Changing Norms
Here is a somewhat offensive piece of history you may not have heard before: when the government first began to sponsor free pre-natal health services in the United States, a lot of doctors got mad. In the 1910s, the pioneering public health nurse Sara Josephine Parker and a number of other nurses drafted a bill to “create a nationwide network of home-visiting programs and maternal and child health clinics modeled on the programs in New York”.1 In three years, infant mortality had dropped by 40% in New York as a result of these programs.1 There too, the services had faced opposition, with a few dozen Brooklyn doctors signing a petition to shut services down.2 (Parker is quotes as saying that the only thing she would have enjoyed more would have been “a similar protest from an undertakers’ association”.2) The American Medical Association (AMA) opposed the bill. How would doctors make a living if people could get medical services for free? An AMA representative at a congressional committee went so far as this:
“We oppose this bill because, if you are going to save the lives of all these women and children at public expense, what inducement will there be for young men to study medicine?” Senator Sheppard, the chairman, stiffened and leaned forward: “Perhaps I didn’t understand you correctly,” he said: “You surely don’t mean that you want women and children to die unnecessarily or live in constant danger of sickness so there will be something for young doctors to do?” “Why not?” said the New England doctor, who did at least have the courage to admit the issue: “That’s the will of God, isn’t it?”1
Social norms fluctuate over time and we must acknowledge for the historical context these doctor’s lived in, with its different class dynamics and health systems. All in all, though, I struggle to avoid judging these physicians. I mean, I understand wanting to preserve your job, but at the expense of dead or sick mothers and babies? When your entire job is to preserve life and health? Really?
This week I read a chapter in the book Predictably Irrational by Dan Ariely that made me understand how such a large group of well-educated people might have wandered down such a clearly unethical road. The answer lies in our responsiveness to circumstance. Ariely has done some experiments that show that we “live in two different worlds – one where social norms prevail, and the other where market norms make the rules.” We are reacting to social norms when we agree to help a friend out with a move, or share our Smarties with the other kids at the lunch table. Market norms, meanwhile, are what shape economic decisions like how much we want to pay for a lawn mower or how much to charge for the art lessons we are giving.
Problems can arise when these realms overlap. Ariely gives the fascinating example of the way some lawyers responded to an ask from a non-profit:
A few years ago, the AARP asked some lawyers if they would offer less expensive services to needy retirees, at something like $30 an hour. The lawyers said no. Then program managers from AARP had a brilliant idea: he asked the lawyers if they would offer free services to needy retirees. Overwhelmingly, the lawyers said yes.
What was happening here, according to Ariely, is that in the first scenario the lawyers were responding to economic norms. They realized that the fee being offered was not worth their time, and declined. In the second scenario, no money was being offered, and so there was no market norm involved. The lawyers instead made their decision based on the social norm that it is good to help people, and were willing to volunteer their services. Ariely and his colleagues have conducted a number of experiments that have similarly found that people will react differently in the same situation depending on whether it is couched in social or economic norms.
As with so much in Ariely’s book, this point is fascinating because it is so visibly applicable to many everyday situations we find ourselves in. It made me wonder if those doctors opposing Baker’s programming felt justified in their actions because they were making decision in the context of economic norms. Their social norms and even their ethical beliefs may not have led them to the same decision. However, Ariely’s findings demonstrate that we are not only capable but unconsciously likely to make economic decisions that oppose our social ideas, and vice versa.
It is yet another layer of complexity in our ‘common sense’ - there are more than one set of ‘common sense’ rules we may function by, and we may not always be aware of which we are drawing on.
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References
1http://www.nybooks.com/articles/archives/2013/sep/26/doctor-who-made-revolution/