Daniel Kahneman and Amos Tversky more or less invented what we now call Behavioral Economics. Tversky passed away in 1996, but Kahneman went on to win the Nobel Prize and his 2011 bestseller, Thinking, Fast and Slow, brought their work to the general public. The big question Kahneman continuously answers in the book is, “How is it possible that we can make decisions that aren’t in our best interest?”
Bringing fast and slow thinking into medicine, Edmund G. Howe describes how he took Kahneman’s ideas and used them to guide patients through difficult decisions in The Journal of Clinical Ethics.
In his article, Howe makes useful and sincere applications to medical ethics and patient care. Going through his work also makes me want to re-read Kahneman’s book.
I have little to add to Kahneman, which should be required reading for anyone who’s had to make a decision or might make one again in the future. The gist of Howe’s article is simple enough. If patients are taught a little about the “fast” (automatic and emotional) system and the “slow” (effortful and conscious) system that operate in all of us, they’re better equipped to think about their care.
Howe’s work also brings up some useful ideas about narratives in the clinic. Instead of focusing on Thinking, Fast and Slow in medical practice, I’d like to focus on these.
Reason and Process
In several different ways in his article, Howe advocates for framing, prefacing, or contextualizing conversations with patients. In medicine, it’s frequently necessary to provide
complex information to [a] person who is under stress. Clarifying the reason for a meeting or for a particular topic of discussion can help everyone involved better process what’s being said.
In one example, when presenting Kahneman’s ideas, Howe made sure the patient understood that he wasn’t being singled out, that
these two types of thinking take place in all of us:
I clarified that my explanation was not a comment about this patient, more than any other person, but rather, that fast thinking is a tendency that is universal, and information about fast thinking was something that he, at that time, might find particularly helpful.
This additional statement is an approach I use often and believe that clinicians and ethics consultants should apply more widely. I anticipate the possible ways that what I say may be ambiguous and may be misinterpreted by patients and families.
In other words, Howe is prefacing a discussion of fast and slow thinking as a universal way that we as human beings process experiences, not something that this patient should think about because he made a dumb choice and needs to undo it.
In another example, Howe mentions scheduling routine meetings for family members of ICU patients:
When we first convene any special kind of meeting, family members may fear bad news…
This apprehension is particularly likely if, in the past, clinicians have always talked with them only informally and when they were “on the run.”
Consequently, our first task when we call for a special meeting is to try to reduce family members’ fast thinking by saying why we will be meeting, before anything else. We should reassure the family, if we can, and if it is true, that we will meet because, in the ICU, such meetings are routine, and this is so because the illnesses of patients in the ICU are more serious.
Whether in a medical situation or not, being called into an unexpected meeting can be unsettling. Particularly in an ICU, families are likely to spend the entire meeting waiting for the bad news instead of being fully present. Telling the family ahead of time that these meetings are routine and are used to share information lets everyone involved enter the meeting ready to hear what’s being said.
Howe presents several more examples of
speaking to the , and how it benefits interactions with patients. Structuring a conversation this way is analogous to storytelling: a story has to have some reason for its existence. A story doesn’t really begin until its problem is presented. Once this happens, everything else in that story makes sense. A story, like a productive conversation, is best understood in the context of why it is happening in the first place.
Fast Thinking and the Dark Side of Stories
There is a connection between fast thinking and our human capacity for narrative and storytelling:
Our faster, intuitive thinking system is, [Kahneman] says, more influential than our slower reasoning. This faster system, he says,is not readily educable.1
A critically important aspect of the concept is that when we engage in fast thinking, we may not know that we seem to be locked into that state. As Kahneman says, we may search for plausible reasons for what we feel, and then believe the stories we may “make up” as a result.
We are wired to see patterns, and sometimes that ability connects things that aren’t related.
Stories and narratives are powerful and useful. They also have a dark side. Our automatic, fast system is good at stitching together explanations for events in the moment, especially under stress. If we act on this first impulse,
it can leave us exceptionally vulnerable to making suboptimal decisions without realizing it, as Howe puts it somewhat clinically.
Discussions of narrative and story involved in decision-making are complimented by an awareness of our fast and slow systems. When we latch on to an explanation for our decisions, is that the real story, or the first and fast story?
What Do You Want?
I remember a footnote in one of the books I read on theater directing in college. It read something like, “People are enigmatic, even to ourselves. Text and character analysis is necessary, but always keep a humanizing sense of mystery.” I remember thinking that was interesting, but pretty unhelpful in the moment.
In this article, Howe writes that when it comes to fast thinking,
what patients and family members do may not be at all what they really most want. What they want may lie outside their awareness and not be able to be known to them.
One of the remarkable things in this article is how patients reconsider their own stories, and arrive at new conclusions which would have seemed foreign to them just a few minutes earlier.
A woman who found out she had breast cancer immediately wanted to remove both breasts with no reconstruction. Upon forcing herself to think slowly about it, she realized that was exactly what her mother had done, and she began to ask herself,
What do I want for myself? The woman decided that she wanted to have only one breast removed, and then have it reconstructed.
We are all mysterious, even to ourselves. It’s useful, though, to know that the first draft, the fast draft, of what our mind puts together isn’t the only option. With a little more analysis and slow thinking, we can often become aware of what we really want:
…just as emotions can hijack slow thinking, a capacity for one part of the brain to influence another goes both ways. A new awareness can change what we feel, and quickly.
The article reviewed: Howe, Edmund G. “At the Bedside Slowing Down Fast Thinking to Enhance Understanding.” The Journal of Clinical Ethics 29, no. 1 (2018): 3–14.
1 Kahneman, Daniel. Thinking, Fast and Slow. New York, NY: Farrar, Straus, and Giroux, 2011. ↑