Showing That You Care

My ambitious theory paper, which attempts to explain diverse health behavior puzzles with just a few assumptions, has finally been published in Medical Hypotheses.  (Print copies were mailed today.)  The abstract

Human behavior regarding medicine seems strange; assumptions and models that seem workable in other areas seem less so in medicine. Perhaps, we need to rethink the basics. Toward this end, I have collected many puzzling stylized facts about behavior regarding medicine, and have sought a small number of simple assumptions which might together account for as many puzzles as possible.

The puzzles I consider include a willingness to provide more medical than other assistance to associates, a desire to be seen as so providing, support for nation, firm, or family provided medical care, placebo benefits of medicine, a small average health value of additional medical spending relative to other health influences, more interest in public than private signals of medical quality, medical spending as an individual necessity but national luxury, a strong stress-mediated health status correlation, and support for regulating health behaviors of the low status. These phenomena seem widespread across time and cultures.



If people with fewer allies are less likely to remain our allies, and if we care about them mainly assuming they remain our allies, then we want them to invest more in health than they would choose for themselves. This tempts us to regulate their health behaviors. This analysis suggests that the future will continue to see robust desires for health behavior regulation and for communal medical care and spending increases as a fraction of income, all regardless of the health effects of these choices.

When I wrote this paper ten years ago I didn’t understand that there is simply no academic market for such grand theory papers, at least written by non-stars.  Reviewers consistently reject them saying they know of phenomena that the theory doesn’t seem to account well for, but sometimes they admit they think grand theorizing should be reserved for academic stars.

Added: As requested, here are some of those referee comments:

"This is bizarre theory [because] … a taxpayer … will not generally place much weight on the health care to a single anonymous individual."

"As for the source of pressure for funding health care, isn’t it mostly employers?  They have an interest in having reliable employees.  … National health insurance provides for everyone, most of whom are not allies. … Contrary to the idea that the poor will have more care forced in them than they might want, there are obviously many countries where they have no access to health care at all. … International health insurance makes no sense because of purely practical matters and its absence does not need any other explanation." 

""The article appears to conflate a number of discrete behaviors (e.g., investing in the health of others vs. encouraging others to invest in their health themselves).  And the suite of health-care behaviors referred to in the article is, I fear too complex to be accounted for by two or three factors.  For example, it is highly plausible that those who invest in the health care of others are motivated by the desire to find a cure in case they (the investors) or their significant others fall victim to the same disease."   

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  • burger flipper

    My conversational citations of the cop/status/life expectancy post probably don’t boost your Web of Science rankings, which is a shame. Glad to have a lengthier treatment of the health care stuff which is always interesting.

    When is the book on disagreement coming out?


    I’m sure it’s an interesting theory but (speaking as a total layman) I think the introduction could have been more clearly expressed and also I think I noticed several typos in the PDF.

    Maybe that is another factor to consider besides your (no doubt justified) suspicion of academic prestige bias?

  • student

    Would the reviewer mention which phenomena the paper couldn’t account for? I first read some of Robin’s theories on health care about six months ago, and I have been amazed by how much behavior your signaling theory accounts for. When I think of types of observations that would disprove your theory I figure that if many people began to show a preference for good health and ceased demand for expensive medicine of dubious benefit, then your theories would be thrown into serious doubt. Or, your theory would be in doubt if people stopped caring whether other people or the government paid for medical services. Additionally, if individuals started taking hospital reviews very seriously or if individuals kept questioning the doctor’s advice for them then the theory would be in doubt. I think I can recall a study that confirmed the first case, I don’t know about the second, though.

    I struggle to think of how the reviewers were able to get the evidence so quickly that they could say Robin’s paper does not account for observations. It strikes me that the confirmation/falsification of Robin’s theories is going to require a great deal more empirical evidence than is presently available. Perhaps the reviewers were just waiting for something empirical. I’ve heard of several publishing biases on this blog.

  • mike kenny

    hm, that theory dovetails with the theory i’ve heard that depression can be sort of like going on strike. a person gets depressed, stops doing what he normally does, and this causes a process to begin of evaluating the depressed person and negotiating with him over what he will do and what he won’t.

    a depressed person might find out what he does that is good and bad for the group by getting depressed and stopping what he normally does. he stops helping collect food and people get angry at him, and he resumes doing that, and he stops chatting in a friendly way with some members of his group, and finds that no one cares one way or the other, so he quits doing this and puts the energy he put into that activity towards something else. he stops being playful with other members of his group, and finds they bring him extra food and try to persuade him into playing more, so he sees that behavior is in demand and he can get more for it.

    the result in a social context might be that he finds a niche, stops doing pointless things, and understanding what behaviors have a point and are useful to others.

  • Robin Hanson

    See my “added” to the post.

  • Hal Finney

    I mentioned yesterday that some of these same concepts might shed light on the religion puzzle. If we stipulate that being religious fosters cooperative behavior (being honest and trustworthy, helping others in need) then the religious would make good allies. Encouraging your allies to be more religious than they might wish to be on their own will benefit you, and also make you a more attractive alliance member since you would have such good policies for strengthening your alliance. In some ways our beliefs about health are almost religious in nature (see the resistance to Robin’s apostasy regarding medicine’s benefits).

  • Eric Falkenstein

    Two more motives for public health care:

    Envy. Given that spending collective resources on the poor will most likely be funded through a progressive tax (no one is for a revenue neutral fix of health care), this is a way to tax ‘the rich’ more, so saying we should pay for indigents is a way to bring the rich closer to the median voter. The beauty is, this petty emotion is masked by a concern for charity, the poor. Concern about status implies envy.

    Countersignaling. I could be so rich, like Buffet, Gates, or Soros, taxing me more will still leave me a billionaire, able to purchase anything I could imagine. My ability to credibly be for taxing ‘the rich’ just shows how really really rich I am, and so status superior.

  • EconLog

    Publishing the Unpublishable Paper

    One of Robin Hanson’s greatest unpublishable papers has finally been published. “Showing That You Care: The Evolution of Health Altruism”…

  • Silas

    Shouldn’t there be more semi-colons and other punctuation in the second paragraph? I found it hard to parse. Here’s what I would have done:

    The puzzles I consider include a willingness to provide more medical than other assistance to associates and a desire to be seen as providing it; support for nation-, firm-, or family-provided medical care; placebo benefits of medicine; …

  • Barkley Rosser

    I will not ask where, but how many journals turned you down before you finally scored?
    Congratulations in any case.

  • martin larsen

    This theory unfortunatley suffers from the same problems as other theories trying to prove aspects of the emotional nature of man in terms of evolutionary psychology: 1) it is and remains unproven speculation, 2) It reveals a lack of insight into the emotional nature of man.

    The attemt to explain these things by inventing a logical flat causative sequence of events is a function of the scientist only being able to use his intellectual thinking side, while being like most other contemporary people, out of touch with his feeling nature.

    One basic and wrong assumption of evolutionary thinking is this idea of egoism and separateness. What is pertinent to remember is that while every living entity is an individual, it is also a part of the whole of its species or group in a much more concrete way than presumed. This connection is through the feeling/emotional nature (that is unfortunatly, as i said undeveloped in contemporary man, and perhaps even more in scientistically minded people who’s intellectual, logical side is dominating, making it paradoxically even harder for these people to understand this). The idea of a group mind is to be found in many traditions and can be verified on a personal level. This naturally explains things like empathy, why birds organze so elegantly while flying, telepathy etc. This may be counterintuitive from the point of view of how we sense the world, but isn’t it a while now since physicists discovered that our senses aren’t telling the truth about reality?

  • eric falkenstein

    I too am working on a paper based on a utility function that cares about other people. I have found that the general dislike of my nontraditional approach has criticisms that are inconsistent, and probably reflect the fact that the initial reaction was negative, and they grabbed a standard criticism. For example, one reviewer said, you need a clean empirical test, another said, you need to generate auxiliary predictions to the main one you address. In both cases, I had, but that was mentioned after page 3, to which the reviewer probably did not get. One esteemed editor said merely that my result was not of general interest. I was asserting risk was not related to return in equilibrium, a rather broad assertion if true. I mentioned this meekly in a reply, and the editor corrected himself and gave me a different irrelevant objection, basically admitting his first objection was BS, but it didn’t matter because my paper didn’t pass the gut feel test. One reviewer mentioned my framework was too simplistic, even though it was identical to the framework it was criticizing but with one change in the assumption (the utility function). Thus, I would not take the articulated concerns at face value, because I think people feel that results they perceive as wrong or irrelevant will disappear soon enough, and it does no good to take them seriously. And surely, if they are right in their gut feel, they are correct.

    But in your case, let me be harsh. If you are hypothesizing that interest in other’s health is because it helps us build coalitions, which we assume are valuable, does the implication that people will then subsidize others health care anything but obvious? Further, if health care policy is decided at a national level, and voting is done in private, how does this relate to the tribal situation you have described? Its not obvious that a large group like nationalized health care advocates, are a status group like my buddies on the savanna. That group seems too big to be a status group, like aligning with Democrats or Republicans, as opposed to joining the KKK or Black Panthers (both small enough to have monitoring, and an us-versus-them mentality).

    Now it is true that some models, like DeLong, Shleifer, Summers and Waldeman’s paper on short-lived speculators (1990), is like yours, in that the model does what the intro says: if you have capital constraints, trend-following noise traders may make it rational to follow trends. They then model this. But that model was never extended by anyone else because it merely did in algebra what everyone expected who read the first two pages. It is often referenced, but only, in my opinion, because it plays into a large thread (efficient vs. inefficient markets).

  • Biomed Tim

    Why do people think that grand theorizing should be reserved for stars? Do they think that stars are better at grand theorizing than non-stars?

  • Craig T. Nelson

    martin larsen said:

    How might I personally verify telepathy? I want my nobel prize!

    Once I have this verification, I also intend to embarrass all those snotty AI researchers who think they can explain bird flocking without recourse to psychic powers and group minds.

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  • Jess Austin

    Maybe the hypothesis would get a bit more traction if it focused just on current observable conditions, and left off the half-baked etiology? The evopsych just-so stories were never scientific, but in these modern times (the last 20 years?) they’re not fashionable either.

    Are you saying that signaling via healthcare is an instinct? Most ethologists would contend that Homo sapiens has essentially no instincts that operate after infancy. Are you proposing some sort of innate mental facility for tracking healthcare-related altruism? That’s bizarre too.

    Anyway, if you’ll forgive me for momentarily donning my evopsych cap, aren’t the sick and injured the least likely to repay one’s efforts on their behalf, in a Paleolithic setting anyway? In my own amateur observation of semi-feral cats, sick and injured individuals seem to receive increased abuse from their fellows. I could imagine some vague evolutionary mechanism for that, but I’ll settle for just wondering why primates would be any different.

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  • Peter David Jones

    ” National health insurance provides for everyone, most of whom are not allies. ”

    Indeed. What’s the response?

    • Stephen Diamond

      I think the Hansonian response would (or should) be coalition politics: creating the NHS was driven by a political coalition (gathered by the Labor Party). Opponents, such as the large-employer class–who pay more than they receive–aren’t viewed as beneficiaries of largesse.

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