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I\u2019m going to start this introduction the way Eric ended our podcast.

You are a GeriPal listener.\xa0 Like us, you care deeply about our shared mission of improving care for older adults and people living with serious illness.\xa0 This is hard, complex, and deeply important work we\u2019re engaged in.\xa0 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?\xa0 We will assume that you are doing the same right now if you haven\u2019t done so already, though we suppose you are free to choose not to if you don\u2019t 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 \u201cnudging,\u201d or using heuristics, biases, or cognitive shortcuts to nudge a person toward a particular decision, without removing choice.\xa0 Jenny just published a terrific book on the topic, \u201cGood Ethics and Bad Choices: The Relevance of Behavioral Economics for Medical Ethics.\u201d\xa0 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. \u201cIn this situation, there is a real risk that his heart may stop\u2014that he may die\u2014and because of how sick he is, we would not routinely do chest compressions to try to bring him back. Does that seem reasonable?\u201d).

Examples of nudges are comparing to norms (most listeners have given us a 5 star rating), the messenger effect (I\u2019m a believer in the GeriPal mission too, we\u2019re on the same side), appealing to ego (you\u2019re a good person because you believe in an important cause), and changing the defaults (you\u2019re giving us a five star rating right now unless we hear otherwise).\xa0\xa0

We distinguish between nudges and coercion, mandates, and incentives.\xa0 We talk about how clinicians are constantly, inescapably nudging patients.\xa0 We arrive at the conclusion that, as nudging is inevitable, we need to be more thoughtful and deliberate in how we nudge.\xa0\xa0

Nudges are powerful.\xa0 At best, nudges can be used to promote care that aligns with a patient\u2019s goals, values, and preferences. At worst, nudges can be used to constrain autonomy, to promote \u201cdoctor knows best\u201d paternalism, and to \u201cstrongarm\u201d patients into care that doesn\u2019t align with their deeply held wishes.\xa0\xa0

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\u2019t have deeply held preferences, goals and values? Hmmm....\xa0

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