C. Norman Shealy, M.D.. Ph.D.

NUDGE-Improving Decisions About Health, Wealth and Happiness, Richard H. Thaler & Cass R. Sunstein, Yale University Press, 2008

Thaler and Sunsteinoffer suggestions that encourage individual responsibility by altering behavior “in a predictable way without forbidding any options or significantly changing their economic incentives.”? The authors emphasize human fallibility, herd instinct and the incentives of welfare, often sickfare or DEPENDENCE on government largess and have led to decreasing personal responsibility for the past 70 years, with little evidence of improvement in the quality of life or encouragement to rise above dependency. One of the best examples the authors give is the tendency of unwed teenage mothers to stay in the rut of total dependency on welfare child after child. By offering a small incentive, such as one dollar a day for the times of non-pregnancy, the authors suggest a far better potential for these unfortunate teens. I think most of us could support this simple but potentially highly rewarding nudge.

More importantly the authors provide multiple examples of the sheepish herd instinct which appears to drive a majority of individuals to avoid personal choices. . For instance, in relation to suspension of free speech when “society is threatened” only 19% agreed; but when confronted with the opinions of only four others, 58% agreed! Similar examples of remarkable lack of individual thought and total group interdependence dominate elections. The brainwashing of the media, Madison Avenue and political campaigns? as emphasized by the authors, reminds me that in my experience in many medico-legal cases the best actors are likely to win. Another example of the frailty of personal choice is the optimism of most couples entering marriage-virtually 100% state they are unlikely to be divorced but the current divorce rate is around 50%. Most people proceed to marriage with minimal discrimination and rush into parenting without first assuring that the marriage is solid. In fact many decide to “have a child” to save a marriage!? Disaster for children and the couple. All too few couples appear to adjust to the constant shifting of individual dynamics essential for personal growth.

Although they offer a few weak incentives for the major health problems, smoking and obesity, one might expect Thaler and Sunstein's gentle nudge to include a surcharge on unhealthy food or perhaps a surcharge on the larger servings of food that are so promoted by the Fast Food Industry. This may be unrealistic BUT the rise of unhealthy fast food has been a major cause of obesity (see UNHEALTHY NATION). Similarly, the only nudge that works to some extent is significant taxes on tobacco, etc. Competition works when there is a reasonable reward for those who succeed.

As a strong Libertarian,? I found this book fascinating. Personally I have? not found much inspiration from either major political party. I can, therefore, endorse Libertarian Paternalism as better than anything the current two parties offer.?

The major problem with Libertarian Paternalism is that it requires great wisdom and detached impartiality to offer healthy nudges and incentives. We have seen little such collective wisdom in the past century. In theory it should be far superior to our current situation! Definitely a book to read and ponder.

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