Although you might not realize it, your choice architect was you when you offered your partner options for dinner. You thought almost immediately about the number of options that you wanted to present. Then you presented them in an order and described each one as either heavy or light, meaty/vegetarian, or tasty or healthy. Although you might not know it, their reaction to your presentation was likely to be different.
It is not just you. Every store, app and financial advisor as well as every parent practice make their own architecture choices. Even though it doesn’t require a license to do so, we can all benefit from it. This affects every aspect of our lives, from the eggs we purchase to where we live. It affects almost every decision that we make.
Choice architecture is the way a decision is presented. It refers to how these aspects can be altered, either intentionally or unintentionally, in order to affect the choices we make. Although the options are the same, the way they are presented can make or break your decision. Many of these characteristics have been molded for you before you can make your decision. These design decisions may affect the final product.
Many people feel uncomfortable or afraid about the concept when it is first presented to them. People are concerned that the choices they make might be affected or exploited by someone outside of their control. Designers worry about how they might influence others in unintentional or harmful ways.
The choice architecture we pick can be intimidating. By setting a default, the car dealership is affecting what trim package you choose for your new vehicle; by sorting wine on their site, the online wine merchant may be making cheap, low‑quality wine seem more attractive.
People may not be aware of the impact of choosing architecture. We could just inform them. You can find warnings on all manner of products, such as vacuum cleaners or cigarettes. Why not include choice architecture?
Unfortunately, it doesn’t seem like disclosing intent and the existence of choice architecture works. Many studies have shown that defaults can be used to alter behavior. This warning seems to be a way to accept the nudge.
It is possible to do harm by choosing poor architecture. Designers don’t always know the power of the tools that are at their disposal. Unintentionally they might harm the choosers, by making unintentional selections.
Consider end‑of‑life decisions. People can make life-extending decisions when they are very ill. However, these treatments are often intrusive and uncomfortable. You may also have to be placed on a ventilator or feed tube. These treatments can be combined to create life-extension. Comfort care is another option. Comfort care is a way to manage pain without resorting to invasive treatments.
In a remarkable study by Scott Halpern and colleagues, patients with terminal illnesses made choices about end‑of‑life care that actually determined their treatment. Researchers asked patients with terminal illnesses what they wanted for their care. They were first asked to choose between comfort or life extension. For a third of the patients, the directive had a comfort‑care default, indicated by a pre-checked box. A second group had no preselection, and the third group had the life‑extension goal already checked. The default selection for comfort care was 77% of the times, 66% of those when there was no choice, and 43% of those when life extension was default. The default could have an impact on specific interventions such as feeding tubes. This is quite remarkable considering the impact of default on an important decision. The next step is more interesting.
The investigators were ethical scientists and explained that all patients had been assigned randomly to these defaults. They also gave them information about default effects. Most importantly, they offered respondents the opportunity to alter their mind. This was the opportunity for patients to voice their opinions. Of the 132 terminal respondents, 2 actually changed their preferences. The effect of defaults remained even after they were informed what defaults were.
It is clear that this shows many people don’t have any preexisting preferences about end-of-life healthcare. It is a difficult decision that many people are unfamiliar with. Most patients have not experienced intubation, the insertion of a feeding tube, or dialysis before, and these aren’t decisions anyone enjoys thinking about in advance. When the time comes, the primary decision‑maker may not be conscious, and the family members who inherit the decisions are overwhelmed.
It is admirable to give people a choice. However, decision-makers who are overwhelmed tend to default to the default. There is a gap between the desires of people when forced to choose and their actual wishes. Comfort care was selected by the majority of patients in the Halpern‑led study when there was no default. But if you don’t make a choice, that is not what happens in reality. If the patient’s immediate family does not agree, they will be treated like they have chosen life extension. Most of the most commonly used advance directives seem to favor life extension. For example, “I want to have life support” is the first option on one commonly used document.
Patients’ autonomy is important. It can have a huge impact on their suffering, costs, dignity, and cost. Doctors may be loath to influence end‑of-life care choices, but then patients also don’t want to make these decisions. This makes defaults more important.
End‑of‑life choice illustrates when choice architecture might have its largest effects. While most choices can be repetitive and mundane, some options are important and uncommon. People often have no idea of their goals or the best way to go about making these choices. Choosing a school, buying a house, selecting a pension plan, and settling on a type of end‑of life care are all examples of infrequent decisions with big consequences. Particularly if the decision‑maker has conflicting goals, choice architecture will play a larger role.
Not all bad choice architecture results from ignorance or naïveté. Some designers experiment to see what works—for example, in direct mail campaigns or by conducting A/B tests on the internet. They could then use their knowledge to promote their interests rather than the chosen ones. This could lead to a sexist choice in architecture.
Choosing professionals are sensitive to the initial cost of their work. This can be exploited by poorly-intentioned designers. We have all made the decision to start or stop a subscription service—say, a newspaper or a streaming service like Spotify or Hulu. It is possible to use these data to build a subscription trap. Newspapers offer a gentle example. It is very easy to start a subscription with a few clicks on most newspapers’ websites for a low initial rate, like $1 a week for fifty-two weeks. But once you have started, it is more difficult to stop—say, when the early rate increases to almost $5 a week. You must dial an 800 number to cancel.
Designers have the ability to use cost-cutting strategies to limit their choices while maintaining status quo. Several years ago, I was interviewed by National Public Radio’s MarketIt is. While he was trying to alter his privacy settings, the interviewer sat with me. Verizon can track the calls of my interviewer and sell this information by default. According to a Verizon representative, opting out from tracking is easy. The reality was different: after a long robotic message that suggested that the interviewer could “restrict or change options to his telecommunications service information,” he was given a long menu of options. He pressed 1, which indicated that he desired to modify his privacy settings, and was then asked if he would like to restrict his account. He seemed to be afraid of giving up some information, and not just changing his privacy settings. He was then asked to type in his ten‑digit telephone number as it appears on his bill, followed by pound. It then read the text back slowly and digit by number, before asking him to type it again. It then asked for the first thirteen digits of the account number from his bill, then asked him to speak his first and last name, remembering to press pound each time, speak his address, then his town, state, and zip code, and finally his first and last name again to confirm that he is the decision‑maker. It is likely that the company knew his number. Verizon reports that opting out is very common.
The most dangerous example of malicious architecture is electronic health records (EHRs). It is the electronic system used by doctors to track patients and prescribe medications.
Smaller practices and individual doctors don’t have the resources to develop and tune EHRs of their own. Many adopted a free system, provided by a successful start‑up called Practice Fusion. Heralded as “the Facebook of health” by TechCrunchThe EHRs were provided by the company through advertising that was targeted at physicians.
This isn’t all. Practice Fusion also received payments from pharmaceutical companies in return for changes in their EHR’s choice architecture. One particularly nefarious example was an agreement between Practice Fusion and a company known in court as “Pharma X.” In exchange for $1 million, in 2016 Practice Fusion added an alert that reminded physicians to ask patients about their pain and then provided options. The alert was presented to doctors 230 million times in a three‑year period, and Pharma X estimated that the alert would add three thousand customers and as much as $11 million in sales. This was happening at the same time that concern was rising about overprescribing of pain medicines, specifically extended‑release opioids. The problem is that the prompts ignored the Centers for Disease Control and Prevention’s guidelines for opiate prescriptions encouraging non-pharmaceutical and non-opioid treatments. If the doctor thought opioids were required, they were advised to avoid time‑release drugs, since they were more likely to lead to long‑term use, and to limit the number of pills to a small supply. But Practice Fusion’s EHR system included an option for extended‑use opioids, even where the guidelines warned against them.
Purdue Pharma was the manufacturer of OxyContin. In 2021, Pharma X settled a case for misleadingly marketing opioids. The settlement included fines of $4.5 million and payments of approximately $4.5 billion. Practice Fusion accepted the $145million it was paid to alter the EHR Choice Architecture, and subsequently settled charges by Vermont. Purdue, Practice Fusion, and Purdue designed a choice architecture that provided doctors with inappropriate choices.
Choice architecture can have an enormous impact on people’s welfare. This can affect how easy or difficult it is to manage our personal data. This can help you save more money for your retirement, and it will also aid students in finding better schools. You can reduce or increase prescriptions of potentially addictive drugs. It is possible to make a significant difference in the way you design your home.
It is evident that choice architecture has a significant impact on the lives of those most directly affected. People with low incomes and less education have greater exposure to choice architecture. In other words, it could prove to be an effective tool in addressing social injustice and income disparity. This also means that choice architectures with a malevolent bent, such as the ones we just mentioned, can be particularly damaging to the most vulnerable.
Although some may try to manipulate others by having a better understanding of the workings of choice architecture, they should be in the minority. A better understanding of the impact our choices have on others will result in more constructive and intentional architectures that we all can benefit from.
It is like choosing a path from a map to design choice architecture. There are many paths, some better than others. Defaults can be selected in choosers’ best interests. It is possible to make good alternatives easily visible, rather than hiding them behind many irrelevant or bad options. Beneficial programs should be easy-to-use, not more complicated. When we know exactly what we are looking for, good architecture design can help us find it. Your new skill can be used however, it is up to you.
Adapted From THE ELEMENTS OFFICE by Eric J. Johnson, published in Riverhead, an imprint Penguin Publishing Group, a division Penguin Random House, LLC. Copyright © 2021 by Eric J. Johnson.