Patient Engagement
Toward Better Health: Choice Architecture vs. Self-Discipline (09:53)

“I have to start with a confession,” begins physician and behavioral scientist Peter Ubel. “I think my Roman Catholic upbringing gave my misguided ideas about how to promote healthy behavior in our patients and in society.”

Ubel attended an all-boys, Roman Catholic military academy high school, where they believed in faith, discipline, and “probably most of all” suffering. “If you do something good, but if you don’t suffer in doing good, you don’t get full credit at the end of your time,” he says, adding that Jesus Christ “didn’t just die, but suffered. Suffering is critical here.”

Having internalized these beliefs, Ubel believed if you finished a workout and didn’t feel miserable at any point during that workout, you didn’t do enough. “That’s a good way to get that much stronger at something,” he says, acknowledging that the audience may feel similarly. “We probably worked hard at something in our lives and got proud from that and knew what we had accomplished.”

“The problem is when we’re all then the people leading in health care and in health policy, [and] we believe that the best way to promote other people to do healthy behavior is to make them into the same kind of masochist that we already are,” says Ubel.

Should clinicians and health systems promote suffering to promote healthy behavior, or should we focus on making it easier? When do we go one way or the other?

A few years go, Ubel’s pelvis broke, leaving him unable to exercise significantly for a couple of years. Before then, he had exercised every day and didn’t worry about gaining weight. He avoided weight gain when unable to exercise, though, thanks to his training in behavioral economics. “I had built all the self-discipline. I knew to get smaller tortillas, to share entrees at restaurants with people,” he explains. “The sad thing is that that is the kind of message I would talk about with my patients: how they just need to be stronger, tougher, more disciplined in order to be as healthy as I am. Because if I could do it, they can.”

But that approach doesn’t work for everyone. Does behavioral economics suggest something different?

In Thinking, Fast and Slow, by psychologist Daniel Kahneman, who earned a Nobel Prize in economics, the fast part is rapid judgements that lead to bad decisions and behaviors. Here, behavioral economics tells us to slow down, to be more rigorous, thoughtful, and careful.

One of the most famous behavioral economics findings is loss aversion. In standard economics’ law of diminishing marginal utility, the same-sized gain brings less pleasure than the same-sized loss that brings us misery. “If I have $1 million net worth and you take $1 million away from me, you’ve ruined my life,” explains Ubel. “If you give me another million dollars, I went from rich to richer.”

If the exact same thing we face in life feels like a gain, we treat it differently than if it feels like a loss, and behavioral economics says this loss aversion doesn’t make sense. For example, if you have a serious illness and are considering surgery with a 90% survival rate, that’s great. But if you look at it as a 10% mortality rate, that’s not great — despite being the same thing. But it feels different. “That’s not a rational way to make a choice, to have that framing influence your decisions,” says Ubel.

If you give people the gain/loss framing and tell them to make a quick decision, they are more susceptible to bias. But if you give them the scenario in, for example, a foreign language they’re competent at but not fluent in, it slows them down enough that they become less susceptible to bias.

Turning to the example of Nobel Prize–winning economist Richard Thaler, Ubel describes a dinner party Thaler threw when he was a young professor. Before the meal, his colleagues munched on cashews to the point where they were going to lose their appetites. Thaler removed the cashews, and his colleagues thanked him for helping them engage in self-discipline.

“A simple little change in the choice architecture, taking the cashews out of their line of sight, improved their behavior,” explains Ubel. Here, it seems that making it easy is the way to go.

Thaler later noticed how people were leaving thousands of dollars on the table by not maxing out their retirement contributions. “But of course, to put money into retirement savings this year means tightening my belt and not living a lifestyle I’m used to living,” notes Ubel. “That’s a hard thing for people to do.” So Thaler and Shlomo Benartzi came up with Save More Tomorrow: When your income increases, a portion of that goes into savings automatically and gets matched by your company to the point you max out. “You make that decision now, you have no suffering today, and if you don’t do anything else, it works in the future,” Ubel explains.

But if you took all the cigarettes out of Thaler’s living room, people who smoke are still going to find a way to smoke; one simple nudge won’t remove all nicotine withdrawal. Over the past few decades, the U.S. has combatted tobacco usage through PSA campaigns, public smoking bans, steep taxation, and stigmatization. “We’ve made it hard to smoke,” says Ubel. “If you can’t make it easier for people to do what’s right, we should think about making it hard for them to do what’s wrong.”

“Sometimes nudges are so appealing because they seem so simple and so hands-off that we forget that some behaviors need more than a nudge and that we need to be more aggressive about doing them,” he says. You can stop smoking and still live your life, but you can’t stop eating food.

“What we need to do is make it harder for people to eat unhealthily,” says Ubel. Taxes are a start, and changing the choice environment people live in is important — improving school food, making it harder to access unhealthy than healthy food, and getting people moving and exercising.

“The more we think, ‘no pain, no gain,’ the less likely we are to get people to move more, because why would you do something that’s miserable?” Ubel says. This approach works for some, but it doesn’t work for many others. “We want to make it fun, we want to make it the kind of things people enjoy, and if by chance they get healthier, that’s a wonderful side effect.”

From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.

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