Asymmetric Paternalism to Improve Health Behaviors
George Loewenstein, PhD Troyen Brennan, MD, JD, MPH Kevin G. Volpp, MD, PhD
ease burden faced by society. Many major health problems in the United States and other developed nations, such as lung cancer, hypertension, and diabetes, are exacerbated by unhealthy behaviors. Modifiable behaviors such as tobacco use, overeating, and alcohol abuse account for nearly one-third of all deaths in the United States.1,2 Moreover, realizing the potential benefit of some of the most promising advances in medicine, such as medications to control blood pressure, lower cholesterol levels, and prevent stroke, has been stymied by poor adherence rates among patients.3 For example, by 1 year after having a myocardial infarction, nearly half of patients prescribed cholesterol-lowering medications have stopped taking them.4 Reducing morbidity and mortality may depend as much on motivating changes in behavior as on developing new treatments.5 Economics, as the social science discipline traditionally most closely tied to public policy, could be a key discipline in addressing behaviors that are potentially harmful to health. Yet conventional economics does not provide satisfactory policy solutions to problems caused by self-harmful behavior. Economics is premised on a rational choice perspective which, by assuming that individuals make optimal decisions given their information, resources, and preferences, in effect assumes away these problems. The main policy tools suggested by conventional economics, providing information or changing prices, only partially address these problems because they fail to exploit what is known about human motivation and behavior change. Responding in part to these limitations of conventional economics, the new field of behavioral economics has, over the last few decades, begun to import concepts from psychology.6 Behavioral economists have identified a number of decision biases and pitfalls in decision making that can help explain when and why individuals engage in selfharming behaviors that contribute to poor health outcomes. Insights from behavioral economics can contribute to solutions for public health problems such as medication nonadherence and sedentary lifestyles that have challenged cli©2007 American Medical Association. All rights reserved.
nicians and public health professionals for years. In this Commentary, we identify some key decision biases that ordinarily lead to self-harming behavior and show how they can be exploited in interventions to instead promote healthy behaviors. Concepts of Behavioral Economics Behavioral economics has identified several patterns of behavior that characterize the way individuals make decisions. For example, individuals are highly prone to keeping with customary (status quo) or default options even when superior alternatives are available, known as the status quo or default bias. For example, in New Jersey, the default on automobile insurance conferred a limited right to sue (with an option to pay extra to acquire a full right to sue), but only 20% of drivers chose to acquire this right. In contrast, in Pennsylvania, where the default was a full right to sue (with a discount if drivers switched to a limited right to sue), approximately 75% of drivers opted to retain the full right to sue.7 Likewise, employees save more when their employer automatically deposits a significant share of salary into a retirement plan than if the default is no contribution.8 Individuals place disproportionate weight on present relative to future costs and benefits, known as present-biased preferences.9 This explains why many behavioral patterns that undermine health involve immediate benefits (such as eating) coupled with delayed costs (such as obesity), or immediate costs (such as the inconvenience of taking a drug or undergoing a preventive medical procedure) coupled with delayed, and often uncertain, benefits. Caring...
References: 1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000 [published correction appears in JAMA. 2005;293(3):298]. JAMA. 2004;291(10):1238-1245. 2. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861-1867. 3. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007; 167(6):540-549. 4. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288(4):462467. 5. Schroeder SA. We can do better—improving the health of the American people. N Engl J Med. 2007;357(12):1221-1228. 6. Camerer C, Loewenstein G. Behavioral economics: past, present, future. In: Camerer C, Loewenstein G, Rabin M, eds. Advances in Behavioral Economics. New York, NY and Princeton, NJ: Russell Sage Foundation Press and Princeton University Press; 2003. 7. Johnson EJ, Hershey J, Meszaros J, Kunreuther H. Framing, probability distortions, and insurance decisions. J Risk Uncertainty. 1993;7:35-53. 8. Madrian BC, Shea DF. The power of suggestion: inertia in 401(k) participation and savings behavior. Q J Econ. 2001;116(4):1149-1187. 9. O’Donoghue T, Rabin M. Doing it now or later. Am Econ Rev. 1999;89(1): 103-124. 10. Weber BJ, Chapman GB. Playing for peanuts: why is risk seeking more common for low-stakes gambles? Organ Behav Hum Decis Process. 2005;97:3146. 11. Camerer C, Issacharoff S, Loewenstein G, O’Donoghue T, Rabin M. Regulation for conservatives: behavioral economics and the case for “asymmetric paternalism.” Univ PA Law Rev. 2003;151(3):1211-1254. 12. Thaler RH, Sunstein CR. Libertarian paternalism. Am Econ Rev. 2003;93 (2):175-179. 13. Baumeister RF, Vohs KD. Time and Decision: Economic and Psychological Perspectives on Intertemporal Choice. Willpower, choice, and self-control. In: Lowenstein G, Read D, Baumeister RF, eds. New York, New York:Russell Sage Foundation Press;2003. 14. Martin A. The school cafeteria, on a diet. New York Times. September 5, 2007. 15. Thaler RH, Benartzi S. Save more tomorrow: using behavioral economics to increase employee saving. J Political Economy. 2004;112(1):S164-S187. 16. Warner KE, Smith RJ, Smith DG, Fries BE. Health and economic implications of a work-site smoking-cessation program: a simulation analysis. J Occup Environ Med. 1996;38(10):981-992. 17. Higgins ST, Wong CJ, Badger GJ, Ogden DE, Dantona RL. Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol. 2000;68(1):64-72. 18. Volpp KG, Gurmankin Levy A, Asch DA, et al. A randomized controlled trial of financial incentives for smoking cessation. Cancer Epidemiol Biomarkers Prev. 2006;15(1):12-18.
©2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 28, 2007—Vol 298, No. 20
Downloaded from www.jama.com on November 27, 2007
Please join StudyMode to read the full document