by Robin Hanson
Prediction 1: Keeping Up with the Joneses
To the extent that medicine functions as a caring signal, it’s going to be sensitive to context. If everyone around you spends a lot on medical care, you’ll need to spend a lot too, or risk looking like someone who doesn’t care enough.
Economists have found exactly this kind of “keeping up with the Joneses” effect. When they compare people with similar incomes and wealth who happen to live in different countries, those who live in richer countries (where their neighbors are richer) spend more on medicine, while those who live in poorer countries (where their neighbors can’t afford as much medicine) spend less.41 In other words, if your income stayed the same as you moved from being a relatively rich person in a poor nation to being a relatively poor person in a rich nation, you would likely increase your medical consumption.
This makes little sense if medicine is a simple transaction where you pay to try to get better health outcomes. For a given dollar amount, you might expect to get similar health benefits regardless of what country you’re in. But it makes perfect sense if one of the benefits you’re paying for is a social benefit: convincing others that you care (or are well cared for). To get these social benefits, you need to spend roughly as much as your “Jones” neighbors.
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. (Recall the disapproval Robertson knew she would receive if she brought a store-bought chicken.) Thus conspicuous care prefers gifts that can be more easily seen as requiring effort and sacrifice.
When we consume medicine for the simple, private goal of getting well, we shouldn’t care how much it costs or how elaborate it is, as long as it works. However, to the extent that we use medicine to show how much we care (and are cared for), the conspicuous effort and expense are crucial.
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.” Patients feel better when given what they think is a medical pill, even when it is just a placebo that does nothing. And patients feel even better if they think the pill is more expensive.42
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; heroic end-of-life care is rarely pleasant for the patient.44 Unfortunately few family members are willing to advocate for lesser care, fearing it will be seen as tantamount to abandoning their beloved relative.
Prediction 3: Focus on Public Rather Than Private Signs of Medical Quality
When you buy something for personal use, you will be equally open to private and public signals of its quality. It doesn’t matter how you know that something is good, as long as it is. In contrast, when using something as a gift, you need your audience to see widely accepted signs of your gift’s quality, in order to maximize the social credit you get for giving it. Observers can’t appreciate quality that they can’t see.
This is the same bias we saw in Chapter 12, where donors rarely do their own research about the effectiveness of different charities, preferring instead to give to charities that are widely seen as good causes.
Similarly, in medicine more than other industries, we focus less on local performance track records, and more on standard and widely visible credentials and reputations. 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. When choosing between doctors, people typically focus on the prestige of their school or hospital, instead of their individual track records for patient outcomes.
In fact, patients show surprisingly little interest in private information on medical quality. For example, patients who would soon undergo a dangerous surgery (with a few percent chance of death) were offered private information on the (risk-adjusted) rates at which patients died from that surgery with individual surgeons and hospitals in their area. These rates were large and varied by a factor of three. However, only 8 percent of these patients were willing to spend even $50 to learn these death rates.46 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.48
Prediction 4: Reluctance to Openly Question Medical Quality
When something functions as a gift, it’s often considered rude and ungrateful to question its quality. (“Don’t look a gift horse in the mouth,” as the saying goes.) So if you want to seem grateful to those who help pay for your medicine, you will be reluctant to openly question the quality of that medicine. After all, it’s the thought (and effort) that counts.
Skeptical attitudes toward medicine seem to be a mild social taboo today (as readers may notice if they discuss this chapter with friends or relatives). 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.49 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.”50
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, as Tabarrok points out, they’re largely ignored by the general public. We’d rather not look our medical gift horse in the mouth.
Another way we’re reluctant to question medical quality is by getting second opinions. Doctors frequently make mistakes, as we’ve seen, and second opinions are often useful—for example, for diagnosing cancer,55 determining cancer treatment plans,56 and avoiding unnecessary surgery.57 And yet we rarely seek them out.
Prediction 5: A Focus on Helping during Dramatic Health Crises
If our goal is really “health at any cost,” then we should expect to pursue the most effective health strategies, whatever form they may take. If we’re using medicine as a signal of support, however, then we’ll provide and consume more of it during a patient’s times of crisis, when they are more grateful for support.
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.
One study, for example, tracked 3,600 adults over seven and a half years. Investigators reported that 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.
15
Religion
Every fall, monarch butterflies from all over the United States and southern Canada flock south to their wintering sites in Mexico, where they hibernate1 in trees until their return trip in March. On the Serengeti plain, giant herds of wildebeest undertake the circular “great migration,” roving in constant search of greener pastures. On Christmas Island, red crabs spend most of the year in the island’s interior forests, but come October, they scramble to the coasts to mate and lay eggs. Their swarms are so thick that the island has to shut down its coastal roads, lest they become littered with flattened crab carcasses.2
Animal migrations are among the most spectacular and cinematic natural phenomena on the planet. But there’s one epic migration you’re unlikely to find in a nature documentary: the Hajj. It’s the largest annual gathering of Homo sapiens on Earth.3 For five days every year, millions of Muslims from across the world converge on Mecca, a sacred but otherwise unremarkable city at the edge of the Arabian desert. Here the pilgrims undertake a series of rituals. They walk seven times counterclockwise around the Kaaba—the black, cube-shaped building at the center of the world’s largest mosque. (See Figure 5.) They also shave their heads; run back and forth between two hills; stand vigil from noon until sunset; drink water from the Zamzam well; camp overnight on the plain of Muzdalifa; sacrifice a lamb, goat, cow, or camel; and cast stones at three pillars in a symbolic stoning of the devil.4
Figure 5. Muslims surrounding the Kaaba in Mecca. source: prmustafa / iStock
What drives these pilgrims is no ordinary biological motive. Unlike the monarch butterflies, they aren’t in search of a more hospitable climate.5 Unlike the wildebeests, Muslims don’t travel to Mecca in search of food. And unlike the crabs of Christmas Island, they aren’t looking for mates; in fact, sexual activity is strictly prohibited during the Hajj.6
From the perspective of an animal struggling to survive and reproduce, the Hajj seems like an enormous waste of resources. A pilgrim traveling from San Francisco, for example, will have to take a week off work, buy an expensive plane ticket to Saudi Arabia, and uproot from her breezy, temperate city to camp out in the sweltering desert—and all for what, exactly?
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. When Henry VIII sought to have his first marriage annulled under the guise of piety, or when religious leaders launch imperialist crusades, we can be forgiven for questioning their motives.7 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.
THE MYSTERY OF RELIGION
The Hajj may be singularly distinctive, but Muslims are hardly alone in undertaking dramatic actions in the name of their religion. Around the world, worshippers wear funny hats, elaborate costumes, special underwear, and tiny logos around their necks. They speak in tongues, dance ecstatically, and dip their babies in baths of holy water. 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. Around the world, worshippers routinely undermine their narrow self-interest by fasting, sacrificing healthy animals, abstaining from certain sexual practices, and undergoing ritual mutilations like piercing, scarification, self-flagellation, and circumcision. Christian Scientists swear off blood transfusions. Mormon men spend two of their prime years stationed off in remote provinces doing missionary work. Many people earmark 10 percent of their income for the church. Even the most mundane form of religious devotion—weekly attendance at church—is like a miniature Hajj: people from a wide geographic area converge at a single location to kneel, bow, pray, sing, chant, and dance in the name of their faith.
The extremes of religious behavior are even more striking. Tibetan Buddhist monks, for example, spend weeks hunched over a flat surface, meticulously placing millions of grains of colored sand to produce an intricate “sand mandala,” only to destroy it almost as soon as they’re finished. Even more astonishing (from a Darwinian perspective) is the fact that these monks, along with religious leaders of many other traditions, take vows of poverty and chastity, effectively removing themselves from both the rat race and the gene pool. Yet other religious zealots undertake the ultimate sacrifice by martyring themselves in the name of their religions.
What, on Darwin’s green Earth, is going on here?
Actually, religion presents not one but two striking puzzles. In addition to the behaviors, we also have to explain the menagerie of peculiar religious beliefs. A quick tour of the these would include gods, angels, ghosts, demons, talking animals, virgin births, prophecies, possessions, exorcisms, afterlives of all sorts, revelation, reincarnation, transubstantiation, and superaquatic perambulation—to name just a few. And that doesn’t even include creation myths, a particularly rich vein of exotic beliefs.
Where—again, on Earth—do these supernatural beliefs come from?
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, as in Figure 6.
Figure 6. Belief-First Model of Religion
Although this turns out not to be the view held by most anthropologists and sociologists, it’s nevertheless a popular perspective, in part because it’s so intuitive. After all, our beliefs cause our behaviors in many areas of life—like when believing “I’m out of milk” causes us to visit the market. In fact, the belief-first model is something that both believers and nonbelievers often agree on, especially in the West. Debates between prominent theists and atheists, for example, typically focus on the evidence for God or the lack thereof. 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.
Before we discuss how religion is strategic, it might help to put the belief-first model in perspective. For one thing, not all religions put such a premium on doctrine. Most religions are fairly lax on questions of private belief as long as adherents demonstrate public acceptance of the religion.11 In this regard, faith-based religions like C
hristianity and Islam are the exception rather than the rule.12 Historical religions, such as those of the ancient Greeks and Romans, were less concerned with doctrinal propositions like, “Zeus rules the gods on Mount Olympus,” and more concerned with ritual observance, like coming out to celebrate on public holidays. Other religions, like Hinduism, Judaism, and Shintoism, are as much ethnicities and cultural traditions as they are sets of beliefs about supernatural entities, and people can be wholly accepted as members of the religion without believing in the literal existence of the gods in question. Many Jews, for example, consider themselves atheists, and yet continue practicing Judaism—going to temple, keeping kosher, and celebrating the high holidays.
At the same time, we engage in a wide variety of activities that have a religious or even cult-like feel to them, but which are entirely devoid of supernatural beliefs.13 When Muslims face Mecca to pray, we call it “religion,” but when American schoolchildren face the flag and chant the Pledge of Allegiance, that’s just “patriotism.” And when they sing, make T-shirts, and put on parades for homecoming, that’s “school spirit.” Similarly, it’s hard to observe what’s happening in North Korea without comparing it to a religion; Kim Jong-un may not have supernatural powers, but he’s nevertheless worshipped like a god. Other focal points for quasi-religious devotion include brands (like Apple), political ideologies, fraternities and sororities, music subcultures (Deadheads, Juggalos), fitness movements (CrossFit), and of course, sports teams—soccer, notoriously, being a “religion” in parts of Europe and most of Latin America. 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.
