Pediatric Intensivists' Perspectives on Nudging: A Multi-Institution Assessment of Ethical Permissibility

Nudging is a behavioral economics concept that describes subtle influences on decisions without restricting options or altering incentives. Though commonly studied in public health, the ethical implications in pediatric critical care are underexplored. This study investigates pediatric intensivists' perspectives on the ethical permissibility of three nudging techniques-framing, saliency, and default.

This is a multi-center survey of pediatric intensivists in which a sample of physicians were presented with 4 clinical scenarios representing framing, saliency, and default nudges. Responses about ethical permissibility for each scenario were assessed via Likert Scale and free text. Physician and institutional demographics were also collected. Data was collected in REDCap and analyzed using descriptive statistics for demographic data and scenario responses, with median and interquartile ranges (IQR) reported for Likert scale variables. Comparative and correlational analyses evaluated relationships between ethical permissibility, participant characteristic, and responses to nudging techniques across the scenarios.

402 surveys were distributed with 132 (33%) completed. Results show a wide range in ethical permissibility of nudging techniques with the widest variability in the application of saliency. An equal number of physicians found negative framing to be "not at all" ethically permissible as "extremely" ethically permissible. Negative saliency showed a statistically significant positive correlation with how often the physician uses the technique, and how much that physician believes saliency affects the family's choice. There was also case-dependent variation in ethical permissibility with negative saliency found to be more ethically permissible in severe traumatic brain injury and positive saliency viewed as more ethically permissible when considering tracheostomy. Qualitatively, variable responses were given for each technique. Intensivists reported a wide range of use of nudging techniques.

Our study suggests there is wide variability in nudging utilization and perceived ethical permissibility. The use of framing, saliency, and default communication techniques is nuanced and further understanding of choice architecture is essential to understand how physicians can optimally engage in shared decision-making with families.