Are Our Choices About Living Causing Us to Die?

With the dawn of a new and potentially difficult year upon us, many Americans will swear that this is the year that they'll eat better, exercise more, or quit smoking. Of course, most of us will fail to stick to these healthy resolutions. And, while we know that getting in shape is good for us, a new study shows the true cost of our tendency not to make wise decisions about taking care of ourselves. According to Duke University's Ralph Keeney, whose work was published last month in the journal Operations Research, America's top killer isn't cancer or heart disease, or even smoking and overeating—it's our inability to make smart choices that leads us to engage in those and other self-destructive behaviors.

"Each year more than a million people needlessly die because of their own personal decisions," says Keeney, whose work gives new meaning to the cliché we're our "own worst enemies." That means more than half the population will make a decision leading to an early grave, he reports, including a full 55 percent of people who die between the ages of 15 and 64. Most alarming, that figure has jumped fourfold since 1900, despite the world becoming a safer place overall thanks to seat belts, smoking laws, health food and a host of other tools to help people stay inside the lines.

Keeney's work raises a philosophical quandary: If we continue to kill ourselves with poor decisions, are we consciously opting for short, zestful lives over long, abstemious ones? Or is it that we simply need a stronger hand prodding us to make better choices? Keeney and a number of public-health advocates say the answer may be more governmental guidance in everything from what kind of food we buy to whether we contribute to our retirement savings. And if Keeney is right, and much of our health and life expectancy is a reflection of our own decisions, are these things we can change or choices shaped by genes and other forces outside our control?

To generate his numbers, Keeney took national death statistics from 2000 and tried to trace the official cause of each death (ranging from cancers, diabetes and AIDS to fatal accidents, suicides and homicides) back to some personal call, such as the decision to smoke, drink, drive without a seat belt or have unprotected sex. Because the numbers can't show for sure that a person's smoking, for instance, caused their lung cancer, he used risk data to make reliable guesses—smoking is known to triple the risk of cancer, for example, which lead Keeney to conclude that roughly two thirds of all smokers who got lung cancer brought it upon themselves.

That's not so controversial when identifying three packs a day as the cause of cancer or the choice to speed as the cause of a fatal crash, but Keeney is on thinner ice when counting all suicides as examples of death by personal decision. His reasoning: the decision to kill oneself may not be rational, or even clearheaded, but it's definitely personal. But with evidence accumulating that many mental illnesses have genetic or physiological origins, labeling the suicidal impulses of someone suffering from major depression or bipolar disorder a "choice" may not be exactly fair. The same goes for certain addictions to drinking, smoking and overeating, which all have significant genetic triggers—yet Keeney holds firm. "Prior to having these habits," he writes, "the individuals made decisions that lead to [them] and these are the personal decisions that are of concern in this paper."

Another of the study's limitations: it ignores the environmental baggage that constrains people's choices. Keeney says he appreciates the importance of peer pressure, poverty and education as well as the fact that fatal decisions aren't necessarily "bad" ones. (Yes, you end up dead but perhaps you had no real choice and were speeding to escape a murderer. Or perhaps you made a conscious choice to live an interesting life, burning out early like Elvis rather keeping to a rigid fitness routine like Jack LaLanne.) It's just that in most cases, he says, people could have reasonably saved their own lives if they had taken a different path. "If it's under a person's control," he tells NEWSWEEK, "I say it's up to them."

Why do so many of us make lousy personal decisions, even ones that kill us? Keeney, for one, chalks it up to short-term thinking and it-can't-happen-to-me exceptionalism. Other scholars, such as Harvard's Cass Sunstein, University of Chicago's Richard Thaler and MIT's Dan Ariely—all loosely organized, like Keeney, under the suddenly hip banner of behavioral economics—have in recent years come up with different reasons for why we sometimes act a fool. Topping their lists are apathy, peer pressure, and the tendency to misperceive in predictable ways—such as judging a mountain of food a molehill if it's served on a massive plate.

However the experts explain our tendencies to self-destruct, they all agree that we could use some help negotiating these choices better—and that government can provide it. For Keeney, it's by adding "decision making" to the standard curriculum in public schools so that more children grow up empowered to recognize and mine all their options, rather than accept those presented by others. "Imagine if they taught World War II as decision making," he says. "That'd be fabulous."

For Sunstein and Thaler, authors of the recent book "Nudge" (Yale, 2008), it's through gently pushing people to make the right move. "Putting the fruit at eye level counts as a nudge," they write. "Banning junk food does not." Ariely cottons to a middle ground between authoritarianism and "complete freedom to fail." In the realm of preventive medicine, for instance, that means encouraging people to go for regular screenings and checkups by establishing a deposit system: the only way to get your $100 back is by making your appointment.

Will any of this actually happen? Brian Wansink thinks so, although he's short on specifics. In "Mindless Eating," his 2007 book about how the brain decides what the stomach gets, the Cornell University marketing professor imagines a tomorrow where regulators promote healthier habits by borrowing the seductions of junk food and leveraging insights into portion control. In one of his more famous experiments, he gives people bowls of soup that were secretly refilled by a tube beneath the restaurant table and discovers that those people with bottomless bowls ate almost 75 percent more than people with normal bowls. "How could I feel full? I've still got half a bowl left," the overeaters wondered. The lesson: tinkering with perception is the key to changing long-term behaviors and, according to Wansink, adding years and quality to our lives. The 19th century was the century of hygiene, he writes, and the 20th was the century of medicine. The 21st? The century of behavior change—with Uncle Sam perhaps leading the charge.

If playing with our perception doesn't work, perhaps manipulating our wallets might. Or at least that's what some cash-strapped state governments are banking on. Last week New York Health Commissioner Richard Daines created a five-minute YouTube video to promote a proposed 18 percent sales tax on sugary drinks in the Empire State. Daines justified the move saying that some taxes can be good for your health.

Still, a more interventionist government isn't up everyone's alley. Not to mention the fact that we learn by making mistakes. If there's always a guardrail in place, we may never remember to watch the ledge.

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