Health by Default
There is a simple yet powerful tool for increasing healthy behaviour in millions of people without forcing the public to do anything, and it has gone largely overlooked: the default.
We urgently need a better system for helping people make healthy choices. Nearly a million people die per year due to obesity and inactivity in the USA alone. Rates of insufficient sleep and social isolation are rising, and both substantially increase the risk of death by all causes. Advertisements and education have proven insufficient to reverse these trends. Government can force people to make some healthy choices, like wearing seatbelts, but in a free society, there is a limit to that strategy. Instead, we should think about our defaults.
In the book Nudge, Richard Thaler and Cass Sunstein advocate for policy interventions that encourage people to “make their lives better,” but without restricting freedom: “choices are not blocked, fenced off, or significantly burdened.” They call this philosophy “libertarian paternalism.”
The most compelling policy solutions they offer are defaults. If healthy food is at the top of a restaurant menu, people eat better. If employees are automatically registered in medical insurance plans — with the option to opt out or change plans at any time — then more people end up with better coverage. If everyone is an organ donor by default unless they opt out, then thousands of lives are saved.
In each case, people have the freedom to make any choice they like. But for everyone who has better things to do than to analyze medical insurance plans, the defaults steer them towards a reasonably optimised path.
The science of how to subtly nudge people to make better decisions is what Thaler and Sunstein call “choice architecture.” The UK and United States have set up government departments to explore how this approach can improve programs such as student-loan websites. But the authors and these departments seem to underestimate just how transformative the concept could be. Choice architecture should define a holistic strategy for building products, homes, and cities that maximize human flourishing.
Consider that every time we walk down the street or use a product of any kind, we are presented with choices. In many cases, the easiest, default choices are terrible, with massive consequences for human wellbeing.
Homes and offices encourage sitting to do nearly everything, and many communities make driving the only decent option to travel between home and work. Choosing to exercise, in contrast, requires time, money, and commitment. In many neighbourhoods, junk food is a cheap and easy to buy while healthy food requires a long trip and more money.
The choice architecture of smartphones makes it hard for people to stop scrolling and go to bed when they would like to. The constant distractions from notifications undermine productivity, which some think may have measurably slowed GDP.
In many homes and communities, the only way to socialize is to actively choose to plan in advance, and it often doesn’t happen at all. Communities often lack any local cafe, bar, or public space where people can easily spend time and casually see neighbours. Few homes have a functioning front porch or veranda, depriving residents of anywhere to sit where they might see friends outside. The most natural, default behaviour in many homes is to walk in the front door, lock it, and spend time alone.
By default, the modern Western human is sedentary, overweight, sleep-deprived, distracted, and alone. Choices that would better support our health and happiness require actively pushing uphill against our environment.
There is hope. As I discussed in a related piece, Western human life was once unsafe by default too. We are now an order of magnitude less likely to die of falls, cuts, or housefires than a century ago, largely because our homes, products, and communities make it easy to live safely without needing to pay it much attention.
Implicitly, safety engineering has long followed a philosophy of libertarian paternalism. By default, skill saws come with safety guards, but people retain the freedom to remove them if they like. People enjoy both safe defaults they can rely on and the freedom to act as unsafely as they like.
Product liability also effectively reflects principles of libertarian paternalism. Hasbro is not responsible if people choose to ride barbie jeeps down steep hills. (See “Extreme Barbie Jeep Racing”). Hasbro is, however, legally responsible to ensure the default way a reasonable person would use their product — children puttering around a backyard — is safe. The distinction imposes ethical rigour on designers and makes life safer the public, while also retaining the public’s freedom to be as unsafe as they like.
Imagine living in a city where designers of all kinds were held to an ethical standard to ensure the defaults in everything around us made it easy to lead a healthy, productive life. In such a world, it would still be possible for people to choose to drive everywhere, sit while doing everything, eat unhealthy food, stay up late, and remain alone in the privacy of their home. But it would also be easy for them to choose to walk to get most things they need, including healthy food. Standing would be a great option at most desks and meeting rooms. Phones would help people go to bed at the time they want, for example, by turning black and white by default at a certain hour. Porches, parks, and local pubs would make it feel natural to see friends and neighbours regularly.
In group photos taken in the 1960’s, few people are obese. With better defaults, group photos in the 2060’s could healthy, thriving people. We know it is possible, because we have made this progress in safety. If we can design the world around us to make choices that improve our lives easy, while maintaining our freedom to live as we like, it is deeply unethical to not do so. It is wrong to place unnecessary barriers between people and living well.
If designers were held ethically responsible for creating defaults that support human flourishing, it would shift research and innovation towards making millions of people’s lives better. It’s possible we could make enormous progress quickly, if we only switched how we think about this one issue.
- Tristan Cleveland