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Ann Fam Med. 2010 May; 8(3): 260–264. doi: 10.1370/afm.1118
PMCID: PMC2866725PMID: 20458111
Beneficent Persuasion: Techniques and Ethical Guidelines to Improve Patients’ Decisions
J. S. Swindell, PhD,1 Amy L. McGuire, JD, PhD,1 and Scott D. Halpern, MD, PhD, MBE2,3
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Abstract
Physicians frequently encounter patients who make decisions that contravene their long-term goals. Behavioral economists have shown that irrationalities and self-thwarting tendencies pervade human decision making, and they have identified a number of specific heuristics (rules of thumb) and biases that help explain why patients sometimes make such counterproductive decisions. In this essay, we use clinical examples to describe the many ways in which these heuristics and biases influence patients’ decisions. We argue that physicians should develop their understanding of these potentially counterproductive decisional biases and, in many cases, use this knowledge to rebias their patients in ways that promote patients’ health or other values. Using knowledge of decision-making psychology to persuade patients to engage in healthy behaviors or to make treatment decisions that foster their long-term goals is ethically justified by physicians’ duties to promote their patients’ interests and will often enhance, rather than limit, their patients’ autonomy. We describe techniques that physicians may use to frame health decisions to patients in ways that are more likely to motivate patients to make choices that are less biased and more conducive to their long-term goals. Marketers have been using these methods for decades to get patients to engage in unhealthy behaviors; employers and policy makers are beginning to consider the use of similar approaches to influence healthy choices. It is time for clinicians also to make use of behavioral psychology in their interactions with patients.
Keywords: Decision making, professional autonomy, informed consent, ethics, persuasive communication
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INTRODUCTION
Physicians frequently encounter patients who make choices that contravene their long-term goals. Smoking, eating poorly, not exercising, failing to get regular mammography and colorectal screenings, and not vaccinating children are among the most obvious of these seemingly bad decisions. More subtly, but also quite commonly, patients make curious treatment decisions. An elderly patient with mild, asymptomatic coronary artery disease might request a percutaneous intervention despite evidence and his clinician’s best judgment that medical therapy would provide a better risk-to-benefit ratio. A patient with surgically resectable lung cancer may opt to forego surgery because she believes it would spread the cancer.1
Behavioral economists have shown that self-thwarting tendencies pervade human decision making, and they have identified a number of specific operating heuristics and biases that help explain why patients sometimes make such counterproductive decisions. In this essay we describe the many ways in which these heuristics and biases influence patients’ decisions and argue that often the most ethically appropriate response will be for physicians to use knowledge of these potentially destructive decisional biases to rebias their patients in ways that promote their health or other long-term goals.
Decision Biases and Heuristics
Traditional models of medical decision making are based on rational choice, which assume that decision makers aim to maximize their utility and that decision makers’ preferences are invariable regardless of how a choice is presented (eg, 60% chance of dying vs a 40% chance of living). Behavioral economists have shown otherwise, however. For example, people tend to over-weigh their utilities for gains and underweigh their utilities for losses, to inaccurately project their utilities in a future time period, to reverse their preferences depending on how their options are framed, and to adopt a passive default position (thereby risking errors of omission) rather than actively make a choice (thereby risking a similar or often smaller error of commission). These biases and heuristics influence all decisions, including medical decisions. Table 1▶ illustrates a number of these biases and heuristics and provides examples of how they might play out in the clinical setting.3
Table 1.