Emotional Adaptation and the End of Economics

Peter A. Ubel, M.D. 

Center for Behavioral and Decision Sciences in Medicine 

Ann Arbor VAMC 

University of Michigan Health System 

Is Experience Overrated

Is Experience Overrated

The answer depends on who you ask
        - TTO utility of ESRD (0-1 scale)
        -  Patients = .56
        -  Community = .39
        - Moods (-2 to +2 scale)
        -  Patients = .66
        -  Community prediction of patients = -.17

Is Experience Overrated

Economic Importance of This Discrepancy
        - Whose utilities should we include in cost effectiveness analyses? 

Is Experience Overrated

As if the “who” question wasn’t enough!
        - We need to figure out what question to ask
        - Specifically:  should policy decisions be based on

 decision utility or

 experience utility

Is Experience Overrated

A Quick and Inaccurate History of Economics
        - Economics = Science of utility maximization
        - Original notion of utility
        - Jeremy Bentham
        - Balance of pleasure & pain = Experience utility
        - More recent view of utility
        - Revealed preferences
        - Rational people’s free choices lead to utility maximization 

			= Decision utility

Is Experience Overrated

Decision Utility and Revealed Preferences

Illustration of distinction between Experience and Decision Utility

Pain

Time

Time

60

60

90

Pain

High

Is Experience Overrated

What happened in this study?
        - Experience utility –
        -  The 60 second bucket was better than the 90
        - Decision utility –
        -  The 90 second bucket was better
        - People misremembered their 2 experiences, causing them to make a bad decision

Is Experience Overrated

Goals of Talk
        - Potential flaw of decision utility
        - Based on mispredictions and misrememberings of experience utility
        - Potential flaw of experience utility
        - Goals of healthcare go beyond mood maximization
        - Point to future research directions
        - Empirical
        - Normative

Global versus Momentary QoL: source of patient overestimation?

Is Experience Overrated

Global versus Momentary Reports of Well-being (SWB)
        - People have difficulty describing average emotions over time
        - There may be a discrepancy between 

moment to moment SWB 

general evaluation of SWB

Is Experience Overrated

No pain, no gain

Pain

High

Pain

Time

Time

60

60

90

Pain

High

Is Experience Overrated

It’s the little things in life

Is Experience Overrated

Imagine a Dialysis Patient’s Quality of Life 
        - How happy are you right now (0 - 10)?

6

5

5

6

8
        - How happy do you feel generally?

7

Is Experience Overrated

Is Experience Overrated

Entry:  Percentage of time, during a typical week, that you are in each of the following moods?

100

Very unpleasant

-2

Slightly unpleasant

-1

Neutral

0

Slightly pleasant

+1

Very pleasant

+2

Easily compared to EMA

Is Experience Overrated

Palm Week

          - Same responses as for the estimation task
          - happy, joyful, pleased, enjoyment/fun
          - depressed/blue, unhappy, frustrated, angry/hostile, worried/anxious 

Is Experience Overrated

Predicted Moods

.61

Controls

.78

Patients 

Predicted Mood

          - Average ... +2 to -2 scale. .. (would be .63 and .66 on a 0 to 1 scale)
          - Power at .8, we can detect differences of .3.
          - None of the demographics were significant covariates, so we used the full sample.
          - Another commonly used technique to demonstrate power is to show that the group predictor is significant if a covariate is added.

Is Experience Overrated

Predicted vs. Actual Mood 

Predicted Mood

.80

.66

Actual Mood

.61

Controls

.78

Patients 

Is Experience Overrated

Specific Moods (0-6 scale)- Palm Data -

.99

1.00

5 negative measures

3.23

Controls

3.21

Patients 

4 positive measures

Is Experience Overrated

Imagining life on Dialysis

P< .001
| Actual Mood | Dialysis Mood |
|-------------|---------------|
| Patients    | .66           |
| Controls    | .80           | -.17 |

Is Experience Overrated

Imagining perfect Health(Never had kidney problems. . .)

P< .028
| Actual Mood | Dialysis Mood | Healthy Mood |
|-------------|---------------|--------------|
| Patients    | .66           | 1.10         |
| Controls    | .80           | -.17         |

Is Experience Overrated

A Whole Lot of Mispredicting Going On
        - Patients
        -  Mispredict life without kidney disease
        - General public
        -  Mispredict life with kidney disease
        - These mispredictions of experience utility could influence decision utility

Is Experience Overrated

Theory Driven Recall Bias: an alternative to scale recalibration

Is Experience Overrated

Hope I die before I get old!
        - Common belief (among rock stars, at least)
        - Getting old stinks
        - But happiness data suggest that
        - Happiness relatively stable across adult years
        - Not much change between 30 and 70
        - If anything, less negative affect with age
        - What do real people believe?
        - < 40 year olds
        - > 60 year olds
        - And how do beliefs compare to “reality”?

Is Experience Overrated

Study Design
        - Internet study of people
        - 21 – 40 (n = 264; median age = 31)
        - 60 and up (n = 255; median age = 68)
        - Asked to:
        - Report current happiness (0 – 10 scale)
        - Estimate happiness of typical
        - 30 year old
        - 70 year old

Is Experience Overrated

Results: Self reported happiness

10

0

Happiness

< 40                                        > 60

6.6

7.3

Is Experience Overrated

Results: Predictions of 21–40 year olds

10

0

Happiness

< 40                                        > 60

6.6

7.3

7.0

6.2

Is Experience Overrated

Results: Predictions of old people

10

0

Happiness

< 40                                        > 60

6.6

7.3

7.0

6.2

7.6

6.3

Is Experience Overrated

A whole lot of mispredicting and misremembering going on
        - Young people mispredict happiness as they age
        - Old people misremember happiness of their youth
        - People are out of touch with their own experience

Is Experience Overrated

Looking forward to a kidney transplant

Is Experience Overrated

Misestimating the benefits of kidney transplantation
        - Surveyed patients waiting for kidney transplant at University of Pennsylvania
        -  Measured QoL
        -  Asked them to predict QoL 1 year after successful transplant
        - Resurveyed them after transplant
        -  Measured QoL
        -  Asked them to remember pre-transplant QoL

Is Experience Overrated

Mispredictions

Domain

Pre-tx	

Prediction for Post-tx

Actual  Post-tx

83

12

15

4.3

QoL (0-100)		    66             	91

Travel (days/yr)	     9            	20

Work (hrs/wk)	    12             	32

Energy (1-5)		   3.2             	5.1

Is Experience Overrated

More mispredictions

Domain

Pre-tx	

Prediction for Post-tx

Actual  Post-tx

3.5

Happy w/ life		    2.8             3.9

3.1

...std. of lvg.                 2.6             3.7

3.5

...love life	               3.5             3.8

...health	               2.4             3.9

3.6

...work	               2.5             3.6

3.1

...family life	               3.8          	 3.8

3.8

...social life	               3.5          	 3.8

3.6

...spiritual life	    3.4          	 3.7

3.6

...leisure life	               3.0          	 3.8

3.3

Is Experience Overrated

Misremembering ESRD

Time

Pre-tx	              	        65             	  91

Pre-tx QoL

Post-tx QoL

Post-tx:

    Immediate                    57                       78	              	

    6 months	                   55             	   80

    12 months                    48             	   83

Is Experience Overrated

What’s it like to have a colostomy?

Is Experience Overrated

Colostomy Patient Survey
        - Surveyed people who have received colostomies at UM within last 5 years
        - some had permanent and some had reversed colostomies
        - 94 permanent
        - 100 reversed
        - What do these two groups think of life with a colostomy?

Is Experience Overrated

Adapting to life with a Colostomy
        - Overall quality of life (0-100)
        - permanent = 67
        - reversed = 71
        - Overall positive affect positive mood (0-4)
        - permanent = 3.1
        - reversed = 3.1
        - Overall negative mood (0-4)
        - permanent = 1.8
        - reversed = 1.9

So ... little to no difference in mood or quality of life

Is Experience Overrated

How Happy:  Now & 5 yrs. ago

Now                                     5 yrs. ago

6.1

6.8

6.4

6.0

7

6

5

Is Experience Overrated

How bad do these groups think it is to have a colostomy?
        - Time tradeoff (TTO) utility question
        - Imagine you will live 10 years with a colostomy then die.
        - How many months (0-120) would you give up to get rid of the colostomy?
        - permanent = 18 months
        - reversed = 44 months

Is Experience Overrated

Decision Utility and Revealed Preferences

Is Experience Overrated

Rational decision making and revealed preferences
        - Ua = P1U1 + P2U2 + ...
        - Ub = P7U7 + P8U8 + ...
        - If I chose A over B
        - Then Ua > Ub
        - Similarly, if I’m willing to pay
        - $10 for X
        - $15 for Y
        - Then Uy > Ux

Flaws with revealed preference assumptions
        - People mispredict utilities
        - As I’ve shown already
        - Even given utilities
        - People don’t always integrate p’s and u’s in rational manner
        - Here’s an example

Imagine you have Colon Cancer 

Surgery A
        - 80% cure without complications
        - 16% die of disease
        - 1% colostomy 
        - 1% intermittent bowel obstruction 
        - 1% wound infection 
        - 1% diarrhea
        - Surgery B
        - 80% cure without complications 
        - 20% die
        - Which surgery would you choose?

Is Experience Overrated

Is Experience Overrated

Give me colostomy or give me death!
        - When we ask people to choose  between being dead or having one of these four complications
        - >90% prefer each of the four complications to death
        - To be consistent with these preferences
        - <10% should choose the uncomplicated surgery

Is Experience Overrated

Our Survey says . . .
        - 50-60% of people choose surgery B,  the uncomplicated surgery

Is Experience Overrated

Kahneman’s case against Decision Utility
        - Based on

 mispredictions of utility

 poor integration of problem and utility

 If we want to maximize utility, we should measure experience utility and devise policies/practices that maximize it

Is Experience Overrated

Narrowing the scope of debate
        - Lots of problems with utilitarianism
        - consequentialism:  ends over means
        - maximizes average “utility” without regard to distribution
        - etc. etc.
        - But consequences do matter to decisions
        - choose dinner at restaurant
        - buy a movie ticket
        - invest in a health care system
        - Surely we want to understand distinction between decision and experience utility

Is Experience Overrated

Advantages of experience utility as welfare criterion
        - People generally want to be happy

But they are often unaware of what would make them happy
        - Recent advances allow for more accurate measures of happiness, mood and other experiences

Ecological Momentary Assessment

Experience Sampling

DRM
        - Policy should be informed by

Actual experience 

Not mispredicted experience

Current approach to experience utility

Focus = mood
        - Outcomes = maximization of mean mood
        - Integral of momentary affect
        - Thus, for example

-3, -3, 4, 4, 4 is better than

1, 1, 1, 1, 1

Limitations of experience utility as welfare criterion

A thought experiment
        - Imagine that you are about to receive a below the knee amputation (BKA)

You will recover, physically, quickly

You will receive a top-of-the-line prosthesis

Physical function – almost normal
        - Able to play sports
        - Sprinting and jumping mildly reduced

A thought experiment - continued
        - Imagine also that you completely adapt emotionally

Mood indistinguishable, on average, from prior to BKA

Some pangs of 

Loss 

Stigma

Balanced by positive emotions from lessons learned

A question about our thought experiment
        - How much would you pay to avoid BKA?

Hedonic Adaptation
        - Our claim

Adaptation to positive and negative circumstances is not
        - Immediate
        - Universal
        - Complete

But is often
        - Rapid
        - Common
        - And substantial

Relevance of adaptation to debate about experience utility
        - If moods largely return to normal after good and bad circumstances
        - Then policies based on experience utility 

Won’t care too much about people’s circumstances

Counterargument
        - Experience utility consists of things other than mood
        - Our reply

We agree, partially
        - Thus, the job of experience utility proponents should be to better capture the aspects of experience that people care about
        - But we also expect that people care about things that go beyond what would ever qualify as experience utility

What is missing from experience utility?
        - Mill’s higher and lower pleasures

Better to be an unhappy person than a happy pig

Consider: wine connoisseur
        - Meaning and purpose

Raising young children
        - Evaluation of experiences matters

Consider two movies

What is missing from experience utility?
        - Capabilities

Walking in the woods with your children
        - Brief episodes

Death of a loved one
        - Self-identity

My mini-van

Moral considerations

I do it even though it won’t make me happy

Empirical exploration of distinction between experience and decision utility
        - Developed intervention to help people take account of adaptation when making affective forecasts
        - Think of bad event from more than 6 months ago
        - more or less upsetting than predicted
        - emotions stronger or weaker over time?

List the 2 most upsetting things about becoming paraplegic

Do you think these 2 things would become more or less upsetting over time?

Thinking about adaptation changed QoL estimates 

						QoL Rating (0 - 100)

Disability		N 	Before 	After 	P

Paraplegia     123		

Paraplegia 	 56

47

 -

52

62

.003

.001

Thinking about adaptation changed policy recommendations
        - Given choice between saving the lives of
        - 100 people who can be returned to perfect health
        - X people who would experience onset of paraplegia
        - X = 1000
        - When given same choice after thinking about adaptation	
        - X = 101

Thinking about adaptation di not change decision utility
        - Standard gamble to elicit utility of paraplegia
        - What chance of death would you take to be cured of paraplegia
        - Time Tradeoff elicitation
        - Imagine you will live 10 more years
        - How many months of that time would you give up to be cured of paraplegia
        - Adaptation exercise
        - Did not influence responses to either elicitation

These 3 studies suggest that
        - Thinking about adaptation changes
        - QoL estimates
        - And potentially experience utility estimates
        - But does not change
        - People’s decision utility

What criteria should guide public policy?

What criteria should guide public policy?
        - Two candidates, with limitations

Decision utility/revealed preferences

Experience utility/ moment-to-moment mood
        - Given that neither option is ideal

What should we use?
        - We propose two answers

Because there are two types of policies that require a welfare criterion

Two kinds of policy
        - Policies that are designed to directly affect the behavior of individuals

Tax laws promoting IRAs

FDA rules requiring food labels

Seat belt laws
        - Policies that operate at a level higher than the individual

Local government deciding how much to spend on schools vs. cops

Federal government corporate taxation policy
        - Distinction between these two types of policy is not sharp

Policies that guide individual behavior
        - Standard approach

Policies should enable people to make free, informed choices

e.g. FDA food labels
        - A step further 

Libertarian paternalism, soft paternalism, pruned decision utility...

Set up decisions so that people are more likely to make optimal decision
        - e.g. Default options for insurance
        - e.g. Physician recommendations

But what criteria/on should guide things like default options?
        - Fact = People influenced by status quo bias/defaults options bias in choosing insurance

So how do you chose the proper defaults?
        - Our proposal 

Base policy on experience utility
        - A maximally thick account of experience 

Inform people about experience when feasible

And let them decide

Why experience utility?
        - Because experience utility does matter to people 

And without “help”, they’ll mispredict it and make potentially bad decisions
        - And because they can still chose to base their decision on non-affective or non-experiential issues

Policies that operate above the level of the individual
        - We don’t have a simple answer

No single, appropriate welfare criterion
        - Policy makers need to consider experience utility

But need to take account of other things that matter to people

Some hybrid of 

Decision utility

Experience utility

Possible approaches
        - Deliberative democracy
        - Informed decision utility
        - But I’d like to see experimental studies evaluation those approaches

Backing up our claim
        - Test of global vs. momentary affect
        - Dialysis study: EMA design
        - Test of conversational norms
        - Parkinson’s study
        - Test of scale recalibration
        - Diabetes and emphysema study

Diabetes example
| Rate                  | PatientsN=367 | Non-patientsN=201 | Significance         |
|-----------------------|---------------|-------------------|----------------------|
| diabetes              | M=73.6SD=24.1 | M=64.0SD=24.2     | t(566)=4.51p<.001 |
| lung disease          | M=54.9SD=24.7 | M=55.6SD=23.6     | t(566)=.33p=.74      |
| all items             | M=51.1SD=16.0 | M=51.6SD=16.0     | t(566)=.36p=.72      |
| health items only     | M=47.1SD=16.7 | M=47.4SD=16.4     | t(566)=.22p=.83      |
| non-health items only | M=52.6SD=17.0 | M=54.1SD=17.1     | t(566)=1.00p=.32     |

Acknowledgements
        - Dylan Smith
        - George Loewenstein
        - Heather Pond Lacey
        - Laura Damschroder
        - Chris Jepson
        - Harv Feldman
        - Norbert Schwarz
        - Ryan Sherriff
        - Brian Zikmund-Fisher
        - Jason Riis
        - NIH
        - Dept. of Veterans Affairs

Is Experience Overrated