Asymmetric paternalism and your health

I like this quote from an article I came across, about asymmetric paternalism. It leads into an assessment of self-harmful behavior, and how asymmetrical paternalism might change the way people respond to adherence efforts: 

“Economics, as the social science discipline traditionally most closely tied to public policy, could be a key discipline in addressing behaviors that are potentially harmful to health. Yet conventional economics does not provide satisfactory policy solutions to problems caused by self-harmful behavior.”

So how do you explain self-harmful behavior? People have been struggling with it for a long time. Freud tried, with his death instinct, elaborated in Beyond the Pleasure Principle, to explain why people are driven to actions which harm them: 

If we may assume as an experience admitting of no exception that everything living dies from causes within itself, and returns to the inorganic, we can only say ‘The goal of all life is death’, and, casting back, ‘The inanimate was there before the animate.’

It’s a little bit Buddhist, and pretty weird. Freud himself admits, “these conclusions sound strangely in our ears”.

Obviously, empirical research has taken us far beyond the subjective cascade (the death of Freud’s daughter Sophie between the first and much darker second editions of the book may have led to his profound pessimism) that Freud set in motion in 1922.

Loewenstein, Brennan and Volpp suggest that a modern answer to this comes out of behavioral economics. In attempting to understand and address self-harmful behavior, a model called “asymmetric paternalism” was developed. Most people are motivated toward actions that provide an immediate, rather than a deferred benefit. When it’s possible to place the opportunity to benefit from a deferred action ahead of the immediate benefit, it may be possible to adjust behavior.

Most individuals are motivated by actions that produce measurable, tangible benefits but are much less motivated by actions that do not produce tangible progress toward a goal. For many behaviors that undermine health, factors working against adherence, such as time costs, are tangible, whereas benefits such as reduced long-term risk of an adverse outcome are intangible and often delayed. Thus, losing weight is difficult because any single indulgence has no discernible effect on weight. The lack of motivation for actions with intangible benefits also helps explain poor adherence to treatments for disorders such as hypertension and hyperlipidemia, which show no tangible manifestation (ie, are usually asymptomatic) for patients.

So who’s ready to sponsor asymmetric paternalistic adherence programs? According to the authors, here’s what it looks like on a basic level:

Asymmetric paternalism is asymmetric in the sense of helping individuals who are prone to making irrational decisions while not harming those making informed, deliberate decisions. Asymmetric paternalism differs from heavy-handed paternalism in attempting to help individuals without limiting freedom of choice. For example, arranging the presentation of food in a cafeteria line so that the healthy foods appear first is likely to increase the amount of healthy food chosen without depriving those who want the unhealthy foods of the opportunity to purchase them.

This is the principle behind reimbursement plans from insurers for gym membership and proven attendance. “Pay” people to choose healthy behavior, reduce the level of cardiovascular illness… Providing an immediate benefit for an uncertain long term gain may motivate some consumers, and maybe the right kinds of consumers – that is, the ones most likely to benefit. We get kids to take their medicine by sweetening it and making it taste like bubblegum. What can be done for adults?

Obviously, asymmetric paternalism is behind the public mandate too, although the mandate doesn’t ensure healthy behavior; it only provides for a distribution of the costs for unhealthy behavior (sort of) onto the healthy by forcing them to pay into the insurance ‘pool’. So was Bismarck an asymmetric paternalist? Sure, but on behalf of the Kaiser, not the people. He made the Kaiser pay to keep the people happy now, so they wouldn’t revolt against him down the road.

Should we be paying people to take their medication? Pharmaceutical companies try this with rebates and coupons, for example. But pharmaceutical companies are often averse to sponsoring adherence programs when they aren’t sure of a measurable short-term benefit. It’s a top-line and a bottom-line decision. Spending this year’s budget on next year’s possible return may not make sense for a marketing manager under pressure to perform. How can asymmetric paternalism help tip the balance of that decision process? I’d come up with an answer, but I’m afraid it might make my head hurt.


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