In their influential book Phishing for Phools: The Economics of Manipulation and Deception two Nobel prize winners, George A Akerlof and Robert J Shiller, describe how businesses profit from exploiting human weakness. Politicians do the same and so, I suggest, do doctors.
(I was about to assume that all BMJ readers know about phishing, but then I thought I might be wrong. It is the fraudulent practice of sending emails that seem to come from reputable organisations asking you to send money, give your credit card details or passwords, or do other things that will exploit you. For example, I get several emails a week asking me to submit papers to predatory journals or speak at conferences that are simply money making exercises.)
Akerlof and Shiller’s thinking grows out of the recognition from behavioural economics that the “rational man,” who is central to traditional economics, doesn’t exist. Rather we are shot through with biases. Cass R Sunstein summarises these in a single sentence in his review of Akerlof and Shiller’s book in the New York Review of Books: “People tend to be overconfident; they display unrealistic optimism; they often deal poorly with risks; they neglect the long term (‘present bias’); and they dislike losses a lot more than they like equivalent gains (‘loss aversion’).”
The financial crash of 2008-09 was caused in part by phishing for phools, argue Akerlof and Schiller. “Geniuses” in the banks invented financial instruments that seemed to abolish risk. These instruments were then approved by credit agencies, which had been corrupted by conflicts of interest in that they were now paid by the banks that developed the instruments. (I thought here of the US Food and Drug Administration, which now is paid by the pharmaceutical companies whose drugs they are assessing.)
Financial instruments that promised generous returns without risk, and which were approved by the previously trustworthy credit agencies, proved irresistible to phools, who signed up in large numbers.
And the problem for banks that might have chosen to stay away from phishing is that the phools flock to the phishers, putting the banks that stayed away at a huge disadvantage—so they too have to become phishers.
Akerlof and Shiller identify tobacco, alcohol, food, pharmaceutical, and social media companies as phishers, and phishers probably exist everywhere, not least in religions. Politicians are certainly phishers, promising the moon and catching phools by the boatload. I think inevitably of the Brexiters and Donald Trump, but all politicians do it. Perhaps the problem of the Remain politicians is that they weren’t good enough phishers, warning of the dangers of leaving the European Union rather than promising of the boon that would come from remaining.
Doctors, I fear, are positioned to be the most powerful phishers in that they are dealing with things that matter hugely (life, death, disease, pain, birth) and with customers almost all of whom are phools in that it’s almost impossible for them to know whether the doctors are being truthful about their offering. And there’s no better place to phish than with the dying; that deep instinct to stay alive distorts people’s decision making more than any other psychological flaw.
I thought here of how Seamus O’Mahony in his marvellous book The Way We Die Now tells two stories of phools being phished, and these two phools were extremely clever people: Christopher Hitchens and Susan Sontag.
Hitchens was a highly successful writer and iconoclast, who had dared even to debunk Mother Theresa. O’Mahony describes him as being in “the premier league of celebrity atheist intellectuals.” As he drank and smoked heavily it wasn’t surprising when he was diagnosed with stage IV oesophageal cancer. Yet the great debunker was a phool when it came to what medicine could offer. He was, writes O’Mahony, “childlike in his enthusiasm for American oncology.” He pursued an “immunotherapy protocol,” the possibility of having a whole new oesophagus created from “tissue engineering,” and having his genome and his tumour sequenced. A correspondent advised that he have himself frozen for when a magic bullet became available. Neither he, his wife, nor his great friend the writer Martin Amis seemed to know that death was imminent, all thinking he would live for years when months are usual. He didn’t last for years.
Sontag, a great American intellectual and author of Illness as Metaphor, had survived two cancers before she developed myelodysplastic syndrome. A non-phishing doctor told her nothing could be done, but two others offered a bone marrow transplant even though they must have known the chances of success in a 71 year old were minuscule. The original doctor was savaged by Sontag—rather as a company refusing to play on human weakness loses business to one that will. Sontag wouldn’t accept that she was dying, and her son described in a book after her death his grief at never being able to have a proper conversation with her about what was happening.
These were two powerful phools who desperately wanted to be phished, and as such are perhaps like the phools who buy cigarettes and excessive amounts of alcohol even though they know they will be harmed. The phishers here weren’t fishing for money, and doctors—like politicians—are not mostly phishing for immediate rewards of money, although in a fee for service health system they may be. They are phishing to build up the reputations of themselves and their specialty—or for the sheer joy and satisfaction of phishing rather as fishermen do. In the long term, of course, they do build up their incomes—because we need more oncologists and cancer researchers.
We know that doctors as a profession and as individuals overpromise, overdiagnose, and overtreat. This, I suggest, is phishing no different from the phishing of the banks who caused the financial crisis. Ironically, the suffering caused by the phishing of doctors is less visible as it happens individual by individual, although the cumulative effect (with the ever climbing proportions of GDP devoted to healthcare) is to crowd out other activities and eventually to bankrupt the states or businesses that pay for healthcare.
Richard Smith was the editor of The BMJ until 2004.
Competing interests: None declared.