Design, Autonomy, and Complexity

I just got back from a grand rounds presentation with Neel Shah, a medical researcher and OB/GYN whose current research concerns overtreatment. One of the most important things to come out of his talk was the fact that the single biggest risk factor for cesarean section for a pregnant woman is the facility she walks into. It’s not her health status, it’s not her preferences, it’s not her birth plan, it’s not even her doctor. It’s the hospital. And it turns out there are a variety of really important hospital design elements that trigger overtreatment.  These include distance between patient rooms, distance between workspaces and patient rooms, limited ability to information share, and so on (full report is linked to here). The problem, of course, is that most women don’t know this. Medicine is supposed to take patient choice and patient autonomy seriously and most women don’t want c-sections.  Yet the c-section rate varies across hospitals tenfold in the United States, ranging from 7% to 70% and the variation is higher for low-risk women than it is for high risk women. So why do so many (32% of all American women giving birth) end up with a surgery they don’t want? Again, a big part of the answer (but not the only part, because incentives and risk also matter) is how the environment around women pushes their providers toward high-intensity treatment. What we have then is a kind of non-coercive violation of autonomy. Women aren’t (most of the time, at least) being actually forced into c-sections, they’re being led into c-sections by an environment that makes it very difficult to give birth vaginally.

This got me thinking about other ways in which we can get non-coercive violations of autonomy (someone in the comments can help me unpack that phrase, but I’m going with it for now). What are the other ways our built environments or our political, legal, cultural, and policy environments lead people into violations of their autonomous choices? Or put another way, how do our environments lead us into outcomes that are the exact opposite of what we would choose if unconstrained?

Other design concerns

Radley Balko’s work on the situation in Ferguson does a great job of demonstrating this problem in the political sphere. Ferguson’s political environment of hundreds of small competing jurisdictions meant that there were a million different ways to inadvertently break the law. Once involved with the legal system, there were a million different ways in which the environment prevented one from quickly or cheaply resolving the situation, involving long travel times, limited hours at clerk’s offices and courthouses, and obvious conflicts of interest. Some, but not all, of these design features were intentional. Many were just functions of understaffing and low levels of resources common to small towns.

Another important thinker in this area is Jane Jacobs, whose work I just read for a conference. While she’s often discussed in the context of urban design, it’s probably more accurate to call her an “anti-designer”, at least insofar as she believes large-scale design of urban areas is generally a bad idea. Her work emphasizes the way in which design can unintentionally change people’s behaviors and discourage neighborly cooperation and interaction (among other negative effects). Something as simple as a sidewalk encourages spontaneous interactions between neighbors, increases community vigilance, and provides an easy way to move about the neighborhood. Well-intentioned zoning laws, on the other hand, can strangle diversity, cut neighbors off from one another, and create dangerous dead zones at night.  Neighborhood design constrains our activities in potentially harmful ways.

What all these writings have in common is a general theme of how environments restrict people’s freedom. Of course, restricting freedom is not always a bad thing. The entire history of rule of law, for example, deals with the best way to restrict autonomy in some spheres so that people can better pursue their ends in others. But the violations of autonomy we’re talking about above are different from general restraints on bad behavior. These violations are leading people into worse outcomes than they would choose for themselves. They’re also paired with poor social outcomes including high health care costs, high incarceration rates, zombie neighborhoods. Thus, these kinds of violations are worth paying close attention to. It’s also worth noting that many of these environmental design issues are something like what is being referred to when people talk about “institutional racism” or the various “industrial complexes.”  Though in those analyses there’s even more intentionality than I think often exists. Many of the design problems we face are not those of poor motives (though again, those certainly exist), but of poor design, design that pushes people toward outcomes they would not choose themselves and that are bad for everybody.

Autonomy and complexity

Some of the problem of design has to do with complexity and how people react to complex environments. The problem with hospital birth is that too often the environment is too complex for people to make good decisions. When that happens, as Shah points out, people will revert from high-resistance modes of operation (waiting for a woman to give birth vaginally) to a low-resistance mode of operation (surgery). Rarely are the providers aware that they are doing this. They are reacting to complexity and to the situation in which they find themselves and they’re trying to find a simple way to deal with that complexity. Same thing for the Ferguson residents who don’t show up in court to deal with traffic tickets. Faced with a bewildering bureaucracy, logistical difficulties, and the high likelihood of further entanglement with the law, they choose the path of least resistance and skip their court date, inadvertently triggering an arrest warrant. Jacobs finds a similar pattern in urban design. City planners clearing slums inadvertently prevent people from solving their own housing problems and instead force them into public housing or other kinds of living arrangements they would not choose for themselves.

Noncoercive despotism?

All these examples remind me of Tocqueville’s description of democratic despotism at the end of Democracy in America. While he also ascribes too much intentionality to the “sovereign”, he does seem to understand the problem of systems that violate people’s wills not through coercion but through the gradual destruction of the ability to make good decisions. As he describes it, “it does not break wills, but it softens them, bends them, and directs them; it rarely forces one to act, but it constantly opposes itself to one’s acting; it does not destroy, it prevents things from being born…” Design – not only of our institutions, but of our built environments, of our health care facilities, of our communities – matters for freedom.  The next question is: can we design for freedom?  Can we undo poorly designed environments without falling into the overdesign/planning trap?

Are there other examples of design limiting freedom in harmful ways? Other authors who might be worth checking out?