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Showing that you care: The evolution of health altruism

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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 that 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. I can explain these puzzles moderately well by assuming that humans evolved deep medical habits long ago in an environment where people gained higher status by having more allies, honestly cared about those who remained allies, were unsure who would remain allies, wanted to seem reliable allies, inferred such reliability in part based on who helped who with health crises, tended to suffer more crises requiring non-health investments when having fewer allies, and invested more in cementing allies in good times in order to rely more on them in hard times. These ancient habits would induce modern humans to treat medical care as a way to show that you care. Medical care provided by our allies would reassure us of their concern, and allies would want you and other allies to see that they had pay enough to distinguish themselves from posers who didn't care as much as they. Private information about medical quality is mostly irrelevant to this signaling process. 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.

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... Altruism and caregiving are closely linked both in research into the motives and practice of healthcare provision (e.g. Gormley 1996 ;Green 1982 ;Hanson 2008 ;Ponthière 2011 ) and in the popular psyche (Green 2003 ;Mattis et al. 2009 ). The literature on aspects of altruism is extensive, spanning evolutionary biology and evolutionary psychology, through economics, to social psychology, medical sociology and philosophy (e.g. ...
... Both Hanson ( 2008 ), an economist, and Sugiyama ( 2004a ) identify the importance to the caregiver of establishing a 'reputation for generosity or unique abilities' (Hanson 2008 :15;Sugiyama 2004a ). Hanson ( 2008 ) directly attributes the development of health-related care provision, or 'deep medical habits' (Hanson 2008 :2), to the importance of creating allegiances in the uncertain environment in which humans evolved. ...
... Both Hanson ( 2008 ), an economist, and Sugiyama ( 2004a ) identify the importance to the caregiver of establishing a 'reputation for generosity or unique abilities' (Hanson 2008 :15;Sugiyama 2004a ). Hanson ( 2008 ) directly attributes the development of health-related care provision, or 'deep medical habits' (Hanson 2008 :2), to the importance of creating allegiances in the uncertain environment in which humans evolved. The cost of care provided to an ally signals caregiver reliability; where the carer is willing to bear signifi cant costs, this strengthens the alliance. ...
Chapter
The Origins of Care Chapter 4 explores the origins of care. It looks at some of the constituent elements of caregiving behaviour and the possible drivers of these (including reciprocity, altruism, cooperation and emotion); at whether caregiving evolved as a biological or a cultural solution to conspecific experience of disease; and at whether it is even possible to distinguish between the processes of biological and cultural selection in relation to care provision. It then considers what the views held on the origins and underlying motivations of care imply for a bioarchaeology of care approach. This chapter does not pretend to provide answers but, in a process most accurately described as a meditation, borrows eclectically from sources in evolutionary biology and psychology, sociobiology, philosophy, cognitive and social psychology, and the archaeology of emotion in an attempt to identify some of the important questions.
... Altruism and caregiving are closely linked both in research into the motives and practice of healthcare provision (e.g. Gormley 1996 ;Green 1982 ;Hanson 2008 ;Ponthière 2011 ) and in the popular psyche (Green 2003 ;Mattis et al. 2009 ). The literature on aspects of altruism is extensive, spanning evolutionary biology and evolutionary psychology, through economics, to social psychology, medical sociology and philosophy (e.g. ...
... Both Hanson ( 2008 ), an economist, and identify the importance to the caregiver of establishing a 'reputation for generosity or unique abilities' (Hanson 2008 :15;. Hanson ( 2008 ) directly attributes the development of health-related care provision, or 'deep medical habits' (Hanson 2008 :2), to the importance of creating allegiances in the uncertain environment in which humans evolved. ...
... Both Hanson ( 2008 ), an economist, and identify the importance to the caregiver of establishing a 'reputation for generosity or unique abilities' (Hanson 2008 :15;. Hanson ( 2008 ) directly attributes the development of health-related care provision, or 'deep medical habits' (Hanson 2008 :2), to the importance of creating allegiances in the uncertain environment in which humans evolved. The cost of care provided to an ally signals caregiver reliability; where the carer is willing to bear signifi cant costs, this strengthens the alliance. ...
Chapter
Chapter 7 corresponds to Stage 4 of the bioarchaeology of care methodology, the final stage of a bioarchaeology of care analysis. The central premise of Stage 4 analysis is that the behaviours making up the giving and receiving of health-related care (embodied in the evidence in human remains for survival with disease) express the agency of caregivers and care-recipients alike; if we can interpret this agency by deconstructing the steps taken in the ‘decision making path’ that resulted in care, this has the potential to illuminate aspects of the group, the individual and the contemporary lifeways. Chapter 5 laid out the background to and justification for this position, and Chapter 7 applies the conceptual framework for understanding care-related decision making developed in this earlier chapter to teasing out insights into culture and practice, social relations and collective and personal identity. Chapter 7 explains the processes involved in Stage 4 analysis, and describes the elements of the corresponding Step 4 of the Index of Care.
... Our methodology seeks a way to circumvent the well-known tradeoff between moral hazard and risk-bearing in health care markets. Hanson notes that in such markets, consumers may spend well beyond the point where marginal cost exceeds marginal benefit [1]. Insured consumers lack the motive to reveal or even assess such tradeoffs [2] and insurance pays for most medical expenses [3]. ...
... Hanson [1] suggests that humans retain an ancient habit of providing medical care in order to "show that they care," i.e., to signal loyalty to associates. His model can integrate explanations of regulatory health paternalism, a low marginal health-value of medical care, and a strong social-status health-gradient. ...
... Some well known economists also claim that increases in health spending has no effect on health status and Milton Friedman (2001) even argued that the return was negative since increased spending tended to increases bureaucracy which meant that even less got done than before. More recently, and more convincingly, Robin Hanson (2008) has argued that increases in health spending has very low or zero return. His main evidence is the Rand Health Insurance Experiment (Manning et al 1987). ...
... One of the health economists who have examined the relationship between health care decisions and motivations, is Robin Hanson (2008). His argument is that health care is treated very differently from other goods because we have very different moral intuitions and norms about health care than other goods. ...
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... These include culturally localized behaviors such as dueling (Allen & Reed, 2006), restrictions of female freedom (Rai & Sengupta, 2013), honor killings (Thrasher & Handfield, 2018), terrorism and political violence (Hoffman & McCormick, 2004;Lapan & Sandler, 1993;Pape, 2006), as well as broad categories of behavior such as aggression (Frank, 1988), grief (Winegard et al., 2014) and regret (Rosenstock & O'Connor, 2018). Others have argued that relatively costly activities widely assumed to be worthwhile, but for which the direct evidence of their success is often underwhelming (such as higher education and healthcare), can be explained as instances of costly signaling (Caplan, 2018;Hanson, 2008). Even behaviors that appear to be deliberately avoiding flamboyance, such as small, hard to observe fashion logos or anonymous donations, may be amenable to a signaling explanation (Hoffman et al., 2018). ...
Article
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... However, Minoiu and Rodríguéz Andres measure public health and welfare spending as a share of total state expenditures. Like Hanson (2008), they argue that these shares signal intensity or effort level of support by the state to those considering suicide. Unfortunately, the Minoiu and Rodríguéz Andres (2008) measure of spending on health and welfare literally implies that suicides can be reduced more by spending $1 million out of a $10 million budget rather than $10 million out of a $1 billion budget. ...
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... Health policy is another striking example of an emotionally charged area, and the treatment of healthcare is accordingly different, even though there are no plausible reasons why provision of health care should be treated differently than provision of any other services on the market. Hanson (2008) links the calls for increased government intervention in healthcare to our desire to show that we care. Further, the Americans with Disabilities Act, with an admirable intention to help people with disabilities find employment or keep their jobs, ended up having the entirely opposite outcome. ...
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... A posthuman healthspan capacity would give one the option of much longer and healthier life, but one could at any point decide no longer to exercise the capacity. 7 Although on the last item, see (Hanson 2000) for an alternative view. 8 (Viscusi and Aldy 2003). ...
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Thesis
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To the Editor. —Dr Hunink and colleagues1 are to be commended for their effort in attempting to model the various contributions of preventive and secondary modalities on the observed decline in mortality associated with coronary heart disease (CHD) from 1980 through 1990. However, their application of the model extends too far into the realm of causal inference, in which mathematical models have a limited role. We believe that their inferential procedures and logical stance are in error.The authors' argument may be summarized in the following syllogism: Their major premise is that reductions in CHD mortality are caused either by changes in risk factors or by changes in treatment; their minor premise is that only 50% of the reduction in CHD mortality can be attributed directly to risk factor changes; and their conclusion is that a large portion of prevented deaths are attributable to improvements in treatment.The major
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Context.— Publicly released performance reports ("report cards") are expected to foster competition on the basis of quality. Proponents frequently cite the need to inform patient choice of physicians and hospitals as a central element of this strategy.Objective.— To examine the awareness and use of a statewide consumer guide that provides risk-adjusted, in-hospital mortality ratings of hospitals that provide cardiac surgery.Design.— Telephone survey conducted in 1996.Setting.— Pennsylvania, where since 1992, the Pennsylvania Consumer Guide to Coronary Artery Bypass Graft [CABG] Surgery has provided risk-adjusted mortality ratings of all cardiac surgeons and hospitals in the state.Participants.— A total of 474 (70%) of 673 eligible patients who had undergone CABG surgery during the previous year at 1 of 4 hospitals listed in the Consumer Guide as having average mortality rates between 1% and 5% were successfully contacted.Main Outcome Measures.— Patients' awareness of the Consumer Guide, their knowledge of its ratings, their degree of interest in the report, and barriers to its use.Results.— Ninety-three patients (20%) were aware of the Consumer Guide, but only 56 (12%) knew about it before surgery. Among these 56 patients, 18 reported knowing the hospital rating and 7 reported knowing the surgeon rating, 11 said hospital and/or surgeon ratings had a moderate or major impact on their decision making, but only 4 were able to specify either or both correctly. When the Consumer Guide was described to all patients, 264 (56%) were "very" or "somewhat" interested in seeing a copy, and 273 (58%) reported that they probably or definitely would change surgeons if they learned that their surgeon had a higher than expected mortality rate in the previous year. A short time window for decision making and a limited awareness of alternative hospitals within a reasonable distance of home were identified as important barriers to use.Conclusions.— Only 12% of patients surveyed reported awareness of a prominent report on cardiac surgery mortality before undergoing cardiac surgery. Fewer than 1% knew the correct rating of their surgeon or hospital and reported that it had a moderate or major impact on their selection of provider. Efforts to aid patient decision making with performance reports are unlikely to succeed without a tailored and intensive program for dissemination and patient education.
Article
This article extends the literature on adverse selection in the medical expense insurance market. Empirical tests are conducted to determine whether low risk individuals purchase less complete individual (nongroup) medical expense insurance than high risk individuals whose risk levels are unobservable by the insurer. The study also investigates whether a separating or pooling equilibrium characterizes the individual medical insurance market and whether policy cross-subsidization from low to high risks occurs. Findings are consistent with the presence of adverse selection in the individual medical expense insurance market, where low and high risks purchase a pooling insurance policy and low risks subsidize the insurance purchase of high risk insureds.
Article
Time series methods are used to make long-run forecasts, with confidence intervals, of age-specific mortality in the United States from 1990 to 2065. First, the logs of the age-specific death rates are modeled as a linear function of an unobserved period-specific intensity index, with parameters depending on age. This model is fit to the matrix of U.S. death rates, 1933 to 1987, using the singular value decomposition (SVD) method; it accounts for almost all the variance over time in age-specific death rates as a group. Whereas e0 has risen at a decreasing rate over the century and has decreasing variability, k(t) declines at a roughly constant rate and has roughly constant variability, facilitating forecasting. k(t), which indexes the intensity of mortality, is next modeled as a time series (specifically, a random walk with drift) and forecast. The method performs very well on within-sample forecasts, and the forecasts are insensitive to reductions in the length of the base period from 90 to 30 years; some instability appears for base periods of 10 or 20 years, however. Forecasts of age-specific rates are derived from the forecasts of k, and other life table variables are derived and presented. These imply an increase of 10.5 years in life expectancy to 86.05 in 2065 (sexes combined), with a confidence band of plus 3.9 or minus 5.6 years, including uncertainty concerning the estimated trend. Whereas 46% now survive to age 80, by 2065 46% will survive to age 90. Of the gains forecast for person-years lived over the life cycle from now until 2065, 74% will occur at age 65 and over. These life expectancy forecasts are substantially lower than direct time series forecasts of e0, and have far narrower confidence bands; however, they are substantially higher than the forecasts of the Social Security Administration's Office of the Actuary.
Article
Previous research has documented consistently that persons holding low-socioeconomic status (SES) positions are more strongly affected emotionally by undesirable life events than are their higher-status counterparts. Two types of resources have been implicated in this differential vulnerability: financial resources and a broader class of coping resources, including social support and resilient personality characteristics. We present an analysis that disaggregates measure of life events and of SES to identify which events and which components of SES are most important for understanding differential vulnerability. We document that the lower-SES vulnerability persists across all types of personal events. In addition, we find that differential vulnerability is not confined to income but extends to education and occupational status as well. On the basis of these patterns, we conclude that differential vulnerability reflects more than a simple economic reality. Previous research offers speculative evidence that status differences in past and current social environments may explain differential vulnerability, especially through their effects on the socialization of resilient personality characteristics. We propose future research that could help to evaluate the validity of these speculations.
Article
Objective. —To examine whether secular trends in risk factor levels and improvements in treatment can account for the observed decline in coronary heart disease mortality in the United States from 1980 to 1990 and to analyze the proportional contribution of these changes.Data Sources. —Literature review, US statistics, health surveys, and ongoing clinical trials.Study Selection. —Data representative of the US situation nationwide reported in adequate detail.Data Extraction. —A computer-simulation state-transition model of the US population between the ages of 35 and 84 years was developed to forecast coronary mortality. The input variables were estimated such that the combination of values led to an adequate agreement with reported coronary mortality figures. Subsequently, secular trends were modeled.Data Synthesis. —Actual coronary mortality in 1990 was 34% (127 000 deaths) lower than would be predicted if risk factor levels, case-fatality rates, and event rates in those with and without coronary disease remained the same as in 1980. When secular changes in these factors were included in the model, predicted coronary mortality in 1990 was within 3% (10 000 deaths) of the observed mortality and explained 92% of the decline; only 25% of the decline was explained by primary prevention, while 29% was explained by secondary reduction in risk factors in patients with coronary disease and 43% by other improvements in treatment in patients with coronary disease.Conclusions. —These results suggest that primary and secondary risk factor reductions explain about 50% of the striking decline in coronary mortality in the United States between 1980 and 1990 but that more than 70% of the overall decline in mortality has occurred among patients with coronary disease.
Article
Intensive food sharing among foragers and horticulturists is commonly explained as a means of re-ducing the risk of daily shortfalls, ensuring adequate daily consumption for all group members who ac-tively pool resources. Consistently high food producers who give more than they receive, however, gain the least risk-reduction benefit from this daily pooling because they are the least likely to go without food on any given day. Why then do some high producers consistently share food, and why do some av-erage producers share proportionally more food than others? We propose that although these individuals may not receive the same amounts they give (i.e., strict Tit-for-Tat), one explanation for their generosity is that they receive additional food during hard times. These include brief episodes of sickness, disease, injury, or accidents—fairly common events in traditional societies that can render individuals incapable of producing food, thereby having long-term effects on morbidity and fecundity and ultimately on life-time reproductive success. Data collected among the Ache, a group of South American forager-horticul-turists, indicate that those who shared and produced more than average (signaling cooperative intent and/or ability to produce) were rewarded with more food from more people when injured or sick than those who shared and produced below average. These results, framed within the context of tradeoffs be-tween short-term and long-term fitness, may provide insight into motivations behind costly expenditures for establishing and reinforcing status and reputation.
Article
Posted 06/26/1998. Mean effect sizes for changes in depression were calculated for 2,318 patients who had been randomly assigned to either antidepressant medication or placebo in 19 doubleblind clinical trials. As a proportion of the drug response, the placebo response was constant across different types of medication (75%), and the correlation between placebo effect and drug effect was .90. These data indicate that virtually all of the variation in drug effect size was due to the placebo characteristics of the studies. The effect size for active medications that are not regarded to be antidepressants was as large as that for those classified as antidepressants, and in both cases, the inactive placebos produced improvement that was 75% of the effect of the active drug. These data raise the possibility that the apparent drug effect (25% of the drug response) is actually an active placebo effect. Examination of pre–post effect sizes among depressed individuals assigned to no-treatment or wait-list control groups suggest that approximately one quarter of the drug response is due to the administration of an active medication, one half is a placebo effect, and the remaining quarter is due to other nonspecific factors.
Book
Is it better to be a big frog in a small pond or a small frog in a big pond? In this lively and original book, the author argues persuasively that people's concerns about status permeate and profoundly alter a broad range of human behaviour. He takes issue with his fellow economists for too often neglecting fundamental elements in human nature in their study of how people make basic economic choices.
Article
Moller (1967/68) proposes that the presence of a large number of adolescents and young adults in a population is a precursor of violent conflicts. But acts of collective aggression are typically perpetrated by males, particularly young males between 15 and 30 years of age. This marked sex difference in the degree of participation is found in all human societies, and it has persisted since the beginning of recorded history. Sexually dimorphic behaviors are invariably found in the context of reproduction, and we discuss male coalitional aggression as a reproductive fitness-enhancing social behavior. This type of social behavior may not increase the welfare of an entire population but it is likely to promote the fitness of the coalition participants. This study argues that the age composition of the male population should be regarded as the critical ecological/demographic factor affecting a population's tendency toward peace or violent conflicts. Our analyses of interstate and intrastate episodes of collective aggression since the 1960s indicate the existence of a consistent correlation between the ratio of males 15 to 29 years of age per 100 males 30 years of age and older, and the level of coalitional aggression as measured by the number of reported conflict related deaths.
Article
We use panel instrumental variables techniques to estimate incremental mortality and cost effects of intensive procedures for treating heart attacks among the elderly. We identify incremental effects by comparing trends in procedure use, hospital costs, and mortality between hospitals that adopted intensive technologies to corresponding trends at nonadopting hospitals. We formalize the identification assumptions required for ‘difference-in-differences’ estimation and present empirical evidence on their validity. Accounting for unobserved heterogeneity substantially reduces estimated mortality effects and additional costs of intensive procedure use. Our most conservative estimate of the average cost of each additional one-year AMI survivor associated with more intensive medical treatment is at least $40,000 in 1987 dollars; more plausible estimates are $70,000 or more.
Article
Much work has been done analyzing the determinants of health care expenditures. Much less effort has been devoted to analyzing the determinants of health itself. The focus of the analysis presented here is the production of health, with special attention paid to disaggregating health into pharmaceuticals and other health care. We also analyze the effects that wealth and certain lifestyle factors have on health. Researchers who have analyzed the determinants of health across geographic units have found certain striking and consistent results. First, basic public health services, in the form of potable water and sanitation services, provide the biggest payoffs in decreased mortality for all age groups. Second, the expansion of health care services does not improve mortality to anywhere near the extent that public health infrastructure development does, if at all. Some researchers have even found positive relationships between some health care inputs and mortality. The results on income and wealth have been more mixed. In studies which have analyzed developing countries, researchers have found that higher incomes are negatively related to mortality. Other researchers have found exactly the opposite result when they have limited their samples to rich countries and/or regions thereof. Many researchers have also found that lifestyle factors such as nutrition, and cigarette and alcohol consumption, are important determinants of health. Very few studies have estimated the effects of pharmaceutical consumption on mortality rates either directly or indirectly. The studies which have dealt with this directly in an international comparison context have had serious flaws. Some micro studies and many studies of restricted formularies in the United States Medicaid program have provided indirect evidence that pharmaceutical consumption has a positive impact on health. To investigate whether such an effect could be found in an analysis of international data, we analyze a sample cons
Article
Sumario: Health values: a comparative analyses -- Valuation of common symptons -- Valuation of serious illness -- Policy
Article
This chapter focuses on the way in which the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm. The term norm that the economist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be offered and purchased and the prices that would be paid for them. The interest in the competitive model stems partly from its presumed descriptive power and partly from its implications for economic efficiency. If a competitive equilibrium exists at all and if all commodities relevant to costs or utilities are in fact priced in the market, then the equilibrium is necessarily optimal. There is no other allocation of resources to services that will make all participants in the market better off. The most obvious distinguishing characteristics of an individual's demand for medical services is that it is not steady in origin as, for example, for food or clothing but is irregular and unpredictable. Medical services, apart from preventive services, afford satisfaction only in the event of illness, a departure from the normal state of affairs.