When nudges are not enough: an ethics of escalating behavioural interventions in clinical decision-making

Abstract Background Ethical debate on nudging in clinical decision-making has largely focused on whether nudges are transparent, autonomy-respecting, and permissible. I argue that this framing is incomplete as the ethical question is not whether nudges are acceptable, but what healthcare organisations owe patients when interventions succeed, fail, or leave the main source of unsafe care unaddressed. This article develops a framework for evaluating when organisations should move beyond nudges or boosts. Methods I conducted a conceptual analysis of behavioural interventions in clinical decision-making and examined three intervention levels, i.e., nudges, boosts, and system redesign. I interpreted their outcomes as evidence that can update a working hypothesis about the likely limiting source of impaired decision quality. I then developed an escalation framework specifying when organisations are ethically required to move between intervention levels. Results The analysis suggests that intervention outcomes can help update hypotheses about whether an important constraint on clinical decision quality is contextual, capability-based, or structural. I introduce the concept of institutional moral displacement, in which organisations respond to structurally generated problems with individual-level interventions, thereby shifting responsibility onto clinicians. The framework is diagnostic rather than sequential, i.e., where evidence already locates the dominant constraint in organisational structure, structural intervention is warranted directly, and interventions at different levels may be combined rather than exchanged. A verified failure does not by itself establish where the constraint lies, but it shifts the burden of justification onto the organisation. An intervention that improves an average outcome while widening a clinically meaningful gap between patient groups is not adequate for the disadvantaged group and may warrant escalation on that group’s behalf. On this view, continued reliance on lower-level interventions becomes ethically problematic once available evidence indicates that the true source of harm lies elsewhere. Conclusions Ethical evaluation of behavioural interventions in healthcare should focus not only on the permissibility of nudges, but also on organisations’ obligations to escalate when lower-level interventions do not address the best-supported source of unsafe care. A diagnostic escalation approach better protects patients, preserves clinician autonomy where possible, and clarifies when competence-building or structural reform is ethically required.