Category: Corroborating Evidence

Using Catalyst as Framework for Moral Healthcare Chapter 5: Corroborating Evidence

[These blog entries are my notes and takeaways from Jonah Berger’s amazing book, The Catalyst as I apply them to Universal Healthcare.]

Prime example here is of a substance abuse intervention. The corroborating evidence is supplied by the overwhelming number of attendees who are there to tell you about your problem and how it affects them. Further examples are provided about taking advice from people about cars or contractors and how corroboration from knowledgeable sources or disinterested sources increases the value of the input. The size of the decision matters also:

“How much weight, or proof, you need depends on how heavy the thing is that you’re trying to move. If you’re trying to lift a pebble, you don’t need much. Add a little evidence and it moves right away. Change happens. But if you’re trying to move a boulder, much more effort is needed. More proof is required before people will change.”

HCR Lessons: Clearly healthcare reform is a boulder. A really big boulder.

The Translation Problem

When people get recommendations, they try to translate that recommendation into what it means for them personally. Is the recommender similar? Prior recommendations? Validity of prior recommendations?

Strength in numbers. Multiple sources of information helps. It is helpful to consider which sources are most impactful, should they be spaced out over time, and how are they best deployed, especially when trying to change minds on a larger scale.

  1. Which Sources Are Most Impactful?
    1. People like me.
    1. Respected people in the community.
    1. People you know. Especially people you know well or with whom you have multiple connections.
    1. Also people from diverse areas improve corroboration. The more independent sources are better.
    1. This also goes for organizations. Substitute organizations for people in the above lines.
  2. When?
    1. Sometimes, all at once like in an intervention.
    1. Closely spacing asks or invitations is more impactful.
  3. When to Concentrate or Spread Out Scarce Resources: sprinklers or fire hoses?
    1. For weak attitudes (pebbles), the sprinkler system works best. It is not as hard to move a pebble.
    1. For stronger attitudes, boulders, the fire hose strategy is best.

HCR Lessons: We should be able to marshal sources in all of the ways described above. I think it is especially true that we do this with doctors and nurses. We have the stories. With some work, we may also be able to marshal organizational sources similarly. I do not think we should discount that businesses who are not profiting within the medical industrial complex are being scalped by the medical industrial complex.

Firehose: I think the Kefauver commission events would be amazing fire hoses. See my previous chapter summary about this.

Sprinkler: given the magnitude of this boulder, I think both techniques will be required in a sustained manner over a long period of time. I have been thinking a lot lately about sending ourselves in two conservative gatherings, or at least mixed gatherings like Rotary, Kiwanis and other such groups. Also on campus groups like the young Republicans and other conservative groups. Op-ed’s in traditional papers, alternative media, university media.

Again, all this is going to take a lot of resources and a lot of time and a lot of commitment.

Pebble or Boulder? How expensive, time-consuming risky or controversial is the thing?

Case study is about getting people to eat organ meats during World War II. They reduce uncertainty by providing recipes and suggesting be part of a larger family dish. To shrink distance they ask people to just try it occasionally. To reduce reactance they had small group discussions with housewives. These discussions provided corroborating evidence from similar people.

HCR Lessons: I totally agree that the campaign will have to be multipronged and this is a long game.

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 181). Simon & Schuster. Kindle Edition.”

We’re not ready for Single Payer Healthcare (because we disagree on basic morality)*

“A common incantation during debates on health reform… is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”
– Uwe Reinhardt
In a 2011 Republican Presidential debate, candidate Ron Paul was asked a pointed question about what to do with someone who needed expensive healthcare but did not have insurance: “Are you saying that society  should just let him die?” Some in the crowd jeered “Yeah!” Paul indicated that as a physician, he did not find it acceptable to do so and offered charitable care from “churches” based on his experience of practicing medicine in the in the early 1960s, before Medicare and Medicaid, eliciting applause from the crowd.
Last year, I attended the Keystone Progress Conference in Pittsburgh, PA for a few hours. I attended a panel discussion of progressive candidates who lost their elections in deep red districts. One of the things I heard was straight out of this Ron Paul universe – all four of these candidates said they were surprised that so many of the conservative voters were afraid, of having others “get over on them.” That these others would get free healthcare and they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.
In 2013, Dan Munro, writing for Forbes magazine, on the anniversary of Martin Luther King, Jr.’s “I have a Dream” speech, pointed to several myths so common to conservative thought about America, in particular our backwards interpretation of the “bootstraps” fable:
“the myth that literally anyone – through hard work and determination – can rise out of any poverty and become rich and prosperous. We salute, praise and deify everyone who does. But there’s a dark side to this myth. Anyone who doesn’t isn’t working hard enough – or doesn’t have enough determination. In effect, they’re a loser – and nobody wants to pay for the healthcare of those losers.”
Veronica Combs paraphrased it as ”There is a real meanness in the conversation about who should have healthcare, an implication that people who need help somehow don’t deserve it, or that they are taking advantage of ‘the rest of us.’”
All of this, of course, is not really news. Making a moral case for universal health care in any form is denounced as socialism or “not the job of government,” or as Ron Paul said, that we must “assume responsibility for ourselves.” The American Medical Association has famously opposed movement towards universal healthcare, from the Truman Administration to the passage of Medicare and Medicaid and through opposition to major parts of the Affordable Care Act.
Martin Luther King, Jr., noted that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Many have railed about the inhumanity of Americans towards each other regarding healthcare, and the late Professor Uwe Reinhardt has asked for decades, “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?” Americans, capable of unbridled generosity in helping individuals pay for a transplant or some other services when the individual in question is deserving, are ruthlessly coldhearted when compassion is requested for those they deem undeserving, as the Tea Party crowd showed us in 2011.
Reinhardt was clearly stung by the idea that his adopted countrymen (he was German born US citizen) rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question. He also pointed out that the way Americans avoid the moral question that faces us is to play the game framed by the introductory quote: we pretend that the problem is that we disagree on policy, writ small and large, and find ourselves down rabbit holes about the reimbursement for an anesthesiologist for a fifteen minute unit of time with or without a nurse anesthetist!
Every other nation has started with the moral and ethical question over their values as a society and worked towards a solution to provide healthcare to all their people, “deserving” or not. As another professor noted:
“The last time I taught in the Semester at Sea program, I found it necessary to interpret for our students the rich “social capital” that runs through the Northern European societies we were visiting. What they knew and had read in their guide books was that not many people are in church on Sunday morning, especially compared to the florid religiosity of the United States. So their working assumption was that Americans take religion seriously and Europeans don’t. The new thought that amazed them was that the unchurched Europeans live in social democracies deeply saturated with historic Christian values, while the much-churched Americans celebrate a society characterized by a ruthless social Darwinism that the God of the Bible, Old and New Testament alike, denounces.”
What is preventing us from having the basic moral argument about our values regarding health care? The answer is three-fold. The first is a strong puritanical streak in American culture that prompts many of us to divide our fellow citizens into camps of deserving and undeserving people. The second is a now unfathomably large industry that has much to lose should efficiency and order find their way into the American Healthcare system. The third is our human cognitive biases that lead us to sloppily assume political and moral positions that will take years of work to overcome, using cognitive psychology to reframe the debate and convince people that doing the right thing is the right thing to do — for everyone.