In his essay “Overkill”, Atul Gawande points out the problem of unnecessary health care, which turns out to be the most popular issue in the current medical system. According to the research studies that Gawande cites, more than 600 thousands patents have received medical treatments that they do not need, which add up to almost 300 million dollars. (Gawande, 884) Besides taking out paychecks from each households, those “low-value” cares can potentially create harm to patient’s health conditions by increasing the risk of inflammatory disease and even cancer.
Among all of the unnecessary health cares, the most common one must be the inappropriate use of antibiotics. According to the Centers for Disease Control and Prevention and Premier, Inc. research reports, the widespread abuse of antibiotics has created a financial burden of nearly 170 million dollars in US national hospitals. Of all the 160 million doctors’ antibiotic prescriptions, 30% of them are considered unnecessary or needless.(USC,1) The reasons for that problem can vary. First, normally doctors have limited time for individual patient’s diagnosis and treatments. Antibiotics are regarded as the quickest way to reduce the bacteria infections and therefore are often used by doctors to help them save tedious explanations about why drugs are not needed. Plus, single pack of antibiotics is inexpensive and will not cause economical pressure to patients. On the other hand, patients are expecting to get a prescription at the visit to make sure they get the right treatment. Studies have shown that patients tend to be more concerned if they are told to wait it out without taking any medicine. As a result, patients are likely to ask doctors for the easiest and effective drug, antibiotics, just to have some comforts and make sure they do not need to come back again.
The main cause behind this unbalanced doctor-patient relationship is what economists called “information asymmetry”. Kenneth Arrow, in his Nobel prized paper “Uncertainty and the Welfare Economics of Medical Care” defines the term “information asymmetry” as: “In many translations, one party(usually the seller) has more information about the product being sold than the other party.”(Arrow, 15) In the case of medical cares, doctors have much more knowledge and expertise than patients, who have minimal abilities to identify the quality of the advice they get. In other words, patients are unable to determine whether the antibiotics they receive are necessary to their health conditions. As patients get more antibiotics prescription every time they go to the doctor, they gradually believe that antibiotics is a fast healing to any health problem and thus ask for it even when it is needless.
One of the solutions to fix this irregular relationship is nudge. The theory was first introduced by Richard Thaler and Cass Sunstein in their book Nudge. In the book, Thaler and Sunstein claim that every day we make decisions that can range from choosing what to make for breakfast and how to go to work to how much money we are going to put in investments and where to take family for vacations. However, they believe in many cases, individuals are not able to make the best decisions, which require full attention, well-depth knowledge and complete self-control. Therefore, Thaler and Sunstein propose the way of nudge: by knowing the way people think, it is possible to create an environment to help people avoid bad decisions and pick the best choice. (Thaler, Sunstien, 624) Specifically, nudge can also be used to doctors and one of the methods is peer comparison. Normally, peer comparison is used in work to compare the results of different employees and give rewards and punishments respectively to the ones with best and worst outcomes. In the case of antibiotic prescription, doctors receive an email every week informing them of their ranking, from highest to lowest, for every inappropriate prescription on antibiotics. Those with the fewest unnecessary prescription will be told they are on top of the rank and receive congratulations in their email box. By contrast, those with a higher rate will receive nothing but the count of their inappropriate prescriptions. Due to the peer pressure, doctors are likely to pay more attention to every antibiotic prescription and effectively reduce unnecessary ones.(USC, 3)
The peer comparison intervention works based on the assumption that doctors are competitive and they care about public opinions. It is not surprising as we see that doctors perform better under the situation that they are being watched and scrutinized by the institution and system. In fact, some related researches had been done by as early as 1920s, when psychologists found out the “Hawthrone Effect”. It was first discovered at a Chicago electric telephone factory, where the owner of the factory found improved lightening could increase manufacturing productivity. The effect goes beyond productivity as psychologists later concluded that human natures tend to change their behavior in a better way when they know that they are being observed or monitored. Based on the theory, a series of discipline are established in our life. The most common example would be the sign of “Camera in the area”, which tells people that their behaviors are monitored by the camera in the particular area in case of theft and arguments. The peer comparison, similarly, lets doctors know that their antibiotic prescriptions are documented and scrutinized every month and will be compared with each other and eventually rank them from lowest to highest.
Michel Foucault, in his book Discipline And Punish: The Birth of The Prison offers us more insights by describing the definition of discipline. Fourault claims, “generally speaking, discipline can be described as techniques for assuring the ordering of human multiplicities and in order to be exercised, this power had to be given the instrument of permanent, exhaustive and omnipresent surveillance.” (Foucault, 118) To prove his point, he also cites an example of a prison with a police on a tower at the center from which the police is able to check each cell and see every prisoner. However, it is impossible for the police to check every prisoner at one time. In other words, prisons are aware that they are not being monitored at some time but they do not know when exactly since they cannot predict where the police is going to observe. The idea of establishing this central tower uses the fake permanent visibility as a trap to ensure the discipline under the assumption that prisons will behave better while they feel being watched. Equivalently in the case of peer comparison, the trap is doctors do not know how many prescriptions that other doctors may have in a month so they have to keep their own prescription amount as low as possible. Even though the hospital does not go through every prescription, it successfully limits the unnecessary ones by creating a fake surveillance based on the theory that doctors will improve their performance when they feel the hospital and peers are watching them.
But here we have to ask the question: Is nudging another way of setting discipline or even regulations? If not, how are we able to distinguish nudge from others? Thaler and Sunstein define nudge as “ any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives.” (Thaler, Sunstein, 625) They claim nudge is based on the “libertarian paternalism” which covers the libertarian aspect of making every choice available for people to choose and also paternalistic of trying to influence people’s behavior in a better way. In other words, libertarian paternalism can be considered as a weaker paternalism because it does not restrict any personal freedom and will not force people to choose certain things. It is not pure libertarian either since it does not believe that human beings are able to make the best decision every time. Therefore, it is necessary to architect choices and lead people to choose in the best way. An example would be influencing the change of dietary behavior. If a corporation wants its employees to eat more healthy vegetables, the staff in the cafeteria will put them in the eye level that are easily to reach whereas put other high-calorie food off the side where employees have to seek them out. Another example happens in health care where hospitals are encouraging more children to get vaccinations by creating policies for parents to feel difficult to opt out. Specifically, a doctor’s signature file or government proof may be necessary for parents to not pick vaccination for their children. In this way, hospitals implicitly influence but not demand parents to choose the way they intend to. Unlike nudge, discipline, as Foucault describes, “is technique to assure the ordering of human masses that elaborate tactics of power that operate economically and invisibly.” (Foucault, 130) Discipline holds more paternalism than libertarianism and sets specific rules to make sure people behave in an expected way. It increases both the docility and the utility of all the elements of the system by restricting personal freedom to choose whereas nudge leaves room for people to make their own decision and will not punish them if their choice is the opposite to what is architected for. Even though we believe that nudge will not limit people’s freedom, is it safe to say that it will never jeopardize people’s interests in any way? If it does, does it contradict to its fundamental libertarian paternalism?
Because of its effectiveness, nudge has been widely used in consumer insights, product development and public policy areas. The most popular kind of nudge in public policy is empathy nudging, which asks choice makers to consider the results of their choice from empathy and potential impact to other people. Natalia Czap is her paper “Empathy Nudging As A New Component of Conservation Programs” conducts a research on public policy on water pollution as an example. Czap and her team used empathy nudging to encourage farmers to talk to those who bring the negative impact of the pollution and asked them to protect the common good for the entire village. As a result, most of the farmers agreed to join and successfully changed their practices upstream with lower costs. (Czap, 630) Empathy nudging asks people to change their perspective and put themselves in other people’s shoes. During the process, people may be willing to sacrifice a bit of self-interest for the shared interests but their freedom of choice is never revoked. It is never mandatory for people to lose their own interest but most of the time people will tend to give it up for sharing behavior.
In summary, the uniqueness of nudge is that it always stands on the ground of libertarian paternalism, which protects people’s choice to opt what they really want. It also differentiates itself from discipline even though they share similar mechanism to apply human natures to achieve the goal. However, we need to pay attention that there is a variety of nudge and some of them may ask for the sacrifice of self- interest but it is never imperative. Overall, nudge provides another path to solve social problems like the overuse of the antibiotics and we may see more of it in the future to nudge us to a better, wiser and healthier life.