Personal choice is a nuanced concept - Lessons learned from the gambling field. •.

This thoughtful framework to minimize the harm associated with emerging technologies by encouraging collaborations among stakeholders would benefit from adopting the WHO precautionary principle in order to keep public health issues at the core of discussions. It would also be helpful to acknowledge and make transparent the differences in stakeholder priorities, the power differentials among stakeholders, and the importance of institutional duty of care.

Swanton, Blaszczynski, Forlini, Starcevic, and Gainsbury (2019) propose a thoughtful framework for minimizing the personal harm that is potentially associated with new technologies. Broadly defined these technologies and behaviors include online gaming, gambling and shopping, online sexual behaviors, and oversharing on social media sites. The framework identifies various stakeholders that need to be involved in identifying and tackling issues as they emerge and discusses principles to encourage fruitful collaboration. I applaud the goal of developing a framework, as it may help minimize the typical lag we find between development of technology and consumer protection policy. I propose, however, that the principles be modified somewhat, based on lessons learned in the gambling field.

The Swanton et al. (2019) paper briefly references the Reno Model, a framework proposed in the 2000s to encourage stakeholder collaboration in the commercial gambling sector (Blaszczynski, Ladouceur, & Shaffer, 2004). Numerous features of the two models (and issues) seem to overlap. Commercial gambling emerged as a growth industry in the 1990s and, as a result, gambling-related harms confronted the diverse stakeholders, including consumers and their families, regulators, industry, and treatment providers. The intent of the Reno model was to promote collaborative and proactive response to harm minimization.

The Reno model was heralded in some circles but also criticized in others (Hancock & Smith, 2017; Livingstone & Adams, 2016; Shaffer, Blaszczynski, & Ladouceur, 2017). In particular, two aspects have caused concern that are relevant to the Swanton framework. First, it is argued that the Reno model overemphasizes individual responsibility and underemphasizes industry responsibility in preventing harm as well as broader social and political determinants. According to the model, responsible gambling is ultimately seen as the responsibility of the individual (the end-user), albeit influenced by other factors, including some controlled by the gambling industry. The same philosophy permeates the Swanton paper. In fact, the authors acknowledge that they have an implicit Western bias that individuals are largely responsible for their actions.

The claim that ultimate responsibility rests with the individual is overly simplistic and does not recognize the reality of how people make decisions about their behavior. Some decisions are limited by the options available to consumers. The seatbelt analogy is often used in the gambling area. Each driver decides whether or not to buckle their seatbelt while driving an automobile. However, such a decision is dependent on seatbelts being available, which is a regulated obligation of the manufacturer. We are able to drive our cars without using the seatbelt, but we are strongly nudged toward buckling up by those persistent reminder buzzers. It would be unpleasant to drive my car without bucking the seatbelt.

The growing literature on choice architect underscores these nuanced influences on “personal informed choice” (Thaler, 2018; Thaler & Sunstein, 2008). We are nudged towards all sorts of decisions, without our full awareness. I am certainly more likely to drop an empty plastic drink bottle in the correct recycling bin, whether I care about recycling or not, if the shape of the opening of the correct bin makes it easier for me than putting it in the bin designed with an opening another object. Personal choice in our behaviors is not absolute. Nudges can also work against public health as well as supporting it. I remember a number of years ago being surprised while traveling by car on the autoroutes to see in some countries that rest stops included well-advertised bars serving alcohol. It seems like the “don't drink and drive” educational message must be undermined by this subtle, implicit permission to do the opposite.

Another complication with holding the end user ultimately responsible is that the information needed to make a fully informed decision may be too complex for most people to incorporate in their decision-making process. For example, the payoff odds in slot machines are not understood by most players even after the players receive educational interventions (Beresford & Blaszczynski, 2020). Only the most simple of messages (e.g., that outcomes are random) are retained and only for a limited time (Wohl, Gainsbury, Stewart, & Sztainert, 2013). Providing clear information about risks is crucial, but this should be done recognizing that it is possibly insufficient to ensure true informed decision-making.

The decreasing prevalence of tobacco use since the 1970s in some western countries illustrates this point. This reduction has not come solely through informed consumer initiatives focusing on educating individuals that tobacco use is unhealthy – the change came about from incremental changes in advertising, marketing, and taxation. In short, regulation of industry via government policy is primarily responsible for reduction in tobacco use.

One additional limitation of the personal choice perspective that is more clearly acknowledged in the Swanton paper is that there are individual differences in the ability to make informed decisions. People with certain characteristics or in certain situations (e.g., mental health issues, lower intelligence) are less equipped for informed decision-making. For potentially addictive activities and substance, personal choice is even more compromised by the emergence of impairment of control in some exposed individuals. By definition, impairment of control involves less than perfect decision-making. Alcohol, other psychoactive drugs, and gambling are described as “no ordinary commodities” for this specific reason (Babor et al., 2010) and involvements related to new technologies are likely similar. People can make decisions about their consumption, but doesn't the responsibility of other stakeholders become even more pivotal?

The second criticism of the Reno model is its failure to account for power differentials among stakeholders and differences in their primary values. Whereas protection of its citizens from harm is presumably the foremost value of government, industry is beholden to shareholder interests. This not to say that governments do not also desire to maximize tax revenues and that industry does not also hold social responsibility ideals of player protection. However, these differences in values complicate stakeholder collaboration, and need to be acknowledged and made transparent in the details of collaborative efforts. It would be helpful if the proposed framework helped stakeholders identify and address incompatibility in values, and power differentials. Oddly, the Swanton paper does the opposite-in stating that the individual consumer has ultimate choice, the authors are suggesting that the arguably least powerful stakeholder holds the most power.

Consumers should, of course, be recognized as an essential stakeholders and collaborators. We are making headway in including people with lived experience as co-designers of research and policy. Nonetheless, no one would claim that parity has been achieved. The Swanton contribution would benefit from discussion of these challenges and incorporation in their framework of the importance and process for transparent handling of them.

The framework's stated goal is to balance “individual civil liberties with societal responsibilities, and institutional duty of care”. I contend that the framework would be stronger if institutional duty of care is privileged, while individual liberties are respected. The World Health Organization, in its mandate to protect public health, adopts the precautionary principle. The precautionary principle, described by the UNESCO World Commission on the Ethics of Scientific Knowledge and Technology, indicates that when it is scientifically plausible but uncertain that human activities might lead to morally unacceptable harm, actions shall be taken to avoid or diminish that harm (World Commission on the Ethics of Scientific Knowledge and Technology, 2005). In other words, pre-damage control is preferred over post-damage control. Better safe than sorry, as my mother always warned me. This approach is relevant to the new technologies covered in Swanton's framework, where we are only beginning to understand the potential harms, although they are more than hypothetical. The need for a framework, however, acknowledges that real and credible concern about harms exist.

In short, a framework that identifies the various stakeholders and their differing and sometimes incompatible perspectives is an important step forward. Modifying the framework to acknowledge these differences, the power differentials among stakeholders, and the importance of institutional duty of care, as well as adopting the precautionary principle would be helpful in keeping public health issues at the core of discussions.