Dr. Dan Ariely discusses decision-making.

Whatever leads people to make difficult decisions is really complicated, involving multiple factors including differences in culture, education, upbringing and training, right? Not so much. According to recent NIMH Director’s Innovation Series lecturer Dr. Dan Ariely, a lot of the time it just depends on how issues are worded. Fact is, he said, loads of people from all walks of life make hard choices based on the default answer.

To illustrate, Ariely, the James B. Duke professor of behavioral economics at Duke University, showed a slide on international organ donation, by country. Why, he and his colleagues wondered, do some nations have a high percentage of organ donation, and others participate in the life-saving procedure only to a rare degree?

“When we look at why some countries give a lot and some give a little, you think it has to be about how much people care about each other, right?” Ariely suggested. “Or maybe it’s about religion, or culture. It has to be something big, right? The trick is the form at the DMV [department of motor vehicles, where people register their organ donation preferences].”

Turns out, donation differences have little to do with caring, societal or religious issues. Instead it’s merely the wording on the questionnaire. In countries where the form said, “check here if you want to participate in organ donation,” a low percentage of people agreed to donate. But in nations where the form said, “check here if you do not want to participate in organ donation,” the percentage agreeing to donate was high. The default answer—wherever respondents didn’t have to actively check the box—always won.

Lecturer Ariely (l), a cognitive scientist, chats with NIMH director Dr. Thomas Insel. Photos: Ernie Branson

Some, Ariely pointed out, might argue that the default wins only when the issue is not considered important. After all, organ donation happens after you’re dead, so people may not view it as vital enough to really worry about. Wrong again. The default phenomenon occurs regardless of the topic—even on subjects seen as difficult and fraught with implications. In fact the tougher and thornier the issue, the more likely we are to opt for the default answer.

“This points to something interesting,” explained Ariely. “The fact is, it’s not because [the question] is easy, it’s because it’s hard. We don’t know how to think about it. Complexity makes it difficult to know what to do, and because it’s difficult, we accept the default.”

But surely decision-making by default does not happen in the medical profession. “After all,” Ariely said, “physicians don’t make decisions one time; they’re experts. They’re paid well to do these things over and over.” The fact is, it happens to everyone, regardless of skill, training or education level, he reported.

Researchers quizzed a group of physicians about whether they would reverse their initial recommendation for a patient to have major surgery in order for the person to try a prescription pain reliever that mistakenly had not been considered. Most doctors reversed course and called off the surgery. However, when researchers added a third treatment option—and thereby made the issue more complex—most physicians went ahead with plans to operate: the default decision.

“We build things to our physical limitations all the time. We need to start building things to our mental limitations. We’re built to see things in terms of what works best for ourselves, so how do we restructure things to create incentives?”

“This should tell you that even for professionals and even for people who are well-trained and well-paid for their opinions, these things do matter,” Ariely said.

A cognitive scientist, Ariely is the author of Predictably Irrational: The Hidden Forces that Shape Our Decisions. He began exploring how the mind works when he was a hospital patient for 3 years. He’d survived an explosion that left him with 70 percent of his body covered by third-degree burns. The daily wound-dressing process, which was “unimaginably painful, became a negotiating point” between him and his nurses. His caregivers thought ripping the bandages off quickly was better than removing them slowly, bit by bit. Ariely begged for slow removal. The nurses refused, telling him they knew best.

Years after leaving the hospital, he learned about the scientific method and how to test his own theory.

“I learned that the nurses were wrong,” Ariely said. “I learned that their intuitions were wrong in multiple ways. It turns out you just don’t interpret duration in the same way that you think about intensity.”

How could they get it wrong? Ariely found himself asking. “When we think about it in economic terms, about people getting things right, we need three ingredients: One, people should want to get things right. Two, they should have incentives to get things right; it should be important for them. And finally, they should have experience with it.”

Are there other cases where, like the nurses, we have all the right ingredients to get things right, but for some reason we get it wrong? Ariely set out to prove that such cases occur all the time in daily life.

It’s a lot like those optical illusions that make their way around the office, he explained. As developed as our eyes are, they can still play tricks on us. What seems obvious is not, and what we should see we often miss.

“We have a fantastic visual sense,” Ariely concluded. “The brain dedicates more to vision than to anything else. We do vision more hours of the day than we do anything else. We’re evolutionarily designed for this. And yet, if we have these structural mistakes in vision that we can’t help but repeat, then what chance is there for things that are not evolutionarily created, things we don’t have a specific brain region for, for example financial and medical decisions? The odds are that we are much more inclined to make these types of mistakes.”

To eliminate the inertia created by complex problems, Ariely said, we need to think about restructuring the world for the way our brains think.

“We build things to our physical limitations all the time,” he explained. “We need to start building things to our mental limitations. We’re built to see things in terms of what works best for ourselves, so how do we restructure things to create incentives?”

To see videos of some of Ariely’s other presentations, or to read his blog, visit http://www.predictablyirrational.com/.