Die the Way You Want To Taking charge of your last days eases everyone’s burden. by Ellen Goodman Time frame: now | Degree of difficulty: easy | Barrier: human nature If there is a condition that everyone in this wide, contentious, diverse world shares, it is this one: mortality. We can say with 100% certainty that all of us are going to die. We all know this, and yet we have been immeasurably slow in recognizing that many of the people we love are not dying the way they would choose. Consider that in surveys 70% of people say they want to die at home, but 70% die in hospitals or nursing homes. “Dying at home” means not just where people want to die but how: in comfort, among people who care about them, and doing what matters for as long as possible. Too few of us have seen our loved ones have what we would call a “good death.” Instead, their deaths often leave us guilty, depressed, and with a sense of foreboding of what our own experience might be. In surveys 70% of people say they want to die at home but 70% die in hospitals or nursing homes HBR List of Audacious Ideas Tackling the World Economy Give People Shares of GDP Double Down on Start-ups Partner with China in Afghanistan Enroll the World in For-Profit Universities Tackling Science Challenges Give NASA a Real Mission Declare 20% of the Ocean Off-Limits Electrify the Bottom of the Pyramid Tackling Social Problems Die the Way You Want To Pay Businesses to Keep People Out of Prison Grow More Apples and Less Corn Tackling Business Problems Stop Tying Pay to Performance Crowdsource Management Reviews Stop Collecting Customer Data So, if we want to tackle a problem that affects all of us, let’s think big. If we want to transform health care, let’s change the way we die. This is the goal of the Conversation Project, which began with a group of caregivers, clergypeople, journalists, and others sharing stories. We talked about the trauma of dealing with a cascading number of medical decisions in the face of uncertainty about the wishes of our loved ones. Now, together with the Institute for Healthcare Improvement, we’ve set a simple and transformative goal: to have every citizen’s end-of-life wishes expressed and respected. We believe that the lever to begin this dramatic change is a willingness to talk as individuals, family members, and a culture about what we want when, as they say, the time comes. The first place for these hard conversations is not in medical offices with doctors, who are often uncomfortable with and untrained in initiating them, and it’s certainly not in emergency rooms or intensive care units. It’s at the kitchen table. There we can talk not only about the treatments we want and don’t want, about “extreme measures” and comfort, but also about values, hopes, and desires for our last days. We can share our wishes with the people who matter and who may end up speaking for us. We have made huge cultural changes before. A generation ago, Americans transformed birth. That didn’t happen because doctors urged women out of stirrups; hospitals didn’t put out the welcome mat for dads and their video cameras. No institution promoted soft lights and doulas. Instead, women recognized that there was a better way and insisted on changing their own experience. Today we’re recognizing how badly we are “doing” death and that we must change our experience with it, too. It won’t be easy to transform a norm. We still engage in a conspiracy of silence and denial. Parents are reluctant to worry their adult children; children are uncomfortable bringing up dying with their parents. In our attempts to protect one another we often end up alone and uncertain. The Conversation Project wants to create a movement that will make these talks easier, with a forum for sharing stories, a marketing campaign, and resources for conversation starters and guides to help people who don’t know where to begin. If our audacious idea were in a course catalog, it would be listed under humanities, not economics. Nevertheless, we know that 25% of all Medicare expenses are incurred by the 5% of people who are in their last year of life. One study has shown that simply having the conversation can cut end-of-life costs for cancer patients by 36%. Another study concluded that conversations with cancer patients in their last week of life alone could make a difference of $304 million a year. Research also shows that people who have had these conversations often choose less aggressive treatment—and yet live longer. Too often talking about death and money raises the specter of “death panels.” The public debate about health care is framed in the language of cost cutting and rationing—as what health care reform will take away from you. But what if we could break out of that frame? This is one area in which letting patients’ choices drive decisions could result in lower costs—financial and emotional ones. We may even be able to rebuild trust in the medical system by respecting people’s wishes. Most important, we can ensure more-humane deaths. So our audacious idea is a simple question: Have you had the conversation? Ellen Goodman is a Pulitzer Prize–winning columnist and a cofounder of the Conversation Project. Pay Businesses to Keep People Out of Prison Reduce recidivism using the profit motive. by Eric Schmidt Time frame: five years | Degree of difficulty: less than you’d imagine | Barrier: public skepticism It’s hard to find a single metric showing that U.S. prisons are working. Right now 2.3 million Americans—about 1% of all adults—are behind bars. That’s the world’s highest incarceration rate. Prisons now cost taxpayers $68 billion a year—336% more than they did 25 years ago. The United States imprisons more juveniles than any other country. Three-year recidivism rates hover around 68%. Research reveals that states that incarcerate more reduce crime less. California spends more on prisons than it does on education. The Statistics Among nearly 300,000 inmates released in 15 states in 1994, 67.5% were rearrested within three years—and that rate has remained roughly constant. Per year cost per inmate to U.S. taxpayer, on average: $22K–$25K. Last year the U.S. spent $68B on corrections, which is about 336% more than it spent 25 years ago. More than 80% of prison inmates in Texas never graduated from high school. 2.3M Americans—more than 1% of all adults—are behind bars. That’s about the size of the population of Houston. Instead of propping up a broken system, we should be thinking boldly about how to prevent people from committing crimes in the first place and how to decrease recidivism. To do both, we need corporate intervention. I’m not proposing that private companies run prisons. That’s been done, with uninspiring results—no surprise, given that the incentives for private prison operators have little to do with reducing crime or recidivism. But a new approach, social impact bonds, could change that equation. Here’s how it would work: The government would float these bonds to investors—typically foundations—who’d bet on the ability of companies, community groups, and other qualified parties to provide services like educating the many inmates who are high school dropouts. The money raised would fund social programs. And if, after a meaningful period—say, five years—the program showed that it had had a significant positive impact (by, for instance, reducing repeat offenses or raising graduation rates), investors would get their money back with a premium. Small trials of social impact bonds are taking place in the UK, but they haven’t caught on in America, despite a huge range of potential uses. If applied to the prison system, they could help provide much-needed insights into the causes of crime and recidivism, because they’d force programs to measure results. Such data could inform better public policy. Technology could play a role; e-learning can provide affordable, accessible tools to institutions that lack a strong educational infrastructure. Programs like the Khan Academy have shown that online learning can quickly achieve impressive results. Technology could also help get nonviolent offenders out of jail faster, so they could begin their reintegration into society. Tamper-proof ankle bracelets that offer GPS tracking and constant monitoring are coming onto the market at prices of $5 to $10. We could ensure that sentences are carried out but slash the cost of keeping people locked up. The existence of a mass incarcerated population is a failure of imagination on the part of American society. It represents millions of wasted lives and idle talent. America is blessed with strong enterprise and a rich tapestry of civil society organizations. Shouldn’t it harness them to create the dramatic change we need? Eric Schmidt is the executive chairman of Google. Grow More Apples and Less Corn A simple change to end obesity and hunger. by Ellen Gustafson Time frame: by 2020 | Degree of difficulty: Herculean | Barrier: Big Ag The modern food system is failing. In the past three decades, an increase in industrial food processing, the divestment of small and medium farms, and the overproduction of subsidized commodity crops like corn and soy have left us with an abundance of the wrong foods. No wonder we’re now grappling with twin epidemics: hunger (in regions where food is scarce) and obesity (in areas where the affordable food is highly processed and lacking in nutrition). What can we do about this? First, we need to dismantle subsidies that favor the overproduction of corn, soy, wheat, and cotton—and replace them with incentives that encourage more diverse, healthful agriculture. Today just 10% of supermarket purchases in the U.S. are fruits and vegetables; there’s no reason we can’t raise that share to half by 2020, consistent with USDA recommendations. To get there, we’ll also need to find a middle ground between global, efficient, yet frequently low-nutrition Big Food, and local, small-farm agriculture. We’ll need to regionalize the food supply. Local food producers can join forces to compete at a regional level, while multinationals must pull regional and local sourcing into their supply chains. The Dominance of Big Ag Most of the food supply is controlled by a few agricultural giants. 90% of world coffee exports are controlled by 3 companies 81% of beef packing in the U.S. is handled by 4 companies 82% of U.S. corn exports are made by 3 companies Both shifts are already under way. In the U.S., an online service called Local Orbit lets customers order food from multiple local farmers and vendors at once. Meanwhile, Unilever plans to pull half a million small farmers into its supply chain by 2020—a smart strategy that helps the company secure diverse, sustainable sources of raw ingredients. Changing what we eat would make us healthier and thus save money on health care. Regionalization would also provide greater food security and lower the carbon cost of shipping food. But those arguments don’t seem to be enough to spur change. So let’s focus on this: Restructuring the food system would spur robust economic development at the local and regional levels everywhere. Our diet is tied to what we produce, and so is our economy. If we change our dinners, we can change the world. Ellen Gustafson is the founder and executive director of the 30 Project. She cofounded FEED Projects and the FEED Foundation and formerly worked for the UN World Food Programme.
