I’m going to start this introduction the way Eric ended our podcast.

You are a GeriPal listener. Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness. This is hard, complex, and deeply important work we’re engaged in. Did you know that most GeriPal listeners have given us a five star rating and left a positive comment in the podcasting app of their choice? We will assume that you are doing the same right now if you haven’t done so already, though we suppose you are free to choose not to if you don’t believe in the mission of helping seriously ill older adults.

Ha! Gotcha.

Today we talk with Jenny Blumenthal-Barby and Scott Halpern, two experts in the ethics and study of “nudging,” or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice. Jenny just published a terrific book on the topic, “Good Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.” Scott published several landmark studies including this study of changing the defaults on an advance directive (e.g. comfort focused care is checked by default) and a paper on how nudging can be used in code status conversations (e.g. “In this situation, there is a real risk that his heart may stop—that he may die—and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?”).

Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I’m a believer in the GeriPal mission too, we’re on the same side), appealing to ego (you’re a good person because you believe in an important cause), and changing the defaults (you’re giving us a five star rating right now unless we hear otherwise).

We distinguish between nudges and coercion, mandates, and incentives. We talk about how clinicians are constantly, inescapably nudging patients. We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge.

Nudges are powerful. At best, nudges can be used to promote care that aligns with a patient’s goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote “doctor knows best” paternalism, and to “strongarm” patients into care that doesn’t align with their deeply held wishes.

What will send your head spinning later are the thoughts we raise: what if nudging people against their preferences is for the common good? And also: what if the ease with which people are nudged suggests we don’t have deeply held preferences, goals and values? Hmmm....

Hey, have you completed your five star rating of GeriPal yet?

-@AlexSmithMD

Other citations:

-Randy Curtis and Robert Burt on unilateral DNR and informed assent

-GeriPal podcast with Angelo Volandes about using video to improve choices

Decugnano Dei Barbi: A Pioneering Winery in Orvieto