The Mission

Christopher Carr

Christopher Carr does stuff and writes about stuff.

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64 Responses

  1. Tod Kelly says:

    It appears I have to be careful about what I say even in my comments!

    However, if the early-baby argument isn’t to your liking, let me try a different tack:

    A banker will, when faced with the prospect of evicting a family from their home for late payment, do so readily.  Unless you can convince the banker that he can make more profit over the long haul by letting your family keep a roof over your head, you will be SOL.

    A doctor will not, at least consciously, look at a sick person and make a decision about which treatment would be more profitable to determine a course of action – and I think Russell would tell you that in many situations doctors and emergency rooms treat people that need care even if they cannot pay.

    This is not to say that doctor’s do not experience greed, or selfishness – or that bankers cannot be altruistic.  But the mission of an organization is important to that organizations culture.

    For example, I work with social service agencies that serve people with developmental disabilities.  Funding is always an issue for these organizations.  There are some that are actually for-profit organizations, that answer to investors.  They will jettison those people with more pronounced disabilities that are more expensive to serve if other costs rise, rather than cut back on profit to investors.  The non-profit organizations do not, and will go so far as cutting management salaries when necessary.  In Texas, there are many vocational rehab facilities for people with developmental disabilities that are for-profit that have stopped hiring the disabled for most positions to increase production; the non-profits would never do such a thing.

    This is because even though each organization serves the DD population, the for- and the nons- have different missions, and run their organizations accordingly.

    They just do.Report

    • Christopher Carr in reply to Tod Kelly says:

      There’s a big difference between allowing someone to die when you have the skills to save them and not allowing someone the rare privilege of owning their own home when it is costing you and your company significantly.Report

    • James Hanley in reply to Tod Kelly says:

      A doctor will not, at least consciously, look at a sick person and make a decision about which treatment would be more profitable to determine a course of action

      But they might look at a healthy person and make such a decision.Report

      • I will probably comment at greater length about this in a post of my own, maybe later this week.  That said, and conceding that some doctors may order unnecessary tests to feather their own nests, as someone who has ordered tests he knows weren’t medically “necessary,” the motivation to do so if often totally divorced from any profit motive.  I may absolutely no money either way when it comes to ordering tests, and when I order them even if I don’t think they’re needed it’s with other considerations in mind.

        But again, I’ll probably post more about this outright later.Report

        • DensityDuck in reply to Russell Saunders says:

          If you ordered the tests so that you wouldn’t get sued, then you made an economic decision to reduce costs.  And it’s a decision that can, in fact, be judged on strict cost basis.

          “These tests will cost five hundred dollars.  If I don’t do them there’s a one-percent chance I’ll get sued.  The cost of a settlement is one million dollars.  One percent of one million is one thousand, which is more than five hundred, therefore it’s economically preferable to order the tests.”Report

          • What an awfully cynical outlook you have, DD.

            No, I really don’t do them because I fear getting sued.  Even the most irritated and unreasonable parents are unlikely to sue.

            When I order tests that aren’t strictly necessary, it’s almost always because I know the patient/parent’s peace of mind won’t really be assured until it’s been done.  It’s not a particularly wonderful reason to order tests, and I really, really try hard to minimize the extent to which this happens, but sometimes it’s the least bad option available.Report

            • DensityDuck in reply to Russell Saunders says:

              …so your attitude is that your patients are petulant children who need placebo testing in order to feel like the doctor “fixed” something and therefore things are better?

              I suppose “veiled contempt” is better than “defensive medicine” but I’m not really sure how.Report

              • How unfortunate that you infer contempt on my part.  Regardless, it seems to me the tone of the conversation has become sufficiently snide as to obviate any desire on my part to continue it.Report

              • DensityDuck in reply to Russell Saunders says:

                Hey, whatever makes you feel happier.  Just remember this conversation when you cry about how Americans spend so much on doctoring and get so little in return.Report

              • Patrick Cahalan in reply to DensityDuck says:

                Geeze, Duck, you over-generalize at the drop of a hat.  It’s like you can’t help yourself.  Given a position and an alternate, you have to push on the alternate until it’s wayyy over there!

                There is a wide chasm of difference between, “in rare cases, which I work hard to avoid and reduce, I make the measured judgment that a small subset of my patients require psychological assistance via placebo testing” and “all my patients are petulant children”.Report

              • DensityDuck in reply to Patrick Cahalan says:

                I’m glad you agree with me that it’s a pointless waste of patients’ money being used as a placebo.Report

              • Patrick Cahalan in reply to DensityDuck says:

                That is not what I said.

                Point of fact, a placebo treatment has a measurable level of efficacy.  So ordering a placebo treatment isn’t necessarily bad medicine.  It depends on how much it costs.

                I can imagine ordering a $5,000 MRI exam would qualify to your point.  A $5 strep culture given to one patient out of 250 is hardly the cause of our ballooning medical costs.

                But you go on being yourself, Duck.  Black.  White.Report

            • I had the same cynical response as Mr. Duck, but I get your reasoning.  I’ve found that both of my last two physicians have come to like me just because I’m not the type of patient you’re talking about here. I recently had a talk with my doc about whether it was time for me to start worrying about my prostrate, maybe get it examined.  Doc looks somewhat uncomfortable, we have an intelligent discussion about my age, what I’m experiencing, the state of our current knowledge concerning dealing with the prostrate, I agree there’s no reason for me to have any concern or get tested at this time, Doc looks greatly relieved that I haven’t pressed to get tested anyway.


    • DensityDuck in reply to Tod Kelly says:

      “A doctor will not, at least consciously, look at a sick person and make a decision about which treatment would be more profitable to determine a course of action…”

      “She’s in here all the damn time, give ‘er a Tylenol and send ‘er home” is most certainly a decision about which treatment would be more profitable–in the sense of allocating limited resources (a doctor’s time) to the places where they’ll give the best return (helping suture a wound instead of pretending like you need to get a full case history for the tenth week in a row just in case this time it’s a heart attack instead of boredom.)Report

      • Chris in reply to DensityDuck says:

        “You have no insurance? See you later.”Report

      • Liberty60 in reply to DensityDuck says:

        Legal or not, it does happen. But more broadly, sick people who cannot pay are in fact turned away, as long as their condition is non-emergency.

        Because, since we as a society have decided that doctors are nothing more than car salesmen and chemotherapy is no different than a Corvette, if you are sick and have no money, you may very likely die.

        This is simply the truth which many discussions of health care prefer to avoid or brush aside.Report

    • KenB in reply to Tod Kelly says:

      A banker will, when faced with the prospect of evicting a family from their home for late payment, do so readily

       A doctor will not, at least consciously, look at a sick person and make a decision about which treatment would be more profitable to determine a course of action

      These two aren’t really commensurate — either make the first one something like “A banker will, when presented with a family applying for a mortgage, push the one that offers himself or his institution the greatest profit regardless of what is in their best interests” (and this is hardly self-evident), or make the second “A doctor will not deny treatment to a patient who’s likely unable to pay for the service”.  In the latter case, while there’s a cultural and to some extent legal obligation to provide the service regardless of ability to pay, there’s also an overall compensation structure that takes that obligation into account. 


  2. Tom Van Dyke says:

    Cheers, Mr. Carr, for citing Adam Smith’s other, and better book.  You are wise men both.

    I don’t think Adam Smith in either book obviates the necessity of ethics.  Neither does he ignore charity:

    “How selfish soever man may be supposed, there are evidently some principles in his nature which interest him in the fortune of others and render their happiness necessary to him though he derives nothing from it except the pleasure of seeing it.”

    The problem I have in many discussions hereabouts is that business is conflated with the need for charity.  [And worse, that [pity-]charity is a no-no: what someone needs is transformed into a “right.”]

    But one runs his business as a business, no more no less: he is obliged to act ethically, no more, no less.  Your doctor [or auto mechanic] is unethical to repair your body or car in the way that suits him best, but not necessarily you.  It’s the nature of the relationship: in a real way, doctor and mechanic are your employees, work for hire.

    But the banker is an equal party to any agreement, and is bound to act in his own interest as long as it’s ethical.  As are you.

    To run a bank like a charity would miss Smith’s whole point about the “invisible hand.” The butcher does not give meat out for free or for less than its cost.  He would go bankrupt, and then there wouldn’t be a butcher in town atall.



    • Jaybird in reply to Tom Van Dyke says:

      [And worse, that [pity-]charity is a no-no: what someone needs is transformed into a “right.”]

      My main hang-up is the question of whether something that does not exist could possibly qualify as a Human Right. It seems obvious to me that it cannot. It seems to me that it follows that something that is a limited good therefore cannot be a Human Right… it cannot be the case that something is a Human Right until it runs out, at which point it ceases to be a Human Right. That Makes zero sense to me.

      I’m sure I’ve gone off on a rant about this before, though.Report

  3. Roger says:

    It seems we are comparing two of the most screwed up, convoluted, over-regulated industries to each other.

    There is no free medical care. There is a system of forced subsidization and missing feedback between cost and payment. This is sending health care into a spiral of un-affordability.  Health care is the last field I would use as a model.

    When I go to a banker it is because I want to get a loan or deposit some money in a safe place. If I take out a loan, I want the interest that goes with the terms. I can get a heck of a lot better deal if I put something up as collateral. This is an expected win/win. If somebody wants to create a world where you get loans and don’t put up collateral (not really that is), then go for it. But expect to pay about ten times higher interest rates. No thanks!

    If Tod or his evil twin Kelly wants to establish a charity for people who can’t pay back loans, they should jump right into it. Please don’t ask any banker to do this though. You’ll screw the industry up even more.

    The key premise of any industry or service is to benefit the producer by benefiting the customer. I agree with Tom. Free enterprise doesn’t work via altruism or charity. It works by setting up simple systems of expected win/win outcomes. When I get medical care I agree to pay. When I get a loan I agree to pay or lose my collateral. The banker, the doctor and I all expect to gain.


  4. Murali says:

    In the comments to Anantharaman Muralidharan’s post

    Thanks for giving my full name! (Though I do want to ask why?)Report

    • James Hanley in reply to Murali says:

      1. It’s a fun name to pronounce; very lyrical.

      2. To remind everyone you’re a foreigner, hence certainly a terrorist, and so we can reject everything you say without examining it.


      • kenB in reply to James Hanley says:

        3. Because your “opposite” alter ego’s name would be substantially more difficult to pronounce.Report

        • Ilarum in reply to kenB says:

          Its not like Mainamarbusalab Nek is any easier to pronounce than IlarumReport

          • KenB in reply to Ilarum says:

            That would be my alter ego’s name if I were my uncle’s son…Report

            • Ilarum in reply to KenB says:

              shoot, did I get your surname wrong? sorry!Report

              • KenB in reply to Ilarum says:

                No problem.  I’m assuming you glanced at my email addy a bit too quickly.  (If you came up with that from nothing more than my handle, it was a helluva close guess!)Report

              • Murali in reply to KenB says:

                 I’m assuming you glanced at my email addy a bit too quickly

                Yeah (I searched trhough my emails and kicked myself for getting it wrong)

                Also, I appologise if I inadvertantly nearly revealed your name (if you object to my doing so)

                BTW do you live in Madison Connecticut?Report

              • KenB in reply to Murali says:

                Yup, that’s where I am.  I get the sense that my first+last name is a globally unique identifier, so whatever you find on Google is likely referring to me.  Do you have some familiarity with the area, or were you just fine-tuning the search?

                Re anonymity, I’d prefer that a search on my name not lead here, but I don’t care if people here know my name (I’m trusting in the absence of stalker tendencies among the commentariat).  So the reversal would not have been a problem if it had been correct.Report

    • Christopher Carr in reply to Murali says:

      A couple (fairly frivolous) reasons exist: (1) I don’t like the first-name/nickname nomenclature norm of the blogosphere; (2) I like your name. I think we should have to learn to spell it instead of you having to simplfy it for us; and (3) I aspire to be the Kenny Mayne of the League.Report

      • I like your name. I think we should have to learn to spell it instead of you having to simplfy it for us

        Thanks 🙂

        However, i dont use my full name except in official documents (like formal contracts). I really think of myself as just Murali. Murali really is what I get everyone to call me in daily life. So, its not a special blogospheric thing. Murali just is my use-name. So, it is feels really odd to be called Anantharaman Muralidharan in a less than official setting.


  5. I have, unfortunately, been busier today than is often the case, so I haven’t had a chance to read this and respond with the depth it deserves.

    I did want to make a small comment to clarify something about the particular case Tod brought up, which is the induction of near-term infants.  I am not arguing that doing so is always more harmful than allowing the baby to go to full term, nor that the outcome is more likely to be increased mortality.  Indeed, advances in the care of premature infants have made mortality an unlikely outcome, even when there is an adverse effect from induction,  Thus, if you compare mortality rates as an outcome measure, you may miss the effect.

    However, it has been relatively convincingly shown that inducing infants at near term does lead to increased complication (for example, respiratory distress), increased NICU admissions, increased testing (eg X-rays) and intervention (supplemental oxygen), all of which increase costs.Report

  6. Scott says:

    All of this is such BS.  If docs are such good folks only looking out for their patients then why is the Stark law governing physician self-referral of patients to a medical facility in which they has a financial interest even necessary?  As if docs never order unnecessary treatments or over code to make money.  All this stuff about bankers only caring about about filthy lucre is just a smoke screen for liberal moralizing.  Of course bankers are trying to make a profit, duh. If they don’t, their bank goes out of business.  If a doc doesn’t make money, their hospital lets them go or if they are solo practitioners they have to close their practice. Liberals wants to pillory bankers b/c the profit motive is much evident in their case than with the supposed noble practitioners of the healing arts.Report

    • Christopher Carr in reply to Scott says:

      Scott, I think you make a good point and one that is probably underrepresented at the League right now. I wish you had made it without assuming malicious intent or ignorance on the part of those with whom you disagree. .Report

      • Scott in reply to Christopher Carr says:


        Do you really think such facial comparisons are made intelligently or in good faith? Maybe I was a bit harsh, I guess I shouldn’t post when tired.  However, I have yet to see anyone tell me I’m wrong.Report

        • Christopher Carr in reply to Scott says:

          Well, my entire argument is that the structure we’ve created makes your argument about doctors insignificant and unverifiable. And I’m arguing that bankers could be morally positive for society if they allocated funds to worthy causes instead of effectively stealing from their own clients because they can.Report

          • Roger in reply to Christopher Carr says:


            You actually believe that bankers — overall — are not currently filling a positive role for society? That the hundreds of millions of loans and deposits made in this country are not “worthy causes?” That they are “effectively stealing?”Report

            • Christopher Carr in reply to Roger says:

              Here is my preference order:

              1. A world where bankers allocate funds to promising businesses.

              2. The present world, with a mixture of productive, honest investment and taking advantage of loopholes for quick cash.

              3. A world where bankers speculate, manipulate prices, and respond to government policy.


              • Roger in reply to Christopher Carr says:


                Yes I prefer a utopian world. Your argument seems to be that a significant share of banking is worthless or unproductive manipulation and the equivalent of stealing. What data are you using to come to the conclusion that banking is less productive than other industries?Report

              • Christopher Carr in reply to Roger says:

                Roger, your comment seems to suggest that either (1) speculation does not exist or that (2) it’s not a problem. I’d argue that it is a problem, and, if you want I could cite lots of sources on the rise of speculation and its associated costs.

                A more-interesting question is whether speculation is replacing investment or replacing other non-financial activities. There have been lots of studies recently on the increasing numbers of our best and brightest that are going into finance instead of going into medicine or engineering or the civil service (IMHO just looking around over the last ten years suggests the government is attracting increasingly stupid and incompetent individuals.) I wouldn’t think this were a problem if these people were going on to study individual companies and make decisions on which to invest in. But, many are exerting their efforts towards creating complex computer algorithms to capitalize on policy loopholes or to be that much quicker than the other guy.

                What societal benefit is there to this? I don’t think hoping for a finance sector that actually finances industries instead of speculating is utopian, at all, or else, we’ve been a utopia at several points in our history already.Report

              • Roger in reply to Christopher Carr says:

                Thanks Christopher,

                Your position is clearer now. It is not banking, finance or bankers which you are concerned with, but speculators.

                If your position is that regulations and rules have gotten ridiculously complex and thus encourage pointless arms races to find relative advantages within the rules (I call this rule wrestling) and that the potential for government bailouts of stupid or risky activity has led to absurd speculation and wealth transfers…. then I agree.

                I would consider this a small but toxic part of banking or finance.

                My position is that free enterprise works by limiting commercial activities to voluntary win/win interactions. I certainly see that some areas of speculation (futures, risk mitigation, etc) work this way. I do agree that some areas have become toxic. I also agree that regulations, government interference and bailouts helped create this market anomaly.  It needs to be fixed to bring incentives back in line.


              • Roger in reply to Roger says:


                Now that we agree completely on the problem, your question was what should be done about it?

                I’d suggest simple, consistent financial rules, preferably sanctioned by a supermajority with a sunset provision. Just as importantly, I would not approve bailouts.  Failure, dishonesty and stupidity need to be penalized within the free market.

                Of course, I do not believe we will get THERE from HERE. Old states, institutions and economies become sclerotic over time. We need fresh institutions.

                By the way, I will repeat that the heath care industry is even more sclerotic and encrusted with regulations and privilege seekers. It needs a refresh as well. I am pretty sure I will get my some of my future health care out of country. I can now fly to Costa Rica and get good care for a fraction of the cost. I need to find an out-of-country health care network to invest in. I would LOVE it if my HCA encouraged out of country care.

                Russell, do you know if any of these exist?Report

              • Scott in reply to Christopher Carr says:


                I definitely vote for the fantasy land with rainbows and unicorns.  So when the banker in that fantasy land tell his bank’s shareholders that there money is gone but not to worry b/c the bad loans were made based on moral considerations and not the ability to pay the loan, they should be okay with it?Report

              • Christopher Carr in reply to Scott says:

                Scott, I agree with Milton Friedman that corporations should be responsible to only their shareholders (You’re right to point out that the corporations that don’t do this lose, but you’re wrong to make me into a straw man.). I believe CSR is the real fantasy land with rainbows and unicorns.

                I reserve the right not to purchase a corporation’s products if I disapprove of how that corporation conducts business. This should be enough 99% of the time. We’re adults, and we should have the rights and responsibilities of adults when it comes to the consumer economy. If we want to spend all our money on Snuggies, so be it. Resorting to the morons in Congress to enforce the crude, regressed judgment of the masses should be a last resort.

                That being said, the situation is complicated if an industry proceeds from the government, such as our financial system, which emerges from standards and structures set by the government and the quasi-governmental Federal Reserve and goes running home to Daddy anytime the economy takes a hit (a la the bailouts). To pretend that the financial sector is free is either ignorance or willful ignorance. To say that the government has no right or no responsibility to fix that which it has destroyed is similarly twisted methinks.Report

          • Scott in reply to Christopher Carr says:


            I’ve got news for you.  Doctors taking financial advantage of their patients by referring them to medical facilities in which they had a financial interest was such a problem that even a liberal like Rep. Stark thought it was necessary to make it illegal.  Too bad it took a federal law to make some docs more moral, I guess they aren’t that different from bankers.Report

            • Christopher Carr in reply to Scott says:

              I’m not really familiar with that law because it probably never made the news, but as you’re framing it, I’m not really seeing a huge problem. People tend to refer people to places they’re familiar with, and if they have a financial interest in that place, they want to see it succeed, and they may even recommend it to clients. How would that be different from referring someone internally?

              Granted, it may be dishonest to refer someone to a place where one has a financial interest if that particular place is demonstrably substandard, but this is neither qualitatively nor quantitatively at the same level as, say, Goldman Sachs taking tax dollars for multi-million-dollar bonuses or credit card companies raising people’s interest rates and fees without informing them in order to extract more fees and interest rate hikes.Report

  7. First of all, I’m embarrassed to admit I didn’t know you were a doctor until reading this post.  Or perhaps I knew and forgot.  Regardless, I wasn’t really aware that you were a fellow physician.

    I agree with almost everything you wrote.  As a general rule, I assume most people try to do the right thing most of the time, in their jobs and otherwise.  Thus, I assume most bankers want to do right by their investors, most engineers want to design good technology, most lawyers want to represent their clients well, etc.  And as people have already mentioned upthread, there are easy examples of doctors valuing lucre over the best clinical decision-making for their patients.  I wrote about my own experience with some of them here.  Things work best for everyone when, as you say, incentives are in phase.

    Where I agree with Tod is that the moral incentive is weightier with some professions than others.  This isn’t to say that there is no moral incentive to go into business, for example, but that it doesn’t predominate the way it does when one enters a field that is directly linked to the welfare of those you work for.  Money or merchandise serves as something of a buffer between the banker or merchant and the direct welfare of the investor or client.  The moral element, while present, becomes more diffuse.

    By way of contrast, physicians and nurses (and lawyers and teachers and police officers, etc) are directly involved with the immediate human needs of the people for whom they work.  The moral element is more proximate and harder (but not impossible) to ignore.  This makes it relatively less likely that the moral, personal and social incentives will become misaligned.Report

  8. Russell,

    I’m not a doctor. Thanks for the compliment though! I am a medical student, currently at the lowest level of the totem pole – i.e. not even in medical school, just taking a postbacc premed course. Maybe I should have used the language, “decided I wanted to become a doctor someday” or some-such to avoid confusion.Report