Nudge: Improving Decisions About Health, Wealth, and Happiness [ハードカバー]

Richard H. Thaler and Cass R. Sunstein are both professors at the University of Chicago and where the Chicago school was once famous for the Milton Friedman doctrine of free markets (look where they've got us today!) Thaler and now his Law professor friend Cass Sunstein have swung the pendulum the other way.

Here in Nudge, they argue that totally free markets can lead to disasters precisely because human individuals are not actually very good decision-makers. As Behavioural Economists (Kahneman & Tversky Judgment under Uncertainty: Heuristics and Biases- who credited Thaler as being a key inspiration - and Dan Ariely, whose Predictably Irrational: The Hidden Forces That Shape Our Decisions has become a best seller) argue, we are riddled with little psychological tics in our decision-making processes. We buy things, then suffer remorse. We get confused by choices and often make no choice at all.

But where Ariely keeps his discourse in the world of the day to day, Thaler and Sunstein develop an argument that is political - and is bound to cause heated debate. What they argue is that, in the face of our decision-making weaknesses, Governments and Businesses can help "nudge" us in the right direction. The elephant in the room can be benign.

They call their viewpoint `libertarian paternalism' and what they argue is that it would be a good thing for some gentle nudging of the citizenry in the right direction. As Thaler said recently in the New York Times: "In light of human limitations, Cass Sunstein and I argue for policies that we call libertarian paternalism. Although the phrase sounds like an oxymoron, we contend that it is often possible to design policies, in both the public and private sector, that make people better off -- as judged by themselves -- without coercion. We oppose bans; instead, we favor nudges."

How does a Government do this without imposing laws and edicts. A primary argument is that defaults can be set that counter the tendency by humans to procrastinate or make no decision. One example is the Save More Tomorrow Plan which Thaler developed back in 1996 as an employer sponsored retirement plan for employees. Instead of presenting the details and asking employees to consciously sign-up to increase their savings each time they got a pay rise, the plan presented the details and asked employees to basically check the box if they wished in future to automatically increase their savings as their pay went up. To pre-commit. Such schemes have proved very successful, yet they offer the same free choice, though with a different default.

As Thaler argues: "Since it is often impossible for private and public institutions to avoid picking some option as the default, why not pick one that is helpful?"

Another form of nudge might be the act of disclosure. Thaler & Sunstein argue, for example that credit card companies should issue annual statements that tell us how much we've spent this year on late fees and interest. Again: we have the complete freedom to use cards as we want, but the additional information may help us reframe our own spending strategies. Or how about stickers on new cars that show how much gasoline each vehicle would burn over the next 5 years under typical usage. Hold that Hummer.

These are examples of what the authors call helpful "choice architecture." Nice phrase. The architecture puts our options on more clear display.

I must say, I like the thinking here, and it gives credence to agent-based simulation modelling I've carried out whereby small changes can lead to big effects.

But this volume is about more than modelling and mere theory. One cannot help but think that the book has been timed to coincide with the meltdown of the present economy. The free market, the totally free market, the authors implicitly argue, needs quite a nudge itself. Rather than seeking highly regulated solutions, the better response might simply be a series of tweaks to the choice architecture that influences our spending, saving, health care and borrowing patterns.

The authors present a clear argument and no doubt it will cause heated and lively debate. This book has landed like a rock, right into the centre of the current and somewhat stagnant economic pond. It will definitely cause ripples. Well worth reading.

I liked the beginning of the book, but it became repetitive and boring after first three chapters. It could be due to the fact that I generally agree with the major premise of the book: people should be "nudged" to make a decision that will make them better off. And yes, the nudge should be transparent and not synonym to manipulating people's minds. And yes, the government has my permission to nudge me in the right direction; if as a result I will make a decision (for example) to exercise more and eat less junk food.
(As a side note, I will be happy to have such a smart government. Or well, this could be an issue. But this is a subject for another book).
I got it, and I don't need three chapters to convince me. Am I alone in this?

I was much more interested in why and how our brain works to react to the "nudges" ("popular psychology" side that was almost non-existent), than in authors' rebukes to the opponents of "libertarian paternalism" - the political implementation of their theory. The other thing that annoyed me was the authors' attempt to be funny and coin terms, names and definitions that were supposed to make the book readable. Instead, it got annoying after the third appearance of the term "libertarian paternalism" and after the fifth time I saw the term "Econ" (used for infamously rational person from economics textbooks).

I had an opportunity to listen to Thaler's presentation on this subject and it was lively and interesting. He is a brilliant speaker with many great ideas; unfortunately, it didn't translate into the brilliant writing.

I would still recommend the book for the ideas of "nudges" in different areas (personal finance, energy conservation, marketing, politics and everyday life). However, it fells short on the inspirational side. You shouldn't be able to put this book down. But you are.

"Buy on apples, sell on cheese" is an old proverb among wine merchants. Taking a bite of an apple before tasting wine makes it easier to detect flaws in the wine, and the buyer who does so will not as easily make the mistake of paying more than the wine is worth. Cheese, on the other hand, pairs well with wine and enhances its flavor, so a seller who offers cheese may command a higher price for the wine (and may even deserve it, if the wine is intended to be drunk with cheese).

The proverb captures important psychological nuances of choice. The same product - a bottle of wine or a risky medical procedure - may be perceived differently depending on its context, and it is often possible to arrange the context to influence a choice while still maintaining the decision maker's autonomy.

The practice of structuring choices is called "choice architecture" in a brilliant and important new book, Nudge, by University of Chicago Distinguished Professors Richard Thaler (Business) and Cass Sunstein (Law). Nudge lays out the groundwork for the science of choice architecture in investing, insurance, health care delivery, and other areas, and argues for a "libertarian paternalism" in which choices are structured to make it more likely that a decision maker will select what is considered the most beneficial option, without impairing the ability to decision makers to select other options. For example, making enrollment in 401(k) plans automatic for new employees, with a form for opting out, is likely to result in greater retirement savings than an opt-in system, without limiting anyone's freedom to choose.

Thaler and Sunstein apply the principles of choice architecture to a few problems in health care (How could Medicare part D be improved? How can organ donation rates be increased? Why shouldn't patients be allowed to waive their right to sue for medical negligence in return for cheaper health care?) But the concepts in the book go beyond their specific examples and could prove very useful to practicing clinicians, who, they note, are often in the position of being choice architects for their patients.

Their principles of choice architecture (paraphrased by me and focused on physicians helping patients make decisions) are:

* Make sure incentives are aligned with desired outcomes
* Help patients map outcomes of different alternatives into formats they can understand (a major focus of Medical Decision Making as well)
* Arrange default options to favor better health. Pediatricians have done a good job of making vaccination a default option.
* Provide timely and relevant feedback about choices and outcomes. A patient seeking to lose weight needs to experience feedback in the form of measurable progress soon enough that they are not discouraged.
* Expect error and develop systems to prevent, detect, and minimize it. For example, pill cases and inhalers with dosage counters are simple and valuable ways to reduce the frequent errors people make in remembering medication. Psychological research provides direction as to what kinds of errors are to be expected when people are making decisions.
* Structure complex choices to reduce the difficulty of making good decisions. In many ways, that's what medical decision making -- and Medical Decision Making -- is about.

I highly recommend Nudge. It's a great read, and has the potential to change the way you think about clinical practice and medical decisions.