What does it really mean to choose with intent—and why do we often go with the default option? On this episode, I am joined by award-winning Cornell University professor and expert in organizational psychology Dr. Sunita Sah to explore the hidden forces behind compliance, consent, and ethical decision-making.
Drawing on her multidisciplinary background in medicine, psychology, and consulting, Sunita unpacks why we say “yes” when we really want to say “no,” and how seemingly simple disclosures can backfire in high-stakes situations. Whether it’s navigating career pivots or teaching kids to stand their ground, Sunita makes a compelling case for redefining defiance not as disobedience, but as integrity in action.
Key takeaways include the difference between compliance and true consent, how to recognize and overcome “insinuation anxiety,” and how to use tools like the Defiance Compass to act in line with your values—especially when it’s uncomfortable.
Guest bio
Dr. Sunita Sah is an award-winning, tenured professor at Cornell University and an expert in organizational psychology. She leads groundbreaking research on influence, authority, compliance, and defiance. A trained physician, she practiced medicine in the United Kingdom and worked as a management consultant for the pharmaceutical industry. She currently teaches executives, leaders, and students in healthcare and business. Dr. Sah is a sought-after international speaker and consultant, advisor to government agencies, and former Commissioner of the National Commission on Forensic Science. Her multidisciplinary research and analyses have been widely published in leading academic journals and media entities including The New York Times, Los Angeles Times, Harvard Business Review, and Scientific American. She lives with her husband and son in New York.
Transcript
Producer’s Note: This transcript was created using AI. Please excuse any errors.
Annie: I’m so excited to have you on. Sunita, in my case, when I am doing a podcast, they always want me to talk about how I got from here to there because I did many different things. And I feel like you’re very much in that world having gone from medicine into organizational psychology, which seems very disparate. Um, and then obviously consulting, following.
So I would just love to hear a little bit about your history and how you got from point A to point B, and then separately what you think the connection between those interests might have been. Did your interest really change or is there like a through line that got you there?
Sunita: Sure. So I grew up with a masterclass in compliance, but I was always really fascinated by people that could defy, uh, especially at high schools, sort of drawn to those people, really interested in how they could speak up and be themselves, because I had such a socialization in being compliant.
And my first career was in medicine largely due to expectations. And in the UK it’s a combined undergraduate and graduate degree. So at the time, the medical degree was five years. And I did take a year to do an integrated degree in psychology. So I did that in my third year of medical school and I absolutely loved that year. And at that point, I was also really fascinated by sort of medical decision-making. And I got the opportunity to do some consulting work for the pharmaceutical industry. And I became fascinated by how the medical profession and industry interact with each other and how they influence each other. And sort of the many conflicts of interest that are there and how it affects our decision-making as physicians and then how that trickles down to the end user the patient.
And while I was working as a management consultant, so that was my second career, I did an executive M.B.A. at London Business School. And I remember speaking to a professor at London Business School and he said, if you really want to look at ethical dilemmas and conflicts of interest, you need to go to the U.S.
So I did. I did a Ph.D. in organizational behavior at Carnegie Mellon University, and that set the path to doing the research that I wanted, why people take bad advice, how different things influence them. And that was my path all perfectly planned.
Annie: I just have to say, this reminds me of my father, and I think it’s common among children of immigrants in particular. So my dad was a child of two immigrants, expected to be a doctor or a lawyer. Went to undergrad, started off in pre-med, queasy, queasy stomach, so he didn’t go that route. But did end up getting into law school, Harvard Law actually.
And after the first year he quit to go get a master’s in English because he wanted to be a teacher. And I don’t think his mother ever forgave him, but he just realized like, you know, before actually finishing the J.D., that it, like, wasn’t for him. He wasn’t excited about the law, but it was such an expectation that he got very deep into the process, right?
Sunita: Yes.
Annie: Before he actually walked away from it.
Sunita: It’s, you know, a lot of people say medicine is very difficult to get into. I always said it’s also very difficult to get out of once you are in there because you have invested in it. But the questions that I was asking at the time were sort of questions about the decisions that we make rather than, you know, what this diagnosis actually is. But it was like, oh, I wonder why we made that decision for that patient and why they decided to go down this line? So we can really tell where passion lies at that point. Like what are we spending extra time on? What are we thinking about? And yeah, I took a few steps to get to the work that I’m doing now, but it’s such a good fit.
Annie: I think that’s interesting when you said it’s so hard to get into, but that it’s even harder to get out of. I think those two things are actually related to each other. So organic chemistry is so hard and if you can get yourself through it and have done it then I think it actually locks you into the path in a lot of ways, just for like sunk cost and reasons having to do with identity. Like, well, why would I have done that if I wasn’t going to stick with it?
Sunita: Interesting.
Annie: Yes. And that’s separate and apart from what you go through with internships and residency and so on and so forth. So every step of the way, I think the fact that it’s so hard and they’re actually kind of expecting things that are inhuman from you makes it really hard to walk away because it becomes much more integrated into your identity. That’s my guess.
Sunita: Yeah. I think that’s true. And it’s also, I think, why it could be very difficult for professors to leave academia because if they’ve worked really hard to get tenure, giving that up, I mean, there’s the element of security there too, that that kind of adds to it. But yeah, when you’ve worked really hard for something, it does become difficult to give it up. And it was a very difficult decision. Interestingly, when I did leave and decide to go into academia, a lot of people said, you know, were saying, including my parents, “Oh yeah, you’d be really good at that. You’re very analytical.”
Annie: Oh, that’s so funny. Well, I think that’s important, right? And I think it will speak to, as we get into your work, you know, a lot of times the way that we think that other people are going to perceive the situation is very different than the way that they do.
Sunita: Mm-hmm. Yeah.
Annie: So there’s a mismatch between how we think people will react. I think in my dad’s case, he was right actually about how his mother was going to react. But like, I think you’re bringing something up, which is, there were expectations.
Sunita: So Stanley Milgram conducted these experiments in the 1960s because he was really interested in trying to figure out whether the, sort of, common phrase from Nazis in World War II, “I was just following orders,” was a psychological reality or not. And so he advertised an experiment for community members to come in and it was advertised as like a learning experiment. And the way that it was set up when the participants came in was, does giving people electric shocks help them learn more?
So if they get an answer wrong, does giving them an electric shock make them more likely to learn an answer? And so participants came in and they thought they were being randomly paired with another participant, and a coin was tossed and one was going to be a teacher, the other, the learner. It was actually set up that the learner was an actor and he was put into a different room that the teacher, now, the participant that came in was called the teacher, would see him being strapped into something that looked like an electric chair.
And the teacher went to another room and he was set with a board in front of him, like some electrical equipment that was labeled with different voltages. And it started at 15 volts and then it went all the way up to 450 volts in 15-volt increments. And the 450 volts was labeled XXX, Danger, Severe Shock. And
then the teacher read out some word pairs and the learner, they would hear through some headphones or a speaker system, would give answers back to repeat the pairs. And if they got something wrong, they would have to give them an electric shock. The experimenter was in the same room as the teacher, and this is the basic setup. And then if the teacher kind of hesitated, they had four prompts, such as, Please go on, You must continue, The experiment requires you to continue, and You have no choice. So there were different prompts and four of them that the experimenter would give. And then if the teacher objected four times, the experiment would stop. Otherwise they would keep pressing the lever up to 450 volts.
And before the actual experiment, Milgram had about 40 psychiatrists assess what they thought people would do, and they thought only about one in a thousand would go up to the severe 450 volts. But what Milgram found in this basic setup was that everyone pulled the lever for 150 volts, when the learner started protesting. Everyone pulled the lever at 300 volts, when the learner would just stop responding. And 66% went up to 450 volts. So that’s a lot. Two thirds of people went up to the full dangerous, severe shock, 450. And, uh, even Milgram said he was shocked at those results.
Annie: No pun intended.
Sunita: No pun intended. So it was really quite eye-opening the fact that this was happening. Um, people just because somebody told them to, were going against what seemed like their values of not harming another person and going up to 450 volts. And when I read about the experiments, what really fascinated me was that even Milgram described the participants that went up to 450 volts—they weren’t just like smiling and going, yes, let’s do it. They were showing elements of tension, sort of nervous laughter. They were sweating, stuttering, swearing, and they weren’t comfortable doing it. They just didn’t know how to say no, and they didn’t know how to get out of that situation.
Annie: You know, just so that the listeners know, there are some critiques of that experiment that have to do like sample size, bias sample, demand characteristics, just meaning them thinking about what the experimenter actually wants.
But I think that that’s actually a piece that you’re cluing in on as not so much a critique, but kind of the point. So there’s a lot of things that have happened in psychology research. One of the things they sort of feel like is happening is that the participants are kind of figuring out what the researcher wants.
Sunita: Mm-hmm.
Annie: Whether they sort of know it or not. And then I think to your core point, they’re sort of complying with that. So they’re behaving in a way that they wouldn’t naturally behave in order to try to please whatever the goals of the researcher might be. In this case, it feels like what you’re sort of queuing in on is that in the Milgram experiments it’s a feature, not a bug.
Sunita: Exactly right. And also what I find fascinating is yes, uh, it was a small sample size. The first experiment, I think it was about 40 participants. But Milgram actually ran a series of experiments and he had different variations and we can learn a lot from those different variations. Even if there were some, you know, demand characteristics, what changed those aspects?
So first of all, Milgram called the participants, the teachers that went up to 450 volts, the compliant subjects and the obedient subjects. And he called the ones that didn’t go up to 450 volts, the defiant ones. So now we see a reframing of defiance as being a positive thing because a lot of people have a negative connotation of defiance. And it’s one of the reasons why I decided to redefine defiance, because we all have this negative connotation. Well, many of us have this negative connotation of defiance. But the variations that Milgram had, like when the experimenter gave orders by telephone, compliance went down from 65% to about 20%. So that was like a huge drop. And what’s fascinating is some of the participants were reassuring the experimenter that they were still giving the electric shocks and increasing, when actually they were just giving the lowest shock whatsoever. That’s what I call quiet defiance, which doesn’t require you to have a confrontation with the other person, but it allows you to live by your values of not harming someone else and not disregard that value just because somebody else is asking you to do so.
Annie: So we think of defiance as like a bad thing, and you’re saying no, no, no, because compliance can be really bad.
Sunita: Exactly.
Annie: We need to think about what the opposite of compliance is. Defiance. And in both cases, like, being compliant can be bad or good. And defiance can be bad or good depending, right? Depending on the situation. And we need to sort of reframe it more neutrally and say, there are situations in which being defiant is a good thing because it actually causes you to align with what your values are.
Sunita: So let’s start with what compliance actually is. So compliance and consent are actually conflated with each other, both involved saying yes or agreeing to something, but they’re actually fundamentally different things.
So compliance is maybe sliding into something. Maybe it’s your default response because you’ve been socialized to comply from a young age, so it becomes very difficult to defy. It’s often a yes that’s not quite a yes, and it comes from something external. So an order, a suggestion, or even expectations, even society’s expectations. That’s compliance.
Consent is actually very different. And I take the definition of informed consent in medicine and encourage us to really look at consent in other decisions that we make because that framework can be really helpful. And for informed consent, or what I call your true yes, five elements need to be present.
So first of all, you need the capacity. So doctors will always assess patients for the capacity to make a decision. They’re not under the influence of drugs or alcohol, they’re not too sick. Then second, we need knowledge, accurate information about the decision that you’re about to make. But it’s not just enough to have the information.
We also need the third element, which is the understanding of that information. So a real grasp of the facts, the benefits, the costs, the alternatives. The fourth element is the freedom to say no, because if you don’t have the freedom to say no, then that’s merely compliance. Then the fifth element is your authorization, your deeply considered authorization that reflects your true values, so it’s not externally imposed. So that’s your true yes. That’s consent and why it’s very different from compliance.
Annie: Got it.
Sunita: And then we come to defiance. The Oxford English Dictionary defines defiance as the power to challenge somebody else boldly and openly. And I grew up in the U.K., so I’m not usually one to disagree with the Oxford English Dictionary, but I think that’s way too narrow. And my definition of defiance is that to defy is to act in alignment with your values, especially when there’s pressure to do otherwise.
When we think about, sort of, children being defiant, when we think about oppositional defiant disorder and all those things, that’s very much seen as a negative thing, right?
Annie: And we’re taught to think it’s negative.
Sunita: Yes. And sometimes it is, you know? So I have a teenager right now, and sometimes teenagers do the exact opposite of what you want them to do. So, um, I remember my son several years ago, when he would be playing on his Xbox or playing a computer game and I would say, are you going to do your homework? And he would like, you know, carry on doing it. And he’d say, “In a bit.” And then, sort of, he wouldn’t stop. And then I would say, “Are you going to do it?” And he said, “You know what? I was going to do it, but now that you’ve asked me to, I’m not going to do it.”
And so, you know, this doing the exact opposite of what a parent asks—that is oppositional. But again, if you think about the definition of defiance. Is it coming from within? No, he’s actually been listening very intently to what I want him to do and doing the opposite of it, which means he’s relying on something external and doing the opposite, which, that is what I call false defiance.
Annie: Gotcha.
Sunita: It looks like defiance, but it’s not actually the way I define it.
Annie: It’s more, it’s more just a reaction.
Sunita: Exactly. You’re doing something in opposition. You’re doing something that’s not reflecting your true values, because if you really wanted to do your homework, it wouldn’t matter whether I wanted you to do it or not. You would align your actions with your values. But right now you are just listening to what I want and doing the opposite of that.
And so false defiance is a trap that we can also fall into when, you know, there’s things that look like defiance, which is like, being controversial to get more likes on social media and things like that, that don’t really align with our values, and yet it’s done for performative reasons or for reasons that really don’t go along with my definition of defiance. That I would call false defiance.
Annie: We think about these things as sort of objective truth.
Sunita: Yes.
Annie: Whereas what I’m hearing you say is, okay, you have some set of values. The goal is to make decisions that align with those values.
Sunita: Right.
Annie: If the decisions that you make don’t align with your values, that is bad for you. You can’t say everybody should defy in a given situation because people’s values may be different.
Sunita: That’s right. But just an asterisk to that is that then we have to get to what we mean by values. And so here I have my students do this value exercise every year because it’s actually one of the really important aspects about learning what is your true yes and your true no. If you don’t know your values, you can’t really consent or defy to anything.
And by values, what I mean are sort of really powerful, but often very sort of simple, often singular words that would be very powerful if we could enact them every day. So my students often tell me integrity is really important to them. They don’t want to be known as being a dishonest person. They want to be trustworthy. Integrity. Benevolence is important. I hear compassion, equality. These are the types of values that I hear over and over again. I’m not talking about, like, goals or moral convictions. They can be experienced as facts because people often believe very strongly in those things, but they often have more than one answer. Like some people will think that’s right. Some people will think that’s wrong. And so they are subjective in a way.
I’m talking about how we enact our behavior on a day-to-day basis. Like if we see ourselves as an honest person, how do we do that every single day? Because you know, there’s a lot of research that shows that who we think we are and how we actually behave—the gap between them is enormous. And one of the tools that I give to people in Defy is how do we decrease that gap between our intention and our behavior?
Annie: Thank you for defining that because I do think that people don’t necessarily have a clear definition of values, and I assume that you would want to leave some room for evolution of those values.
Sunita: Who we are actually does change. So I have a defiance compass with three questions on it. The first question is, who am I? And that’s really figuring out your values. And another reason to actually think about your values and write them down is that the research shows that if you do write them down, then you’re more likely to act in alignment with them. And you have decreased your stress levels. You have a lower cortisol level, like you really know what your values are. And then there’s a question about what type of situation is this? Is it safe, is it effective—where you are looking outwards.
But the third question that we get back to is, what does a person like me do in a situation like this? So if you have these values, what does a person like me—with these values of integrity, fairness, whatever your values are—do in a situation like this? It gets you closer to how you want to act, right? You still need the ability aspect of it. You still need the skillset, but you’re connecting with your responsibility and ability.
And what you do then goes back to the first question, who am I? Because how you act is really who you are. So if you are acting in a way that doesn’t reflect your values, then it changes who you are as well. So maybe that reveals your real preferences. Maybe it reveals your lack of a skillset of being able to act in alignment with your values, which is a separate thing, but it reveals something and it does change who you are.
Annie: Gotcha. It may tell you where you have work to do.
Sunita: Exactly.
Annie: So there’s a few studies that you’ve done, and one of them I actually read in a book a long time ago. It was an amazing study to me because it goes back to this thing that you talked about, uh, that has to do with information. Those five pieces to consent, and information is one of them.
Sunita: Yes.
Annie: So the idea was, look, people in the medical profession have a bias toward recommending a solution that’s within their area of expertise. So surgeons are more likely to recommend surgical solutions to things. Right? So if you have a hurt shoulder, they’re more likely to want to do surgery on it than say, send you to pt.
Sunita: Right.
Annie: What you did was say, okay, what if we give patients more information? In other words, the surgeons are now instructed to tell people just so that you know, I have a bias and my bias is toward recommending surgical solutions. And the question was, how likely were the patients to seek a second opinion?
What I thought was so interesting about it was that intuitively, we obviously think that that’s going to decrease compliance. Compliance in this case being going with whatever the surgeon recommends, right?
Sunita: Yes.
Annie: But it actually increases compliance.
Sunita: Yes. Let me tell you something that happened to me in my first year as a junior doctor in the U.K. So I was working what we call, like, a one in two, which meant that I worked a full day, I stayed on call overnight, worked a full day the next day before finally going home to get some sleep, only to do the same thing again the very next morning. So I was so tired and overworked and underpaid. And so when I received this invitation out of the blue to meet with a financial advisor for free in the hospital in which I was working, I was surprised, but I thought, why not take a break? And so I went to, um, this room that I didn’t even know existed in the hospital because it was quite fancy, you know, like it had a carpet and it had a couch with cushions, which I kind of sank down into.
And I was almost asleep when Dan, the financial advisor, arrived and he was tall and handsome and he greeted me with this big smile. And he built up this great rapport with me. And then after about an hour, he recommended that I invest in a particular fund and that he would write a detailed report for me and get it back to me in about a week. And all of this was for free. And because I was so tired, I blurted out like, what’s in it for you? And he said, well, there’s no such thing as a free lunch and I will receive a commission if you invest in the fund that I’m recommending.
So. He had this disclosure of his conflict of interest, and that did change everything for me. It changed the whole dynamics of the situation. So I did feel less trust in his advice, which is arguably the intended purpose of disclosure and why we have lots of conflict of interest types of disclosures. But the strange thing was that I didn’t want Dan to know that I no longer trusted him. I didn’t want Dan to know that his disclosure had now corrupted our great rapport. And so I started to feel even more uncomfortable. I felt like I just had to say yes and sign on the dotted line just to avoid signaling distrust.
And this really fascinated me because imagine that you are seeing your doctor and your doctor says, you know what? I think you should enter this clinical trial, but then discloses the receipt of a referral fee if you enter the trial, which actually is part of the code of ethics. And patients say they want to know, right? They say they will go to a different physician. They say all the right things like disclosure is working in the right way. But if you really think about how hard it is to reject a doctor’s advice, now there could be reasons you don’t want to go into the clinical trial. It could have too many side effects. You’d rather stick with something that you tried. You don’t want to take the risk. You don’t know you’ll be in the control group or the placebo group. So there could be a number of reasons for you to reject it. But now that they’ve disclosed that they receive a referral fee, there’s another reason why you might reject it.
And that’s very salient. And now rejecting the advice is more likely to be interpreted that you’re doing so because of this referral fee, which actually insinuates that the doctor is biased or corrupt or they’re not giving you the best advice possible, and that’s really difficult. So that’s what I call insinuation anxiety, this fear of implying anything negative to someone else, especially when they’re standing right in front of you.
So I had it with a financial advisor. I didn’t want to signal distrust, but I also felt pressure to go along with it because he’s just told me that if I don’t, I’m going to deprive him of his commission, which you know, I should be looking after my own finances, not him. But both of those pressures lead you to comply more with advice that you trust less. So giving people this extra information in this particular way, direct from the advisor, has backfired.
Now the specialty bias disclosure’s a little bit different in that, these situations where I tested and I did it with the lottery studies, where I gave people full information on this is what you can get with die roll A. These are like, you can roll the dice. There’s prizes from one to six. Die roll A was over two times the expected value of die roll B. And if you just ask people, what do you want? Over 90%, 95% is going to say die roll A, right? So that’s the superior die roll. But once we have people recommending that you go with the inferior one, then 50% will go along with it. That’s bad enough by itself. But once they start disclosing their conflict of interest, that I recommend you go with die roll B and I should let you know that I will receive a commission or a bonus if you take die roll B. So now in these die roll studies, we see compliance going up to about 85% and trust is less. Trust has gone down, but compliance has gone up. Why? Because they don’t feel comfortable to reject the advice.
With the specialty bias disclosure, it’s a little bit different here because in these situations we were looking at, um, people receiving their diagnosis of localized prostate cancer, and there’s two equally effective treatments. One is surgery and one is radiation. And surgeons are supposed to present both treatments. And actually they spontaneously disclose sometimes that they are biased towards recommending surgery because they’re a surgeon. So I wanted to really look at how does that affect the patients? And what we found was that when they disclose their specialty bias, more people will comply and take surgery. But in this case, trust is increasing, not decreasing. So there’s a difference here. In the first set of studies, trust was decreasing and compliance increases. With these studies, the specialty bias studies, trust was increasing and compliance was increasing. So again, with both types of disclosures, compliance increased, but what was happening to trust? Why is it different?
And with a different set of studies that I did on social media, blogging and disclosures there, what I find that makes the difference is not just the salience of the disclosure, but the competing information. When you are cognitively overloaded, so you have lots of information, you’re making a decision about your medical treatment or you’re making a decision on a particular product to buy that bloggers are telling you, you’re more focused on that than you are with the disclosure. And even on these social blogs where we had the disclosure sort of bolded, explained, you know, I am writing about this product because I’ve received this money. You know, just really explicitly explaining what the conflict of interest was. A lot of people couldn’t recall it in that situation, but they had read it because trust increased and likelihood to buy the product, click on the link, recommend it to other people, also increased.
And it was all to do with whether you were processing the disclosure centrally or peripherally. So if it’s a very simple disclosure and an easy decision, you process it centrally and you can say, oh, that means they have a conflict of interest. Trust decreases and compliance only increases if you have that social interaction where rejecting it in front of the other person is going to signal distrust or it’s going to signal unhelpfulness. If you can break that social interaction by making the choice in private, you get rid of that unintended consequence. But if you are cognitively overloaded and not really processing the disclosure centrally, then trust actually increases because you make these associations that this person is an expert, the surgeon is an expert.
All they’ve said is that they’re a surgeon and they’re biased towards surgery. But for some reason it’s the trust in expertise that increases, not trust in integrity or benevolence. They go up too. But what explains and mediates the effect is the trust in expertise. They see them as more competent.
So what we need to do with that information is be very specific as to how it’s given. It’s got to be given not directly from the advisor, separately. It’s got to be given before any other information and make sure it’s thoroughly understood, and they need to have a choice. Like if your advisor has a conflict of interest, can they choose a different type of advisor?
And we did test this out in Cleveland Clinic. We had physicians that had $20,000 or more that they had received from industry in the past year have to disclose it to patients. And we had to give them a letter beforehand, not directly from the doctor, but from the hospital to explain this. And we found some of the unintended effects went away. So compliance didn’t increase in those situations. It didn’t actually decrease either because they didn’t have a choice of which physician to go to. Before they make the decision about which physician to see, if you could see whether they had a conflict of interest or not, that’s when you might see those differences.
So the bottom line is disclosures of conflicts of interest can make matters worse unless they’re given in certain ways that people can process it centrally and not have to send a signal of distrust. So we have to be very careful as to how the information is given. I think it should still be given, but we need to give recipients, advisees, patients a choice.
Annie: Is it only in the first case trust goes down, compliance goes up, where you get the insinuation anxiety? Or are people experiencing that in both cases?
Sunita: It’s only in the first case where you feel uncomfortable, because insinuation anxiety is the reluctance to signal distrust. So you feel more pressure to comply when you don’t want to. So you are going along with it. But in my studies, if you have an opportunity to change your mind, you will change your mind as soon as they’re not there. So as soon as you break that social interaction, then people will change their mind, which is quite powerful actually. It shows that our, sort of, private preferences are very different from our public beliefs.
In the second case, you’re cognitively overloaded, and so you’ve, we really had to be heavy hitting. Think about what that disclosure statement meant. Write down your thoughts about what it meant. Only then when we were really sort of heavy hitting with it, did we see trust go down. So they’re not uncomfortable about going along with it because they are processing peripherally. They’re, uh, making associations with expertise with the disclosures, and so they’re happily going along with it. Trust it’s increased and compliance is increased.
Annie: If we go back to this idea of behavior that’s aligned with your values, it sounds like in the first case where you have insinuation anxiety, what’s happening is that part of that discomfort is that, well, I actually don’t trust this person. But then I’m complying and that feels bad to me. And so there’s this conflict. It’s causing me anxiety. I’m afraid that I’m going to insult the person, but also I think that may be doing harm to me. And this is all horrible.
In the second case, it sounds like there kind of actually isn’t a conflict between your values and the choice that you’re making, because trust has gone up because of the way that we’re delivering the information. So in that case, it’s not so much like you need to separate the person from the person that they’re being asked to comply with. It’s not anxiety that’s causing the problem because there isn’t anxiety because you’re actually kind of aligned with your values. It’s that you have to get them to actually process the conflict of interest separate from the interaction, meaning like give it to them beforehand for example.
Sunita: People find it very difficult to shop around when they’re ill. So if they’ve already made a decision about the physician, you also get this motivated reasoning, which is what we saw in Cleveland Clinic. Yes, you know, conflicts of interest affect physicians, but not my own physician, you know? So you get this motivated reasoning that actually it’s not going to make a difference once you’re in that situation because it’s too difficult for people to change at that point.
With specialty bias, that’s a little bit different from a financial conflict of interest. I think in this situation it would be asking them, do you think surgeons are more likely to be biased to recommend surgery or not? But yes, if they’re cognitively overloaded, I think making things as easy as possible for them to choose beforehand and having a choice. That’s the biggest thing, and not having it costly. Because seeking second opinions and seeking a different physician is really costly to people. And so that’s when you get the motivated reason in that I’m sure it’s all fine.
Annie: I want to go back to the sort of like, give yourself advice thing.
Sunita: Yes.
Annie: So we’re talking about interventions and it feels like I’m feeling this umbrella across the interventions, which I would put under psychological distancing. So if you’re calling someone on the phone and saying, give them a shock—and it turns out people actually lie in that situation, which I think is hilarious and very telling—you’re creating psychological distance, right? Like I don’t have to be right in front of that person.
Sunita: Right.
Annie: If you give somebody distance from the person recommending the lower expected value choice that’s getting money for it, they’re less likely to comply, got me thinking about this problem, right, which is—a lot of the ways that our decisions can go wrong is that we are trying to satisfy some sort of short term need, and what we sacrifice is a long term need.
Sunita: Right.
Annie: So it’s no doubt that if we take the bad lottery, for example, we choose the choice that has the lower expected value, that’s bad for us in a certain way. Long term we’re not going to have very much money. And if we do that over and over again, it’s going to be very bad. But in the moment, we’re faced with this insinuation anxiety and the desire to relieve that in the moment becomes stronger than what we know is good for us longer term. Right? So we always have this conflict between some future version of us who’s had surgery or had radiation, who’s taken that bet or hasn’t taken that bet, so on and so forth, right? Who chooses to be a doctor instead of the thing that you actually want to do, but we’re afraid of how people are going to react, particularly people who invested in us and love us and so on and so forth, that we have that conflict. So, you know, I’d love to kind of just hear your thoughts around that problem, that trade off that’s happened.
Sunita: Yeah, absolutely. And I think this aspect of distance, both physical and psychological, is a key aspect of correcting some of these things. Because if we think about just how dangerous insinuation anxiety can be, when you think about when it starts to harm other people here is when it gets very dangerous, right?
So insinuation anxiety could be one of the reasons that one study found that on average, nine out of 10 healthcare workers, most of them nurses, did not feel comfortable speaking up when they saw a colleague or a physician making an error. And there was one situation that I read actually in a book by Michelle Lamont about how professors behave, where she was talking about this faculty meeting. And a young woman professor went into it and she was with four senior male professors and it was to assess grants. And this woman said when it came to one particular application, the conversation changed and it seemed to be more about negative gossip than about the actual applicant. And she was a black woman and the applicant was a black man and she thought she should say something and she tried and she just couldn’t.
And when she came out, she said the one thing that she wanted to say was the thing that she just couldn’t say. You know, like being in that meeting for the first time with these people, she didn’t want to question their integrity. But yes, we are trying to save their face, not signal distrust, but then we lose some of our own integrity in the process.
Like when your boss asks you to do something unethical, if you are not even processing, if you’re just saying, I’m going to obey my boss, right? Because that’s what I should do, really, this is ethical fading too. We are not thinking about the bigger picture, we’re not thinking about the consequences, and we’re not thinking about the long-term effects as well. And so that aspect of getting some, both physical and psychological, distance is the best way.
I call it the power of the pause. We ask for timeout, right? We are not going to say yes to the person standing right in front of us straight away, and we are just going to take a minute or maybe longer to think about this. And if we are in the moment, then we can get psychological distance by talking to ourselves in the third person. So we get that psychological distance aspect as well. “Sunita, is this situation going against your values?” But what I really show is in terms of our ability to be able to speak up when it really matters, is preparing before that moment of crisis. Because if we don’t know how to do it, if we haven’t developed that skillset, we can’t just wish ourselves to be able to do it in the moment. Like when we see, if you’re a nurse and you see a physician doing something wrong, how do we say something if we’ve never practiced for that? If we’ve been brought up to socialize and be deferential and we need to practice for it before the moment of crisis.
Annie: Yeah. So one of the things that I recommend to people when they’re facing those types of decisions down, is to take a moment and say, a week from now when I look back at this, how am I going to feel about it?
Sunita: Right.
Annie: Which is similar to, like, sort of just giving yourself advice in the moment. It sort of creates the same thing. It turns you into a different person in that sense, and like you’re looking back on yourself. So I think that that would get you there as well. How do we get better at this as a skill?
Sunita: Well, we can start practicing because if—that’s the only thing that’s going to change our neural pathways is if we start behaving differently and strengthen other neural pathways.
Because if we’ve never, ever been defiant, if we’ve never heard ourselves say no or have those defiant words come out of our mouths, we’re never going to know how to do it, right? It’s too difficult. It’s going to feel too unnatural. And if you think about it, a lot of these like really defiant acts that people think are iconic, like Rosa Parks saying no on the bus, it’s preceded by hundreds of moments of compliance.
She complied with segregation laws on the bus many times before she defied. And so we shouldn’t really feel bad or, you know, beat ourselves up for having complied. Because we can learn from that. Like in this situation, next time I want to do this. So we anticipate it, we visualize it, we script it out. Like this is what I wish I could have said. And then we start practicing it because it’s not just intellectually understanding. We need the behavioral training. And we can also start small in small situations.
You can start by, you know, telling the hairdresser that they should stop cutting. You don’t like the way they’re doing that, instead of just sitting in that square when saying, trust me, trust me. And you just don’t want to say anything.
Annie: That’s every single one of my female friends: I hate this cut. Did you tell the hairdresser?
Sunita: Yes.
Annie: No, I told her I loved it.
Sunita: Told her you loved it. And even tipped them and said thank you.
Annie: Yeah. I could imagine, for example, if you are going in to get advice from a doctor that it might be helpful if you said, look, I know that I’m going to have this issue when I’m actually in front of the doctor. So what I’m going to do is I’m going to book two appointments at once with two different doctors.
Sunita: Hmm.
Annie: So I’m just going to pre-commit to the second opinion in order to help myself to not comply and to get both points of view. You could say, I’m making a pre-commitment, that if I go to a doctor or I see a financial advisor or something like that, that I won’t decide in the room, that I’ll listen to the information. I’m going to commit to saying, “Thank you for the information. I’ll get back to you in a week.”
Sunita: Yeah, I think that’s great. Something else I should add that makes it easier for us to defy is when we do it for a loved one, and sometimes we find it much easier than when we do it for ourselves. So I have found that I can speak up and I can defy and I can seek second opinions for my son so much easier than I could for myself. Because we’re connecting with our value. We’re connecting with our responsibility that I am responsible for this. And actually I would like to get a second opinion before we make a decision. And it’s really leaning into that aspect. If we can do it when it’s about a loved one, we can also do it for other members of the community and for ourselves as well.
Annie: Well, speaking up for your loved ones reminds me of a lovely story that you tell about your mother who was pretty compliant.
Sunita: Yes.
Annie: Except for in a particular situation in an alleyway. So, you know, I would love for you to just tell that story because I think it does show that it can be situational. Like, are you defying for yourself? Are you defying for somebody else? When does that part of us come out?
Sunita: Yeah. So that is a story that stayed with me for a really long time. And so my mom is, like, quite petite. She’s about four, eight or something at the most, and when we were growing up, she used to wear her sari all the time. On a particular day, she had this blue-green sari on, she had her hair sort of neatly in a single plait at the back, and I was about seven or eight. We were walking back from the grocery store and she was pulling along this rickety shopping cart, which just looks like luggage onto two wheels. And it was quite a long walk back home.
And we decided to go through what we call in England, in West Yorkshire anyway, a snicket, which is a very narrow alleyway. And I had always been told, like if I was walking by myself back from school and stuff, never go through the snicket. But there were the two of us together and we were tired, so we wanted to go through this alleyway. And in that alleyway, we were confronted by a group of teenage boys, and they did start shouting out some things to us. They blocked our path and told us to go back home. And my reaction was instant. I grabbed my mom’s arm and I looked down. I wanted to avert my gaze, and I just wanted to maneuver as fast as possible through those boys to actually get home.
And my mom did something different that day, because I had seen her as very compliant. Like she was quiet, she was subservient, she did all the cooking, the cleaning, the grocery shopping. And she was very generous and big-hearted, and always serving other people’s needs. So I thought she was just going to do the same as me. But she actually stopped that day and she looked at the boys directly in the eyes and she said, “What do you mean?” And my heart started racing at that point, I was like, I whispered to her, “Come on, Ma.” And she said no to me. She put the shopping cart up vertical, and she put one hand on her hip and she looked back at the boys again, who hadn’t answered her.
And she said, again, “What do you mean?” And the boys didn’t say anything. They just started looking at each of them and she went, “Hmm, yes. You think you’re big tough boys. Yeah, big strong boys.” And she started telling them off until one of them just said to the others, “Let’s just go.” And they dispersed. My mom grabbed the shopping cart and then she just walked really fast through that alleyway.
And I was just like, what happened? Because I would never have expected someone like her to have done this. And that showed me so many things because it showed me that, first of all, defiance is not a personality, it’s a practice, it’s a skillset. We can choose to utilize it or not. And maybe she utilized it that day because I was there, and I think she also had seen those boys or people like those boys before because she used to come home and she used to be muttering and I thought she was complaining about the shopping cart.
But I think it was those boys. And she really showed me that it’s possible for us to be defiant even if it’s not something that we use every single day. And defiance also had a ripple effect because that really stayed with me, that moment. And it showed me how strong somebody can be when they decide to show that.
And Rosa Parks, when I read her biography, her mom, she had experienced her mom saying no on the bus when she was a child. And that stayed with her too. And now I’ve, like, spoken to so many people that have told me about the ripple effects of parents. That really stood out to me because she wasn’t that type of person. And it showed me defiance is a practice, not a personality. And also it has a ripple effect and it affects other people. So if you just say something like, if I just say in that faculty meeting, “What do you mean by that?” That person might not ever change and might still carry on doing those things, but I’ve changed the water a little bit. Maybe they won’t do it in front of me. Maybe they won’t do it in front of the other people that are there. Maybe the other people that observe it will start to behave differently too and say more. So it really has this effect that carries on in time.
And I think if we can teach our children to be defiant, not just compliance, we actually train them for defiance. What I’m really hoping for with this book and the work that I’ve done is that one day one of the teenage boys would speak up and tell his friends to stop acting in that way so my immigrant mother wouldn’t have to. And that’s the type of society I really hope we can build if we see defiance as a positive thing.
Annie: That’s amazing. I, well, I think that’s such a wonderful way to sort of start to wind things down. It’s such a beautiful story and as you say, so many lessons in there. Do you mind if we do a little lightning round that we always do at the end of this particular podcast?
Sunita: Sure.
Annie: So what decision-making tool or idea or strategy would you want to pass down to the next generation of decision makers?
Sunita: The defiance compass, for sure. Yes, those three questions—very, very powerful.
Annie: And. I assume you would want to start getting that to people early, right? Like you’re doing it with, it sounds like executives, with your students. What if we could do that with kindergartners?
Sunita: Yes. Yes. So many people said we should teach this in schools. And I would love to write a children’s book on defiance too, because people are saying, “Oh, do kids have values?” You know what? They do. Like if you have siblings, you know all about fairness, right? And kids will always say, that person was left out of the group, or I was left out. And all they have to say is like, invite that person. If you see something like that, like let’s reinforce our values, you know, this is what we want to do.
Annie: I would love to see that. I think that the ideas that you’re talking about are so powerful and like you say, like when you were little, you saw this act of defiance from your mother. Rosa Parks saw an act of defiance from her mother. You talk about the ripple effects. If we could explicitly get that to more children, they wouldn’t just have to sort of happenstance see someone do that and then figure out that they ought to model that. But we could actually be teaching them explicitly how to think about it, because it really comes down to how do you actually help children to figure out, first of all, what their own agency is, right? Which I don’t think we teach enough of. Um, and then also to explicitly think, what are your values and how do you make decisions that are aligned with those values?
Do you have a book in particular that you recommend to listeners to improve their decision-making? Separate from Defy, which obviously everybody should now go get and read.
Sunita: Am I allowed to say your book?
Annie: Well, I mean, I guess you are. It’s not the point of the question, but.
Sunita: I did read your book when I was going through a major decision, um, How to Decide. I love that book. And of course, Quit, right? It’s also very much related to some of these concepts, so definitely recommend it.
Annie: Okay. All right. I’ll take it and I won’t demand another one, but thank you, now I’m blushing. Thank you. If you were to think about, like, what the impact on society would be if the Alliance for Decision Education actually succeeds in its mission to ensure that Decision Education is part of every K through twelve’s learning experience, like how do you think that would change society?
Sunita: You know, I have this concept I talk about in Defy called Moral Mavericks, where we can sort of speak up and defy when needed, and I think if we could achieve that mission in schools and with young people, we would get more intellectual humility, better decision-making for sure, more critical thinking. These are the things we want. And I do think that people have great values, you know. Maybe it’s a demand characteristic, but my students, their values that they talk about and why they are important to them—really, really inspiring. It’s usually some experience that they’ve had in childhood or early adulthood that really sort of reinforced some of these values, which could just be integrity, but they’ve come to them in different ways and why it’s important for them to think about those values every single day. I think we would have a world of moral mavericks, which would change society greatly.
Annie: Your focus on values is so incredibly important, because one of the things that I hear when I tell people about what we’re doing at the Alliance with decision science, they’re like, well, where’s the emotion in that? Where’s the feeling in that? You know, they sort of think of this like, are you teaching kids to make decisions like robots or something like, I mean, I think that sometimes that’s where people’s heads go. But I think that you’re pointing out this incredibly key component, right? Which is, who are you?
Sunita: Yes.
Annie: What are your values? Which is, I think, what they mean when they’re talking about sort of where’s the emotion in it? And you’re pointing out that these things have to live together. In fact, there’s no way for you to make high quality decisions without exploring that side of you. What’s your identity? What type of person do you want to be?
How do you make decisions to align with what those values are? How have you identified those values in an explicit way and figured out what those mean to you? And I think that you’re articulating it so beautifully how that sort of construction of decisions and thinking probabilistically and those kinds of things goes hand in hand, really. And one can’t exist without the other—both sides.
Sunita: No, that’s, I think that’s lovely. Thank you. And you know, when we think about decisions that have affected society a lot. So if we go back to Rosa Parks again, was her decision based on emotion? Of course, but it wasn’t an emotional reaction, you know, and that’s the difference. That she connected with her values. Of course there’s emotion behind do we have equality or not? But she connected with those values and she defied in a way that, if you think of the two questions, is it safe, is it going to be effective? It was probably never safe for her. You know, she actually did receive like quite a lot of costs from that, but she was already receiving costs, you know. So for every person it’s a different decision.
And values are often based on something that we’ve experienced that is very meaningful to us. Certainly my values have been informed by things that I experienced as a child. And even the work that I do now, it was very much based on the socialization I got and how I came to the career that I now have.
So yes, I think that’s a great connection, is why are we doing this? What’s the meaning behind it? And how are we connecting with our values? How we want to create the society—we are building this society. Every act of consent, dissent, compliance is building the society that we live in.
Annie: Okay, so just for our listeners, if they want to go online and learn more about your work or follow you on social media, where would be a good place for them to start?
Sunita: I think everything is on my website, which is sunitasah.com, so that’s SUN like the sun in the sky, I-T-A-S-A H.com. And on that website you’ll find a quiz for defiance, so you can find your defiance style. You can subscribe to my newsletter for free, which is called Defiant By Design, which is on Substack, and you’ll find my social media links, LinkedIn and Instagram. So please do connect with me.
Annie: Well, wonderful. And for anything that we’ve talked about in the book, any studies that we’ve referenced, any books that we’ve talked about, they’ll all be linked in the show notes for our listeners so they’ll be able to go and check all of that stuff out and learn so much more about your work.
So, Sunita, thank you so much. This has been such a fun conversation. I know that I have learned so much and have so much to think about. And my understanding of this conceptually is so much better. I feel like I’m better for having had this conversation, so I really appreciate the time that you’ve given, to come on the podcast and chat with me.
Sunita: It’s been wonderful. I’ve enjoyed it very much. So thank you for delving into this topic with me.
Show notes
Books
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Defy: The Power of No in a World That Demands Yes – Dr. Sunita Sah (2025)
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How Professors Think: Inside the Curious World of Academic Judgment – Michèle Lamont (2009)
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How to Decide: Simple Tools for Making Better Choices – Annie Duke (2020)
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Quit: The Power of Knowing When to Walk Away – Annie Duke (2022)
Articles
Resources
Websites
Social Media