From entitled citizens to nudged consumers? Re-examining the hallmarks of health citizenship in the light of the behavioural turn
| Author | Benjamin Ewert |
| Date | 01 July 2019 |
| Published date | 01 July 2019 |
| DOI | 10.1177/0952076718774612 |
| Subject Matter | Articles |
Public Policy and Administration
2019, Vol. 34(3) 382–402
From entitled citizens
! The Author(s) 2018
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to nudged consumers?
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DOI: 10.1177/0952076718774612
Re-examining the
journals.sagepub.com/home/ppa
hallmarks of health
citizenship in the light
of the behavioural turn
Benjamin Ewert
Heidelberg School of Education (HSE), Project heiEDUCATION –
Cluster Society & Health, Heidelberg Germany
Abstract
Behavioural Public Policy seeks to produce behavioural change by altering people’s
choice architecture. As exemplified in the field of health, this behavioural turn in
public policy comes at a cost since policymakers (‘nudgers’) tend to disregard the
historical policy legacies and policy rationales that have shaped the notion of health
citizenship. Behavioural interventions challenge the traditional hallmarks of health citi-
zenship, such as trust in providers and professionals, lifestyle as a matter of individual
choice, and healthcare provision and voice within healthcare governance arrangements.
As demonstrated in the areas of health promotion, health insurance provision and the
doctor–patient relationship, nudge tactics make state–citizen relations more patchy and
inconsistent. This calls for a behaviourally informed citizenship model, which accom-
modates human flaws and the inevitability of systematic exploitation, offers a way to
explore new forms of protecting individuals from coerced behavioural change strate-
gies, and helps to maintain the collective engagement of citizens in the process of public
policymaking.
Keywords
Behavioural Public Policy, choice, health citizenship, health policy-making, nudge, voice
Corresponding author:
Benjamin Ewert, Heidelberg School of Education (HSE), Project heiEDUCATION – Cluster Society & Health,
Voßstraße 2, D-69115 Heidelberg, Germany.
Email: ewert@heidu.uni-heidelberg.de
Ewert
383
Introduction
There are growing indications that public policymaking is currently witnessing
a ‘behavioural turn’ (Bogliacino et al., 2016). Behavioural insights, i.e. precise
knowledge on human behaviour in policy-relevant situations, have increasingly
become a legitimate basis for designing policy frameworks in fields such as
consumer protection, energy, health and taxation (Oliver, 2013a). Around the
globe, Behavioural Public Policies (BPPs) are currently being developed, tested
and evaluated by the so-called ‘nudge units’ (Halpern, 2015), signalling a pending
shift in public policymaking. In academia, behavioural interventions inspired by
the theory of libertarian paternalism (Sunstein, 2014; Thaler and Sunstein, 2003,
2008) have already triggered controversy at more fundamental levels. In particular,
scholars have questioned nudge tactics from ethical (Selinger and Whyte, 2011;
White, 2013), philosophical (Rebonato, 2012, 2014), sociological (Brown, 2012;
Mols et al., 2015) and regulative (Jones et al., 2013a, 2013b; Leggett, 2014)
perspectives.
Building on these interdisciplinary works, this paper investigates the impact of
BPP on state–citizen relations. In this context, it is hypothesised that BPP has
serious implications for the established characteristics of ‘health citizenship’
(Huisman and Oosterhuis, 2014). As set out in this paper, behavioural policies
tend to circumvent and undermine health citizenship based on collective voice,
choice and trust-based relations. Moreover, nudgees are obliged to co-produce a
key goal of the ‘behaviour change state’ (Leggett, 2014: 4) – maintaining and
improving health – to a much more significant extent than under previous policy
goals. Behavioural health policies therefore address a certain kind of active citizen
who, with the help of nudges, is enabled to do voluntarily what (s)he ought to do in
the eyes of policymakers. On the other hand, ‘querulous citizens’ (Jones et al.,
2013b: 174), who prefer to make their own decisions concerning health issues
and are critical companions of the ‘healthcare state’ (Moran, 1999), tend to be
overlooked by BPP. However, a closer look at BPP reveals that the apparent
‘behavioural turn in public health policy’ (Crawshaw, 2013: 622) merely adds an
additional layer to an already fragmented state–citizen relationship. We must there-
fore ask what a behaviourally informed citizenship model in the realm of health,
which re-engages with previous rights and obligations, might look like. And, more
straightforwardly, is BPP reconcilable with established features of citizenship, such
as trust, choice and voice?
This paper starts by revisiting the notion of health citizenship as it has evolved
through three distinct phases of health policymaking up until now. Then, with
respect to the current phase, which is labelled as the knowledge- and behaviour-
based health society, different forms of applying behavioural health policies will be
introduced. The direction in which the definition of health citizenship may shift due
to the increasing use of health nudges will be exemplified next within the areas of
health promotion, health insurance provision and the doctor–patient relationship.
Drawing on insights from the field of health, the general repercussions of BPP for
384
Public Policy and Administration 34(3)
the overall meaning of citizenship in public policy are addressed next before finally
having a brief look forward to a possible future of behaviourally informed citizen-
ship, both in health and beyond.
Health policymaking and the meaning of health
citizenship: A brief recent history
Current behavioural health policies ‘do not supervene onto a blank (. . .) canvas’
(Pykett et al., 2011: 309) but unfold within a field that is very much characterised by
previous policies and configurations of state–citizen relations. In this section, the
concept of health citizenship as it has evolved from the ‘kindly welfarism of the
post-war era’ (Pykett, 2011: 218) will be summarised. This involves references to
the health-related rights and responsibilities citizens obtained in Western (mainly
European) welfare states. Since many of the reported experiences with BPP origin-
ate from the US, the lessons learned there (though not necessarily universal) may
be applicable to European healthcare systems where the use of BPP is increasingly
being proposed (see Lourenc¸o et al., 2016). As shown in the course of this paper,
behavioural health policies challenge the traditional hallmarks of health citizen-
ship, such as trust in providers and professionals, lifestyle as a matter of individual
choice, and healthcare provision and voice within healthcare governance arrange-
ments. First, however, let us remind ourselves of citizens’ existing rights and
responsibilities in relation to health(care).
Since ‘health and citizenship are ambiguous and multi-layered concepts’
(Oosterhuis and Huisman, 2014: 6), three consecutive phases in health
policymaking, determined by different policy rationales, policy approaches and
knowledge bases for policymaking, constitute the nature of health citizenship
today: the establishment of health as a social right; the challenging of the health-
care state; and the emergence of healthcare consumerism. Each phase has resulted
in a dominant frame for state–citizen relations, which has been spawned by a
specific set of rights and obligations (see Table 1). Thus, the most recent policy
phase has not simply overridden the features of the previous phases, but has
referred to and re-engaged with them in a new way that changes the meaning of
previous policy rationales. Behavioural policies (see next section) are no exception
in this regard.
Healthcare as a social right
The first phase of health citizenship is associated with the foundation of the welfare
state in the 1950s and 1960s. Health protection and the establishment of universal
healthcare were significant cornerstones in this phase (Porter, 2005). Symbolic
achievements such as the foundation of the NHS in the United Kingdom and
‘broad coverage and open-ended for-free service’ (Oosterhuis and Huisman,
2014: 34) in most other welfare states were based on twin objectives: firstly,
Ewert
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Public Policy and Administration 34(3)
universal access to health services and large-scale health protection schemes (e.g. in
terms of environmental, industrial and occupational safety) were granted to...
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