Peter Ubel

In the last few posts, I’ve told the story of a couple heated debates. One still ongoing: “Does capital punishment deter criminals?” Another ended: “Do antiarrythmia drugs save lives?” The latter debate is over because people on both sides of the debate got together to find out the answer!

If we really want to improve political discourse in this country, we need to do what the cardiologists did in the 1980′s-convince opponents to collaborate with each other to find the facts. The CAST study, after all, brought together people who had been aggressive adversaries and turned them into constructive collaborators.

Take school vouchers: Imagine if a group of anti-voucher Democrats got together with pro-voucher Republicans and funded a research program comparing their favorite approaches. Both groups want what is best for their children and grandchildren, after all, so they ought to be sufficiently motivated to spend money in ways that will determine what’s best for the kids.

Now let’s take their partisan partnership a step further, and imagine that these adversaries are not only teaming up to fund the research, but are even joining forces to design the research. Not that I expect the legislators, themselves, to design such studies. But I can envision their respective scientifically-trained staffs playing a role in the design of the research trial. Indeed, by involving opponents in the design of a research study, we’ll end up with a better study. For if the study was put together exclusively by opponents of vouchers, rather than a bipartisan group, the study would hardly be likely to end up as a fair test of their efficacy.

Suppose that a bipartisan research committee-one that also includes social scientists knowledgeable about education-decides to conduct an experiment: They pick, say, 80 school districts from around the country, and randomly decide that 40 will have a voucher program for the next three years.

After intense debate the committee comes to consensus about what outcome measures they will use to evaluate the voucher program-some combination of, say, standardized tests scores and graduations rates. They even agree on the statistical methods they will use to assess these outcomes. What, then, is the likely outcome of their experiment?

Did you think I’d have an opinion on whether vouchers would benefit students? Well I hate to disappoint, but that is not at all what I meant by “the outcome of the experiment.” What I meant was: What will happen once the experiment is complete? And that, perhaps, can best be answered by looking at what will not happen…

Let’s imagine for a moment that a pro-voucher interest group funded a study which demonstrated that vouchers improve students’ test scores. It is pretty easy to envision the anti-voucher crowd criticizing the study-complaining about the outcome measures, for example, or about the use of an inappropriate control group. If the anti-voucher crowd, by contrast, helped design the study, it would be much more difficult for them to oppose vouchers on the grounds that they harm educational outcomes. Moreover, important legislators would be on board with the facts, having played a role in obtaining the data. As I’ll demonstrate in later chapters, the progress of science depends as much on psychology as it does on the nuts and bolts of any given research study. Partisan partnerships can help overcome some of those psychological barriers that so persistently prevent us from basing our policies on the best information science has to offer us.

I know this must sound woefully idealistic. But middle-age hasn’t caused me to abandon my ideals. In fact, to the contrary-my career in science and medicine has taught me that social progress depends on people striving for ideals, and it has shown me, too, that the scientific method is one of the very best tools humankind has created to help pursue those ideals.

I recognize that science is rarely as clean as it may appeared to have been in the anti-arrhythmia trial. Often it is quite messy, in fact-plagued by some of the same problems that afflict our political system: Strong opinions and even stronger emotions; name-calling and lies; even the frequent inability of scientists to admit when they are wrong. Indeed, “scientific truth” is often a matter of opinion, frequently a function of political consensus rather than indisputable evidence. For years, after all, Newton’s laws were the “truth,” until later physicists, most notably Einstein, revealed the laws to have been only better approximations of the truth than those of Newton’s predecessors.

Nevertheless, even if science is often more ‘truthy’ than truth-determining, the scientific method remains the best method humans have created by which to inch themselves, bit-by-bit, toward the truth about how the world works and how it might be improved. After all, people used to think that epileptic seizures were evidence that a person was possessed by the devil; whereas now scientists can pinpoint the area of the brain responsible for seizures, reducing future seizures with medications or surgery. Similarly, people used to think that continents were immovable, and now scientists have discovered that the continents used to be joined as one super-continent and, indeed, are continuing to drift across the globe.

Science is awfully good at revealing certain kinds of truth about how the world works. I would like to find ways to bring more of these truths to bear upon our social policies.

What do you think?

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When I last posted to this site, I was recounting my experience as a medical resident in the late 80s, presumably saving my patients’ lives with wonder drugs.

A few weeks into my cardiology rotation, the senior cardiologist who had been mentoring me took leave of the hospital and was replaced by another experienced cardiologist. On his first day, this new cardiologist listened as I told him about one of my patients, who had benefited from these amazing new drugs. He wasn’t impressed: “We are treating patients,” he sniffed, “not ECGs. What evidence do you have that the drug is improving his life?”

I was stumped. Many of my arrhythmia patients did not even notice when they were experiencing these premature beats. “Well he may not be feeling any better because of the meds,” I recall saying “but at least he should live longer.” The cardiologist peered at me skeptically: “Are you sure?” he said. “What study has proven that these drugs save lives?”

I had no idea. Humbled, I trudged over to the library later that day to find the answer, all of that World Book training finally coming in handy. A glance at the medical literature quickly showed me that there were plenty of research studies showing that these drugs reduced arrhythmias, but, as my mentor anticipated, none showing that they saved lives.

No proof? Then why were these drugs on the market, I wondered? As it turns out, the FDA found itself under great pressure in the 1980′s to speed up the pace of drug approvals, particularly for patients with dangerous or incurable illnesses. In the face of such pressure, the FDA decided to approve the arrhythmia drugs, Encainide and Flecainide, based simply on their ability to reduce how often patients experience premature beats. The FDA, then, was settling for evidence that the drugs influenced an intermediate outcome-premature beats-without demanding proof that the drugs influenced the outcome that really mattered-whether patients live or die.

The FDA’s reliance on this intermediate outcome was not particularly controversial at the time. Patients die from arrhythmias, after all, and these drugs reduced the frequency of such arrhythmias; so it was logical to conclude that these drugs would reduce deaths from arrhythmia.

But my Mayo training had now shown me that not all doctors agreed. Indeed, cardiology meetings in those days were often the scene of heated debates about the merits of these drugs, sometimes devolving into shouting matches. Had the leaders of the American College of Cardiology been the Supreme Court of medical care, they might have decided 6 to 3 in favor of the drugs. But the minority would have no doubt written passionate dissenting opinions bemoaning the lack of evidence supporting these drugs.

Once again-people divided not so much by irresolvable moral conflicts as by a simple matter of fact: The drugs either saved lives or they didn’t, but experts could not decide what was true.

Is there any hope?

OK-In these last few posts, I’ve introduced you to two disputes, one from the 70′s over whether the death penalty saves lives by deterring future murders, and another from the 80′s over whether new heart drugs save lives by preventing fatal arrhythmias. Both disputes were characterized by passionate opinions. Supporters of the death penalty, and of the arrhythmia drugs, were convinced they were saving lives. Opponents, on the other hand, believed that the benefits in either case were unproven and, therefore, that it was wrong to put these interventions into practice.

Let me put it plainly: We do not need to let decades pass by without trying to figure out what is true; indeed, we cannot afford to do so. The Supreme Court remains divided over deterrence forty-plus years after the Gregg case. But such has not been the case for the second dispute I’ve introduced you to. Because cardiologists-so vehemently divided in the 1980′s-finally joined together to embark upon a fact-finding mission: Proponents of the arrhythmia drugs, even the companies who made the drugs, got together with leading critics of these same drugs, and conducted an experiment. They recruited patients with arrhythmias and decided, randomly, who would get the drugs and who would not, and then observed the patients closely over the following months to assess the results.

What they discovered shocked almost everyone involved in the study. Flecainide and Encainide not only failed to prevent people from dying of arrhythmias, they actually killed patients: Out of 743 people receiving placebo, 26 died during the first 10 months of the research trial, the majority of them dying of arrhythmias just as predicted. But out of 755 people receiving the arrhythmia drugs, 63 died, a 120% increase over the placebo group. A person with an arrhythmia who wanted to stay alive, then, was better off taking a sugar pill than one of these supposed miracle drugs!

If a few dozen deaths seems small to you in a trial involving almost 1500 patients, consider the huge number of people who were taking these drugs at that time. These were blockbuster drugs, prescribed for literally hundreds of thousands of patients. By one estimate, some 42,000 patients in the U.S. died from using Encainide and Flecainide. Just to put that in perspective, that’s about the same number of U.S. soldiers killed in the entire course of the Vietnam war.6

To wit, then: A controversy: do these drugs benefit patients?

A resolution: a study showing that they do not.

And a change in decision making: doctors stopped prescribing these drugs to these patients.

Cardiologists in the 1980′s didn’t simply settle into opinion camps and joust with each other over the merits of anti-arrhythmia drugs. They disagreed about a question of fact, and joined together to determine the truth. Why, then, can’t we join together in a similar manner to solve some of the socio-political disputes that have held us grid-locked for two or more generations?

Gun control advocates believe that stricter gun control laws will save lives, by reducing crimes of passion and accidental deaths, and by keeping guns out of the hands of criminals. Gun rights advocates, on the other hand, believe that stricter gun controls will increase death from guns, because criminals will be worried that potential victims will be armed. Can’t we figure this out?

Many pro-life advocates claim that abortions are bad for the mental and physical health of the women who have the abortions, causing them to not only experience depression, but also to suffer an increased risk of breast cancer. Many pro-choice advocates dispute these facts. Can’t science give us an answer?

Free market enthusiasts oppose minimum wage laws as being obtrusive policies that harm more people than they help, hurting employers and ultimately reducing employment. More intervention-minded politicians, on the other hand, claim that raising the minimum wage will put cash into people’s hands without bringing on such ill-effects.

Why argue, when we can run an experiment?

Stay tuned for Part 5, when I will throw out some ideas about what medical experiments can teach us about politics.

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We live in an era of strident partisanship, with elections often decided by candidates’ attitudes towards morally and emotionally charged issues like gun control or abortion. Each presidential election seems to hinge on some set of irresolvable moral and cultural divisions, leaving the winner with at best a tenuous majority, while a firmly ensconced and angry minority plots their retribution. Tune into cable news for an hour just about any day and you will see a world divided over matters of fact. Does gay adoption harm children? Do school vouchers improve education? Does the minimum wage help low-wage workers? Each side in most of these debates appeals to their version of the facts in making their case. I am sure I am not alone in finding this discourse maddening.

But our disputes don’t always have to fester like this, in a puddle of factlessness. Because when people disagree, the right approach to facts-pursued honestly, objectively, and in genuine earnest-can resolve their disagreement. When I was a kid, arguing with my siblings at the dinner table, my parents would inevitably send us to the family room, where we kept our World Book Encyclopedia, so we could find out who was correct. Opinion didn’t win arguments in my household-facts alone were the key to success. (Of course, when the World Book failed to offer answers, we were left to utilize other, usually noisier, rhetorical weapons. But that’s a story for my memoir, not this blog.)

How is that we, as a society, can let decades pass without finding a neutral authority that will help us to figure out answers to so many important policy questions? What can we do when we are continually divided over matters of simple fact? For the beginning of an answer, I’m going to ask you to think about your heart.

The beating of your heart depends on the precise coordination of four chambers. The top two chambers, the atria, collect blood from the body and gently push this blood through to the lower, stronger chambers of the heart, the ventricles. In doing so, these two atria must coordinate their movement by sending out electrical impulses. The electricity starts up in the atria, causing those small chambers to push blood into the ventricles, by which point the electrical impulses have reached these larger muscles, spurring them on to eject the blood out into the rest of the body.

Should the electrical system in your heart go haywire, you could die from what us doctors call a cardiac arrhythmia, as happened to the beloved political journalist, Tim Russert. In his case, Russert’s doctors had already discovered that he had a narrowing of his coronary arteries, the blood vessels that supply the heart. But they had not suspected that he was at high risk for a fatal arrhythmia.

Fortunately, many people show warning signs of such arrythmias, giving doctors a chance to correct the situation before these electrical disturbances lead to disaster.

During my training at the Mayo clinic in the late 80s, I took care of many patients suffering from chronic arrhythmias. I remember monitoring their hearts with ECG recorders, watching the electrical tracings move up and down the screen. As a medical student, I had learned to recognize each of these squiggles-the spiky-looking QRS complex and the afterthought-like T waves. Some of my patients, back then, displayed scary irregularities on their heart monitors-a pulse of electricity would burst out from a rebellious location in their atria, jumping ahead of their natural pace makers. Electricity would pulse around their hearts in backwards and sideways directions. Some people would experience one or two of these premature beats every minute. Others would experience dozens of premature beats each minute, sometimes in rapid runs of four, five or six beats.

In general, people don’t die from these short bursts of electricity. But even early in my career, I was acutely aware that those six beat runs could devolve into sixty beat runs-the kind of sustained, rapid rhythms that often prove fatal.

But what could we doctors do to prevent such a tragedy? In the first few weeks of my cardiology rotation, I was being mentored by a senior cardiologist who explained that I should prescribe a powerful new anti-arrhythmic drug for my patients, a medicine like Encainide or Flecainide. These drugs, he told me, were specifically designed to prevent electrical disturbances in the heart.

So I dutifully prescribed these drugs, and was amazed-my patients’ arrhythmias invariably retreated in shame. I would watch their heart monitors, fascinated; thirty irregular heart beats per minute would become fifteen, then five, then almost none. I had seen the value of these drugs with my own eyes, and I was a believer.

But was I right to believe? And what does any of this have to do with political partisanship?

Stay tuned for Part 4.

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In my last post, the fate of a cold-blooded killer depended on nine U.S. Supreme Court Justices who could not agree whether his death would deter potential criminals.

It is easy to understand why Supreme Court Justices, forced to make difficult judgments about highly subjective issues, so often disagree with each other. No one knows, for instance, exactly what the authors of The Bill of Rights intended when they chose the words “cruel and unusual.” Indeed, the Founding Fathers themselves may not have agreed upon what these words meant. No surprise, then, that 200 years later, Justices of the Supreme Court would disagree with each other as to whether the death penalty is either cruel or unusual.

But the Justices hearing the Gregg case were not disagreeing with each other over the meaning of these two words. They weren’t divided over some fuzzy issue of semantics or original intent. Instead, they differed with each other over a matter of fact. The judges disagreed about whether the death penalty deters crime. And Gregg’s life hinged on this disagreement, because the justices agreed that if the death penalty did not deter crime, then they would not allow Georgia to execute Gregg.

Indeed, few people on either side of the political spectrum doubt the importance of the deterrence question in deciding the legitimacy of the death penalty. For example, in the 2000 presidential debates, George W. Bush was asked whether he believed the death penalty deters crime. He responded with characteristic confidence: “I do,” he said. “That’s the only reason to be for it. I don’t think you should support the death penalty to seek revenge. I don’t think that’s right. I think the reason to support to the death penalty is because it saves other people’s lives.”

Let’s for a moment try and place ourselves in the situation those Justices found themselves in back in 1976. They did not have any definitive research they could draw upon in order to prove whether the death penalty deterred criminal activity more than alternative penalties, like life without parole. Justices aren’t scientists, after all; they are judges. And because the science of the day wasn’t up to the job, the Justices had to rely on their best judgment in guessing whether the death penalty was, in fact, an effective deterrent.

Fast forward thirty plus years, to 2008, and you will find the Supreme Court once again deciding the fate of a brutal criminal-a whole slew of them, in fact. Death row inmates in Kentucky had petitioned the Court to determine whether lethal injection was cruel and unusual punishment, because the muscle paralyzers used as a part of the drug “cocktail” could potentially mask suffering-if the prisoner’s heart wasn’t stopped by one of the other drugs, then the inmate would effectively suffocate to death, unable to even open his eyes in distress.

Once again, the court found itself divided over the question of deterrence. Antonin Scalia cited what he called “a significant body of recent evidence” which proved “that capital punishment may well have a deterrent effect, possibly a quite powerful one.” Justice Stevens vehemently disagreed: “Despite thirty years of empirical research in the area,” he wrote, “there remains no reliable statistical evidence that capital punishment in fact deters potential offenders. In the absence of such evidence, deterrence cannot serve as a sufficient penalogical justification for this uniquely severe and irrevocable punishment.”

Disheartening isn’t it? Almost forty years after the Gregg case, and the Supreme Court is still divided a matter of fact.

Is there a way out of this intellectual and political stalemate?

Stay tuned for Part 3.

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On November 23, 1973, Dennis Weaver read a disturbing article in his Atlanta newspaper. Two men were found dead in a ditch along the very same highway where he had been hitchhiking the day before. Even more disturbingly, Weaver recognized that these were the very same men who had picked him up. Weaver called the police and told them he knew the victims, and that two other men had been sharing the car with them that day. He described the men and the car to the police, and the authorities quickly went after the two suspects.

Only one of those suspects was an adult-Troy Gregg, who had been hitchhiking from Florida to North Carolina with a 16-year-old named Floyd Allen. When the police found the two suspects, Gregg admitted to killing the two men, but claimed that he had done so in self defense. But Allen, interrogated in another room, told a different story. The teenager told the police he had been sleeping in the back seat of the car when the two victims pulled over so they could take a leak-they had been drinking heavily. Earlier that night, Allen said Gregg had seen the two victims holding a large wad of cash. So when the two victims stumbled down a hill to pee, Gregg lay in wait for them by the car with a loaded gun. Without any warning, he fired three shots, waking up the now startled Allen, who saw the two victims lying on the ground. His heart racing, Allen watched as his traveling companion walked calmly over to the two fallen men and shot each one again at close range in the head, execution-style, and then just as calmly emptied their pockets of cash and walked back to the car, as if he had just completed a routine conversation with his favorite bank teller.

Confronted with the testimony of his 16 year old companion, Gregg admitted to the crime. “You mean you shot these men down in cold-blooded murder just to rob them?” the police officer asked. With an air of calculated indifference, Gregg said yes.

The jury didn’t have difficulty making their decision. They sentenced Gregg to death.

But his death at the hands of the state was far from assured. Four years earlier, the Supreme Court had commuted the death sentence of another Georgian, William Henry Furman. The Justices had concluded, at that time, that Georgia was not applying the death penalty in a predictable and fair manner-it was disproportionately executing African American defendants, for example, and people without financial resources-and therefore the death penalty qualified as “cruel and unusual punishment.”

In the intervening four years, Georgia had carefully crafted new statutes laying out precisely which crimes would qualify for the death penalty. By the time Gregg executed those two men, the Attorney General of Georgia was convinced that his state’s death penalty law would pass constitutional muster. So he wasn’t worried when Gregg’s lawyers brought his case to the U.S. Supreme Court. And in fact, the Court studied the Georgia statutes, and agreed unanimously that its death penalty law was no longer cruel and unusual in its arbitrariness. They were split, however, in their assessment of whether the death penalty itself was inherently cruel and unusual, deeply divided over the issue of deterrence. After reviewing available evidence, some justices concluded that “the death penalty undoubtedly is a significant deterrent.” But others, looking at the same evidence, vigorously disagreed, writing that the death penalty “serves no penal purpose more effectively than a less severe punishment.”

Troy Gregg’s life was in balance, then, because members of the highest court in the land could not agree whether his death would deter other potential killers from following in his footsteps.

I’ll come back to the death penalty debates in subsequent posts. In fact, over the next few weeks, I’ll post a series of linked essays laying out my preliminary vision for how we, as a society, could make better use of science in making policy decisions.

Here, after all, were nine of the smartest people in the country at loggerheads over a question that was best answered by social scientists. The consitutionality of death penalty laws hinged on whether there was good evidence that it deters crimes.

What did they decide and why?

Stay tuned for Part 2.

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In a recent post, I asked for your thoughts on how you would feel if your doctor posted an anti-health reform letter in his waiting room. Link

The letter was a direct quote from one posted in Dr. Hal Scherz’s urology clinic in Atlanta. Scherz is president of Docs4PatientCare. For all I know, Scherz is a talented and knowledgable urologist. But let’s look for a minute at his confusion about what he calls “ObamaCare.”

To quote Scherz again:

“Dear Patient: Section 1311 of the new health care legislation gives the U.S. Secretary of Health and Human Services and her appointees the power to establish care guidelines that your doctor must abide by or face penalties and fines.”

Sounds serious. Guidelines! Penalties and fines!

Should we be worried? That depends. We have to consider the alternative first, which, in this case, would be for Medicare to pay doctors without any regard to whether they are offering appropriate care.

Don’t you think doctors should be accountable for the quality of care they provide?

Or is it impossible to figure out whether doctors are practicing good medicine?

As it turns out, the science of measuring quality of medical care is still in its infancy, or maybe entering its preadolescent period, but there’s enough evidence in enough domains of medicine, that it would be irresponsible to ignore our ability to tell whether doctors are doing what they ought to do.

Yet Scherz would have us believe that no one other than the individual doctor is in a position to judge that doctor’s professional competence:

“In making doctors answerable to the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions.”

This is horribly confused. Let’s look at a couple of errors Sherz made.

Error #1: Saying that doctors would be government employees. Physicians have made gazillions of dollars caring for Medicare patients over the years. Yet now that the Medicare office is planning to develop some guidelines to assess the quality of such care, with modest financial incentives to encourage doctors to follow such guidelines… only now does Scherz think doctors are becoming government employees?

Error #2: Concluding that a financial incentive to follow guidelines suddenly means that you and your doctor are no longer in charge of your health care decisions.

Has Dr. Scherz ever interacted with a health insurance company?

Medical decisions haven’t been exclusively controlled by doctors and patients for quite some time. Some doctors perform excessive numbers of procedures on their patients, either out of ignorance or greed. Insurance companies have been trying to reduce such overutilization for a few decades now.

Now the government wants to promote some well-established clinical guidelines, backed by evidence from medical literature, vetted by leading medical organization, and suddenly “big brother” is controller our doctor’s every thought?

I don’t know if Scherz is legitimately confused about the health care reform legislation, or if he is simply worried that any effort to control Medicare expenditures will reduce his sizable income.

Either way, we shouldn’t let doctors scare us off from developing a Medicare system that holds health care providers accountable for the quality of their care.

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I need to know what you think of the following situation.

You walk into your doctor’s office, turn your insurance information into the clerk, take a seat in the waiting room and discover the following letter sitting on the couch-side table, authored by your very own doctor:

“Dear Patient: Section 1311 of the new health care legislation gives the U.S. Secretary of Health and Human Services and her appointees the power to establish care guidelines that your doctor must abide by or face penalties and fines. In making doctors answerable in the federal bureaucracy this bill effectively makes them government employees and means that you and your doctor are no longer in charge of your health care decisions. This new law politicizes medicine and in my opinion destroys the sanctity of the doctor-patient relationship that makes the American health care system the best in the world.”

The letter goes on to add:

“The current party in control of Congress pushed this bill through with legal bribes and Chicago style threats and is determined now to resist any ‘repeal and replace’ efforts. This doctor’s office is non-partisan-always has been, always will be. But the fact is that every Republican voted against this bad bill while the Democratic Party leadership and the White House completely dismissed the will of the people in ruthlessly pushing through this legislation. [...]Please remember when you vote this November that unless the Democratic Party receives a strong negative message about this power grab our health care system will never be fixed and the doctor patient relationship will be ruined forever.”

I will evaluate the content of this letter in an upcoming post. But first some questions for you readers:

1. Was it ethical for this doctor to place copies of this letter in his waiting room?
2. Would you feel the same way if the letter stated strong support for the health care reform bill?
3. If you were seeing this doctor for the first time, would this letter have an impact on your relationship with him?

I’m very interested in your thoughts.
Thanks.

The source of the letter can be found at: http://online.wsj.com/article/SB100014240527487033697045754618405…

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Suppose you are at the car dealer and have narrowed your choice down to two automobiles. One is a little nicer looking, and the other has a more comfortable interior. One gets twenty miles per gallon and the other gets twenty five. You typically drive about twelve thousand miles in a year, which means (queue Jeopardy Music) the annual cost of gasoline will be how much lower for the first car than the second?

Answer doesn’t leap to mind? No wonder. That is not a top-of-the-head kind of question. But wouldn’t having that answer at your fingertips help you make this difficult decision?

Currently, automobiles post mile-per-gallon stickers on their windows, in a large font, and then in a significantly smaller font they post the annual fund cost of driving the car.

So the Obama administration is proposing to redo the labels, to help make this job easier for consumers. One proposal is a “dollars per year” plan. Under this proposal, the sticker would indicate how much money a typical consumer would spend per year filling up the car in a big, open-space-large font; easy to see.

The other proposal would, instead, place a more intuitive label on each car- a grade of A+ to the most fuel-efficient cars, B’s and C’s for worse cars. You know: grade school revisited. I call this the “school grade” proposal.

I have spent my career taking insights from behavioral economics and applying them to public policy situations. So, I thought I’d tackle a few questions about these proposals from the Obama administration.

Are these proposals examples of behavioral economics being applied to public policy?

Behavioral economics is perhaps best understood in contrast to traditional neoclassical economics. In traditional economic theory, consumers are assumed to be rational decision makers. That means that typically, if a market is free, and consumers have adequate information about their choices, they will make consumer purchases that maximize their best interests. This is a simplified version of a more complex theory, but it suffices for the purposes of contrasting traditional economics with behavioral economics.

Those of us who work in behavioral economics tend to critique traditional economics by questioning the assumption of human rationality. In behavioral economics, we take insights from psychology -which has documented thousands of ways that people make irrational decisions-and we try to see what that means about the behavior of markets and the purchasing decisions of consumers.

One of the key insights of behavioral economics is that the way a decision is “framed” can strongly influence people’s choices. A patient might be more interested in a surgical operation with a 90% survival rate, for instance, than one with a 10% mortality rate. These two ways of framing the outcomes of the surgery change the way people feel about their alternatives. That’s not rational, because it’s really two ways of saying the same thing.

By this view, the dollars-per-year alternative seems to be a good example of behavioral economics at work. Miles per gallon should give consumers enough information to determine how much they’ll spend per year on gasoline. They’ve got the information; they should be able to make a rational choice. But since people can’t do the math, or don’t often do the math, framing this issue as gasoline costs per year may change people’s choices. It’s the same basic information, but framed in a way that might better advise people about the true costs of their decisions.

The school grade proposal is even more out of the behavioral economics playbook. It doesn’t appeal solely to people’s rational decision-making processes, to frame their choices. It actually puts a qualitative grade-an evaluative label-onto specific choices. I discussed this kind of issue in my book Free Market Madness, where I talk about the difference between a bottle that has the word “poison” on it versus one that has the skull and crossbones picture. Both inform people about an important aspect of a product, but the highly emotive picture does a better job of persuading people to be careful about products-such as keeping them away from children-than the word “poison” would do on its own.
Do these proposals violate the spirit of libertarianism?

The most prominent behavioral economics expert in the Obama administration is Cass Sunstein, a lawyer and coauthor of the influential book Nudge. Sunstein describes his take on behavioral economics as “libertarian paternalism.” He wants to use the insights of behavioral economics not to force people to make better decisions in their lives, but to set up choices in such a way that they’re more likely to make the right decision, even at the same time that they still have full freedom to choose whatever they want.

By this account, both of the car-labeling proposals are relatively libertarian. They’re not restraining anyone’s choices. People would still be free to buy any car they want to buy. At most, these new labels would gently influence people’s choices.
But wouldn’t such influence be a heavy-handed form of government paternalism?

If you believe that, then you’d have to think the same thing about the current stickers on automobiles, because the information about miles per gallon influences choice too. It just has a different influence on choice than a sticker which indicated gasoline costs per year. So would having no sticker. Whatever we do -sticker-no sticker, miles per gallon vs. costs per year – we are going to influence choice. The government’s job, then, is to choose the way of framing information that would help people make choices that maximize their best interests. I think it’s very plausible that considering gasoline costs per year would improve people’s choices. It would give them a better sense of what the true cost is of buying a gas guzzler.

But isn’t the school grade proposal too heavy handed to be libertarian?

I guess it depends on how you define libertarian. Does the skull and crossbones picture reduce people’s freedom to place poisonous materials within children’s’ reach? At what point does persuasion shift into coercion? I was a philosophy major in college, but I don’t feel philosophically gifted enough to parse out all these issues. I think the basic point remains: neither of these proposals constrains people’s choices. They are less heavy handed than taxing gas guzzlers. They’re less restrictive than forcing automobile manufacturers to abandon gas guzzling models. But they try, nevertheless, to change the kind of automobiles that are on American roads, so that Americans are more likely to drive fuel efficient vehicles. This seems like a laudable public goal, and if it can be achieved without unduly restricting people’s freedoms, all the better.
But will it change people’s behavior?

In a recent New York Times Op Ed, George Loewenstein and I argued that it’s important for public policies to take advantage of the insights of behavioral economics, but that we can’t expect such insights on their own to be enough to meet important public policy goals. Sometimes we simply need to change economic incentives to better align people’s behaviors with the public’s best interest.

I think either of the proposed automobile stickers would be an improvement over the current one. But I doubt that stickers alone are going to dramatically change people’s car purchasing behaviors. If we really think it’s socially important to use less gasoline-to improve our environment and reduce our dependence on the Middle East-then it would be far more effective for us to put a gasoline tax in place. Put that together with a more informative sticker, and I can imagine a real change in behavior.

Which of these proposed stickers is best?

I like the dollar per year sticker, because it gives people the information they need to make this kind of a decision. The school grade proposal is trickier. It doesn’t give great information. It takes a continuous measure -gasoline costs per year- and lumps it into a bunch of seemingly arbitrary categories. Nevertheless, I’ve done a bunch of research that shows these kinds of labels are very important. People often are insensitive to changes along a continuum.

But this school grade proposal is going to meet stiff resistance from industry. Nobody wants any of their cars to be given a grade of C, and that’s inevitable if this proposal is implemented. All large automobile manufacturers make gas guzzlers, so all of them will stand to lose sales of some of those vehicles under that kind of proposal.

Which raises the possibility that the Obama administration is using behavioral economics to promote behavioral economic policies.

What do I mean?

I think it’s possible that the Obama administration floated the idea of two proposals knowing well that the industry would vehemently oppose the school grade proposal. They might have done this to make the cost-per-year proposal more palatable.

If the administration had only floated the idea of the cost per year proposal, it too would have probably been opposed by industry. And that might have made the proposal go down in defeat.

By floating two ideas, one more objectionable to industry than the other, the Obama administration is possibly using a behavioral trick to promote a behavioral policy.

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Sarcopenia: a mysterious disorder that causes people’s muscles to shrink away. 25%, 30%, even greater loss of strength… until the victim is struggling to make it up to the second floor bedroom. Would you undergo a treatment for this disorder if it was safe and effective? And do you think your insurance company should pay for such a treatment, if it were to become available?

What if I told you that sarcopenia is another word for “the way people’s muscles get smaller as they age”? That’s what sarcopenia is. Even if they stay active, 70 year olds and 80 year olds have smaller muscles than 30,40,50 year olds. Our muscles naturally atrophy as we age.

The question now is if this natural atrophy (dare I call it “natrophy”?) is a disease–whether it is a process that should be reversed by medications and other treatments if we can find a way to do so.

This is a profound and difficult question that I’m not going to answer today. Instead I’m going to comment on a related issue. It is this: if industry has any hope of making money treating sarcopenia, it’s very important they get the world to accept the word “sarcopenia.” If you want something to feel like a disease, give it a Latin sounding name.

If someone announced they were going to try to help older people stop losing muscle strength as they age, they probably wouldn’t get many members of the general public thinking that government research dollars should go to help them. They probably wouldn’t get people clamoring for their insurance company to cover any treatments for this problem. The public would say there are more important social issues for us to tackle, and better ways to spend scarce government resources.

But perceptions can change over time. Yesterday’s normal can become tomorrow’s disease. And it often starts with a name.

Sarcopenia. With all those Latin roots, the word convinces us that even if muscle loss is normal, it isnevertheless a sickness.

As a physician, I recognize that muscle weakness in aged populations leads to lots of problems. Older people fall. They become less mobile, which can lead to social isolation and misery. I would like older people to maintain more muscle strength if they could.

I also know, however, that much of this weakness could be avoided by regular exercise. Healthy older people, if they “use it” regularly– if they lift weights, do knee bends, take walks, etc– don’t “lose it” so much that they become immobile. My worry is that the word sarcopenia is going to lead to the medicalization of this normal aging process. The next step will be some wonder drug that causes yet more of our retirement dollars, and more of our society’s wealth, to get sucked up by the medical industrial complex. I worry that we’ll start popping pills instead of working out.

I would elaborate on my concerns, but I need to get to the gym!

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It is a dangerous time to compromise in the U. S. government. A Republican working with Obama is dead meat in the next primary. A Democrat who works with Republicans? Well, you saw what happened to Joe Lieberman the last time he ran as a Democrat.

Politicians are understandably worried that if they collaborate across the aisle, their political careers will soon end. They fear losing their next election.

But their fears are misplaced, at least from my perspective as a researcher who has studied the kinds of ways people mispredict what will make themselves happy or miserable.

People frequently overestimate the emotional impact of adversity. Early-career professors imagine that if they fail to receive tenure they’ll be miserable the rest of their lives, even though long-term studies show that tenured positions have no impact on well-being. Making these same mistakes, elected officials assume that if they lose the next election, they will be miserable. In making these mispredictions, they focus too narrowly on the feelings they will experience as the results of their election loss trickle in – the shame of the failure, the challenge of telling staff that they’ll have to find new jobs, and the misery of giving up all that power and prestige.

But what happens to legislators after they lose elections? Remember, these are often very talented people, with large social networks and often with access to lots of money, through previously accumulated fortunes or through the business connections they have developed in office. These people more than land on their feet again. Most of them thrive. They live extremely full lives, working at the intersection of business and government. Fromrom what I’ve seen, I’d guess that most of them are happier than they were when they were in the government. I mean look at those cool eyeglasses Tom Daschle started wearing after he lost his reelection campaign. And how about Al Gore and his Nobel Prize!

Indeed, I would go a step further in characterizing politicians’ mispredictions. Most imagine, incorrectly, that losing the next election will make them miserable. Instead, I’d guess that doing what it takes to get reelected is really what will make them miserable.

That brings us to Bart Stupak, Democratic Congressman from Michigan — notable for his pro-life views as well as his embrace of social programs to help poor people. When Stupak considered whether to vote for health care reform legislation, he found himself attacked from the left for focusing too much on making sure that such reforms did not expand federal funding for abortions. And he found himself attacked from the right, for supporting Obama’s “socialist” agenda. By looking for middle ground, a compromise, he set himself up for a very difficult election campaign.

But he didn’t care. He thought the legislation was important enough that he was going to do what he thought was right, even if that made everyone angry. And now, he is retiring, rather than face a brutal reelection campaign. And here is my prediction: he will soon be a very happy man. He will be able to look back on the end of his political career convinced that he acted on principle to do what he thought was best for the country, regardless of the political consequences of those same actions.

By caring more about his country than he cared about his political fortunes, Stupak has taken a large step towards living a happy and fulfilled life.

Let that be a lesson to all his colleagues, as they fret over their next reelection campaign.

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