听力课堂TED音频栏目主要包括TED演讲的音频MP3及中英双语文稿，供各位英语爱好者学习使用。本文主要内容为演讲MP3+双语文稿:为什么做出健康的决定如此困难，希望你会喜欢！
【演讲人及介绍】【David Asch】
行为经济学家、卫生政策专家David Asch通过改善医生和患者在卫生保健和日常生活中做出决定的方式来促进个人和人群的健康。David Asch通过改善医生和患者在医疗保健和日常生活中做出决定的方式，促进了个人和人群的健康
【演讲主题】为什么做出健康的决定如此困难
【演讲文稿-中英文】
翻译 Jessie Zhang 校对 Jiasi Hao
It's April of 2007, and Jon Corzine, theGovernor of New Jersey, is in this horrific car accident. He's in the rightfront passenger seat of this SUV when it crashes on the Garden State Parkway.He's transported to a New Jersey trauma center with multiple broken bones andmultiple lacerations. He needs immediate surgery, seven units of blood, amechanical ventilator to help him breathe and several more operations along theway. It's amazing he survived. But perhaps even more amazing, he was notwearing a seat belt. And, in fact, he never wore a seat belt, and the NewJersey state troopers who used to drive Governor Corzine around used to beg himto wear a seat belt, but he didn't do it.
那是 2007 年的 4 月，新泽西州的州长，荣·科赞（Jon Corzine），陷入了一场可怕的车祸。当他乘坐的那辆 SUV 在花园州高速公路撞毁的时候，他正坐在副驾驶的座位上。他被转移到一家新泽西的创伤治疗中心，身上伴有多处骨折和撕裂。他需要立即接受手术、7 品脱的输血、一个帮助他呼吸的呼吸机，以及即将面临的又几场手术。他能活下来真的令人震惊。但可能更令人震惊的是，他当时在车里根本没系安全带。事实上，他之前从来不系安全带，曾经开车载过科赞州长的新泽西州巡逻队员曾求着他系上安全带，但是他从来没系过。
00:55
Now, before Corzine was Governor of NewJersey, he was the US Senator from New Jersey, and before that, he was the CEOof Goldman Sachs, responsible for taking Goldman Sachs public, making hundredsof millions of dollars. Now, no matter what you think of Jon Corzinepolitically or how he made his money, nobody would say that he was stupid. Butthere he was, an unrestrained passenger in a car accident, at a time when everyAmerican knows that seat belts save lives.
其实，在科赞当上新泽西州州长之前，曾是新泽西州的联邦参议员，再之前，是高盛投资公司的 CEO ，负责高盛的上市，并为其赚取了上亿美元。不论你从政治上还是挣钱方式上是如何看待荣·科赞这个人的，没人会说他是个蠢人。但是你瞧他，在每一个美国人都知道安全带能救命的时候，他就是那个车祸现场中不系安全带的人。
01:23
This single story reflects a fundamentalweakness in our approach to improving health behavior. Nearly everything wetell doctors and everything we tell patients is based on the idea that webehave rationally. If you give me information, I will process that informationin my head, and my behavior will change as a result. Do you think Jon Corzinedidn't know that seat belts save lives? Do you think he, like, just didn't get thememo?
这个简单的故事反映出我们在改善健康行为的方法中的一个基本的弱点。我们告诉医生和病人的一切东西几乎都是基于“人类行为是理性的”观点。如果你给我信息，我会在脑袋里分析那个信息，然后我的行为会随之改变。你觉得荣·科赞不知道安全带能救命吗？你觉得他只是没收到提示便笺吗？
01:49
(Laughter)
（笑声）
01:50
Jon Corzine did not have a knowledgedeficit, he had a behavior deficit. It's not that he didn't know better. Heknew better. It's that he didn't do better.
荣·科赞没有知识缺失，他有的是行为上的缺失。他不是知道的少，他知道的并不少。而他，没能做好。
02:02
Instead, I think the mind is ahigh-resistance pathway. Changing someone's mind with information is hardenough. Changing their behavior with information is harder still. The only waywe're going to make substantial improvements in health and health care is tomake substantial improvements in the behavior of health and health care.
另外，我认为人的思想是个抵御性很强的东西。用信息改变一个人的思想已经够难的了，用信息改变他们的行为更是难上加难。我们能在健康和医疗保健方面做出较大改善的唯一方法，就是尽可能改善人们在健康和医疗保健方面的行为方式。
02:26
If you hit my patellar tendon with a reflexhammer, my leg is going to jerk forward, and it's going to jerk forward a lotfaster and a lot more predictably than if I had to think about it myself. It'sa reflex. We need to look for the equivalent behavioral reflexes and hitch ourhealth care wagon to those. Turns out, though, that most conventionalapproaches to human motivation are based on the idea of education. We assumethat if people don't behave as they should, it's because they didn't know anybetter. "If only people knew that smoking was dangerous, they wouldn'tsmoke." Or, we think about economics. The assumption there is that we'reall constantly calculating the costs and benefits of every one of our actionsand optimizing that to make the perfectly right, rational decision. If thatwere true, then all we need to do is to find the perfect payment system fordoctors or the perfect co-payments and deductibles for patients, and everythingwould work out.
如果你用一个反射锤敲击我的膑腱，我的腿会向前弹起，而且会比我自己想着让它弹起的时候弹得更快，更具可预测性。这是一种反射行为。我们得找到相似的反射行为，并把我们的医疗保健都靠到这些反射行为上来。但实际上，最常规的激励人们的举措却是建立在“教育”这一理念上的。我们假定如果人们没有做出他们应有的行为是因为他们缺乏知识。“如果人们知道抽烟很危险，他们就不会抽烟了。”或者，我们会从经济的角度思考。我们假定自己会不断地计算我们每一个行为蕴含的成本和收益，以及为了收益最大化，我们会做出完全正确且理性的决定。如果这是真的，所有我们需要的仅仅是给医生找到一个完美的付费系统，或是能给患者完美计算出部分承担费用和免赔额，然后一切就自然解决了。
03:22
A better approach lies in behavioraleconomics. Behavioral economists recognize that we are irrational. Ourdecisions are based on emotion, or they're sensitive to framing or to socialcontext. We don't always do what's in our own long-term best interests. But thekey contribution to behavioral economics is not in recognizing that we areirrational; it's recognizing that we are irrational in highly predictable ways.In fact, it's the predictability of our psychological foibles that allows us todesign strategies to overcome them. Forewarned is forearmed. In fact,behavioral economists often use precisely the same behavioral reflexes that getus into trouble and turn them around to help us, rather than to hurt us.
行为经济学中有一个更好的方法。行为经济学家意识到我们其实是非理性的。我们的决定是建立在情绪上的，或是被社会环境或规则框架所影响的。我们不总是会做出有利于我们长远利益的行为。但是，对行为经济学最主要的贡献不是对“人类是非理性的”认识，而是意识到“人类的非理性行为是高度可预测的”。事实上，正是我们心理上那些小缺陷的可预测性使我们能设计出策略来攻克它们。预先警告就宛如事先武装。事实上，行为经济学家经常精准利用 那些让我们陷入麻烦的 行为反射，转而让它们来帮助我们，而不是伤害我们。
04:08
We see irrationality play out in somethingcalled "present bias," where the outcomes in front of us are muchmore motivating than even more important outcomes far in the future. If I'm ona diet -- and I'm always on a diet --
我们可以在一种叫做“即时偏误”的现象中看见非理性的作用，这种现象，是我们正在面对的结果比将来会出现的更重要的结果更能调动我们的积极性。如果我在节食——其实我一直在节食——
04:24
(Laughter)
（笑声）
04:26
and someone offers me a luscious-lookingpiece of chocolate cake, I know I should not eat that chocolate cake. Thatchocolate cake will land on that part of my body -- permanently -- where thatkind of food naturally settles. But the chocolate cake looks so good anddelicious, and it's right in front of me, and the diet can wait 'til tomorrow.
这时有人给了我一个看上去很美味的巧克力蛋糕，我知道我不应该吃那个蛋糕。那块巧克力蛋糕会沉积在我身体中——永远——就在这类食物会自然沉积的身体部位上。但是那块巧克力蛋糕看起来如此美味，而且它就在我的眼前，那节食可以明天再说了。
04:47
I used to love the comedian Steven Wright.He would have these Zen-like quips. My favorite one was this: "Hard workpays off in the future, but laziness pays off right now."
我曾经很喜欢一个喜剧演员，史蒂文·赖特。他经常说些很有禅意的玩笑话。我最喜欢的是这个：“努力了将来会有回报，但是懒惰了现在就会有回报。”
04:58
(Laughter)
（笑声）
05:00
And patients also have present bias. If youhave high blood pressure, even if you would desperately like to avoid a stroke,and you know that taking your antihypertensive medications is one of the bestways to reduce that risk, the stroke you avoid is far in the future and takingmedications is right now. Almost half of the patients who are prescribed highblood pressure pills stop taking them within a year. Think of how many lives wecould save if we could solve just that one problem.
患者也有即时偏误。如果你有高血压，即使你极度想避免中风，而且你知道吃降血压药是降低这种风险最有效的方式之一，然而，中风是很久以后可能发生的事，而吃药则是现在要做的。几乎有一半开了降血压药的患者在一年内就停止了服药。想想如果我们单单解决这一个问题就能拯救多少生命。
05:31
We also tend to overestimate the value ofsmall probabilities. This actually explains why state lotteries are so popular,even though they return pennies on the dollar. Now, some of you may buy lotterytickets -- it's fun, there's the chance you might strike it rich ... But let'sface it: this would be a horrible way to invest your retirement savings. I oncesaw a bumper sticker -- I am not making this up -- that said, "Statelotteries are a special tax on people who can't do math."
我们也容易高估小概率事件的价值。这也许能解释为什么国营彩票即使回报极小，却依旧这么受欢迎。在座的一些人可能会买彩票——买彩票挺有意思的，你有可能中大奖、变富有——但是咱们清醒一点吧：这可能是个花掉你养老金的很糟糕的方式。我曾经看到过一张车尾贴——这不是我编的——写着，“国营彩票是向不会数学计算的人征收的智商税”。
06:00
(Laughter)
（笑声）
06:01
It's not that we can't do the math, it'sthat we can't feel the math.
我们并不是不会做数学计算，我们是感受不到这种计算。
06:06
And we also pay much too much attention toregret. We all hate the feeling of missing out.
而且我们花太多精力在后悔上。我们都痛恨错过机会的感觉。
06:12
So, actually, there was this recentlottery, a mega-jackpot lottery, that had a huge payoff, something like over abillion dollars. And everyone in my office is pooling money to buy lotterytickets, and I'm not having any of this. There I am, like, swaggering aroundthe office, "Lotteries are a special tax on people who can't domath."
所以，事实上，最近有个彩票，大乐透彩票，回报超高，大概超过 10 亿美元。我办公室里的每个人都在掏钱集资买彩票，我一点都不理解。我在办公室里转悠，嚷嚷着：“彩票是向不会数学计算的人征收的智商税。”
06:29
（笑声）
06:30
And then it hits me: uh oh. What if theywin?
然后一个想法击中了我：啊呀，万一他们中奖了呢？
06:34
(Laughter)
（笑声）
06:36
I'm the only one who shows up at work thenext day.
我就成了第二天唯一来上班的人了。
06:39
(Laughter)
（笑声）
06:40
Now, it's not that I didn't want mycolleagues to win. I just didn't want them to win without me. Now, it wouldhave been easier if I had just taken my 20-dollar bill and put it into theoffice shredder, and the results would have been the same. Even though I knew Ishouldn't participate, I handed over my $20 bill, and I never saw it again.
不是我不想让我的同事中奖。我只是不想让他们丢下我，自己中奖。如果我当初拿出一张 20 美元钞票直接塞进办公室的碎纸机里，事情本会简单很多，而且结果也会是一样的。即使我知道我不应该参与，我还是递出了 20 美元钞票，之后我再也没见过它。
07:00
(Laughter)
（笑声）
07:01
We've done a bunch of experiments withpatients in which we give them these electronic pill bottles so we can tellwhether they're taking their medication or not. And we reward them with alottery. They get prizes. But they only get prizes if they had taken theirmedication the day before. If not, they get a message that says something like,"You would have won a hundred dollars, but you didn't take your medicineyesterday, so you don't get it."
我们和患者做过一些实验。我们给患者们电子药瓶，以便于知道他们是否在吃药。我们用彩票奖励他们。他们能得到奖品。但他们只有在前一天吃药的情况下才能得到奖品。如果没吃，他们会收到一条诸如此类的信息：“你本来能赢 100 美金，但是你昨天没吃药，所以你没法得到这笔钱。”
07:28
Well, it turns out, patients hate that.They hate the sense of missing out, and because they can anticipate thatfeeling of regret and they'd like to avoid it, they're much more likely to taketheir medications. Harnessing that sense of hating regret works. And it leadsto the more general point, which is: once you recognize how people areirrational, you're in a much better position to help them.
事实证明，患者们痛恨那种感觉。他们痛恨错过的感觉，而且因为他们能预判到那种悔恨的感觉，于是想要尽量避开它，所以他们更有可能会吃药了。掌控那种痛恨后悔的感觉是有用的。它引出了更一般化的观点，即：一旦你认识到人是非理性的，你就会处于一个能够更好地帮助他们的位置。
07:54
Now, this kind of irrationality works outeven in men's restrooms. So, for those of you who don't frequent urinals, letme break this down for you.
这种非理性甚至在男厕所也能用得上。在座的不常光顾小便池的人，让我给你们解析一下。
08:05
(Laughter)
（笑声）
08:06
There is pee all over the floor.
地板上全是尿。
08:08
(Laughter)
（笑声）
08:11
And it turns out that you can solve thisproblem by etching the image of a fly in the back of the urinal.
事实证明，你只要在小便池上蚀刻一个苍蝇的形象，就能解决这个问题。
08:17
(Laughter) (Applause)
（笑声）（掌声）
08:21
And it makes perfect sense.
这完全说得通。
08:22
(Laughter)
（笑声）
08:24
If I see a fly, I'm gonna get that fly.
如果我看见一只苍蝇，我一定要射中那只苍蝇
08:27
(Laughter)
（笑声）
08:31
That fly is going down.
那只苍蝇会被冲入下水道。
08:33
(Laughter)
（笑声）
08:34
Now, this naturally begs the question thatif men can aim, why were they peeing on the floor in the first place? In fact,if they were going to pee on the floor, why pee in front of the urinal? Youcould pee anywhere.
这自然地引出了一个问题：如果男人们上厕所时能瞄准，他们一开始为什么要尿到地上？实际上，如果他们本来就打算尿到地上，又为什么要跑到小便池前面去尿？你可以在任何地方尿。
08:45
(Laughter)
（笑声）
08:46
And the same thing works in health care. Wehad a problem in our hospital in which the physicians were prescribingbrand-name drugs when a generic drug was available. Each one of the lines onthis graph represents a different drug. And they're listed according to howoften they're prescribed as generic medications. Those are the top areprescribed as generics 100 percent of the time. Those down at the bottom areprescribed as generics less than 20 percent of the time. And we'd have meetingswith clinicians and all sorts of education sessions, and nothing worked -- allthe lines are pretty much horizontal. Until, someone installed a little pieceof software in the electronic health record that defaulted the prescriptions togeneric medications instead of the brand-name drugs. Now, it doesn't take astatistician to see that this problem was solved overnight, and it has stayedsolved ever since. In fact, in the two and a half years since this programstarted, our hospital has saved 32 million dollars. Let me say that again: 32million dollars. And all we did was make it easier for the doctors to do whatthey fundamentally wanted to do all along.
同样的道理也适用于医疗保健。我们医院当时有个这样的问题：当普通药可供选择的时，医生们却一直在开品牌药。这张图上的每条线代表一种不同的药物。这些药根据被当做普通药开的频率被列了出来。位于顶部的，是一直都被当做普通药开的。下面那些，不到 20% 的机率是被当做普通药开的。我们跟临床医师们开过会，也办过各种教学会议，但是都没用——所有的这些线，几乎都没变。直到，有个人在电子健康记录表里安装了一个小软件，把处方设置为默认开普通药，而非品牌药。现在，不用统计分析员也能看出来，问题一夜之间就解决了，而且之后再没有出现此类问题。事实上，在这个项目上线的两年半内，我们医院已经省下了 3200 万美元。让我再说一遍： 3200 万美元。我们所做的，只不过是把医生们一直以来想做的事变得容易做了而已。
10:00
It also works to play into people's notionsof loss. We did this with a contest to help people walk more. We wantedeveryone to walk at least 7,000 steps, and we measured their step count withthe accelerometer on their cell phone. Group A, the control group, just gottold whether they had walked 7,000 steps or not. Group B got a financialincentive. We gave them $1.40 for every day they walked 7,000 steps. Group C gotthe same financial incentive, but it was framed as a loss rather than a gain:$1.40 a day is 42 dollars a month, so we gave these participants 42 dollars atthe beginning of each month in a virtual account that they could see, and wetook away $1.40 for every day they didn't walk 7,000 steps.
利用人们对损失的概念也有用。我们办了场比赛来帮助人们走更多路。我们想让每个人至少走 7 千步，我们也用他们手机上的计步器以记录他们行走的步数。A 组，控制变量组，仅被告知他们是否走够 7 千步。B 组，有金钱刺激。每天如果他们走了 7 千步，我们就奖励他们 1.4 美金。C组，有相同的金钱刺激，但这种刺激被包装成损失而不是收益： 每天 1.4 美金 即 42 美金一个月，所以在每个月的头一天 我们给这些参与者 42 美金，就放在他们能看见的虚拟账户里，然后如果他们每天没走够 7 千步，我们就从账户里取走 1.4 美金。
10:52
Now, an economist would say that those twofinancial incentives are the same. For every day you walk 7,000 steps, you're$1.40 richer. But a behavioral economist would say that they're different,because we're much more motivated to avoid a $1.40 loss than we are motivatedto achieve a $1.40 gain. And that's exactly what happened. Those in the groupthat received $1.40 for every day they walked 7,000 steps were no more likelyto meet their goal than the control group. The financial incentive didn't work.But those who had a loss-framed incentive met their goal 50 percent more of thetime. It doesn't make economic sense, but it makes psychological sense, becauselosses loom larger than gains. And now we're using loss-framed incentives tohelp patients walk more, lose weight and take their medications.
一个经济学家可能会说，这两种金钱刺激的结果是一样的。因为每天你走够 7 千步的话，你都能赚 1.4 美金。但是一个行为经济学家会说，它们的结果是不同的，因为我们为避免损失 1.4 美金会比赚取 1.4 美金来得更有动力。实验结果也确实如此。那些每天因为走 7 千步而收到 1.4 美金的人并不比控制变量组（没有金钱激励）更能达到目标。金钱刺激没能起作用。而那些受到损失刺激的人则有 50% 更高的可能完成目标。这在经济学上说不通，但在心理学上是说得通的，因为损失比收益带来的刺激更大。现在我们已经在用这种损失刺激法去帮助患者走更多路、减肥，以及吃药了。
11:43
Money can be a motivator. We all know that.But it's far more influential when it's paired with psychology. And money, ofcourse, has its own disadvantages. My favorite example of this involves adaycare program. The greatest sin you can commit in daycare is picking up yourkids late. No one is happy. Your kids are crying because you don't love them.
钱可以是一个激励因素，我们都知道这一点。但当它与心理学配对使用时更具有影响力。当然，金钱有其自身缺点。我最喜欢的例子，说的是一个日托项目。你能在日托中犯下的最大的罪孽就是接孩子接晚了。没人开心。你的孩子在哭，因为你不爱他们。
12:08
(Laughter)
（笑声）
12:09
The teachers are unhappy because they leavework late. And you feel terribly guilty. This daycare program in Israel decidedthey wanted to stop this problem, and they did something that many daycareprograms in the US do, which is they installed a fine for late pickups. And thefine they chose was 10 shekels, which is about three bucks. And guess whathappened? Late pickups increased. And if you think about it, it makes perfectsense. What a deal! For 10 shekels --
老师不开心，因为他们下班晚了。你也觉得极其内疚。以色列的这个日托项目就想解决这个问题，而且他们做的，是许多美国日托项目也在做的事，就是给晚接孩子的人设置罚款。他们把罚款定为 10 谢克尔（以色列货币单位），大概相当于 3 美元。猜猜然后发生了什么？晚接孩子的情况恶化了。如果你仔细想想的话，这完全说得通。多合适的买卖啊！ 10 谢克尔——
12:39
(Laughter)
（笑声）
12:40
you can keep my kids all night!
你就能一晚上不用接孩子！
12:42
(Laughter)
（笑声）
12:45
They took a perfectly strong intrinsicmotivation not to be late, and they cheapened it. What's worse, when theyrealized their mistake and they took away the financial incentive, the latepickups still stayed at the high level. They had already poisoned the socialcontract.
家长们卯足了内在动机，准时接孩子，结果日托机构把这个动机因素变得廉价了。更糟的是，当日托机构意识到自己的错误，把迟到罚款的规则撤回时，晚接孩子的情况丝毫没有改观。他们已经毒害了社会契约。
13:02
Health care is full of strong intrinsicmotivations. We have doctors and patients who already want to do the rightthing. Financial incentives can help, but we shouldn't expect money in healthcare to do all of the heavy lifting. Instead, perhaps the most powerfulinfluencers of health behavior are our social interactions. Social engagementworks in health care, and it works in two directions.
医疗保健充满了强大的内在动机。医生和患者本身就想做正确的事。金钱刺激也有正面作用。但是我们不能盼着金钱能在医疗保健中承担全部的重任。相反，对健康行为最有效的影响因素可能是我们的社会互动。社会参与在医疗保健中是起作用的，主要体现在两个方面
13:29
First, we fundamentally care what othersthink of us. And so one of the most powerful ways to change our behavior is tomake our activities witnessable to others. We behave differently when we'rebeing observed than when we're not. I've been to some restaurants that don'thave sinks in the bathrooms. Instead, when you step out, the sink is outside inthe main part of the restaurant, where everyone can see whether you wash yourhands or not. Now, I don't know for sure, but I am convinced that handwashingis much greater in those particular settings. We are always on our bestbehavior when we're being observed.
第一，我们本能地在意别人对我们的看法。所以改变我们行为最有效的方法之一就是让我们的行为能被别人看见。我们在被观察，和不在被观察时候的行为表现是不同的。我去过几个饭店，它们厕所里没有水槽，但当你走出来，水槽在外面，在饭店的主要位置，这时候所有人都能看见你洗没洗手。我不是很确定，但我敢保证在那些特定环境下洗手的人变多了。我们在被观察的时候，总能表现出最好的行为。
14:04
In fact, there was this amazing study thatwas done in an intensive care unit in a Florida hospital. The handwashing rateswere very low, which is dangerous, of course, because it can spread infection.And so some researchers pasted a picture of someone's eyes over the sink. Itwasn't a real person, it was just a photograph. In fact, it wasn't even theirwhole face, it was just their eyes looking at you.
事实上，在佛罗里达一家医院的重症监护室里，进行了一项很棒的研究。这里的洗手率非常低，当然，这很危险，因为该行为会传播疾病，导致感染。所以一些研究员在水槽上贴了一张人眼的照片。那不是一个真人，只是一张照片。实际上，那甚至都不是一整张脸，只是一双眼睛看着你。
14:26
(Laughter)
（笑声）
14:27
Handwashing rates more than doubled. Itseems we care so much what other people think of us that our behavior improveseven if we merely imagine that we're being observed.
洗手率翻了不止一倍。我们似乎是如此在意别人对我们的看法，以至于我们的行为会就此改进，即使我们仅仅只是想象我们在被别人观察着。
【碍于字符限制，讲稿无法全部呈现。建议大家：点击播放界面上的“词”按钮就能看到同步的完整版中英文字幕哦~】
