Do You Really Want to Know?

Theodore Dalyrymple has a wonderful article on whether doctors should give terminally sick patients the brutal prognosis or whether they should soften the sentence by giving them more hope than they can reasonably expect. Most of the commenenters on the article’s site clearly said they wanted to know the truth — however unpleasant — when their time came.

… the patient who wants to know, deserves the truth. the doctor who lies to his patient should lose his license … If it’s my time, I want to know. I have things to do and affairs to close. …

My mother was diagnosed with a very aggressive cancer and died 3 months later. I would have highly preferred the doctors to be honest (I had to push them to get the honest answer). I thought they didn’t tell me because I was 6 months pregnant at the time, but it sounds like they do this with every patient. Knowing the truth helps you prepare for it, not only mentally, but financially as well …

It is false mercy to tell a dying man that he isn’t dying. He needs to prepare himself spiritually to meet his Judge. Call in a priest to give him the Last Rites as he draws near to death, and pray for God to heal what doctors cannot, but do not lie to him by denying that he is beyond the help of man’s medicine.

But are those commenters the exception rather than the rule?

Dalyrymple’s major point is that many listeners are themselves deaf to the news of death. The doctors may bear the bad tidings and still they may choose to misunderstand. Dalyrymple quotes literature to explain why we avert our gaze. “Human kind cannot bear very much reality, wrote T. S. Eliot … as La Rochefoucauld said back in the seventeenth century, one can stare neither at the sun nor at death for very long.”

The market for denial is huge and evergreen. Nothing sells so well and the cosmetics industry and politics are testaments to that fact. “On the whole oncologists do tell their mortally ill patients that they are dying,” says Dalyrymple, but from a commercial point of view the truth is poor salesmanship. How many used car salesmen would sell the inventory if they told the customer what the cars on the lot were really like?

Recently the American electorate was faced with a choice between a candidate who told them they economy was sick and another candidate who told them that Happy Days were just around the corner; between a politician who told them that only hard work might save them from bankruptcy and another who promised the certainty of free healthcare, foodstamps, education for all and universal respect for lady parts. Guess who the voters chose?

Hope is a commodity which by definition you can sell even when you can’t deliver . Ran Spiegler wrote an economic paper called The Market For Quacks. In it he defined quacks as suppliers who “possess no skills relative to the default”. By that he meant a patient’s chances of survival are neither improved nor degraded by quackery. What a quack does has no effect on anything but his pocket-book.

If patients understood this model, they would realize that the entire industry provides a worthless service, and the “market for quacks” would be inactive. Indeed, standard market models presuppose that all market agents, firms and consumers alike, have “common knowledge of the model”.

But the market for quacks is not inactive. On the contrary it is quite lucrative because it is arguably easier to sell false hope than it is to sell the unvarnished and unpleasant truth. Why is this so? Spiegler argues this springs from the individual belief that they will be the exception to the rule. The mortality tables may say that a given disease is 99.9% fatal in 3 months. But there is something about the individual that allows him to think he will be in the 0.01%.

Instead of reasoning probabilistically with respect to a correct market model, patients reason anecdotally: they rely on random, casual stories regarding the quality of treatments, and react to these stories as if they are fully informative of the actual quality of treatments. As a result, patients are exposed to exploitation by healers, because they attribute their occasional success to skill rather than luck. The question is whether market competition could mitigate this exploitative e¤ect. I examine the extreme case of a “market for quacks” – that is, a market for a completely worthless good or service – in order to bring this question into sharper focus.

What Spiegler does not address very well is what I would call the breakdown of rationality in life and death conditions. The normal scale of values is altered at the point of death. A billionaire in health might not consider it worthwhile to spend a 100 million dollars on a .00001% chance of survival. But since he can’t take the money with him, wagering on a quack at the point of dying may seem more attractive if he is given a dire prognosis by a doctor.

Jay Kim and John Haleblian in another economics paper argue that desperation can make a firm overpay for assets it might otherwise not acquire, something that all of us probably intuitively understand. Historians have long known that men entering battle have steadied themselves by thinking that however dire the situation, they might be the ones to just make it out.

Hope is most valuable when it is least plausible. Hence the market for quacks.

This raises the interesting possibility that Barack Obama’s re-election was in part aided by the abject failure of his first term. The patient, having been brought by the quack to the point of death, then had a choice between a doctor who, as Dr. Dalyrmple’s commenters preferred, told them the truth. The alternative was even more quackery. Realizing that Dr. Romney’s treatments might be painful and uncertain, is it any wonder that so many voters chose the medico who promised free, easy and miraculous recovery?

Those who think that a second, even more disastrous Obama second term will ensure the rejection of his policies should consider whether they might not make things so bad that the only possibility of survival is more of the same.