging for health and to formulate a clear a demarcated definition of nudging for health. In the first section I will clarify the concept of health. What is health? When are we healthy? In the second section I will focus on human fallibility; the reason for why we live so unhealthy. After that, in section III, I argue that nudging for health is our lifebuoy for a healthier life. In section IV, I address the objections to nudging that it would be paternalistic and coercive.

Section I. What is health?

Our health is probably the most precious possession humans have. It enables us to fulfill our life goals and chase our dreams. But what exactly is health? The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease of infirmity." I believe that the definition of the WHO is too broad and unrealistic. Because how many times do you feel that you are in a complete state of physical, mental and social well-being? Probably not often and that is fine. It does not mean that you are sick and unhealthy if one of the factors are a little low for a while.

Moreover, the definition of the WHO is missing an essential key factor: the environment in which people live. It was only 15 years ago that scientists believed that DNA was our destiny. We thought that the answers for diseases and the holy grail of longevity and health were in our genetics, but a breakthrough in empirical evidence showed that our lifestyle is our most important determinant for health. 80% of the risk of disease in later life is due to lifestyle factors; the genes we inherit can explain merely 20% of our lifelong health (Herskind, et al., 1996). In other words, most of our health is determined by how we live our lives. The quote of Reid (2008) sums it up strikingly: "Genes load the gun, but environment pulls the trigger."

I argue that health is more about a dynamic balance between our environment and personal health. Therefore I will adopt the definition of health of The Pando Network (2019):

“Health is a dynamic balance between physical, mental and social being, where the well-being of an individual is connected with the physical social and natural well-well-being of the whole community.”

This definition of health contains more nuances, by the emphasis on the balance between the factors, than the definition of the WHO. An essential addition to this definition is the connection between personal health and the health status of the whole community. By this addition, our health status becomes not only a personal responsibility but also a collective responsibility. This is remarkable because in our current world, health is mostly seen as an individual responsibility, which is odd because the health challenges of today are closely related with the way we structure our societies as human beings. What are the health challenges of today?

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At this moment, non-communicable diseases (NCDs) are estimated to account for 90% of all deaths in The Netherlands.5_{NCDs are diseases that are driven by rapid unplanned urbanisation} and the globalisation of unhealthy lifestyles. Examples of NCDs are cardiovascular diseases, obesity, strokes, cancers, chronic respiratory diseases and diabetes. The culprit for most of these diseases is our lifestyle. Overweight and obesity, for example, can lead to diabetes type-2, cancer and cardiovascular diseases and are related to our diet and physical activity. In 2018, 50.2% of the Dutch people were overweight and 15% were obese.6_{Following the projected} trends, this will significantly increase over the next years. Thereby, stress puts the physical and mental health under enormous pressure. Men face their first chronic disease at the age of 46; for women this is 41.4 years.7_{So our years in good health are almost equal to the unhealthy} years. This fact is astonishing. All of these figures are the result of our unhealthy lifestyles. Our lifestyle is making us sick.

5_{See Non-communicable diseases country profiles. (World Health Organization, 2018).} 6_{See https://bronnen.zorggegevens.nl/Bron?naam=Leefstijlmonitor. Retrieved April 22, 2019.}

7_See https://www.volksgezondheidenzorg.info/onderwerp/gezonde-levensverwachting/cijfers-context/huidige-situatie#node-gezonde-levensverwachting-naar-geslacht. Retrieved April 22, 2019.

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Section II. Human fallibility.

Why do we live unhealthy? I argue that this is due to human fallibility. We are not able to make healthy choices because humans are imperfect decision makers (Simon, 1957; Dawes, 1988; Kahneman & Tversky, 1979; Katz & Kahn, 1966). A range of cognitive quirks and stumbles affect how we make choices and decisions (Amir & Lobel, 2008). Some arise as a result of our conscious and reflective cognitive processes, while others come from our automatic and reflexive ones (Quigley, 2014). Multiple factors can lead to mistakes in human judgment and decision-making, such as optimism and overconfidence, loss aversion, a status quo bias, framing, anchoring, availability and representativeness. In this section I will highlight a few of the factors that affect our decision-making and consequently our health in more depth.

People are overconfident and unrealistically optimistic even when the stakes are high. An example; 39% of the marriages in The Netherlands will end in a divorce, and most people know this statistic.8_{However, around the time of the ceremony, approximately 0 per cent believes} that their marriage will end in a divorce; even the people that have already been through a divorce (Sunstein, 1998). It is illustrative for the overconfidence and unrealistic optimism humans can have. Another example; Thaler (2008) once did an experiment with his master Business Administration students. They had to fill out an anonymous survey about the course. One of the questions asked was: “In which decile do you expect to fall in the distribution of grades in this class?" The students are aware that half of the group will be in the top 50 per cent while the other half is in the bottom per cent. Of course, only 10 per cent of the class can end up on the in the top decile. The results of the survey showed that the students had an unrealistic optimism about performance in the class. More than half of the class expects to perform in one of the top two deciles. The largest group put themselves in the top second decile, but this is likely explained by modesty. They actually think that they will be in the first decile.

Unrealistic optimism is a feature of human life and can explain a lot of individual risk-taking, especially in the domain of risks to life and health. If you ask students to envision their future they are likely to say that that chances are low that they will: get fired from their job, get a heart attack or cancer, have a drinking problem or getting divorced after a few years of marriage. Older people believe that they are less likely to get into a car accident or suffer from a disease. The vast majority of smokers know the statistical risks of smoking, however, most of the smokers believe that it is less likely that they get diagnosed with lung cancer and heart disease than most nonsmokers (Sunstein, 1998). This mechanism shows why lotteries are so successful; they make maximum use of this human flaw. In this light, it is to be expected that people fail to take reasonable preventive steps regarding their life and health. So if people are running risks because of unrealistic optimism, they might benefit from a mild push into the right direction.

8_See https://statline.cbs.nl/StatWeb/publication/?VW=T&DM=SLNL&PA=37425ned&D1=3-9&D2=%28l-11%29-l&HD=100526-0713&STB=G1,T. Retrieved April 18, 2019.

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Humans hate to lose and roughly speaking, losing something makes you twice as miserable as gaining the same thing makes you happy (Thaler & Sunstein, 2008). Kahneman, Knetsch and Thaler (1991) have an experiment to illustrate that people are "loss averse". In a class, half of the students get a coffee mug with the logo of their university embossed on it. The students who do not have a mug are asked to examine the mug of their neighbours. Next, the mug owners are invited to sell their mugs to the non-owners by answering the question: "at each of the following prices, indicate whether you would be willing to give up your mug or buy a mug?". The results indicate that people who have a mug roughly want twice the price that non-owners are willing to pay.

The experiment tells us that once you have a mug, you do not want to give it up, but if you are a non-owner, you do not feel the urgency to buy one. Thus, people do not assign specific values to objects, but when they have to give something up it is hard for us. Loss aversion stimulates the tendency to do nothing and stick to your current holdings. In another experiment, half of the students could choose between a chocolate bar and a coffee mug. The costs of the two items were about the same. When they got the opportunity to switch, from the bar to the mug and vice versa, only 10% switched (Thaler & Sunstein, 2008). So loss aversion works as a cognitive nudge, it steers us not to make any changes, even if these changes are in our interests.

The way information is presented to us changes the probability that we will choose in one direction rather than another: this phenomenon is called "framing" (Tversky & Kahneman, 1981). For example, Pete is diagnosed with heart disease, and the doctor proposes a radical and dangerous operation. Pete is curious and asks the doctor about the odds. The doctor tells Pete that there is a 95% probability that the operation will go well and everything will be fine. On the other hand, the doctor could also tell Pete that there is a 5% chance of death. For most of the people, this statement is very alarming and Pete might not opt for the operation. The Automatic System thinks: "A significant number of people are dead, and I might be one of them!" (Thaler & Sunstein, 2008, p. 36). Objectively the statistical risks are the same, yet the way in which the doctor present the information about the operation may influence whether or not Pete wants to undergo the operation.

The decision of whether or not to go ahead with the surgery might also be influenced by someone, that Pete knows, that has had a similar surgery. So if his friend Laura has recently had surgery, regardless of the actual risks involved, this may affect his assessment of the probability of complications or success of the surgery. This human flaw is known as the availability heuristic (Tversky & Kahneman, 1974, pp. 1127-1128). So, framing works because people are passive decision makers and tend to be somewhat mindless. Our reflective system does not do the work that is required to check whether reframing questions will result in different answers. The reason that humans do not do this is because we do not know what to make of the contradiction (Thaler & Sunstein, 2008). This notion indicates how sturdy frames act as nudges.

To sum up this section; humans have different cognitive quirks and stumbles, which affect our decision-making. Humans live in a complex world and cannot afford to think thoroughly about

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every choice they have to make. Therefore, people use sensible rules of thumb that can result in undesirable and harmful choices for themselves. Moreover, people are busy and have limited attention. They accept how information is presented to them rather than questioning it and wonder if their answers would vary under alternative formulations. People's choices, even the most critical life decisions, are influenced by the choice architecture around the available options. Humans are not perfect rational decision-makers and the health challenges we face today are a reflection of our human fallibility. How can we overcome our shortcomings? In the following section I will lay out how nudging for health can be the solution to our problems.

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Section III. Nudging for health.

In this section, I will formulate a clear and demarcated definition of nudging for health and explain how it can improve our health. Thereby, I will describe successful examples of nudges. To overcome our human fallibility and improve our health significantly, I argue that we should opt for far-reaching and powerful health nudges, which are invasive to a large extent in our personal lives. Therefore I discuss the three variables that affect the strength of nudges.

What is nudging?

Imagine you are the director of food for a large system of business cafeterias. You are in charge of hundreds of thousands of employees spread over hundreds of businesses that eat in your cafeterias every day. Moreover, you are a creative type and like to think unconventionally. You are curious whether the arrangement and presentation of the food items in your cafeterias affect the choices employees make daily during their lunch. Without changing the menus, you start an experiment and tell every cafeteria how they should display and arrange the food and beverages. You vary the position of the food items from one cafeteria to another. The desserts in one cafeteria are placed last, while in others first. In one cafeteria the French fries, but in others, carrots are placed at eye level. The results of this experiment are shocking. With only small changes in the context, you can increase or decrease the consumption of food items by as much as 25% (Thaler & Sunstein, 2008, p. 1).

This outcome can be used in two ways: for better or for worse. After analysing the data, you believe you have a considerable power to increase the consumption of healthy foods and decrease the consumption of unhealthy foods. What to do? According to Thaler and Sunstein (2008, p. 2), you have four options:

1. Arrange the food to make the employees best off, all things considered. 2. Choose the food order at random.

3. Try to arrange the food to get the employees to pick the same food they would choose on their own.

4. Maximise profits.

Option 1 is very appealing and seems like the right thing to do, but also seems paternalistic. The second option, arranging the food order randomly, can be seen as neutral and fair. However, if all the food items are ordered randomly in every cafeteria, then some employees will end up with a healthier diet than others. Should you choose this neutral option, when at the same time you could opt for an option that will improve everyone's diet and eventually their health? At first sight, option 3, arranging the food in a way that they would pick themselves seems like an excellent attempt to avoid interference in the personal choices of the employees. Though the experiment shows us that the choices we make are strictly related to the order in which the food items are displayed. So the implementation of this option is difficult because you have to track down what the true preferences are of the employees and what they would choose "on their own". Besides, it is impossible in a cafeteria to avoid some form of organising the food items.

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Option 4 has some appeal to you if you believe that the best cafeteria is the one that makes the most money. However, should you maximize profits at the cost of employee health?

As the director of food for the large system of business cafeterias, you are a 'choice architect'. The choice architect has the responsibility for organising the context in which people make decisions (Thaler & Sunstein, 2008). Choice architects are everywhere around us; most of the time we do not even realise it. For example, if you are a doctor and must describe different treatment plans to a patient, you are a choice architect. The designer of the ballot paper voters use to choose candidates is a choice architect. As a parent, you are a choice architect when you describe educational options to your children. There are similarities between traditional architecture and choice architecture. For instance, a 'neutral design' does not exist as we have seen in the cafeteria example. Traditional architecture and choice architecture both assume that 'everything matters' because small and seemingly insignificant details can have a significant impact on human behaviour. Another illustrative example is the painted fly in the men's urinals at Schiphol airport, which resulted in a spillage decrease of 80% (Vicente, 2006). How does this work? Men typically do not pay attention to where they aim during their toilet visit, which results in quite a mess. However, if they see a target, they aim at it. It is so simple, yet so effective.

Architects realise that they can make some design choices that have beneficial effects, such as open stairways at workplaces that will improve the social interactions between colleagues and stimulate more movement. Moreover, the same is true for the scenario for the director of food of business cafeterias. Eventually, the director has to pick a way in which he or she displays the food items and by doing so, this person influences what people eat. Choice architects can nudge; they give a light and mild push. In this thesis, I will adopt the definition of nudging that is described by Thaler & Sunstein (2008, p. 6) in their book Nudge, which is as follows:

'A nudge is any aspect of the choice architecture that alters people's behaviour in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a small nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates.’

For example, putting fruit at eye level counts as a nudge. Banning junk food does not. An essential aspect of this definition is that the choice architects do not take options away. Every individual still has the freedom to choose the option that makes him worse off if he wants to. Now we know the definition of nudging, however, when is a nudge for health successful? A successful nudge

In the following paragraphs I describe examples of successful nudges. Thereafter, I argue that a nudge for health is successful when the nudges convince us to choose the option that improves our health. According to Thaler and Sunstein (2008) a nudge must be cheap, avoidable and relatively easy to implement. I agree with this notion and believe that these requirements are important. However, I would like to add three variables that affect the strength, and hence the effectiveness of the nudge: content, sender and presentation.

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An example of an effective nudge is presented by Shultz (2007) et al. In their research they examined the powerful effect of social norms on the energy consumption of 290 households in San Marcos, California. Each household received accurate information about the amount of energy they consumed in the weeks before. In addition, they obtained information about the average energy consumption in their neighbourhood. The effects on people's behaviour were both striking and clear. In the weeks after they received information, the above-average consumers significantly decreased their energy consumption, while the below-average consumer increased their consumptions. This is called the boomerang effect and is undesirable because they wanted to reduce the energy consumption. Schultz (2007) et al. concluded that if you want to nudge people to adopt socially desirable behavior, then you must not let them know, under almost any circumstances, that their current behaviour is better than the social norms. The researchers found another fascinating outcome. Half of the households did receive not only descriptive information about their energy consumption but also received a small non-verbal signal in the form of a happy J or sad L emoticon. The big energy consumers showed an even more substantial decrease when they presented them the sad emoticon. However, even more important, the below-average users that received the happy smiley, did not change their consumption anymore, and the boomerang effect totally disappeared. So when the information was combined with an emotional nudge, they did not use the ‘room’ to increase their energy consumption. This is an excellent example of a successful nudge, because the change of behaviour is avoidable, cheap, easy to implement, but above all, effective.

Another example and one of my favourite nudges is the anti-littering campaign implemented in Texas. Officials were frustrated that their expensive and highly publicised advertising campaigns to reduce the littering on its highways did not work. They tried to convince people that it was their civic duty to stop littering. However, the target audience were men between the age of 18 and 24, and were not impressed by the message of the Texas officials who wanted to change their behaviour. So officials decided to change their strategy and formulated a message that was 'tough-talking’ and in line with the unique spirit of Texas pride. The new message was: "Don't mess with Texas!" To reach the unresponsive target audience, the state asked the popular Dallas Cowboys football players to participate in television ads wherein they collected litter, smashed beer cans and shouted the new slogan. Other spots included famous Texan singer Willie Nelson. They started to sell "Don't mess with Texas" products such as t-shirts, coffee mugs and the famous patriotic flag with the slogan. The results of this nudge are stunning, 95% of the Texans now know the slogan, and in the first year, littering dropped with 29%. Over the first six years of the campaign, littering was reduced with a remarkable 72%. These results were not the effects of coercive mandates or threats, but of an effective and creative nudge.

Nudging as the lifebouy

These examples of successful nudges illustrate that nudging can effectively change people’s behaviour. Earlier in this chapter I pointed out that lifestyle is the most crucial determinant for our health. Lifestyle is the sum of the choices we make every day; and all these daily choices together determine our health, from the food we eat to the hours we sleep. So lifestyle is not only the culprit but also the solution at the same time. When people can change their behaviour

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and start to make healthy choices then good health can be just around the corner. Nudges can effectively help us to obtain and retain a healthy lifestyle. Nudging for health is comparable with a lifebuoy for drowning people.

Nudging for health is an essential tool to create an environment in which the healthiest option is the easiest option. Through an environment that stimulates healthy choices, it becomes more likely that we achieve the lifestyle changes that are required for good health. In our modern society it is hard to adopt such a healthy lifestyle. Humans are being negatively influenced all the time by advertisements, technologies and other misleading choice architecture. A set of nudges, such as changing the layout of a supermarket that stimulates the sales of fruit and vegetables, are not only effective but also abundantly cheaper to tackle diabetes type-2 or heart diseases, than advanced and expensive medical treatments. A beneficial by-catch is that it helps to curb the health expenditure tremendously. It is not only in people's interest, but also the public interest.

Though nudging for health can only be effective in improving people’s lives when the nudges are stronger than the misleading nudges that steer us to unhealthy behavior. Therefore I argue that health nudges must be powerful and invasive to a large extent in our personal lives. The strength of a health nudge is dependent on three variables: content, sender and presentation. First, the content of the nudge is important to how we conceive the nudge. There is a difference between a nudge regarding organ donation and a nudge that discourage people to eat junk food. The former nudge is more invasive than the latter because it is more personal and tangible. Whether or not you want to donate your organs is more invasive than whether you stop eating cheeseburgers for the rest of your life.

The second variable that affects the strength of a nudge is the sender. Milgram’s (1963) famous experiment has shown us that humans are sensitive for authority.9_{If a doctor tells you that it is} crucial to exercise more if you want to get rid of diabetes type-2 then it is more likely that you will follow his advice in comparison to an uncle with obesity that gives you the same advice. For a successful health nudge, the sender must be authoritative, credible and trustworthy. Despite the falling trust in governments worldwide, I claim that governments can potentially tick all these boxes.10

The third variable is the presentation of the nudge. The way the options are presented to us influences the probability that we opt for a specific option. Think of the cafeteria example whereby the presentation of the food had a significant impact on the sales of specific items. A strong health nudge could be that healthy salads are at eyesight beside the counter, while the

9_{The experiment wanted to find out how easy it was to get someone to follow orders, even if the orders went} against their conscience. In the experiment, a test subject was ordered by a scientist to inflict electric shocks on another person, though the shocks were faked. Most subjects did as they were told until the very end of the experiment, though many found it difficult. There have been many repetitions and variations of the experiment, with similar results.

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junk food is in a black box in the back of the cafeteria. To sum up, there are three variables that affect the strength of health nudges and I claim that all three must be on full strength for a maximum effect. As a result the nudges can be perceived as highly invasive in the lives of people.

The goal of this section was to get a better understanding of nudging for health and to formulate a clear and demarcated definition of nudging for health. Thereafter, I described a few examples of successful nudges. Lastly, I argued that nudging is our lifebuoy for a healthier life, but will only be effective if the health nudges are far-reaching and powerful. The consequence of this account is that health nudges are invasive to a large extent in our personal lives.

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Section IV. Critique on nudging.

A range of objections to nudging has been raised in the literature.11_{Most of these objections} can be boiled down and linked to the overarching objection that nudging would be paternalistic. In this section, I discuss how nudging for health can be paternalistic and subsequently undermines our liberty and autonomy. Thereafter, I address the objection that nudges are coercive. Other objections are problematic as well, but for this project I will be limiting the scope and only focus on the two objections; that nudging for health can be paternalistic and coercive.

Paternalism

A paternalistic action is intended to promote people’s own good, but limits people’s autonomy and freedom in order to reach this goal. People might be concerned that nudging for health fails to respect people’s agency. Jonathan Quong (2010) argues that all forms of paternalism are wrong because they fail to treat people as free and equal. Quong (2010, p. 80) defines paternalism as any act where:

(1) “An agent A attempts to improve the welfare … of agent B with regard to a particular decision or situation that B faces,” and (2) “A’s act is motivated by a negative judgment about B’s ability … to make the right decision or manage the particular situation in a way that will effectively advance B’s welfare.”

Paternalism is problematic since it involves a negative judgment regarding people’s ability to lead their own lives. Thereby A gets moral power over B. How does A know what is better for B? It is essential that individuals can make their own choices without being limited; even if they opt for the option that makes them worse-off. Nudging for health is paternalistic because it takes advantage of people’s human fallibility to improve their health. Paternalism not only affects the freedom of choice, but also people’s autonomy. Hausman and Welch (2010, p. 128), whom define autonomy as "the control an individual has over his or her own evaluations and choices", illustrate strikingly how paternalistic nudges undermine our autonomy and freedom:

“If an employer sets up a voluntary retirement plan, in which employees can choose to participate, and what she does when, owing to her understanding of limits to her employees’ decision-making abilities, she devises a plan for increasing future employee contributions to retirement. Although setting up a voluntary retirement plan may be especially beneficial to employees because of psychological flaws that have prevented them from saving on their own, the employer is expanding their choice set, and the effect of the new plan on employee savings comes mainly as a result of the provision of this new alternative.”

The freedom of the employees is virtually unaffected because alternatives are still available. However, this nudge does not take the form of rational persuasion, and with that, the autonomy

11_{Critics (Hausman & Welch, 2010; Caloia, 2015; White, 2013) claim that nudges may lead to a decrease in} responsibility in decision-making, lack of transparency, involve deception and manipulation.

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of the employees is diminished, because their action reflects the tactics of the choice architect rather than exclusively their evaluation of the available options. So paternalism is objectionable because it is inconsistent to treat people free and equal. Nudging for health seems like a clear violation of this condition because its main motivation is based on the fact that people make unhealthy choices.

Coercion

The second objection to nudging is that it is coercive. Critics (Caloia, 2015; White, 2013) claim that nudging is coercive because its purpose is to manipulate people’s decision-making processes to change their behavior in pursuit of interests that are not their own. Coercion is not merely the same as steering people's behaviour, so how could we then speak of coercion? It is typically said that coercion "involves the intentional use of force or threats to compel a person to act, and is often differentiated from instances of physical compulsion" (Quiqley, 2014, p. 147). An example of coercion is when John holds a gun to the head of Tom, and says 'your kidney or your life'. In this example, we could rightly claim that Tom has been coerced. The coercer puts pressure on the will of the coerced to do what is requested. They are controlling their behaviour. We might think that this example is not a fair representation of what coercion might look like in the context of influencing people's choices, which trigger shallow cognitive processes.

Critics like White (2013, p. 91) agree on this notion; "to be sure, nudges are not comparable to a mugger holding a gun to your head or a police officer standing ready to arrest you." One way how nudging and the assessment of coercion align is the involvement of agents who attempt to bring about particular outcomes. Nudges have an explicit intention of getting people to take (or not) action or decision. Private and public actors could implement nudge-type interventions. Both marketers and governments employ techniques that rest on the power of social norms. One uses it to sell their products, while the other try to reduce smoking or alcohol consumption. This could lead to decisions, all things considered, that individuals might not prefer to.

However, these activities that steer us into specific directions are too weak to count as coercion. Nudges do not involve the use of force or threat to achieve their ends. It does not forbid people to choose other than the desired direction. By focusing on force or threat the conception of coercion is too demanding. Most activities would not count as coercive under this conception. Therefore we should focus on the mechanism behind coercion: the pressure on the will of the coerced. Critics of nudging might feasibly claim, "that the effect of interventions utilising non-rational cognitive influences is to apply such pressure to the will of nudgees” (Quiqley, 2014, p. 151). If a nudge could be considered as coercion, the pressure would need to be sufficiently controlling. Therefore the resistibility of a choice is vital because coercive pressure is not easily resistible. The example of the cafeteria layout does not seem to put enough coercive pressure because the burgers still look like a viable option. This does not appear to be in standard cases of coercion.

It is possible that other nudges can be classified as coercion. Caloia (2015, p. 23) argues that nudges can impose psychic costs on people: “psychic costs can have a profound enough effect

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on the agent’s life as to be coercive.” Psychic costs could be stress and other forms of “cognitive discomfort”, such as graphics on cigarette packages or information about societal norms. The idea is that this forced confrontation with the consequences of smoking or overeating will lead to negative emotions by people. The coerciveness is dependent on how resistible the created feelings are and how much impact these feelings have on the life of the individual. If it is correct that the psychic discomfort works as a pressure on the will and eventually leads to behaviour change, then we might think nudges are coercive. This theory sounds plausible but it seems unlikely to state that the graphics on cigarette packages put enough coercive pressure on an addicted smoker to stop smoking. It remains possible that other nudges are irresistible, but the nudges that are suggested here are probably resistible. The pressure approach is not able to construct a convincing argument how nudging is coercive. Again, this account of coercion seems to be too strong and demanding. For that reason, I will discuss one last alternative understanding of coercion.

The enforcement approach focuses on the power disparity between agents and formulates coercion “as a kind of activity by a powerful agent who creates and then utilizes a significant disparity in power over another in order to constrain or alter the latter’s possibilities for action” (Anderson, 2010, p. 1). According to this account the coercer is responsible to create a power differential or take advantage over some pre-existing differential in power. This can be reached through brute physical power or conferred by being a civil servant or part of particular institutions (Anderson, 2010, p. 12). If it is true that coercion involves the exploitation of power imbalances by one agent over another in order to (not) undertake a specific action, then the enforcement approach seems relevant to nudging in a way that the pressure approach is not. There are two ways in which the enforcement approach can classify nudging as coercion. First, even if the nudges can be construed as pressure on our will, they do not cause us to feel any overt pressure (Quiqley, 2014, p. 154). Hence, if one wants to claim that nudging is coercive it is important to have an interpretation of coercion whereby this is not a requirement. This approach offers that. Second, private organizations and governments can use their power over people when they try to nudge us. Big companies may have a large marketing budget and experts who know how to take advantage of our human fallibility to construct a convincing campaign. There is a power imbalance between individuals and companies not only in monetary, but also in informational terms. Moreover, states also have a variety of ways to wield power over their citizens. There is more than only creating or maintaining a power imbalance; while overt pressure might not be an explicit requirement for the enforcement approach, there is still a focus on control. It is evident that coercion requires a substantial element of control be exerted over the behaviour of people. Anderson (2010, p. 28) states that coercion “generally disables or threatens to disable its target from being able to take effective countermeasures.” It is more than likely that some nudges are in fact controlling not only because their influence is hard to counter, but also because people believe that options have been foreclosed; even when this is not the case. To conclude, I believe that there are nudges that can be labeled as coercive under this specific interpretation of coercion.

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The aim of this section was to highlight objections to nudging. First, I discussed how nudging for health can be seen as paternalistic and how it fails to treat people equal and free. Second, I addressed the objection that nudging can be coercive based on the enforcement approach instead of the pressure approach.

Conclusion

The goal of this chapter was to get a better understanding of nudging for health and to formulate a clear and demarcated definition. In Section I, I defined health and the challenges we face today. The focus of section II was on human fallibility, which is the underlying reason why we are not able to make healthy choices. In Section III, I adopted the definition of nudging formulated by Thaler and Sunstein (2008): 'A nudge is any aspect of the choice architecture that alters people's behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.’ Furthermore, I argued that nudging is our lifebuoy for a healthier life, but will only be effective if the health nudges are far-reaching and powerful. The consequence of this account is that health nudges are invasive to a large extent in our personal lives. This was the core of Section IV, in which I addressed the objections that nudging is paternalistic and coercive.

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Chapter II. Liberalism.

The goal of this chapter is to get a better understanding of the core idea of liberalism. What types of freedom do liberals want to protect and why? Section I explains liberalism in general terms. Thereafter, I discuss two concepts of freedom; namely negative and positive freedom. Traditionally, political liberalism focuses on negative freedom, however, I argue that we should also be concerned with positive freedom if we want to be truly free. Although these two concepts seem divergent, in Section III I examine whether the concepts have any common ground and discuss a possible third conception of freedom. Section IV answers the question whether the conceptions of freedom that I will discuss are compatible with my far-reaching definition of nudging for health. Lastly, I want to clarify that the terms liberty and freedom are used interchangeably in this chapter.

Section I. What is liberalism?

In this section I want to elaborate on the historical core idea of liberalism, which I believe is the protection of freedom. Because of the scale of this project, I will not be able to discuss all types and interpretations of liberalism; the focus will therefore be on the conception of freedom, which is the root of liberalism. I am aware that liberalism is not one thing. It is a range of related and sometimes competing visions. For some it is the object of a desire or goal, while for others it is a nightmare that signifies either the vicious logic of capitalism or a step towards moral relativism. Most of us see liberalism probably as “the ideological perquisite for living a reasonably and comfortable life in affluent democratic states – the least worst option” (Bell, 2016, p. 62). So why is liberalism then about the protection of freedom?

To quote the English philosopher Maurice Cranston “a liberal is a man who believes in liberty” (1967, p. 459). Traditionally, liberal philosophers (Locke, 1689; Mill, 1963; Feinberg, 1984) stated that people are in a state of freedom that enables us to act, as we think fit, without depending on the will of any other individual. John Stuart Mill (1963, p. 262) argued that “the burden of proof is supposed to be with those who are against liberty; who contend for any restriction or prohibition… The a priori assumption is in favour of freedom…” Freedom is seen as normatively basic, so if one would use coercion to limit freedom they would need compelling arguments to justify interference in someone’s personal freedom.

States limit the liberty of citizens, so it is crucial that political authority and laws are justified. The main question of liberal political theory is whether state intervention can be justified, and if so, how. The social contract theorists (Hobbes, 1651; Rousseau, 1762; Kant, 1965) formulated an answer to this question; their starting point is a state of nature in which every individual is free and equal and every limitation of this freedom and equality must be justified through the social contract. Although Hobbes is not seen as a liberal, there are reasons to regard that he is the instigator of liberalism. He questioned on what grounds citizens owe allegiance to the king in a time that the relation between citizens and the sovereign was taken for granted.

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Hobbes implicates that citizens are not the king’s property; on the contrary kings are accountable to sovereign citizens.

As I mentioned before, Hobbes is one of the first social contract thinkers and is seen as an advocate for unlimited monarchy. According to his theory, Leviathan (Hobbes, 1651) is authorized to do whatever is necessary to restore and keep the peace. It justifies almost any means, including radical limitations on people’s liberty. To be clear, Leviathan’s (Hobbes, 1651) only job is to keep the peace, not to do everything worth doing. Paradigmatic liberal thinkers agree with this notion that only a limited government, which only task is it to protect the equal liberty of all citizens, can be justified. Rawls’ (1971, p. 213) first principle of justice grasps the balance between personal freedom and a political authority strikingly: “each person is to have an equal right to the most extensive system of equal basic liberty compatible with a similar system for all.”

However, liberals strongly disagree about the concept of liberty. Consequently, different conceptions of the liberal idea of protecting individual liberty lead to different ideas of the task of the government. In this section I explained how liberty is the ideological fundament of liberal political theories. In the following sections I will discuss different types and interpretations of freedom.

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Section II. Two concepts of liberty

In this section, I distinguish two different types of liberty: negative and positive. By setting out this distinction, I want to show that these two types are rival and incompatible interpretations of a single political ideal. Negative liberty essentially about the absence of obstacles and constraint. Whereas positive liberty is about the possibility of acting in a way that individuals take control over their lives, and could realize their fundamental purposes. Political liberalism originally leans towards the negative definition of liberty because liberals generally argue in favour of strong limitations on state activities in order to protect individual liberty. Critics of liberalism claim that this rationale is not adequate. They argue that the pursuit of liberty should be understood as self-determination or self-realization and this could require state intervention of a kind that classical liberals normally would disallow.

Imagine you are driving your bike through the city and you arrive at an intersection. You decide to turn right, but no one was forcing you to go straight or left. Next, you come to a roundabout and go left; again no one was preventing you from going one way or the other. Moreover, there is no traffic, diversions or police roadblocks. You seem entirely free to do whatever you want. The picture of your situation may change drastically if we consider that the reason you first went right and thereafter left is because you are addicted to cigarettes and you are cycling like mad to get to the tobacconist before it closes. You feel like if you are being driven, instead of driving yourself. Your addiction and the urge for nicotine leads you uncontrollably to steer your bike first right and then left. You are perfectly aware that following this route will mean that you will miss the train that would bring you to an important meeting you care about very much. You want to get rid of this irrational desire that is not only threatening your health and well-being, but is also holding you back from the thing you think you ought to be doing: attend the meeting.

This example gives us two contrasting ways to think about freedom. On the one hand, you are free because no one is stopping you from doing whatever you want to do. You are free to buy cigarettes and miss an important appointment. On the other hand, one can think of freedom as the presence of control on the part of the agent (Carter, 2016). In this sense of freedom is about the ability to control your destiny. In the example above you appear to be unfree, in this sense, because you are not in control of your destiny. You are failing to control a passion that you would rather want to get rid of, which is preventing you from realizing what you recognize to be your 'true' interests (Carter, 2016).

Notion of negative freedom

In Isaiah Berlin’s famous essay, Two Concepts of Liberty first published in 1958, the distinction was made between negative and positive liberty; where Berlin advocated for a negative conception of freedom. According to Berlin (1969, pp. 121-122) we use the concept of negative freedom in an attempt to answer the question “What is the area within which the subject – a group or a person – is or should be left to do or be what he is able to do or be, without interference by other persons?" The simple answer is that one is free to the degree to which no man or collective interferes with my activity. Conversely, if others prevent people from doing

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what someone wants to do, then people are to that degree unfree. If people have contracted this in a way, we may speak of coercion. However, coercion does not cover every form of inability. For example, if I say that I am unable to fly over the city myself or cannot hear because I am deaf, it would be odd to say that I am to that degree coerced or even enslaved. Coercion implies that people deliberate interfere in the area within you could act otherwise. So consequently, this means that political freedom is only lacking when you are prevented from attaining a goal by human beings (Berlin, 1969).

The incapacity to attain a goal is not a lack of political freedom. However, some make the argument that the lack of capacity does affect our freedom. They argue that if someone is too poor to afford something, on which there is no ban, such as a bag of apples, an expensive car or recourse to go to the law courts, his lack of freedom to obtain that good would be the same as if it were forbidden to him by law (Berlin, 1969). If the poorness of a person were a type of disease, which prevented him from buying the bag of apples, the car or getting his case heard in court, such as a physical disability that prevents the man from running, then this inability would not be regarded as a lack of freedom. We would accept the theory if the lack of material means is the result of mental or physical capacities, which in turn might result in a deprivation of freedom.

The core aspect of negative freedom includes non-interference; the opposite of coercion. Berlin (1969, p. 127) describes this notion of negative liberty strikingly as liberals in the modern world have conceived it:

“To threaten a man with persecution unless he submits to a life in which he exercises no choices of his goals; to block before him every door but one, no matter how noble the prospect upon which it opens, or how benevolent the motives of those who arrange this, is to sin against the truth that he is a man, a being with a life of his own to live.”

All arguments in favour for more individual rights and civil liberties, all protest against humiliation and exploitation or government intrusion, which sprout from this individualistic conception of man that Berlin sketches. Freedom in this sense is not concerned with the source, but rather with the area of control. For this reason, this conception of freedom is compatible with some kinds of autocracy and even with the absence of self-government. In a democracy, it is possible that individuals are deprived of many liberties that they would preserve in some other form of society. It would even be conceivable that a liberal-minded despot allows its people a considerable amount of freedom. The wide area of liberty might be unjust or encourage inequalities, or virtue, care little for others; but once provided, the despot does not curb their freedom or at least restrain it less than many other regimes. In this sense, freedom is not related or connected to democracy or self-government at all. Libertarians argue that self-government may provide a better guarantee to protect civil liberties than other regimes though there is no necessary connection between individual freedom and democratic rule.

In short, the idea of negative freedom concentrates on the external sphere in which individuals interact. This seems to provide a better guarantee against the dangers of authoritarianism

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perceived by Berlin. If one wants to promote negative freedom, one must promote the existence of a sphere of action whereof the individual is sovereign, and within which he can pursue his goals, provided that he respects the spheres of others. Mill (1859) and von Humboldt (1993), whom are defenders of negative freedom, often make the comparison between a plant and the development of an individual. Individuals, like plants, must be allowed to 'grow', in the sense of developing their faculties to the full and according to their inner logic (Carter, 2016, p. 7). Personal growth is something that cannot be imposed from without but must come from within the individual.

Notion of positive freedom

According to Berlin (1969), the 'positive' sense of the word derives from the wish on the part of the individual to be his own master. Defenders of positive liberty are focused on the internal factors that affect the degree to which individuals or groups act autonomously. Berlin is a liberal himself and wishes that all decisions in life depended on yourself rather than external forces of any kind. Berlin accurately described the essence of positive freedom (1969, p. 131):

'I wish to be the instrument of my own, not of other men's acts of will. I wish to be a subject, not an object; to be moved by reasons, by conscious purposes, which are my own, not by causes which affect me, as it were, from outside. I wish to be somebody, not nobody; a doer – deciding, not being decided for, self-directed and not acted upon by external nature or by other men as if I were a thing, or an animal, or a slave incapable of playing a human role, that is, of conceiving goals and policies of my own realizing them. This is at least what I mean when I say that I am rational and that it is my reason that distinguishes me as a human being from the rest of the world. I wish, above all, to conscious of myself as thinking, willing, active being, bearing responsibility for my choices and able to explain them by references to my ideas and purposes. I feel free to the degree that I believe this is to be true and enslaved to the degree that I am made to realize that it is not.'

In a sense, as described above, positive freedom may seem more relevant to psychology or individual morality than to political philosophy. Though, positive freedom has a place in the most hotly debated issues in political philosophy, which are the following: Is the positive concept of freedom a political concept? Is it possible for the state to promote positive freedom of citizens on their behalf? Moreover, if so, is it desirable for the state to do so? Scholars are divided over how these questions should be answered. Theorists like Constant (1819), von Humboldt (1993) and Mill (1859), have answered ‘no’ and therefore defend the negative concept of political freedom. While scholars like Rousseau (1762), Hegel (1807) and Marx (1848) would answer 'yes' to these questions and support the positive conception of political freedom.

It has often been thought that it is necessary to achieve positive freedom through collective means. For example, Rousseau's theory of freedom, whereby political freedom is achieved through participation in a process whereby the community exercises collective control over its affairs, which are under the 'general will'. In other words, a democratic society is free because it is a self-determined society, and the members are liberated because they can participate in a

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democratic process. Though there are also individualist applications of the notion of positive liberty. For instance, it is said that governments should provide the conditions necessary for its citizens to be self-sufficient or to achieve self-realization. The ideas of the welfare state and basic income are being defended on this basis.

On the other side, liberals argue that positive freedom carries the danger of authoritarianism with it. Consider the members of oppressed minorities in a society. They might be said to be free on the ground that they are members of a democratic society where they have 'self-control' over their fate. However, the democratic process is characterized by majority rule, which leads to the oppression of the minorities and makes them surely unfree. Furthermore, it is not a necessity to live in a democracy in order to have self-control. One can also think of a society as a living organism and might believe that this organism will only act rationally and have control over itself when all different parts align with some rational plan created by its wise governors (Carter, 2016, p. 6). The government could be seen as the brains of the living organism in this metaphor. In this case, even the majority could be oppressed in the name of liberty.

There are notorious historical examples of authoritarian political leaders that justify oppression in the name of liberty in this way. Berlin (1969) was moved by how totalitarian regimes twisted and distorted the idea of freedom as self-mastery and self-realization. For example, how the Soviet Union claimed that they, not the liberal West, were the true champions of freedom. This paradoxical conclusion starts with the idea of a divided self.

True self

The smoker in our story illustrates a clear example of a divided self. There are two conflicting desires; one is to get cigarettes at the tobacconist and the other to get to the appointment. If we state acceptably that one of these selves is superior to the other, then we can determine what is our ‘true’ self. In this case, the keeper of appointments is the 'higher' self and the smoker the 'lower' self. The higher 'self' is rational, able to reflect, capable of moral action and can take responsibility for its actions. The 'lower' self, is the self of the passions, led by unreflecting desires and irrational impulses. One is truly free when the higher and rational self is in control, and one is not a slave of the passion or to one's empirical self. This is the 'true' self.

The next step of the paradoxical conclusion is to point out that some individuals are more rational than others and therefore know what is in their rational interest. This is a justification to force people who are less rational to do the rational thing and help them to realize their 'true' self. By doing that the ‘superior’ rational people liberate the ‘less’ rational people from their empirical desires. According to Berlin (1969, pp. 132-133) the 'true' self “may be conceived as something wider than the individual, as a social whole of which the individual is an element or aspect: a tribe, a race, a church, a state, the great society of the living and the dead and the yet unborn.” In this light, coercion seems to be justifiable at times to coerce men to reach a goal, which they would otherwise pursue themselves if they were more enlightened and not blind or ignorant. An example of a goal is to live as healthy as possible.

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Berlin argues that the true interests of the individual are to be identified with the interests of the whole, and individuals can, and should, be coerced in fulfilling these interests. Consequently, it would be irrational to resist coercion if they were as rational and wise as their coercers. Berlin (1969, p. 132-133) argues:

“Once I have taken this view, I am in a position to ignore the actual wishes of men or societies, to bully, oppress; torture them in the name, and on behalf, of their 'real' selves, in the secure knowledge that whatever is the true goal of man (happiness, performance of duty, wisdom, a just society, self-fulfilment) must be identical with this freedom, the free choice of his 'true', albeit often submerged and inarticulate, self.”

This is the essence of the paradox. It is one thing to claim that I will be coerced for my own good, which I am too blind to see. This may be for my benefit and enlarge my scope of liberty. However, it is another thing to say that if it is my good that I am not coerced even if I wanted it. I could be truly free at this moment even while my “poor earthly body and foolish mind” (Berlin, 1969, p. 127) reject it and struggle with the greatest desperation against the entity that benevolently imposes it on me. In Chapter I, we have seen that people cannot make proper rational choices regarding our health due to human fallibility. If we want to be truly free, which among other thing good health grants us, we could use a helping hand with pushing us in the right direction. Hume would support the conception of positive freedom based on the notion that one is truly free when he or she is able to follow their ‘higher’ desires and can come closer to the realization of their ‘true’ self. In Chapter Three, I discuss “Humean liberalism” and his view on rationality extensively.12

Freedom through equal resources

One way to put positive freedom in practice is to act according to our ‘true’ self. To do what you truly want. However, there is also another form of positive freedom, which relates to the equality of resources. Do you, independent from what you truly want, have the capacity and material means to do the things you want to do? For example, having money gives us effective freedom to engage in a variety of activities and experiences. Egalitarians, like Dworkin (2000), support the idea of equal distribution of resources, whereby no one prefers to modify or want any other person’s resources to their own. The realization of this idea would enable people to enjoy effective freedom to the same extent. To be the master over our own lives we need an equal distribution of the resources.

An egalitarian and just society is not obligated to do whatever is needed to bring citizens any given level or share of quality of life. Individuals should take responsibility for their ends, which is typical liberal thought (Rawls, 1971; Dworkin, 2000). The reasons that states are not responsible for the quality of life of its citizens is because the level of freedom depend on many actions and life choices taken by the individual. The state may not be responsible for the quality

12_{I do not discuss “Humean liberalism” extensively here because it makes more sense to discuss this form of} liberalism in the context of practical rationality. For now, it is only important to bear in mind that “Humean liberalism” falls into the camp of positive liberty.

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of life of its citizens but it is obliged to treat all citizens with equal concern and respect. Therefore, we should formulate an appropriate conception of resources and its distribution to achieve positive freedom for all.

Resources are not only material goods such as properties, but talents or instruments that help achieve the ends of individuals are also considered resources. However, by extending the domain, the account becomes more complex because these resources, which are attached to individuals and cannot be easily transferred, should also be equalized. An idea is to take people’s valuable talents into account in determining how material resources should be distributed. If one wants to achieve a distribution that can be considered as sufficiently equal (Arneson, 2013). If John lacks full-functioning arms, then assigning John with extra resources so he can buy prosthetic arms can compensate this personal deficit. This problem seems straightforward and John improved his freedom in this case. However, all people vary in different personal traits and talents and these traits interact with their material resources and other features of their circumstances to determine what each one is able to do and be with a given resource share (Arneson, 2013). So how can we rate one talent to material resources or the lack of talent? Moreover, if we can, how should we distribute these things?

Dworkin (2000) comes up with the fairness test as a solution to these practical difficulties. It does not require interpersonal comparison of welfare and therefore has an appeal if the interpersonal comparison is ethically problematic or incoherent. Imagine we can separate the human features for which we are responsible from the features we should not held to be responsible. One fairness norm says that egalitarian transfers should not vary depending on people’s features for which they should be held responsible (Arneson, 2013). Furthermore, another fairness norm says that people with the same features for which they are responsible should be treated the same. A viable account of equal distribution must be sensitive for personal responsibility by dictating compensation for unchosen talents, but not for ambition and choice. However, I have troubles with accepting that we must hold people responsible for their chosen luck but not for their unchosen luck. This does not make sense because unchosen luck of genetic inheritance and early socialization determine the individual’s choice making and value-selecting (Arneson, 2013). If someone makes a bad choice, it may simply reflect the unchosen luck that one lacks the ability to be a good chooser. Suppose for example that Peter chooses to experiment with liqueur and cigarettes and these chooses turn out horrible. Peter gets a form of lung cancer and becomes an alcohol addict. It is evident that Peter is worse off than Jade who does not experiment with these things, but his bad fortune is a result of his own choices. According to the Dworkian idea of equality of resources, he is not compensable. However, that Peter opts for these bad gambles and Jade does not may be the result of Peter’s genetic inheritance and early socialization, and therefore could be classified as unchosen bad luck. Consequently, holding Peter fully responsible for his misfortune caused by his bad gambles may make no sense if we follow Dworkin’s theory.

For this reason, the idea of the ‘true’ self appeals more than the idea of equality of resources in achieving positive freedom. It requires less quirks and the practical feasibility seems more

Nudging for Health: a Genuine Push or the Pinnacle of the Nanny State?

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