Reply to Bryan Caplan on abortion nudges

UPDATE: Caplan has responded, and makes an interesting point: it looks like the turnaway study shows reduced depression and anxiety for women who are turned away from abortions, relative to women with similar physical health and financial situations. There may be problems with drawing that inference from the study design – I can’t make a clear determination on that because it looks like the most relevant publications from the study are still in press. Based on the NYT writeup, it looks like the Turnaway researchers were trying to show that mental health outcomes in people who had abortions were no worse than in people who carried the pregnancy to term – I don’t know if there are problems with using non-inferiority studies to show actual equivalence, so it seems possible that the women who had abortions actually did have better mental health and the study just wasn’t constructed/powered to detect an improvement. (If that line of reasoning is nonsense, please let me know!)
All that said, it sounds like a relevant pro-natalist point, and one that ought to be included in the shared decision making that would ideally exist around pregnancy/termination decisions. Maybe in the idealized environment I described below, it would be sufficient to tip the balance in favor of nudging women away from abortion, but it’s certainly not a strong enough independent finding to have substantial policy implications yet.

Bryan Caplan had an interesting query for Richard Thaler yesterday, which started on Twitter and then Caplan expanded in his blog post on Nudges and Abortion. In it, Caplan – who, it’s worth noting, is a strong natalist with good arguments for having kids – proposes several policies that would, in a vaguely non-coercive way, reduce access to abortions, and so (perhaps) make people better off.

The post amounts to a challenge primarily because it at least appears to be the case that most would-be “nudgers” are pro-choice, so the issue has at least the potential to test whether nudgers are serious about making people better off, or are simply using nudges as a stealth tool to push their preferred policies.

Obviously, the current legal regime around abortion complicates the discussion. I would bet that, encountering them in a modern context, most pro-choice would-be nudgers find Caplan’s suggested anti-abortion nudges revolting and even infuriating. That’s not because of anything inherent in the suggestions – they are, at least in principle, well-motivated and fair-minded. But since the modern abortion debate boils down to transparently disingenuous claims that we need to make abortion “safer for women,” and proposals for doing so that serve only to limit or eliminate abortion access so society can use pregnancy to punish women for having sex, nobody who seriously proposed the changes Caplan suggests “to make women better off” would (or should) be taken at his word.

That in itself illustrates the first problem: nudges are often best directed at decisions people make casually, and that are driven by unnoticed cognitive errors. That risk is already low when we as a society have made it deliberately difficult to pursue a particular decision. It would hardly be reasonable to support nudges to reduce chocolate consumption if you had to drive across three states and wait 24 hours to buy a Snickers bar; it’s when you’re faced with a half-dozen candy displays on an average Tuesday that slightly reducing access looks reasonable.

But imagine, for the duration of this argument, that abortion was accessed as if it was any other aspect of the medical system, with no onerous regulations beyond those deemed generally appropriate for regulating procedures with a commensurate level of risk. In such a system, it would not be inherently repugnant to suggest that decisions about abortion are subject to some of the same cognitive biases that plague decisions about saving for retirement, becoming an organ donor, or eating more fruits & vegetables.

Even in such a world, I think Caplan’s basic assumptions are misguided. From the post:

“Parents very rarely regret having children – even initially “unwanted” children.  This is not mere status quo bias: Most childless adultseventually regret not having children.  As I’ve said about parenthood before, ‘Buyer’s remorse is rare; non-buyer’s remorse is common.’  Implication: Most women who want to terminate their pregnancies would probably change their minds after their babies are born.  Most won’t go through the next eighteen years thinking, ‘I wish I’d gotten that abortion.'”

Even if all of that is accurate, it’s not especially relevant to this specific discussion. In most cases, choosing to have an abortion now is not the same as choosing never to have kids, so the comparison to childless adults is nearly irrelevant. Rather, the relevant choice is generally between “kid now” and “kid later,” bearing in mind that there’s at least some (probably predictable) chance that whatever conditions make having kids now unappealing (unstable family circumstances, poverty, being in high school/college/grad school/&c.) will later be alleviated.*

Second, the data saying that women are generally happy with their children, even after unplanned pregnancies, are unlikely to be representative of the population we’re trying to nudge. More relevant evidence comes from the recent study of women who were just barely denied abortions (vs. women who just barely got them) presents a far less rosy picture of life outcomes and mothers’ relationships with their children.

Finally, most of Caplan’s proposed “nudges” aren’t very good examples of the concept. Here they are:

1. Waiting periods: Abortions must be scheduled at least a week in advance.  This gives women time to reconsider their decision, so they don’t abort rashly.

This one is hard, because waiting periods are already part of the policy space, and so are steeped in existing messaging that women can’t be trusted to make the right decision. Moving away from that, though, this still strikes me as more coercive than a nudge ought to be. The nudge version of this would be for the default scheduling to be a week after the first appointment – patients should still be able to choose an earlier appointment if they want one. Also, it’s worth noting that abortions (particularly safe ones) can be time-sensitive, especially for people who find out they’re pregnant close to fetal viability.

2. An opt-out rule for counseling.  The libertarian paternalist could schedule all women who want an abortion for a pre-procedure session with a psychologist – or maybe just volunteer mothers who previously considered abortion.  Women who don’t want counseling would have to explicitly refuse to participate.

This one actually qualifies as a nudge, and well-implemented, could be really good policy: it’s low-cost to opt out, and offers a service that some substantial number of women would be happy to use. The tripping point is, of course, the content of the counseling (I’m skeptical of specifically involving mothers who previously considered abortion without the other side), but I’ll assume that it’s aimed at offering emotional support during a difficult decision and helping women understand and consider all of the available options, not at shaming women into not having abortions. Shared decision making about pregnancy and abortion is a great idea, and I wish it was more commonly available. Props to Caplan for suggesting it.

3. Inconvenient locations: Abortions have to be performed in remote rural hospitals.  Women who definitely want abortions will make the extra effort, but more ambivalent women will decide to keep their babies.

This illustrates another general principle about nudges: they have to be well-targeted. Restricting abortions to facilities in rural areas will obviously limit abortion access for the urban poor more than for other groups – so why is the policy targeting them? Are the urban poor more susceptible than the rural poor or suburban middle class to abortion-related cognitive biases? If not, it doesn’t make sense. (Never mind that this would be a substantial infringement on the rights of OB/GYNs to practice where they wish, and place an unconscionable burden on women whose wanted children are inviable, and who would have to schlep out to the middle of nowhere, away from their emotional support systems, to have medically necessary abortions.)

4. Deny government funding for abortion.  If the government thinks that a procedure is generally ill-advised, the first step is to refrain from encouraging it.  If people want to pay for it out of their own pocket, they’re still free to do so.

Another general principle: a good nudge is not a financial incentive (or barrier). Again, financial barriers inherently pose targeting problems, but perhaps more important is the violation of the “low-cost avoidance” rule. Limiting public funding for abortions, or soda, or coal-burning power plants is perfectly reasonable public policy, but it doesn’t really qualify as minimally invasive.

Finally, here are a few anti-abortion (or at least pro-natalist) nudges that might be closer to what Caplan was looking for:

  1. Posters at clinics with messages along the lines of: “Most couples keep their unexpected pregnancies,” “Kids can be a lot of fun,” or “You’re more ready for a baby than you think.”
  2. PSA campaign for young people considering delaying childbearing: “Your baby may be healthier if you have her now.”
  3. Condom wrappers with baby faces on them and slogans like “Don’t you want your own?” (I can imagine this doing double-duty, encouraging some young men to complain less about using condoms, and perhaps encouraging some couples to decide not to.)
  4. Placing condoms right in the front of the drugstore, where you can’t hide when looking at them, and limiting their sale to between 8 AM and 6 PM.

*You can argue that in some cases, conditions are unlikely to improve, but in that case, using Karl’s model, the abortion isn’t the rational decision in the first place. Under those circumstances, we’d more likely be talking about nudges to encourage abortion – or, preferably, nudges to reduce unwanted pregnancy.

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About Joe Colucci

From Michigan, now in Boston via DC and NYC. BA in Economics from NYU. A geek and a nerd, of the type that thinks there's a meaningful difference between the two. Avid fan of good TV, good argument, good beer, good food. I work at the Lown Institute on reforming the health care delivery system, and I blog on anything else that strikes my fancy at wonkinakilt.wordpress.com. Obviously, anything that I post on Twitter or Wordpress is my own rambling, and is not endorsed by any employee, colleague, or acquaintance, past, present, or future. View all posts by Joe Colucci

7 responses to “Reply to Bryan Caplan on abortion nudges

  • bodycrimes

    Really good and fair analysis.

  • John Thacker

    “That risk is already low when we as a society have made it deliberately difficult to pursue a particular decision.”

    I’m having a difficult time distinguishing between making “it deliberately difficult to pursue a particular decision” and “nudges,” other than one’s moral gloss.

    “But since the modern abortion debate boils down to transparently disingenuous claims that we need to make abortion “safer for women,” and proposals for doing so that serve only to limit or eliminate abortion access so society can use pregnancy to punish women for having sex, nobody who seriously proposed the changes Caplan suggests “to make women better off” would (or should) be taken at his word.”

    And yet the modern debate about obesity (and nudges about chocolate and so forth) seems to boil down to transparently disingenuous claims that it’s about the individual’s health, when it really seems to be about repugnance against fat people and having to look at them. Consider for example how various data suggesting that what is considered “moderately overweight” is associated with greater life expectancy with the various efforts to stigmatize it. People that I know who are overweight do not, and should not, take those who seriously propose nudges against chocolate or large beverages at their word.

    Hatred against and repugnance at fat people is real, along with a desire to punish them. It discredits the arguments against nudges against chocolate at least as much as your beliefs about what those who are anti-abortion really feel discredits their arguments.

    • bodycrimes

      What’s wrong with a lot of the fat discourse is that weight and health are conflated in unhelpful ways. But health nudges for the whole population e.g. Mayor Bloomberg’s stair initiatives in NY, could be interesting. You don’t HAVE to take the stairs – the elevator is still right in front of you, so it’s a real nudge, not a restriction or a prohibition.

    • Joe Colucci

      Great points. To the first, I do think there’s a substantial difference between a nudge and a substantial barrier. As I tried to emphasize in the post (and as Thaler/Sunstein’s examples in the book illustrate), a good nudge requires only minimal effort to avoid, say, reaching up to a higher shelf for a cookie, or checking a box to opt out of a retirement savings plan. Barriers to getting an abortion, particularly the recent stream of regulations intended to shut down clinics altogether, pose much higher barriers – but it is a matter of degree, not of kind.

      (I hadn’t considered this, but you might actually be able to call something like mandatory ultrasound viewing a nudge – presuming it’s not unduly time-consuming, it doesn’t require a particular choice – just influences a decision in a way that is, at least in theory, entirely possible to ignore. I remain opposed to it, but on policy grounds rather than because it’s particularly coercive.)

      Your second point is totally right – animus against fat people is definitely part of the motivation for anti-obesity efforts. Part of the motivation for nudges, though, is the inconsistency between people’s expressed preferences and the results of their behavior – something that’s particularly relevant to nutrition & other health-related choices. There’s a question worth asking of how much of that expressed desire is rooted in unhealthy/unrealistic body image and how much is genuine, but it seems appropriate to me to help people meet their own expressed goals if we can do so in a low-cost, low-coercion way.

      There is also at least some genuine justification for public concern over obesity (because true obesity *is* related to poor health outcomes, and much of health care is publicly funded), while the evidence for any long-term health consequences from abortion (over and above the consequences of having an unwanted pregnancy in the first place and relative to carrying said pregnancy to term) is poor.

  • John Thacker

    “Under those circumstances, we’d more likely be talking about nudges to encourage abortion – or, preferably, nudges to reduce unwanted pregnancy.”

    We could also be talking about nudges to encourage giving one’s child away for adoption, noting that in Foster’s study only 9% of the turnaways gave their child up for adoption. Surely doing so would have decreased the financial problems associated with having a child from an unwanted pregnancy? If we think that the financial problems are worth a nudge, then the same logic leads us to nudge them towards giving the child up, no?

    • bodycrimes

      Adoption is a really terrible option for most women. There’s a for-profit adoption industry in the US that would have people believe otherwise, e.g. by aggressively selling women on the idea that they’re brave loving mothers by giving up kids, and promising ‘open adoptions’ but the evidence is that adoption causes long term grief for mothers and a kind of identity hunger in adoptees denied access to their birth mothers. Open adoptions bring a whole other set of problems. In comparable countries where adoption agencies are government run and have no profit motive, adoptions are almost negligible – and the rates dropped dramatically after the decline of coerced adoptions in the late 1970s/early 1980s.

  • What Happens to Women Who Are Denied Abortions? - Unofficial Network

    […] Joe Colucci’s thoughtful response to my “Nudge and Abortion,” he writes: [D]ata saying that women are generally happy […]

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