More on this book
Community
Kindle Notes & Highlights
by
Kevin Simler
Read between
January 18 - February 17, 2018
But the fact that medicine is often effective doesn’t prevent us from also using it as a way to show that we care (and are cared for). So the question remains: Does modern medicine function, in part, as a conspicuous caring ritual? And if so, how important is the hidden caring motive relative to the overt healing motive?
However, if the conspicuous caring motive is half as strong as the healing motive, then it could make a huge difference to our medical behaviors.
To find out just how important conspicuous caring really is, we will need to look at some actual data on our medical behaviors.
The biggest prediction of the conspicuous caring hypothesis is that we’ll end up consuming too much medicine, that is, more than ...
This highlight has been truncated due to consecutive passage length restrictions.
Medical treatments vary greatly, in both their costs and potential health benefits. If patients are focused entirely on getting well, we should expect them to pay only for treatments whose expected health benefits exceed their costs (whether financial costs, time costs, or opportunity costs).
But when there’s another source of demand (i.e., conspicuous caring), then we should expect consumption to rise past the point where treatments are cost-effective, to include treatments with higher costs and lower health benefits.
Instead we’re going to step back and examine the aggregate relationship between medicine and health. Given the treatments that people choose to undergo, across a wide range of circumstances, does more spending lead on average to better health outcomes?
We’re also going to restrict our investigation to marginal medical spending. It’s not a question of whether some medicine is better than no medicine—it almost certainly is—but whether, say, $7,000 per year of medicine is better for our health than $5,000 per year, given
In the United States, for example, the surgery rates for men with enlarged prostates vary more than fourfold across different regions, and the rates of bypass surgery and angioplasty vary more than threefold. Total medical spending on people in the last six months of life varies fivefold.12 These differences in practice are largely arbitrary; medical communities in different regions have mainly just converged on different standards for how to treat each condition.
These variations result in a kind of natural experiment, allowing us to study the effects of regionally marginal medicine, that is, the medicine consumed in high-spending regions but not consumed in low-spending regions. And the research is fairly consistent in showing that the extra medicine doesn’t help.
Patients in higher-spending regions, who get more treatment for their conditions, don’t end up healthier, on average, than patients in lower-spending regions who get fewer treatments.
All these studies found that patients treated in higher-spending places were no healthier than other patients.
For each extra day in the ICU, patients were estimated to live roughly 40 fewer days.
In short, the researchers found “no evidence that improved survival outcomes are associated with increased levels of spending.”
Still, these are just correlational studies, leaving open the possibility that some hidden factors are influencing the outcomes, and that somehow (despite the absence of correlation) more medicine really does improve our health.
As expected, patients whose medicine was fully subsidized (i.e., free) consumed a lot more of it than other patients. As measured by total spending, patients with full subsidies consumed 45 percent more than patients in the unsubsidized group.
Despite the large differences in medical consumption, however, the RAND experiment found almost no detectable health differences across these groups.
Doctors who were asked to look at patient records couldn’t tell the difference between the fully subsidized and unsubsidized patients. Severity of diagnosis and appropriateness of treatment were statistically indistinguishable between the two groups.30 The marginal medicine wasn’t “less useful medicine,” at least in the eyes of trained professionals.
Like in the RAND study, lottery winners ended up consuming more medicine than lottery losers.32 Unlike the RAND study, however, the Oregon study found two areas where lottery winners fared significantly better than lottery losers. One of these areas was mental health: lottery winners had lower incidence of depression.
subjective: winners reported that they felt healthier. Surprisingly, however, two-thirds of this subjective benefit appeared immediately following the lottery, before the winning patients had any chance to avail themselves of their newly subsidized healthcare.34 In other words, lottery winners experienced something akin to the placebo effect.
We’ve now arrived at the unpalatable conclusion that people in the United States currently consume too much medicine. We could probably cut back our medical consumption by a third without suffering a large adverse effect on our health.
Relative to our great-great-grandparents, today we live longer, healthier lives—and most of those gains are due to medicine, right? Actually, no. Most scholars don’t see medicine as responsible for most improvements in health and longevity in developed countries.
Other factors often cited as plausibly more important include better nutrition, improvements in public sanitation, and safer and easier jobs. Since 1600, for example, people have gotten a lot taller, owing mainly to better nutrition.
It’s perfectly consistent to believe that modern medicine performs miracles and that we frequently overtreat ourselves.
People also find it hard to reconcile the unpalatable conclusion with all the stories we hear from the media about promising new medical research. Today, it’s a better drug for reducing blood pressure. Tomorrow, a new and improved surgical technique. Why don’t these individual improvements add up to large gains in our aggregate studies? There’s a simple and surprisingly well-accepted answer to this question: most published medical research is wrong.38 (Or at least overstated.)
The fact that we consume too much medicine has many possible explanations. Perhaps the most tempting is the idea that health is so important to us that we’re willing to try anything, even if it’s unlikely to help much (like the RAND experiment shows). To show that our medical behaviors are driven by the conspicuous caring motive, rather than “health at any cost,” we have to look at other predictions made by the conspicuous caring hypothesis.
Prediction 2: Preference for Treatments Requiring Visible Effort and Sacrifice To maximize social credit for giving a gift, you need other people to see how much you sacrificed for it.
Patients and their families are often dismissive of simple cheap remedies, like “relax, eat better, and get more sleep and exercise.” Instead they prefer expensive, technically complicated medical care—gadgets, rare substances, and complex procedures, ideally provided by “the best doctor in town.”
This bias is especially pronounced in how we treat patients who are terminally ill, and even more so for elderly family members.
Roughly 11 percent of all medical spending in the United States, for example, goes toward patients in their final year of life.43 And yet it’s one of the least effective (therapeutic) kinds of medicine. Even where it succeeds in prolonging life, it rarely succeeds in helping the patient achieve a reasonable quality of life;
Unfortunately few family members are willing to advocate for lesser care, fearing it will be seen as tantamount to abandoning their beloved relative.
For example, even though randomized trials have found nurse practitioners to be just as medically effective as general practice doctors,45 we only let the doctors treat patients.
Similarly, when the government published risk-adjusted hospital death rates between 1986 and 1992, hospitals with twice the risk-adjusted death rates saw their admissions fall by only 0.8 percent.47 In contrast, a single high-profile news story about an untoward death at a hospital resulted in a 9 percent drop in patient admissions at that hospital.
Many people are quite uncomfortable with questioning the value of modern medicine. They’d rather just trust their doctors and hope for the best. And yet medicine deserves its share of public scrutiny—as much, if not more so, than any other area of life. One of the simplest reasons is the prevalence and high cost of medical errors, which are estimated to cause between 44,000 and 98,000 deaths in the United States every year.
As Alex Tabarrok puts it, “More people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS and yet physicians still resist and the public does not demand even simple reforms.”
Such simple reforms might include •Regulating catheter use. Studies have found that death rates plummet when doctors are required to consistently follow a simple five-step checklist.51 •Requiring autopsies. Around 40 percent of autopsies reveal the original cause-of-death diagnosis to have been incorrect.52 But autopsy rates are way down, from a high of 50 percent in the 1950s to a current rate of about 5 percent.53 •Getting doctors to wash their hands consistently. Compliance for best handwashing practices hovers around 40 percent.54 Some of these problems are downright scandalous, and yet,
...more
And this is exactly what we find. The public is eager for medical interventions that help people when they’re sick, but far less eager for routine lifestyle interventions. Everyone wants to be the hero offering an emergency cure, but few people want to be the nag telling us to change our diets, sleep and exercise more, and fix the air quality in our big cities—even though these nagging interventions promise much larger (and more cost-effective) health improvements.
people who reside in rural areas lived an average of 6 years longer than city dwellers, nonsmokers lived 3 years longer than smokers, and those who exercised a lot lived 15 years longer than those who exercised only a little.58 In contrast, most studies that look similarly at how much medicine people consume fail to find any significant effects. Yet it is medicine, and not these other effects, that gets the lion’s share of public attention regarding health.
There are other ways to explain each of these phenomena, of course. But taken together, they suggest that we are less interested in “health at any cost,” and more interested in treatments that third parties will appreciate.
Like King Charles II, we want the very best medicine for ourselves (especially when others can see that it’s the best). Like the woman bringing food to a sick friend, we want to help people in need (and maximize the credit we get for it). And because there are two reasons to consume and provide medicine—health and conspicuous care—we end up overtreated.
Religion. There’s perhaps no better illustration of the elephant in the brain. In few domains are we more deluded, especially about our own agendas, than in matters of faith and worship.
But most of what people do in the name of God isn’t so blatantly opportunistic. And yet, as we’ll see, there’s a self-serving logic to even the most humble and earnest of religious activities.
And while all of these practices are peculiar, many of them seem downright counterproductive—a waste of precious energy, resources, and even fertility and health.
DO BELIEFS EXPLAIN BEHAVIORS? It’s tempting to try to collapse these two puzzles into one, by assuming that the strange supernatural beliefs cause the strange behaviors. This seems straightforward enough: We believe in God, therefore we go to church. We’re scared of Hell, therefore we pray.8 All that would be left to explain, then, is where the beliefs come from.9 Let’s call this the belief-first model of religious behavior,
In fact, the belief-first model is something that both believers and nonbelievers often agree on, especially in the West.
Implicit in these debates is the assumption that beliefs are the central cause of religious participation.10 And yet, as we’ve seen throughout the book, beliefs aren’t always in the driver’s seat. Instead, they’re often better modeled as symptoms of the underlying incentives, which are frequently social rather than psychological. This is the religious elephant in the brain: We don’t worship simply because we believe. Instead, we worship (and believe) because it helps us as social creatures.
The fact that these behavioral patterns are so consistent, and thrive even in the absence of supernatural beliefs, strongly suggests that the beliefs are a secondary factor.
And we’d like to give them the benefit of the doubt that they know what’s good for them.15 In fact, the vast majority of weekly churchgoers are socially well-adjusted and successful across a broad range of outcomes.
Compared to their secular counterparts, religious people tend to smoke less,16 donate and volunteer more,17 have more social connections,18 get and stay married more,19 and have more kids.20 They also live longer,21 earn more money,22 experience less depression,23 and report greater happiness and fulfillment in their lives.
If religions are delusions, then, they seem to be especially useful ones.
