Booknotes: The Elephant in the Brain

Last update: Jan 21, 2022

BookNotes on The Elephant in the Brain, by Kevin Simler and Robin Hanson

When I was in elementary school, I bought a tiny notebook. On the first page, I wrote, “notes to understand why people do what they do.” Years later, I would read this book. It is the most dense set of explanations I have found to answer my question, and provided clear justifications for so many things that had been puzzling for so long.

Education doesn't seem to always be about education. Neither does charity, or politics. Even the field of medicine breaks down when you look at it closely. Why are there so many paradoxes when we look at human behavior?

This book tries to explain some of them by proposing possible underlying motives through the lens of evolutionary psychology, and does a fantastic job of probing at hard questions. At times, reading felt like taking the famous red pill, even though the reader does not necessarily have to agree with everything that is being presented.

Social status, sex, and politics are the three most important “games” played by our ancestors - and we still instinctively act accordingly. Yet people don’t typically think or talk in terms of maximizing those elements. In fact, we’re able to act quite skillfully and strategically, pursuing our self-interest without explicitly acknowledging it, even to ourselves. All three of there "games" are competitive struggles, though, which tend to be quite wasteful.

Thesis: We, human beings, are a species that’s not only capable of acting on hidden motives —we’re designed to do it in order to come out ahead in social games. Our brains are built to act in our self-interest while at the same time trying hard not to appear selfish in front of other people. The less we know of our own ugly motives, the easier it is to hide them from others. Self-deception is therefore strategic, a ploy our brains use to look good while behaving badly. This is why we mostly portray our motives as cooperative and prosocial.

Setting up some context:

The game of status

Social status is traditionally defined as one’s rank or position within a group—where you stand on society’s totem pole. It’s a measure of respect and influence. The higher your status, the more other people will defer to you and the better they’ll tend to treat you. Status can be divided into two categories:

Dominance is the kind of status we get from being able to intimidate others (think Joseph Stalin), and on the low-status side is governed by fear and other avoidance instincts.

Prestige, however, is the kind of status we get from being an impressive human specimen (think Meryl Streep), and it’s governed by admiration and other approach instincts. Another way to think about prestige is that it’s your “price” on the market for friendship and association (just as sexual attractiveness is your “price” on the mating market). Prestige seems much less competitive, at least on the surface. It’s all about respect, which can’t be taken by force, but rather must be freely conferred by admirers. Nevertheless, there’s only so much respect to go around. In this regard, prestige is like a popularity contest, similar to the kind found in high schools around the world (only perhaps not quite as vapid). Prestige-seeking itself is more nearly a zero-sum game. Even the poorest members of today’s world are richer, by many material standards, than the kings and queens of yesteryear—and yet they remain at the bottom of the prestige ladder.

Since status is relative, it creates a zero-sum market, so price is driven by supply and demand. We all have a similar (and highly limited) supply of status, sex, and friendship to offer to others, but the demand for what we can offer varies greatly from person to person. How does this market match 'buyers' and 'sellers' then?

Signaling (aka Judge and be judged)

We are constantly evaluating others, looking for certain traits or qualities and trying to estimate certain values. In our mates, we want those with good genes who will make good parents. In our friends and associates, we want those who have skills, resources, and compatible personalities—and the more loyal they are to us, the better. And we’re looking for similar qualities in our political allies, since they’re basically friends chosen for a specific purpose.

The game requires two complementary skill sets: the ability to evaluate potential partners and the ability to attract good partners. Both of these tasks—judging and being judged—are mediated by signals.

A signal, in evolutionary biology, is anything used to communicate or convey information. Signals need to be expensive so they’re hard to fake. More precisely, they need to be differentially expensive—more difficult to fake than to produce by honest means. This is the principle of honest signaling.

Knowledge suppression

“We deceive others, to better deceive ourselves.”

And, on the flip side, “wear a mask long enough and it becomes your face.”

Thanks to generations of signaling and signal-reading, we have gotten pretty good at catching intentional deception. However, the harsh reality remains: dishonest signaling can be incredibly beneficial for the signaler, who can get access to better mate, friends, and allies than they would otherwise. However, only the best deception survives through the generation. And the best deception is self-deception.

Our brains can maintain a relatively accurate set of beliefs in systems tasked with evaluating potential actions, while keeping those accurate beliefs hidden from the systems (like consciousness) involved in managing social impressions. Essentially, there are some games that have evolved to be played with a level of self-deception, and refusing to play that way will actually put you at a game-theoretic disadvantage.

Knowledge suppression is useful when:

  1. Others have partial visibility into your mind and when
  2. They’re judging you, and meting out rewards or punishments, based on what they “see” in your mind.

Raising up altruistic motives

To summarize the last three sections: in our quest for status and status-allocation, we are constantly evaluating the signals of others to find characteristics that we describe as virtuous. We have many reasons for our behaviors, but it makes sense that we accentuate and exaggerate our pretty, prosocial motives and downplay our ugly, selfish ones. This exaggeration is only tolerated when it involves a level of self-deception, or else it is picked up by the other members of the group, and turns into suspicion.

Altruistic motives, then, will oftentimes pop up alongside other, hidden motives - this is the elephant in the brain.

For example, parents will usually enforce a bedtime for their kids “for their own good.” However, a self-serving motive seems just as likely—that parents simply want an hour or two of peace and quiet without the kids. Of course, many parents genuinely believe that bedtimes are good for their children, but that belief is self-serving enough that we should be skeptical that it’s the full story.

Consider how awkward it is to answer certain questions by appealing to selfish motives. Why did you break up with your girlfriend? “I’m hoping to find someone better.” Why do you want to be a doctor? “It’s a prestigious job with great pay.” Why do you draw cartoons for the school paper? “I want people to like me.” There’s truth in all these answers, but we systematically avoid giving them, preferring instead to accentuate our higher, purer motives.

Admittedly, this seems like a cynical view, but even the fact that it appears cynical - a word that carries some social stigma - means that there might be a grain of truth hidden within. And the search for that grain makes this set of questions worthwhile. The quest for truth should matter more than what we would like to believe, and it is possible that there is a deeper level of beauty within an explanation that, at first glance, seems to threaten some of the beautiful parts of our lives.

Rationalization/ The Press Office

Rationalization, sometimes known to neuroscientists as confabulation, is the production of fabricated stories made up without any conscious intention to deceive. They’re not lies, exactly, but neither are they the honest truth. They are the explanations that we can create at a moment’s notice that make our decisions seem reasonable, virtuous, acceptable.

“You are not the king of your brain,” says Steven Kaas. “You are the creepy guy standing next to the king going, ‘A most judicious choice, sire.’ “

All of these ideas lead to some interesting observations about otherwise common-place phenomena. In the spirit of keeping reading time manageable, I have chosen to only cover education, charity, politics, and medicine in depth, leaving out brilliant insights on conversation, religion, art, and consumption. Again, these are just snapshots - if any of these arguments are intriguing to you, please buy the book. They are also free-standing, so feel free to only read the ones that interest you the most, and then to skip to the end for some key lessons and implications that can lead to great social benefit.


We ignore the elephant because doing so is strategic. Self-deception allows us to act selfishly without having to appear quite so selfish in front of others. If we admit to harboring hidden motives, then, we risk looking bad, thereby losing trust in the eyes of others. And even when we simply acknowledge the elephant to ourselves, in private, we burden our brains with self-consciousness and the knowledge of our own hypocrisy. These are real downsides, not to be shrugged off.

However, having a more honest view of motives allows us to better understand why people do what they do. Incentives are like the wind: we can choose to row or tack against it, but it’s better if we can arrange to have the wind at our backs.

The next time we’re worried that we can’t afford the best medicine, we may find comfort in the idea that it’s not necessarily our health that’s at stake, but maybe just our self- and social images. The next time someone at a party exhorts us to visit some great museum or exotic travel destination, it helps to consider that such advice may not actually be for our benefit, even if it’s presented that way. We shouldn’t let other people make us feel inferior—at least, not without our consent.

Nor should we explicitly label all behavior as secretly self-serving. A good rule of thumb for applying “hidden motive” explanations is not to use them in the second person, but only in first and third (and ideally in the plural).

After all, many of our perceptions are colored by self-interest, including our perceptions of what other people are up to. So let’s set aside the speck in their eyes, and attend to the log in our own.

The next time you butt heads with a coworker or fight with your spouse, keep in mind that both sides are self-deceived, at least a little bit. What feels, to each of you, overwhelmingly “right” and undeniably “true” is often suspiciously self-serving, and if nothing else, it can be useful to take a step back and reflect on your brain’s willingness to distort things for your benefit. There’s common ground in almost every conflict, though it may take a little digging to unearth it beneath all the bullshit. Above all, what the elephant teaches us is humility.

And finally, to admit the ubiquity of selfish motives is not to deny the existence of lofty motives; both can (and do) coexist within the same person.

No excuses

We need to be careful to avoid the naturalistic fallacy—the mistaken idea that what’s natural (like some amount of human selfishness) is therefore good. So let us be clear: this book is not an excuse to behave badly. We can acknowledge our selfish motives without endorsing or glorifying them; we need not make virtues of our vices.

And even when our motives are fundamentally selfish, there’s still a huge and meaningful difference between violent criminals and people whose “selfishness” causes them to provide (too much) medical care or donate to (inefficient) charities. Even if a philanthropist’s motives are selfish, her behaviors need not be—and we would be fools to conflate these two ways of measuring virtue.

Please note, however, that other people may care much less about our motives and more about the consequences of our actions. Yes, we might really work hard to become a great scientist or surgeon for personal glory (rather than for the greater good), but if a selfish motive is what it takes to create a great scientist or surgeon, the rest of the world may be OK with that.

Whatever we may have said about evolution’s tendency to produce selfish creatures, the fact remains that humans get along with each other spectacularly well, and nothing we’ve seen in this book can take that away from us. It is a wonderful quirk of our species that the incentives of social life don’t reward strictly ruthless behavior.

As if our oversized brains and hairless skin didn’t make us an uncanny enough species, our genes long ago decided that, in the relentless competition to survive and reproduce, their best strategy was to build ethical brains.

When John F. Kennedy described the space race with his famous speech in 1962, he dressed up the nation’s ambition in a suitably prosocial motive. “We set sail on this new sea,” he told the crowd, “because there is new knowledge to be gained, and new rights to be won, and they must be won and used for the progress of all people.” Everyone, of course, knew the subtext: “We need to beat the Russians!” In the end, our motives were less important than what we managed to achieve by them. We may be competitive social animals, self-interested and self-deceived, but we cooperated our way to the god-damned moon.

Important implications

Looking more honestly at so many human behaviors can lead to incredibly positive benefits. Namely, it can allow us to design far better institutions.

Our institutions (education, charities, and politics) do end up achieving many of their official, stated goals, but they’re often rather inefficient because they’re simultaneously serving purposes no one is eager to acknowledge.

A common problem plagues people who try to design institutions without accounting for hidden motives. First they identify the key goals that the institution “should” achieve. Then they search for a design that best achieves these goals, given all the constraints that the institution must deal with. This task can be challenging enough, but even when the designers apparently succeed, they’re frequently puzzled and frustrated when others show little interest in adopting their solution. Often this is because they mistook professed motives for real motives, and thus solved the wrong problems.

Designers can then search for arrangements that actually achieve the deeper goals while also serving the surface goals—or at least giving the appearance of doing so. Unsurprisingly, this is a much harder design problem. But if we can learn to do it well, our solutions will less often meet the fate of puzzling disinterest.

Below are individual breakdowns on education, charities, politics, and medicine:

On Education

Any state-elected official, passionate parent, or aspiring college application essay will say the same thing: that school is a place for students to learn.

And yet, by this metric, schools have massive systems-level failures.

On average, every year of additional high school or college gives you +11% earnings for the rest of your life. But the first 3 years give +4%, while the final year gives +30%. Yet the classes that students take during senior year aren’t crammed with much more learning than are classes in other years. Employers seem to care about something besides what students learn in classes.

Additionally, schools consistently fail to use better teaching methods, even methods that have been known for decades. For example, students learn worse when they’re graded, especially when graded on a curve. Homework helps students learn in math, but not in science, English, or history. And practice that’s spaced out, varied, and interleaved with other learning produces more versatility, longer retention, and better mastery. While this feels slower and harder, it works better. Instead, most schools grade students frequently (often on curves), give homework, and lump material together in ways that make it feel like students are learning faster, when in fact they’re learning less.

Many of these mysteries can be explained by considering education as a zero-sum game (heresy, I know! But a version of heresy that answers several questions). In 2001, the Nobel Prize was awarded to economist Michael Spence for a mathematical model of one explanation for these puzzles: signaling.

Thus, to the extent that education is driven by signaling rather than learning, it’s more of a competition than a cooperative activity for our mutual benefit.

If superior instruction could explain the value of college—then why not franchise the Ivy League? Why not let more students benefit? It will never happen because the top U.S. colleges draw their mystique from zero-sum competition.

Before going any further, it is important to note that signaling does not explain all the value of schooling - just a larger portion than we care to admit.

The signalling model

Within this paradigm, each student has a hidden quality—future work productivity—that prospective employers are eager to know. But this quality isn’t something that can be observed easily over a short period, for example, by giving job applicants a simple test. So instead, employers use school performance as a proxy. This works because students who do better in school, over the long run, tend to have greater work potential. It’s not a perfect correlation, of course, and there are many exceptions, but by and large, school performance predicts future work performance (and therefore earnings).

As Caplan argues, the best employees have a whole bundle of attributes—including intelligence, of course, but also conscientiousness, attention to detail, a strong work ethic, and a willingness to conform to expectations. These qualities are just as useful in blue-collar settings like warehouses and factories as they are in white-collar settings like design studios and cubicle farms. But whereas someone’s IQ can be measured with a simple 30-minute test, most of these other qualities can only be demonstrated by consistent performance over long periods of time. In other words, educated workers are generally better workers, but not necessarily because school made them better. Instead, a lot of the value of education lies in giving students a chance to advertise the attractive qualities they already have.

The traditional view of education is that it raises a student’s value via improvement—by taking in rough, raw material and making it more attractive by reshaping and polishing it. The signaling model says that education raises a student’s value via certification—by taking an unknown specimen, subjecting it to tests and measurements, and then issuing a grade that makes its value clear to buyers. Of course, these two processes aren’t mutually exclusive.

Obviously, school serves a wide variety of useful functions, even beyond learning skills and signaling work potential. For young children, for example, school plays a valuable role simply as day care. Not only is it typically subsidized by the government, but the kid-to-“babysitter” ratio is quite high. Additionally, both primary and secondary schools give students an opportunity to socialize with, and be socialized by, their peers—an opportunity that homeschooled children, for example, must pursue by other means. Meanwhile, for young adults, college serves all sorts of useful functions that aren’t typically considered “educational.” College campuses are a great place to network, making friends and contacts that can be valuable later in life, both professionally and socially. It’s also a great place to meet a future husband or wife.

Beyond intrinsic personal enjoyment, college may also serve as conspicuous consumption—a way to signal your family’s wealth and social class (in addition to your own qualities as a worker).

Nevertheless, these functions get short shrift in public discourse. All else being equal, we prefer to emphasize the most prosocial motive, which is that school is a place for students to learn.

On Charity

Taken at face value, Americans are a fairly generous people. Nine out of 10 of us donate to charity every year (~2% of GDP). But only 13% of private American charity goes to helping those who seem to need it most: the global poor. In another example of apparent dissonance, a study asked participants how much they would agree to pay for nets that prevent migratory bird deaths. Some participants were told that the nets would save 2,000 birds annually, others were told 20,000 birds, and a final group was told 200,000 birds. But despite the 10- and 100-fold differences in projected impact, people in all three groups were willing to contribute the same amount. People are willing to help, but the amount they’re willing to help doesn’t scale in proportion to how much impact their contributions will make. This phenomenon is called “scope neglect.”

Upon closer inspection, there are several factors that have an outsized influence on our donations:

  1. Visibility. We give more when we’re being watched. Very few people give more than they’ll be recognized for. By helping donors advertise their generosity, charities incentivize more donations. This is also called “blatant benevolence,” or “conspicuous compassion.”
  2. Peer pressure. Our giving responds strongly to social influences (up to 95% of donations are solicited) - in stark contrast to purchases, which we typically prefer to initiate ourselves in anonymous markets.
  3. Proximity. We prefer to help people locally rather than globally (called parochialism - inescapable part of human nature).
  4. Relatability. We give more when the people we help are identifiable (via faces and/or stories) and give less in response to numbers and facts (called the identifiable victim effect - causes without them slowly die out)
  5. Mating motive. We’re more generous when primed with a mating motive. (Men especially are more likely to give when the solicitor is an attractive female, or even when nearby observers are female rather than male). Interestingly, people were more likely to report altruistic intentions (the thought of pursuing a romantic partner made them more eager to do good deeds - but only for conspicuous good deeds.)

If we gave only to “help,” why do all of these mismatches exist?

Andreoni theorized that much of charity is a selfish act: the act of donating makes us feel good, regardless of the results (aptly called the “warm glow” theory). But why does it make us feel good?

The answer, again, lies in signalling. We want to help others, but we also want to be seen as helpful. We therefore use charity, in part, as a means to advertise some of our good qualities, in particular our wealth, prosocial orientation, and compassion (even and especially when it is “spontaneous”).

In other words, charitable behavior “says” to our audiences, “I have more resources than I need to survive; I can give them away without worry. I will help others in need, so if you are ever in need, I will help you, too. Also, I care about others, so you know I’m not a psychopath. I am a hearty, productive human specimen.” Maybe this is why Jesus was seen as so controversial when he said, “when you give, do not let your right hand know what your left hand is doing” - effectively calling out the false selflessness in the charitable donations of his time.

Some would decry this as an attempt to turn something beautiful (selflessness) into something ugly (selfishness and false selflessness). However, I would argue that the beauty actually lies in the fact that the selfish route is selflessness - the most selfish thing you can do, then, is to help others. Also, if we only allowed donations with absolutely pure motives (which rarely exist in the real world), then our charities would run dry. Better to give people the benefit of the doubt, and to let their money go to good use.

Action steps

However, there is objective value in efficient charity - solving actual problems, regardless of their ‘sexiness.’ If we, as a society, want more and better charity, we need to figure out how to make it more rewarding for individual donors. Primary avenues include a better job marketing the most effective charities, by improving their value as a signal. The other approach is to learn to celebrate the qualities that make someone an effective altruist.

On Politics

We hold political beliefs for reasons other than accurately informing our decisions (shocker, I know).

Why do real voters seem apathetic about practical details, and prefer instead to focus on values and ideals? We’d rather debate hot-button identity issues, like gay marriage or immigration, than issues that hinge on an understanding of facts, like trade agreements or net neutrality. Across the board, we seem to prefer high-minded rhetoric over humble pragmatism. The fact that we attach strong emotions to our political beliefs is another clue that we’re being less than fully honest intellectually.

In more practical domains, we feel much less pride in what we believe, anger when our beliefs are challenged, or shame in changing our minds in response to new information. However, when our beliefs serve non-pragmatic functions, emotions tend to be useful to protect them from criticism.

Political Coalitions

Given the vast range of issues and the positions we can take on those issues, it might seem strange that people who support strong border controls also tend to favor lower taxes, school choice, and traditional marriage—and that people who oppose any of these also tend to oppose the others. We find this clustering of positions not just among citizens, but also in our politicians. For example, 80 percent of the votes of U.S. congressional representatives are explained by a single left–right ideological dimension, and a similar focus is found in other nations. Why do we see such a high degree of correlation among political beliefs?

These largest coalitions can break down and re-form during national political “realignments,” exposing some of the underlying tensions. For example, prior to the 1850s, politics in America was driven largely by economic issues like tariffs, the national bank, and public lands. Then, in the 1850s and 1860s, it became polarized instead between pro- and antislavery (leading ultimately to the Civil War). What this and other realignments make clear is that the main political parties have not always stood firm behind fixed principles, but instead are a complex patchwork of (sometimes conflicting) agendas—strange bedfellows brought together by common interests and held together, in part, by the bonds of loyalty.

Politics as Performance

Each of us is a member of many different groups, which can be nested within each other or else partially overlapping, as in a Venn diagram. And how much loyalty we feel to each group depends on many factors, both personal and cultural. These tensions among our various loyalties are, in part, what makes politics so complex and full of drama.

Our political behavior (note this isn’t just for political parties - any group will do) is confusing until we realize that it’s not just an attempt to influence outcomes; it’s also, in many ways, a performance. Whenever an issue becomes factionalized, framed as Us against Them, we should expect to find ourselves competing to show loyalty to our team.

We use far-off national politics as a medium in which to jockey for local advantages. At the extremes, we’re motivated less by civic virtue than by the desire to appear loyal to our political coalitions. And if politics is a performance, then our audience is mostly our peers—friends and family, coworkers and bosses, churchmates and potential romantic partners, and anyone who might follow us on social media.

Signalling Loyalty

A sacrifice we make in the name of politics is limiting our social, professional, and romantic opportunities. A 2010 survey found that 49 percent of Republicans and 33 percent of Democrats said they would be upset if their child married someone from the opposite party. In professional and social arenas, political favoritism is sometimes stronger than racial favoritism. All these incentives—romantic, professional, and social—undoubtedly put pressure on us to adopt the political beliefs of our local communities.

The desire to signal loyalty helps explain why we don’t always vote our self-interest (i.e., for the candidates and policies that would bring us, as individuals, the greatest benefit). Rather, we tend to vote for our groups’ interests. Naturally, on many issues, our group and self-interests align. But when they don’t, we often choose to side with our groups. In this way, politics is a team sport.

On the rare occasions when our political beliefs do suggest concrete actions, we’re happy to ignore their suggestions and act as we would even if we believed the opposite. For example, we might think, “Everyone deserves access to the same opportunities” and yet fiercely compete to get our kids into the best schools. This kind of mild hypocrisy might bother us on occasion, but it probably won’t keep us up at night.

The fact that we use political beliefs to express loyalty, rather than to take action, also explains why we’re emotionally attached to our beliefs, and why political discussions often generate more heat than light.

It only demonstrates loyalty to believe something that we wouldn’t have reason to believe unless we were loyal. A common symptom of loyalty signaling is an unwillingness to compromise. Additionally, if we adopt beliefs that are too far-fetched, we risk looking foolish, thereby offsetting the benefit we get for showing loyalty. Thus the best political members are highly intelligent and even skeptical, as long as their skepticism stops short of questioning the sacred tenets of their political groups.

Badges are powerful ways of signaling a specific loyalty. We embrace slogans like “Black lives matter” or “Guns don’t kill people; people kill people.” As arguments, these slogans radically oversimplify the issues—but as badges, they work great.


Political scientists often distinguish between “instrumental voting” and “expressive voting.” Instrumental voters use their votes in order to influence outcomes. They may be entirely altruistic or entirely selfish, but regardless, they want their votes to make a difference. Expressive voters, however, don’t care about outcomes, but instead derive “expressive” value from the act of voting. Even if all of their chosen candidates end up losing in the election, expressive voters will still be happy to have cast their ballots.

Some treat expressive voting as an act of consumption—something we do in order to feel good, without concern for external benefits. In this view, voting is seen as providing a psychological reward, like getting to “affirm one’s identity” or “feel a sense of belonging.” But a strictly psychological explanation is incomplete - the social benefit provides a much stronger external incentive, which is why expressing oneself at the polls draws social rewards.

On Medicine

Two fun facts:

Americans today spend more than $2.8 trillion a year on medicine (~17% GDP).

Large randomized studies have found that people given free healthcare consume a lot more medicine (relative to an unsubsidized control group), yet don’t end up noticeably healthier.

Meanwhile, non-medical interventions—such as efforts to alleviate stress or improve diet, exercise, sleep, or air quality—have a much bigger apparent effect on health, and yet patients and policymakers are far less eager to pursue them. Patients are also easily satisfied with the appearance of good medical care, and show shockingly little interest in digging beneath the surface—for example, by getting second opinions or asking for outcome statistics from their doctors or hospitals.

Finally, people spend exorbitantly on heroic end-of-life care even though cheap, palliative care is usually just as effective at prolonging life and even better at preserving quality of life. Altogether, these puzzles cast considerable doubt on the simple idea that medicine is strictly about health.

The conclusion is that medicine isn’t just about health—it’s also an exercise in conspicuous caring.

Conspicuous caring

Consider the case of a toddler who stumbles and scrapes his knee, then runs over to his mother for a kiss. The kiss has no therapeutic value, and yet both parties appreciate the ritual. The toddler finds comfort in knowing his mom is there to help him, especially if something more serious were to happen, and the mother is happy to deepen her relationship with her son by showing that she’s worthy of his trust. The thesis we will now explore in this chapter is that a similar ritual lurks within our modern medical behaviors, even if it’s obscured by all the genuine healing that takes place.

The role of the mother is played not just by doctors, but everyone who helps along the way: the spouse or parent who drives the patient to the hospital, the friend who helps look after the kids, the coworkers who cover for the patient at work, and—crucially—the people and institutions who sponsor the patient’s health insurance in the first place. These sponsors include spouses, parents, employers, and national governments. Each party is hoping to earn a bit of loyalty from the patient in exchange for helping to provide care. In other words, medicine is, in part, an elaborate adult version of “kiss the boo-boo.”

This third-party scrutiny of medical treatments isn’t just a historical phenomenon. Even today, there are strong incentives to be seen receiving the best possible care. Whenever we fail to uphold the (perceived) highest standards for medical treatment, we risk becoming the subject of unwanted gossip and even open condemnation. Our seemingly “personal” medical decisions are, in fact, quite public and even political. When you pay for medicine, you are also paying for 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.

(There’s another way to look at it, of course, which is that we are getting our money’s worth when we buy medicine, but the value isn’t just health; it’s also the opportunity to demonstrate support. It only looks like we’re getting ripped off if we measure the health benefits but ignore the social benefits.)

Getting well is secondary

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 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.

Patients show surprisingly little interest in private information on medical quality. In fact, 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.

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.

Too much medicine

We might hope to see that patients live longer when local hospitals decide to keep them in the intensive care unit (ICU) for longer periods of time, relative to patients in hospitals that kick them out sooner. What the study found, however, was the opposite. For each extra day in the ICU, patients were estimated to live roughly 40 fewer days.

Staying in the hospital puts patients at higher risk of contracting infections and communicable diseases. According to the Centers for Disease Control and Prevention, improper catheter use alone is responsible for 80,000 infections and 30,000 deaths every year.

There is considerable data to back up 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.

Most scholars don’t see medicine as responsible for most improvements in health and longevity in developed countries. A study in 1969 found that variations in death rates across the US were predicted by variations in income, education, and other variables - but not by variations in medical spending.

Action steps

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.
  • Requiring autopsies. Around 40 percent of autopsies reveal the original cause-of-death diagnosis to have been incorrect.But autopsy rates are way down, from a high of 50 percent in the 1950s to a current rate of about 5 percent.
  • Getting doctors to wash their hands consistently. Compliance for best handwashing practices hovers around 40 percent.

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. 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 attention.

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.