I recently won $1000 (sharing a $10k prize) for the following essay on how to solve what people in healthcare call the adherence problem, which costs the healthcare system “billions of dollars in unnecessary hospitalizations and nursing home and rehab costs”.
My prize-winning essay in its entirety follows. (I gave the actual money to Bethany in exchange for solving my own medical adherence problem, namely, dealing with all our health insurance paperwork.) It’s adapted from the inaugural post on the Beeminder blog, which I recommend over this version. But this version now comes with a nice stamp of credibility, thanks to Innocentive.
How do you induce someone to take needed medication who (1) doesn’t consider their personal health a priority, (2) is not sure they even want to deal with their condition, (3) is not always convinced of the value of medication, and (4) lacks confidence in their doctor? The answer is: patient education. For every one of those obstacles, there’s no shortcut. But this challenge is about an even deeper problem, exemplified by the patient who claims their personal health is indeed a priority, very much wants to deal with their condition, has no doubts about the value of their prescribed treatments, has full confidence in their doctor, and yet still fails to comply, simply because their good intentions fall by the wayside.
This problem goes far beyond compliance with medication. Many of us have a problem following through on our intentions in all aspects of life. And it’s more than just a difficulty in predicting our future desires. It’s not that you say to yourself, “Gee, I thought I wanted to get in shape but it turned out there was always something really good on TV!” No, even in hindsight, you regret not doing what you said you wanted to do. It’s not even that you’re merely conflicted about what you want. The trade-off you made — more TV watched, still not in shape — was patently ridiculous. You somehow don’t do what you genuinely want to do. Philosophers back to Plato and Aristotle have a fancy term for this paradoxical failure of the will: akrasia. It encompasses procrastination, lack of self-control, lack of follow-through, and any kind of addictive behavior. Another way to define akrasia is by generalizing from procrastination to include preproperation as well. Procrastination is the irrational delay of tasks with immediate cost and delayed benefit. Preproperation is the irrational not delaying of (overindulgence in) activities with immediate benefit and delayed cost.
Why do we have this problem? The technical answer is time inconsistency and is illustrated nicely in a study on grocery-buying habits: When buying groceries online for delivery tomorrow people buy a lot more ice cream and a lot fewer vegetables than when they’re ordering for delivery next week. In other words, our preferences are inconsistent — in fact, logically contradictory — over time. Your ability to weigh the costs and benefits (yumminess, healthiness) is severely compromised when some of those costs or benefits are immediate, which is why the ice cream vs vegetables decision plays out so differently when you decide it from a distance.
How do we solve this problem? The answer is self-binding, that is, the use of commitment devices. The term commitment device is from game theory and applies to strategic situations. It refers to a way of changing one’s own incentives to make an otherwise empty threat or promise credible. This can be quite rational. A classic example is from Thomas Schelling, who pioneered this aspect of game theory. You’ve been kidnapped and you’d like to promise your kidnapper that if they let you go you won’t rat them out to the police. The promise is useless because the kidnapper knows you’ll have no incentive to keep it once you’re free (and so they won’t set you free). But if you can change your future incentives (implicate yourself in the crime, perhaps?) then suddenly your promise can carry weight.  Limiting your future options by voluntarily imposing consequences on your future self can be quite valuable in a strategic negotiation or conflict.
But it’s hard to characterize as rational the use of self-binding with no one but oneself… until you appreciate that there’s in fact more than just one self. 
Sapid Sweets and Seductive Sirens
Here’s a ubiquitous example. Why not save money by buying bulk-size candy? It’s technically entirely irrational not to. You should buy the bulk size, save the money, and then ration it to match the pace you’d eat it at when buying the individual sizes. Same consumption rate, less cost. The problem is your future self won’t be rational with a pile of candy in the house. Sugar is a bit addictive, after all. So it’s worth spending some extra money to constrain the choices of your gluttonous future self. Similarly, some smokers buy cigarettes by the pack instead of the carton, paying a hefty premium to throttle their future consumption.
The classic, prototypal example of self-binding is Odysseus tying himself to the mast of his ship so he could listen to the Sirens without getting lured onto the rocks. Calling Homer’s Sirens addictive is an understatement since they pretty much literally control your mind. But there are a lot of things in modern society (hello, Internet) that are at least a little addictive and getting more so.  In “The Acceleration of Addictiveness Paul Graham argues that this trend is fundamental to the growth of technology itself.
So what’s the antidote? There’s an endless stream of advice about how to beat akrasia but I believe that most of it misses a very fundamental point that renders it nearly useless: The myopic future self that thwarts your intentions is every bit as smart as your current, forward-looking self. You can make lists and set rewards and break tasks into small chunks, or plan diets and buy treadmills and establish routines, but mostly your future self will see right through all the tricks and just won’t give a damn. That version of yourself just wants to surf the web and/or eat pie. So that’s what you do, when the chips are down.
The only way to be immune to future-you thumbing his or her nose at your current intentions is self-binding. Which is to say that successful anti-akrasia tricks will involve commitment devices. That’s because, by definition, a commitment device meaningfully constrains your recalcitrant future self’s actions. Here are a slew of commonly and not-so-commonly used commitment devices.
List of Real-World Commitment Devices
- Buying the individual-sized instead of the bulk-sized candy
- Buying a gym membership even when it would be cheaper to buy individual passes, i.e., purposefully making it a sunk cost
- Getting a mortgage in part to force yourself to save [see the first reason listed at messymatters.com/buyrent for buying vs renting]
- Deleting games from your computer
- Going somewhere without internet access to get work done or using a purposefully handicapped computer
- Signing up for a class (or hiring a private instructor) when in theory you could just draw/run/paint/whatever regularly on your own (but without the commitment of the class you won’t)
- Using software that stops you from visiting time-wasting sites like facebook; e.g., LeechBlock or SelfControl
- Not having a TV in the house (even though it would be worth having for certain occasions)
- Identifying and eating as a strict vegetarian/vegan despite not actually minding whether you eat an occasional animal product
- Starting a project close to its hard deadline to limit the amount of time you can spend on it (though more often this is a manifestation of rather than a remedy for akrasia!)
- Not buying an unlimited metro card because once the subway fare is a sunk cost you won’t be as motivated to commute by bike
- Choosing to live somewhere that will force you to walk/bike further (in theory you could live closer and take a longer route, but you won’t)
- Having more than the minimum tax witheld from your salary, a zero-interest loan to the government, to force yourself to save enough to pay your taxes
- Using Certificates of Deposit with withdrawal penalties that outweigh the slightly higher interest rate they pay compared to a savings account
- Not taking a high-paying job for fear of getting hooked on the lifestyle it will lead to
- Using debit cards instead of credit cards, which force you not to spend more than you have
- Withdrawing less cash from the ATM to limit future spending
- Putting money in a Christmas Club (aka Santa Saver) account — a savings account that you cannot withdraw from until December 
- Taking a diet pill that causes diarrhea when you eat too much fat
- Putting your alarm clock across the room (a cheap example since it involves an explicitly compromised future self, in this case a groggy one)
- Taking Antabuse to cause yourself to get sick if you consume alcohol
- Using the kind of piggy bank that you have to smash open to get the money out
- Undergoing bariatric surgery, which works by causing pain/nausea whenever you eat too much in a sitting
- Banning oneself from casinos or online poker sites (they offer this functionality)
- As a domestic violence victim, preferring no-drop prosecution 
- In an experiment by Dan Ariely on his students, “irrationally” choosing to be bound by spaced-out deadlines for course projects 
- Getting married as a way to make it hard to break up? (this may be more about proving your commitment than about imposing a commitment device on yourself)
- Using a device to ration out pain medication
- Preferring coupons or gift certificates with expiration dates to ensure you’ll eventually get around to using them 
- Preferring gift certificates at all instead of cash
- Using a layaway program to force yourself to save up for a cherished item
- Using a so-called kosher phone, actually available in Israel, that stops working on the Sabbath
- Traveling somewhere to do something that you could but won’t do at home, like to escape distractions that you don’t have the willpower to simply ignore
- Investing in mutual funds instead of index funds to keep yourself from overtrading
- Using MasterCard’s inControl credit card that shuts off once a set budget is reached
- Using Blackberry’s “NOTXT n’ Drive” which shuts off texting when your car is moving
- Preventing drunk-dialing with iphone apps like “Don’t Dial” and “The Bad Decision Blocker”, or Google’s “Mail Goggles”
- Using the noprocrast feature on Hacker News (to block your own access to the site after a pre-specified amount of time)
- Dumping salt and pepper on the rest of your dessert
- Preventing yourself from making impulsive purchases with your credit card via a collection of tips from LifeHacker
- Not getting a parking permit or otherwise making it more expensive to use your car, as a way to encourage your future self to drive less
What I find fascinating about that diverse list of commitment devices is the minuscule dent they put in the overall problem of akrasia. The tricks people actually use are mostly — with some interesting exceptions, such as #23 — band-aid solutions. The problem is not with the concept of precommitment. (Remember that akrasia is fundamentally a problem of your future self failing to follow through on your current intentions.) The problem is failing to commit hard enough. Take a goal like weighing twenty pounds less in a year. Band-aid commitment devices are things like keeping junk food out of the house and joining a gym. Why not get straight to the heart of the problem and make a contract with a friend that commits you to forfeiting a very painful sum of money if you don’t follow through on your weight-loss plan?
Websites like StickK.com and Beeminder.com make it easy to do just that, also breaking down long-term goals like losing weight into weekly or even daily commitments to stay on track, using monetary commitment contracts to ensure compliance.
Many people react viscerally to the idea of involving money. I’m partial to money myself but I don’t claim it’s the only way. Still, many obvious alternatives — like harnessing social disapproval — can fail if implemented naively. To make the long-term consequences of failing at your goal immediate, you need a bright and painful line. Using shame as a motivator with a public graph of your progress doesn’t quite cut it because there’s minimal shame in having one datapoint slightly off track — you’re still totally going to catch back up, right? As you then gradually drift away from your target the shame grows only gradually as well. You’re back in “one more day won’t matter” akrasia-addled fantasy land. (I speak from experience.)
What sites like StickK and Beeminder offer, in addition to tangible and immediate consequences for going off track, is setting a bright line so you know exactly what going off track means.
To return to the specific case of healthcare, I would like to conclude with an example of a patient committing on Beeminder to gradually lower their fasting blood sugar (used with permission): beeminder.com/heavyg/bs.
In addition to the links included above, I recommend the following:
- Choice and Consequence by Thomas Schelling, in particular the chapter “The Intimate Contest for Self-command” (I believe this subsumes his seminal 1978 AER article on Egonomics)
- “A Tale of Two Selves”, a discussion of commitment devices by Dan Goldstein including his own strategy of committing to leaving cash on the subway for failing to meet a writing goal (and actually doing it)
- “How to Use a Commitment Contract to Change Your Habits”
- Carrots and Sticks by stickK.com co-founder Ian Ayres
- A Paul Bloom article in The Atlantic, “First Person Plural”, on the multiple selves theory of akrasia
- Article in Fast Company, “Why Customers Will Pay You to Restrain Them”
- Breakdown of Will by George Ainslie (creator of picoeconomics.org); this book lays out the case for hyperbolic discounting, the basis of my claim that the secret to beating akrasia is to not make decisions under the influence of immediate consequences
- Stanford researchers debunk theory that willpower is a limited resource
- Radio Lab episode (from 7:07 to 16:10) discussing the Stanford marshmallow experiment on delayed gratification (see also this New Yorker article); the ability to delay gratification at age four is highly predictive of future life success, and the key to success for the kids who could delay gratification was the use of tricks to distract themselves from the marshmallow staring at them
- The “You Are Not So Smart” blog on procrastination
- Time inconsistency illustrated in a comic
- An example of what not to read on procrastination: the only purportedly practical thing in this Psychology Today article is saying that procrastination can be solved with “highly structured cognitive therapy”; everything else is just psychobabble and pointless taxonomizing
- RadioLab episode featuring Thomas Schelling
- Short article by Dan Ariely in Scientific American, “How Self-Control Works”, recapping the Stanford Marshmallow Experiment and the conclusion that it’s all about self-binding tricks
- The earliest treatment of akrasia and time inconsistency that I know of in the economics literature: Myopia and Inconsistency in Dynamic Utility Maximization by R. H. Strotz in Review of Economic Studies, 1955-1956
 Or take the example of Cortez burning/sinking his ships to remove the possibility of retreat and thus increasing his chances of defeating the Mayans. More abstractly, in a game of Chicken against a rational opponent, if you can manage to remove your own option to yield (like ripping the steering wheel out of your car so you can’t swerve) then you win.
 Although I’m using the multiple selves terminology, I view it as no more than a rhetorical device. There are not multiple selves in any real sense. Rather, as I will argue, there’s in fact just one true you whose decision-making is sometimes distorted in the presence of immediate consequences, which act like a drug. Which is to say (as an empirical fact) that when a decision involves some consequences that are immediate and some that are distant, humans irrationally (no amount of future discounting can account for it) over-weight the immediate consequences. So I refer to multiple selves but I believe there is one true self: the one not under the influence of immediate consequences.
 James Surowiecki, in a recent New Yorker book review, “Later: What does procrastination tell us about ourselves?”, cites a survey in which the percentage of people who admit to difficulties with procrastination quadrupled between 1978 and 2002.
Christmas Club accounts [were] a staple of American banking in the 1970s. The Christmas Club account was, on the surface, a bizarre idea: You gave the bank money every month. The bank paid you no interest, and it would not let you take the money out until Dec 1. This was not much of a bargain. And yet Americans happily put their money into Christmas Club accounts, even though that same money in a savings account would have earned them interest.
 No-drop prosecution is an option to press charges against an abusive spouse and stipulate that you don’t want to be allowed to drop them (the charges). Actually I believe you don’t literally have the choice to stipulate that — you’re either in a no-drop jurisdiction or you’re not — but some economists have inferred that many domestic violence victims would choose no-drop prosecution if they could. In the case of an abusive relationship I could imagine strategic reasons for that (so you can’t, and your spouse knows you can’t, cave to threats to get you to drop charges) but the claim is that due to the sad psychology of domestic violence victims, it’s really about forcing your future self to follow through with what you know (when you sit back and reflect) is the right thing to do.
 The setup is that he let his students pick their project deadlines for the whole semester. Once they’re picked they fail the course (they paid thousands for this course, we presume) if they don’t meet them. So rationally they should choose all the deadlines to be on the last day, to maximize flexibility. But it was clear to students that that was a terrible idea. And sure enough, the ones who precommitted to spaced-out deadlines did better.
 In another study, students were given coupons — some of which had expiration dates — for free ice cream. The students expressed greater value for non-expiring coupons but got more value from the coupons with expiration dates. Without a deadline they would often put it off until they lost the coupon.
Image: The History of Money