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Levy N. J Med Ethics 2017; 43: 495–500

'Post-truth' was named the word of the year by Oxford dictionaries. But where does this leave patients when they want the truth; for example they may have to weigh-up the merits or otherwise of bovine bone or autogenous bone to support their implant reconstruction balancing possible competing information and pressures from advertising, particularly from the internet, and the healthcare provider.

Counter-intuitively, the author who is a professor of philosophy, argues their choice is often at variance with the evidence. To illustrate this, the 'scare caused by Andrew Wakefield's infamous and fraudulent linking of vaccination to autism has never receded'. Consequently, refusal denies the social good accruing to both the vaccinated and the nonvaccinated.

Disturbingly, it would appear that individuals become more entrenched in false beliefs when they are offered good evidence to the contrary. They become more 'perversely responsive to evidence.' This is known as the backfire effect. Using a dental example, there is almost an obsession with smile design. But then placing invasive ceramic restorations instead of a more conservative approach 'when people are motivated to reject the evidence' can result in 'outrageous overtreatment' (quote from J Esthet Restor Dent 2009: 21: 144–146). The backfire effect may occur because of misremembering. Pressures and desires for a beautiful smile will be recalled, but prudent advice from the dental practitioner describing the invasive nature of the treatment becomes dissociated and rejected. There is also fluency, in that if the information is processed fluently, it is intuitively plausible.

A more subtle point is asymmetrical scrutiny of evidence. If faced with equivocal evidence those who do not believe, for example the stereotype of 'What is beautiful is good', become indeed more convinced of this point if their view is changed. The backfire effect can be minimised by adopting a exploratory approach or if the informant has shown past credibility.

Using the example of smile design again achieved with ceramic veneers, when a rebuttal comes from a source that was perceived to support such an approach it is better accepted than if this rebuttal comes from a supporter of the more conservative treatment option.

But nudges may take advantage on reliance on the status quo and not embrace responsiveness based on reason. The author therefore argues that if such nudges are tempered by reason (nudges to reason), the fundamental ethical pillar of autonomy is not compromised, nor are individuals as responsible agencies.