Decision by Design: Harnessing Choice Architecture in Healthcare Contexts
What makes for a good decision? As psychologist Utpal M. Dholakia explains in Psychology Today, a good decision extends beyond its outcomes. His definition:
A good decision is one that is made deliberately and thoughtfully, considers and includes all relevant factors, is consistent with the individual’s philosophy and values, and can be explained clearly to significant others.
Every day we make over 35,000 micro-decisions, often in environments not conducive to thoughtful choices. As decision-makers, our minds navigate a tangled web of biases, options, and external cues. We’re barraged by a deluge of opinions — many oversimplified or missing nuance, and with their own bias. As AI increasingly becomes an ally in our decisions, the intersection between design and decision science has become more critical than ever.
Enter choice architecture — a deliberate fusion of psychology and design that aims to curate choices in a manner that gently steers decision-makers. Coined by Richard Thaler and Cass Sunstein, “choice architecture” refers to the art of shaping decisions by strategically structuring the environment in which they’re made. Anchored in the tenets of behavioural science, choice architecture wields tools like defaults and nudges — subtle yet powerful adjustments within the decision-making framework that nudge users from one choice to another. Whether it’s choosing a retirement plan, selecting a health insurance policy, or ordering a meal, the context and presentation of choices matter.
As designers, we inherently mold decision-making through the systems we create. There’s no neutral design. While we inevitably bring our own bias to the table, the choice architect’s ethical duty remains clear — empowering individuals to make informed decisions aligned with their preferences. Ways that we can do that by design is what I’ll focus on below.
Here, I’ll share my learning about employing choice architecture principles in designing digital products for healthcare and human services — domains where decisions are often complex, and carry enormous weight on our present and future.
Goal setting
Healthcare and human services programs frequently involve setting goals. Principles of choice architecture can be used by digital products to help users craft and achieve more meaningful goals.
The power of priming, and anchoring goals in personal values
The first piece of information we receive about a topic becomes an anchor, and we interpret newer information from the reference point of this anchor instead of seeing it objectively. In the user journey of setting and pursuing a goal, this principle can help individuals set goals that are ingrained in their core values and priorities. We can systematically have someone reflect on their level of satisfaction or importance in categories of their life that could be relevant to the goal — be it their health, relationships, or finances. By evaluating their satisfaction in various life domains, individuals gain clarity on what truly matters to them. This primes them to set internally-motivated, desirable goals — factors which research indicates can bolster goal attainment and commitment. Interestingly, research also indicates that externally assigned goals can be equally effective as long as the larger purpose is clear.
Instilling SMART goal setting principles
Crafting effective goals necessitates adhering to the gold standard — Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals. We can augment the process of setting a goal through progressive disclosure of each step involved in the art of setting a precise, structured goal. The process is akin to using a GPS: users determine their own destination, or goals, while the system offers guidance to plot a SMART course. A few key defaults that can influence choices made when setting a goal:
- Categorization: Requiring users to categorize a goal reinforces the goal’s significance among the life values and priorities they reflected on prior to goal setting.
- Goal completion date: Based on the number of tasks associated with a goal, we can propose a realistic timeline — such as 1 task/week. Even if users opt for a different deadline, this serves as a useful benchmark to gauge a realistic timeframe for goal completion.
- Proximal goal setting: Guiding users to deconstruct their goals into actionable tasks enhances clarity, and outlines a clear path to achievement.
- Examples (including other individuals when possible): Rather than starting with a blank slate, default messaging can model what a well-constructed goal might look like. Examples drawn from peers in the goal setting community are particularly impactful, as social norms and peer behavior significantly influence choices.
Templates as tools: anchoring and defaulting to SMART Goals
Another effective strategy involves using goal templates. These templates, tailored to the life domains a user initially assessed, serve as a starting point for customization. Whether applying for SNAP or FAFSA; securing housing or employment, or preparing for life changes, goal templates serve as both defaults and anchors. They embody SMART principles that nudge users towards creating well-structured goals — whether they choose to use the templates directly, or just draw inspiration from them.
Closing the intention-action gap
Many people struggle to achieve their goals despite having good intentions. The intention-action gap — the divide between what people intend to do and what they actually do — can be attributed to various factors: barriers in the environment, overly ambitious targets, or a human tendency to prefer instant gratification over future rewards.
According to behavioural scientist BJ Fogg, three elements must converge for a behaviour to happen: motivation, ability, and a prompt. Reminders (via SMS, email, notifications) can provide prompts that help users remember their motivation and ensure they have the necessary tools and resources to take an action. These messages can also highlight what people stand to lose by not making progress, tapping into the psychological principle of loss aversion.
The power of nuanced language shouldn’t be underestimated. For instance, when the Department of Veterans Affairs altered the phrasing in their email communications from “you are eligible for benefits” to “you have earned these benefits” for a benefit program, there was a notable 9% uptick in veterans who initiated the enrolment process.
Guiding users to plan their actions as a default in their user journey can also improve their chances of success. Known in the literature as implementation intentions, this involves creating a specific plan outlining the when, where, and how of goal-directed behaviour. Despite this being one of the most well-established techniques for bridging the intention-action gap, it’s important to note that some research suggests ‘obstacle identification’ can backfire by leading to low self-efficacy. Instead of having users focus on all of the reasons a behaviour might be difficult or barriers to goal success, they should be encouraged to think about how they can bring about a successful behaviour change. This involves using motivational interviewing approaches to enhance an individual’s motivation to make a change.
Empowering with autonomy
In our daily lives, we often find ourselves in situations where our biases are exploited without even realizing it. Maybe it’s unintentionally binge-watching a Netflix series (status quo bias). Or maybe you’ve felt convinced that you’re getting a fantastic deal after seeing the original price (framing).
I believe it’s paramount to prioritize an individuals’ autonomy. It’s an ethical imperative, but it also fosters trust, and motivation (in the case of goal setting). In designing decisions, we should aim to transparently share information; never impose time restrictions or pressure, and guard against users using mental short-cuts based on common known human biases. Messaging that is empowering, rather than manipulative, should remind users of their agency and capability to make choices. By creating an environment where informed and self-determined choices can flourish, we put patients back in the driver’s seat of their healthcare journey.
Patient Education
When a patient first receives a diagnosis, they may feel overwhelmed by the flood of information from their healthcare providers. The challenge of assimilating this vast array of new information can be daunting, even terrifying. Choice architecture offers tools that help patients make decisions with more clarity and confidence.
The Power of defaults in learning
Carefully curated defaults can play a crucial role in guiding patients through their educational journey. By thoughtfully designing a default learning path, we eliminate the paralysis of choice, allowing patients to absorb information sequentially and avoid the stress of deciding where to start.
Dan Ariely discussed how default options impact organ donation rates in his TED talk, Are we in control of our own decisions?. Countries with an opt-in system tend to have lower participation than those with an opt-out system. As Ariely says:
It’s not because it’s easy, trivial, or because we don’t care. It’s precisely because we care — deeply — yet the complexity paralyzes us. In the face of such complexity, we often defer to the path already chosen for us.
Well-chosen default options allow people to focus on the information, rather than the choices.
Personalization based on a user insights
We can use interactivity and feedback to help users to be more engaged with the decision making process. For instance, incorporating questions can shed light on the decision’s significance, content, and any preconceived notions.
Consider a patient who needs to decide on their dialysis options. They may have a preference, but may not be entirely confident about it. We can tailor their learning experience based on this information. Similarly, understanding a patient’s values — such as a strong familial bond or a love for travel — enables us to create narratives that truly resonate, empowering patients to make decisions that are both confident and personalized.
Conversational engagement with educational content
Learning can also adopt a more conversational style that gives patients control over their learning journey. Two examples:
- Asking patients what they’d like to learn about next: After a user has finished learning something, ask them to choose what they are most interested in learning next among a few options. By providing relevant information based on a user’s choice, we’re signaling the impact of their decisions. We’re also conveying that they have control and agency over their learning process.
- Asking users about their personal experience with a specific topic (such as symptoms, lifestyle changes, caregiver support, dietary changes, etc.): When a user learns about something, encourage them to understand the significance of the topic in their own life. If users are learning about common symptoms, they could be asked which symptoms they’ve experienced, or are concerned about. This prompts users to internalize the knowledge they acquire, while fostering a sense of communal understanding. It subtly gives users the impression that their lived experiences are shared, alleviating feelings of isolation. Like example 1., it also provides further opportunities to personalize their learning experience going forward.
Importantly, when including interactive segments in their program, it’s important to limit the number of options presented. Limiting the number of options to three at a time avoids overwhelming patients. These incremental choices build confidence and skills for more complex decisions ahead. By mastering these low-stake choices within the safe confines of their learning journey, the user is primed for the more complex and impactful decisions that lie ahead.
Making decisions for someone else
Allowing patients to “practice” making choices can lower the anxiety experienced when the time comes to make a choice “for real”. Think of a choose-your-own-adventure narrative, which grants users agency and autonomy in shaping their journey. Applying this concept to healthcare, patients can simulate scenarios where they make choices reflecting their own experiences, aiding in knowledge application without the direct pressure of personal implications.
This strategy helps users to be more deeply engaged and informed as they explore possible decision paths and potential outcomes.
Social influence
Choice architecture can also be used to promote information-seeking behaviour by providing suggested questions, perhaps in the form of Frequently Asked Questions (FAQs). As patients engage with questions posed by peers, they are subtly prompted to reflect on various aspects of their own journey and life as a patient, without the pressure of trying to get the query right. Seeing examples of questions posed by people they recognize as being “like them” can aid patients in formulating questions of their own, facilitating a deeper understanding of the subject matter and highlighting areas where clarity is needed. Importantly, FAQs serve to normalize the act of questioning, thereby dismantling any stigma or embarrassment in not knowing an answer that may deter patient curiosity.
Shared Decision Making
Decision aids help patients understand and systematically work through complex decisions. In turn, they help patients to collaborate with their doctor, and make treatment decisions that are in harmony with their values, preferences, and lifestyle. As Thaler and Sunstein point out in the book, Nudge: Improving Decisions about Health, Wealth, and Happiness (emphasis mine):
“…people make good choices in contexts in which they have lots of experience, good information, and prompt feedback — say, choosing among familiar ice cream flavors. People know whether they like chocolate, vanilla, coffee, or something else. They do less well in contexts in which they are inexperienced and poorly informed, and in which feedback is slow or infrequency — say, in saving for retirement or in choosing among medical treatments…”.
To design an effective decision aid, principles of choice architecture can be used to give users an effective framework to help them hone in on what’s important in their lives, and provide instant feedback on the potential paths that could stem from their choices.
Values as a Frame of Reference
The foundation of a productive decision-making process is to help users determine their decision-making criteria. This involves empowering individuals to establish a personal framework that aligns with their values and needs. Here are ways to achieve this:
- Encourage users to reflect on their daily routine and lifestyle: This information will help them establish their own frame of reference for how a treatment option might fit into their current life.
- Share stories from other patients: Understanding the unique decision-making criteria of others who have faced similar choices can provide valuable insights and help users to clarify their own priorities.
- Discuss future aspirations: What are the users’ hopes and dreams, and how might different health choices help or hinder the achievement of these goals?
By engaging in these exercises, users can sort through various lifestyle aspects that may be impacted by a treatment or health decision. For instance, when considering birth choices like a C-section or natural birth, or different dialysis options, users can decide if each aspect ‘matters a little’ or ‘matters a lot.’
Forced Ranking
It’s common for users to initially feel that everything matters a great deal, making the communication of priorities to their clinical team difficult. To help in expressing priorities that can be used in clinical decision-making, a useful final step is to require the ranking of which aspects matter most to them. Directing them to select their top 3 priorities from a longer list can enable a more focused and productive conversation with their doctor.
Clarity and Framing
The way options are framed can significantly influence a user’s choice. For instance, wording choices like ‘avoiding something’ versus ‘having more of…’ can have different implications due to the user’s loss aversion bias — where the pain of losing is typically felt more strongly than the pleasure of gaining.
By incorporating these principles of choice architecture into decision aids, we can create an environment where patients feel supported and confident in their healthcare decisions, fostering a stronger partnership with their doctors. The result is a healthcare journey that reflects each individual’s unique set of values and life circumstances.
Takeaways
The ability to choose is a powerful freedom. Yet in today’s world of excess information and opinions, making good choices has become increasingly complex. Principles of choice architecture are something that everyone should be aware of, as we navigate our decisions in life.
The role of ‘choice architect’ extends far beyond ‘designer’ titles to most professions, and the roles we play in presenting decisions to our friends, colleagues, and families.
I’ll end with a personal example: In the realm of product design, I noticed a surprising parallel to the world of sales and business development (my previous career focus) — an unwavering focus on understanding the intricacies of decision-making. Although seemingly disparate, the fields converge on a singular obsession — engineering an environment where decisions are not left to chance, but are carefully architected to ensure clarity, confidence, and conviction. Steering clients towards knowledgeable and assured decisions is more than just a successful strategy; it’s the foundation for building trust. Sales teams incessantly pondered over ways to facilitate decisions — how to empower clients to choose, ensuring meetings lead to actionable outcomes rather than inertia. Sales methodologies, like the Challenger Sales model, urge to educate prospects on their available options and help them see the future consequences of potential decisions (or not making a decision).
Similarly, designers can use principles of ethical choice architecture to create an environment that’s conducive for patients to make informed, deliberate, and timely decisions about their health.
That’s all! You can follow what I’m up to on LinkedIn at https://www.linkedin.com/in/jessicadorazio/.
