The Sacred and the Taboo Trade-off

From Robin Hanson’s post today, “Medicine is Sacred,” a quote from the New England Journal of Medicine about the health care reform bill (aka ACA – Affordable Care Act):

“The recently enacted Patient Protection and Affordable Care Act (ACA) created a Patient-Centered Outcomes Research Institute to conduct comparative-effectiveness research but prohibited this institute from developing or using cost-per-QALY [quality-adjusted life years measurement]  thresholds. … The ACA’s language might be seen as symptomatic of the legislation’s aversion to policies that critics might see as enacting “big-government” health care or “death panels.” … The antagonism toward cost-per-QALY comparisons also suggests a bit of magical thinkingthe notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness farther down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints.”

As Hanson notes, “to the US public, medicine is a sacred; tradeoffs are taboo,” then citing a Scientific American article from March 2010 that explains the concept of taboo tradeoffs for sacred values:

What truly distinguishes sacred values from secular ones is how people behave when asked to compromise them. When people are asked to trade their sacred values for values considered to be secular — what psychologist Philip Tetlock refers to as a ‘taboo tradeoff’ — they exhibit moral outrage, express anger and disgust, become increasingly inflexible in negotiations, and display an insensitivity to a strict cost-benefit analysis of the exchange. What’s more, when people receive monetary offers for relinquishing a sacred value, they display a particularly striking irrationality. Not only are people unwilling to compromise sacred values for money — contrary to classic economic theory’s assumption that financial incentives motivate behavior — but the inclusion of money in an offer produces a backfire effect such that people become even less likely to give up their sacred values compared to when an offer does not include money. People consider trading sacred values for money so morally reprehensible that they recoil at such proposals.”

What I find odd about the taboo tradeoff, though, is that negotiations can be successful if other words are used for tradeoffs — words like “‘costs and benefits’ and ‘analysis’ ….  This vague utilitarian language appears to mask the emotion-laden taboo nature of the exchange.” Using the words “costs” and”benefits” masks the actuality of money sufficiently enough to do an end-run around moral outrage and disgust? Really? I would have predicted that this kind of language would have the same effect that talking about cold hard cash has, because these words are themselves so cold and calculating, and they still seem to be trying to appeal to the mercenary, or at least the rational, in us. And the sacred, by definition, is that which we believe to be inviolable. transcendent of the profane world of the rational and concrete.

The second way to negotiate successfully in this realm makes much more sense to me:

“Another strategy is to emphasize the dire, obligatory nature of the trade-off. For example, people are more willing to sell their body organs for medical transplants when told it is the only way to save lives because this framing posits the exchange as one sacred value for another.”


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