In another installment of 'people are stupid - except me and my friends' we have nudge healthcare reform. People don't make the 'right choice'? Nudge them. Grandma too old to be economically viable? Nudge, nudge. Kid has a terminal illness? Wink, wink. Home schooling parent gets pregnant, should she be allowed to keep the baby? Say no more.

I take it you haven't read Nudge?

Why not just write: Hitler, Stalin, socialism bad, me choose liberty, even if it barely fits to the article at hand?

I was referencing a more venerable text. I know of Thaler and Sunstein.

I understood your reference, but you also seemed to be badly misrepresenting the idea of nudges as presented by Sunstein and Thaler. Choice architecture is hugely important and, as they point out, unavoidable. My employer nudged me into retirement savings with automatic enrollment and I am very happy they did so instead of using an opt-in system.

Fair enough. I wasn't addressing the unavoidable creation of a choice architecture. You are right, to a point, we push people in a certain direction, even by something plain and/or simple. So, one might think, it is a good idea to push people towards things that 'make sense.' And we are right back to the discussion of values. *sigh*

I've lent my copy out so I can't quote directly, but the authors had several rules for something to qualify as a nudge rather than a push. One is that choosing an alternative must be very very easy. They lead with an example of a cafeteria layout where they end by proposing that dessert should be laid out after all the other choices and veggies up front. At most they would accept a separate dessert table.

I think I get where are you coming from re: values but I don't think they need to play a large role in most of patient care. Simply permit easy opt outs if opt in is the default and make opt in very easy when its not. For example, covering payment for end of life counseling adds choice but it would be fairly horrible if it were required.

This is where the trouble starts with a public plan - taxation to provide a service is more than a push, it is a 'put him in the cuffs and march him this way.' Now, from the patient side, it looks more like a nudge, perhaps; but then, there is also serious disagreement over some things - whether they should be nudged toward/pushed toward/enforced or forbidden absolutely. This is not a small gap, and it is a values gap. The problem is that all the small differences of opinion get completely washed out when held up against the glaring examples of these huge disagreements.

That's why I portrayed the process of moving health care decision making into the federal bureaucracy as one of moving from nudges, to ever more forceful urges in directions that are fiercely opposed by a large number of people - people who do not hold the offices which will make these decisions.