Although we talked extensively about the shared clinical decision between doctor and patient, many decisions made in health care are not chosen fully consciously. Among these "decisions", one powerful example is the power of default options: those established protocols that indicate what will be done if no other decision is actively made.
Some behavioral economists, such as Dan Ariely, have pointed out the enormous capacity of influence that the design of the option that will be taken by default can have, taking advantage of the psychological biases that we, as human beings, suffer, such as the lack of attention to all the relevant factors or difficulties incorrectly interpreting statistical information on risks. Although this ability to influence causes some controversy among those who oppose the traditional paternalistic approach to health, it can nevertheless be useful in certain contexts. The most famous example is that of the article by Johnson and Goldstein from 2003, in which they show the graph, reproduced below, with the rates of effective consent for organ donation by the deceased in different European countries. Evidently, there is a huge contrast between the countries in yellow, where the rates of consent to donate organs are very low, and the countries in blue, with much higher rates. A careful look at the countries being compared shows that these differences can hardly be due to religious or cultural factors: taking the countries in pairs, it seems that the cultural factors are not very different between Germany and Austria, Denmark and Sweden or between the Netherlands and Belgium. What explains the variability of the rates of consent to donate organs after death?
The most plausible explanation is that the option that each country has chosen by default is the determining factor. In the countries in blue, when someone dies, it's automatically assumed that they want to donate their organs unless they have carried out an explicit administrative procedure expressing the contrary. On the other hand, in the countries in yellow, you have to actively register as a donor to express your consent. In neither of the two types of countries is the procedure to declare oneself a donor or a non-donor particularly expensive, but the mere fact of having to actively take a decision induces a very high proportion of citizens not to do so, and to take as a reference what the health system has declared as default option.
This example should urge us to reflect on the extent to which we citizens have formed clear preferences about our health options and also on the extent to which the system excessively influences citizens with their default options. As you can imagine, the use of measures whereas patients have to actively decide to do something ("opt-in") or not to do something ("opt-out") has enormous potential to affect vaccination rates or increase the use of generic drugs when the prescriber has indicated a specific brand of a certain active ingredient.
In recent weeks, I have seen firsthand the power of default options, even as physicians claim to offer the patient some freedom of choice. An elderly relative has been diagnosed with a tumor. Since he lives in another province and was facing the decision to be treated in his home province, we have ended up having the opinion of two different oncology services on how to treat him. Although the diagnostic evidence available to the two teams was the same, one of them has recommended conservative treatment, taking into account the patient's age, while the other has offered us a "curative" surgery that involves a much more aggressive intervention, a longer hospital stay, and the certainty of tube feeding for several weeks. Although I believe that both services – both highly qualified and recognized – offered what they deemed the best option for the patient, both also presented us with "their" view on "what is normally done in these cases". However, if we didn't have the option of two such contradictory opinions, the normal thing would have been to let ourselves be carried away by the principle of the authority of the only available option, with opposite consequences.
Naturally, the default options must exist, because often, a certain course must be taken even when the patient or the person in charge of the patient is not in a position to make a decision or does not have any relevant information to do so. But let's be aware that the pure design of which option is defined as the default option is not innocuous. We must give the prescribers of decisions by default a responsibility and not allow convenience, natural order, or tradition about "how things have been done" to cloud what may end up being the best possible option. Let us seek that, in environments where there are various possibilities on which there is no consensus, the potential benefits and costs are presented in a balanced way so that whoever ends up deciding, does so in a consented and informed manner.
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