I’ve recently been reading some work on health incentives – the kind of incentive that may be used to encourage people to pursue ostensibly desirable courses of action in return for some kind of reward (frequently monetary). Some schemes are aimed at promoting a vague healthy lifestyle, as when people are rewarded for losing weight or smoking less; others are directed at ensuring that people stick to a course of medication.
This has got me thinking about a debate in metaethics between internalists and externalists. Imagine some action agreed to be right, obligatory, virtuous, or whatever. Bluntly, an internalist will say that this provides you with a reason for doing it, and that the recognition of the virtue of the action will have at least some efficacy in making you do it. An externalist will deny the internalist’s claim: for them, you need something else to make you do it, such as a disposition or desire to do virtuous things. Or, as Stephen Finlay and Mark Schroeder put it on the Stanford Encyclopedia of Philosophy website:
Often, when there is a reason for you to do something, it is the kind of thing to motivate you to do it. For example, if Max and Caroline are deciding whether to go to the Alcove for dinner, Caroline might mention as a reason in favor, the fact that the Alcove serves onion rings the size of doughnuts, and Max might mention as a reason against, the fact that it is so difficult to get parking there this time of day. It is some sign—perhaps not a perfect sign, but some sign—that each of these really is a reason, that Max and Caroline feel the tug in each direction. Mention of the Alcove’s onion rings makes them feel to at least some degree inclined to go, and mention of the parking arrangements makes them feel to at least some degree inclined not to. According to some philosophers, reasons for action always bear some relation like this to motivation. This idea is variously known as ‘reasons internalism’, ‘internalism about reasons’, or ‘the internal reasons theory’. According to other philosophers, not all reasons are related to motivation in any of the ways internalists say. This idea is known as ‘reasons externalism’ or ‘externalism about reasons’.
With me so far? OK.
Let’s just take for granted that we all agree that health is a good and desirable thing – to be healthy might even be a mark of virtue. More importantly, allow that we all roughly in agreement concerning what counts as health. Now, an internalist account would imply that someone who smoked and who came to believe that smoking erodes health would, de facto, come to recognise that he had a reason to stop smoking, and would be nudged towards doing so by that recognition. That is to say: abstinence would have a certain kind of moral gravity. If he particularly enjoyed smoking, then this gravity would be counteracted by a positive reason in the other direction; call such a person a “positive smoker”. In the end, though, anyone’d be motivated to give up or not to depending on his evaluation of the relative merits of smoking and not smoking. And I’d guess that the number of positive smokers falls with age: teenagers are far more likely positively to want to smoke.
For the externalist, on the other hand, merely recognising the virtues of being a non-smoker won’t be enough. He’d have to want not to smoke as well in order to do the virtuous thing; if you’re an externalist, it’s possible to imagine someone saying that there are all kinds of very good things about action A, but that that’s a brute fact about the world with no motivational power of its own – he could say that A is indisputably the right or a good idea, but that that won’t generate a reason to, isn’t going to, make him do it. Obviously, for an externalist account, incentives serve as a proxy motivator: give someone the carrot of something that they might want and tie it to the virtuous behaviour, and you’ll have given him a reason to get out of his chair.
Let’s concentrate on the internalists, though, for whom the picture seems to be slightly different. On the most basic level, we might expect that an incentive would simply serve to boost the moral gravity of the desirable action until it’s irresistable – the moral equivalent of Jupiter being supplemented by monoliths at the end of 2010.* But a more sophisticated account might make it unclear why we’d need such a supplement in some cases, or what it’d achieve in others.
It seems reasonable to think that a lot of the reason why people don’t adopt healthier lifestyles is not because they’re positive smokers, drinkers, couch-potatoes or whatever, but simply because of inertia. A lot of people will admit – perhaps ruefully – that they accept that they have a reason to change, but they never quite manage it. Many people accept, in principle, the virtue of, say, a brisk daily walk… but, when it comes to the crunch… well… meh. And it’s not always because of the comfort of the sofa that this happens: some people do just seem bad at doing what they ostensibly think most worthwhile.
Now, if we are really dealing with simple inertia, rather than a positive reason for the unhealthy lifestyle, we shouldn’t see this. For internalists, merely accepting the desirability of something will make us do it, as long as there’s not a bigger pull in the other direction. If I’m right to think that there is frequently no such pull, then an incentive oughtn’t really to add anything; it’s not going to generate an outcome that we wouldn’t have go eventually anyway.
There’s a couple of explanations for this. One is that people are simply mistaken about their own thoughts; some things are actually less worthwhile to them than they care to admit. That might be the case in some instances, but probably not all: it’s possible for people to reach the end of the day genuinely disappointed with how little they’ve actually done. (We’ve all had days that we waste and about which we feel genuinely awful.) Besides – this sort of account would have to be able to tell a story not just about desirable actions that are obviously motivating, but about how other actions or inactions can be motivating in a more occult manner – it’d have to be able to account for two quite distinct psychological mechanisms, which seems too complicated.
The other explanation is in terms of weakness of the will. The possibility of such a thing has bothered metaethicists and moral psychologists for quite a while – especially internalists, for whom it seems to cede too much to externalism – and I don’t pretend to have kept up with the argument. But if it is weakness of the will doing the work here, then it’s not clear that incentives would make all that much difference. After all, if the inherent virtue of an action isn’t sufficient to rouse you, then it’s unclear what an incentive would add: you seem simply to be immune to the internal virtues of desirable things, so it’s not obvious what difference would be made by boosting the gravity of the desired action. Put another way: if one ostensibly inherently attractive thing isn’t going to make you budge, then it’s not clear that two would.
Or, at least, it’s not clear that two would when the incentive is of the sort that we would reasonably want to offer. It might be that a HUGE incentive would kickstart the lazy internalist: but there comes a point when the cost of providing the incentive is no longer proportionate to the benefit we think we’ll be getting. This isn’t a point that’s restricted to a world in which ill health as a public cost; it’d also apply in a world where the costs of ill-health were wholly private, inasmuch as that if a government wants to promote health, it presumably attaches a value to it, and would want to ensure that the cost of the incentive is less than the value of the health promoted thereby.
So if the incentive is too small, it won’t make any difference at all; if it’s too big, it won’t be the sort of thing that’s worth offering. It has to be just right; and my hunch is that that’s quite a fine point.
OK. I’ll stop now. My brain’s hurting. The point is that I’m curious about these things, but I really don’t know what to think – or even whether I’ve identified a real problem, let alone whether I’m tackling it in the right way. So I suppose I’ll make a request: has anyone come across anything on internalism and incentives for healthcare? Does the success or otherwise of incentive schemes tell us anything about whether internalists or externalists are right? Are there any X-philes who’re familiar with experimental philosophical literature on this and who also read this blog? Suggestions in the comments, please, if you have any.
Or should I just shut up?
*Yes, I admit it: that was a bit of a stretch!