Market Fundamentalism and the Denial of Conflicts of Interest, and of Worse Offenses

While we often point out the pervasiveness of conflicts of interest in medicine and health care, and the likely ill effects of this state of affairs, it seems that the powers that be in health care tend to airily dismiss conflicts of interest as at most a minor problem that needs management (e.g., look here.) 

How Market Fundamentalist Ideology Nullifies the Concept of Conflicts of Interest

On the Hooked: Ethics, Medicine and Pharma blog, Dr Howard Brody discussed how application of the reigning orthodoxy in economics, sometimes called neoliberalism, market fundamentalism, or economism, can be used to dismiss the concept of conflicts of interest.

Basically, supporters of market fundamentalism et al seem to assume that all markets are idealized free markets, and that free markets are like a super computer combining all human thought to provide wisdom in the form of price information.  Furthermore, since the market is based on supposedly rational choices made by free individuals, one cannot go back to question such choices.

 So when, for example, an academic physician makes the "free choice" to accept thousands of dollars from a drug company as a "market consultant," and then also gives talks about clinical topics that happen to favor that drug company's products, such choices cannot be questioned.  Therefore, the notion that these choices constitute a conflict of interest, and that the choice to accept the drug company money in particular might increase the likelihood of abuse of the physician's entrusted responsibility to make the best decisions for individual patients, and to teach other physicians honestly and without bias, essentially makes no sense within this framework.

Dr Brody further enlarged on the internal contradictions within the ideology of neliberalism/ market fundamentalism/ economism, in another post on his Economism Scam blog.

Of course, the ideology seems to ignore the possibilities that 1) people's choice may not be free, may not be rational, and may not be based on coldly rational cognition and the best possible knowledge; and 2) one person's economic choice may limit another person's choices, or directly harm another person.

 By Extension, Fraud and Corruption Denialism

Furthermore, not only does neoliberalism et al seem to deny the existence of meaningful conflicts of interest, it also could be used to deny the meaningful existence of deceptive marketing, of market domination through oligopoly or monopoly, and then of outright fraud, bribery, and extortion. 

See for example how former US Federal Reserve chairman Alan Greenspan seemed to deny the existence of fraud, which he asserted would always be nullified by the ideal market.  As we posted here, according to an article in Stanford Magazine,  Greenspan told Ms Brooksley Born, the federal regulatory agency head who tried to develop some effective regulation of financial derivatives,

'Well, you probably will always believe there should be laws against fraud, and I don’t think there is any need for a law against fraud,' she recalls. Greenspan, Born says, believed the market would take care of itself.

By further extension, market fundamentalism could be used to deny the evils of chattel slavery.

The Conflicted as Defenders of Conflicts of Interest

Finally, notice that neoliberalism/ market fundamentalism/ economism ideology seems to have conveniently been adopted by pundits, both in economics and in medicine and health policy who may be personally profiting from conflicts of interest on one hand, and whose conflicts seem to arise from payments from large corporations whose management seem to be personally profiting even more so. 

For example, we have discussed examples of how defenders of existing financial relationships - which in my humble opinion are actually conflicts of interest - employ logical fallacies to make their points.  Some of these defenders seem to have obvious conflicts of their own (for example, this post included examples of physicians rationalizing their financial ties to drug companies,  and this post included fallacies employed by a current medical school leader, but former extremely well paid biotechnology company executive.).  On the other hand, I have yet to find a logical, reality-based defense of these conflicts of interest made by anyone who demonstrably does not have such conflicts of their own.  

Summary

Human beings have been wrestling with corruption since the dawn of history.  There are ancient arguments against bribery in the Bible  (e.g., in the Old Testament, in Exodus and Deuteronomy), and fraud (e.g., in Leviticus, the Proverbs, and the Gospel of Mark).  One can argue that a fundamental purpose of civilization is to reduce self-serving misbehavior such as bribery, fraud, and extortion, and other varieties of corruption.  The notion that free markets make the concepts of fraud, and of conflicts of interest (that are risk factors for corruption - look here) meaningless is nothing more than school playground sophistry.

To truly reform health care, we need to return it from its current Wild West mentality to a state more resembling civilization.  We need to reject silly notions that free markets erase the concepts of conflict of interest, or of fraud, or of other aspects of corruption.     

Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institute for Medical Humanities at University of Texas - Medical Branch at Galveston, and blogger at Hooked: Ethics, Medicine and Pharma. 

Danielle Ofri, a prominent internist/author at Bellevue in New York, started a recent op-ed piece, “Last week I was ready to quit medicine."

She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.

Ofri’s plaint caught my attention because I had recently put up a guest post on Health Care Renewal about another highly skilled, caring physician who was seriously considering quitting practice. This led me to write a column for some of our local newspapers about demoralized doctors

In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.

We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.

There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.

Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports either quality care orefficient resource use?

If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look here - Ed]  . And we know that at least at the high end, these managers are paid munificent sums, and are lauded for their supposed genius (look here for example). 

So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.

All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.

This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I explained some time ago, most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or economism. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look here.)

Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look here), or "financialization." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this generic management. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now.

Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "learned helplessness." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.

After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, “when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”

Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means? 

Dr Howard Brody

Why Health Care Leaders Remain Unaccountable: How the Family Invisibly Promoted the "Divine Right of CEOs"

We have frequently discussed the lack of accountability of health care leaders, which we sometimes have described as CEO exceptionalism. We have noted how health care leaders almost never seem to need to take responsibility for their organizations' misbehavior and its outcomes, (look here) and in fact can command ever increasing compensation, no matter how badly they or their organizations do. 

Some of the more recent examples of this phenomenon were:

• William Weldon, soon to retire as CEO of Johnson and Johnson, has commanded eight-figure yearly compensation despite severe manufacturing problems leading to 30 product recalls since 2009, and multiple ethical lapses leading to legal settlements and guilty pleas (see this post).
• Non-profit hospital system CEOs got bonuses and raises, or departed with golden parachutes as their systems faced financial losses and laid off employees, or after their medical staff questioned their management (see this post).
• A non-profit hospital CEO got a golden parachute ostensibly because he engineered a successful merger.  However, the merger never took place (see this post.)

Others examples can be found here.  Moreover, such executive compensation is almost never justified with anything approaching evidence or logic.  When health care organizations can be bothered to try to explain executive compensation, they revert to rote compliments (executives are called "brilliant" or "visionary") without further explanation, e.g., look here and here and here), or even fall back to logical fallacies (e.g.look here).

Why Does Unaccountable Leadership Persist Unchallenged?

Why this absurd state of affairs persists and is getting worse, and why it is so little noticed outside of this blog, is a real question.  One explanation we just raised is that society has gotten used to "the divine rights of CEOs," partially because of the success of an ideology that has been called "economism," that in turn is based on some old and now rarely accepted religious teachings that have somehow infiltrated what is supposed to be a science.

The Family as a Supporter of the "Divine Right of CEOs"

A related explanation comes from The Family, published in 2008, written by Jeff Sharlet.  It suggests that such outmoded beliefs have been promoted by an extreme, nearly invisible, but influential religious sect called "The Family" that has been around since the 1930s.  The Family has powerfully promoted its fringe religious beliefs to influence policy and politics.  I strongly recommend reading the book for further details, or at least a summary article, Jesus Plus Nothing, Shalet published in 2003 in Harpers.

Let me summarize the relevant points.  Because many will seem far-fetched, I will provide quotes from the book to back each up, with page references from the Harper Paperback edition.  Italics were added for emphasis.

Secrecy

The Family, formerly the Fellowship, is secretive, and functions behind a variety of front organizations.

The family has operated under many guises, some active, some defunct: National Committee for Christian Leadership, International Christian Leadership, National Leadership Council, the Fellowship Foundation, the International Foundation. (P 20-21)

Extreme Theology
While nominally Christian, the Family is at the far extreme of the spectrum, and embraces beliefs that many would find far-fetched, or worse.

It discounts the Bible and the Holy Trinity, and hence is hardly fundamentalist in the usual sense of the word.

The Family’s

origins lie not in the New Testament, which is ultimately little more than a fabric from which the Family constructs contemporary realities....” (P 61)

Not Jesus plus scripture, since scripture, after all, contains a great deal besides Jesus. No burning bush, no voice in the whirlwind, no Daniel, no lions. (P 252).

It discounts the Holy Trinity.

[Current Family leader Douglas] Coe and his inner circle do believe in the trinity; a Washington fundamentalist activist told me,’ but they’ll given the Father and the Holy Ghost the weekend off. Because they clutter the conversation. Jesus is so easily presented. (P 252)

Some call it a dominionist sect, that is, one that seeks a return to the very earliest Christianity, before any organized churches.  

The Family’s beliefs appear closer to a more marginal set of theologies sometimes gathered under the umbrella term of dominionism, characterized ... by William Martin, a religious historian at Rice University, and Billy Graham’s official biographer.... Dominionist theologies hold the Bible to be a guide to every decision, high and low, from whom God wants you to marry to whether God thinks should buy a new lawn mower. Unlike neo-evangelicals, who concern themselves chiefly with getting good with Jesus, dominionists want to reconstruct early Christian society, which they believe was ruled by God alone. (P 44)

(Note, however, that the emphasis on the Bible as guide appears to contradict the discounting of scripture above.)

Links to the Powerful

The Family has had ties to numerous powerful politicians.

The Family is in its own words an ‘invisible’ association, although it has always been organized around public men. Senator Sam Brownback (R., Kansas), chair of a weekly off-the-record meeting of religious right groups called the Values Action Team (VAT) is an active member, as is Representative Joe Pitts (R., Pennsylvania),... Others referred to as members include senators Jim DeMint of South Carolina,...; Pete Dominici of New Mexico...; Chuck Grassley (R., Iowa); James Inhofe (R., Oklahoma); Tom Coburn (R., Oklahoma); John Thune (R., South Dakota); Mike Enzi (R., Wyoming); and John Ensign.... ‘Faith-based Democrats’ Bill Nelson of Florida and Mark Pryor of Arkansas,... are members.... (P18)

Many other politicians, some very well known, from both major parties appear as Family members or friends in the book.

Since the 1950s, the Family has supported the National Prayer Breakfast. (P 195). 

The "Divine Right" of Leaders

The Family believe that those who are powerful are those chosen by God to be powerful, and hence must obeyed.

Family founder Abraham Vereide, better known as Abram

“would become an exponent of religion for the elite - the ‘up and out,’ as he called them.... He termed this trickle-down faith the Idea, and it was really the only idea he ever had - the only one, he believed, God gave him. In one sense, it was nothing more than a defense of the status quo. It neither challenged power nor asked for anything from the powerful but their good intentions. ( P 91)

“Power lies in things as they are. God has already chosen the powerful, his key men. ( P 96)

‘We work with power where we can, build new power where we can’t.’ The words belong to Doug Coe, who seized the Fellowship’s top spot in a succession struggle following Abram’s death in 1969 and began transforming it into what I eventually encountered as the Family. ( P 121.)

The "Divinely Chosen" Leaders Need Not be Accountable to Any Man

The powerful, because they are chosen by God and are instruments of God’s will, need not be accountable, at least to any other humans.

This, Abram decided, was what it meant to die to the self: to turn all responsibility over to God. That such a transfer meant the abdication of any accountability for one’s actions, that it provided justification for any ambition, did not occur to him. (P 125)

A Fellowship tract titled Studies for Public Men, 10,000 of which were printed up by a Chevron Oil executive, claimed that such abuses [refers to an Army General who worked with Coe and was subsequently jailed for selling surplus weapons to 'Third World gangs'] are inevitable, but not attributable to the piety with which such men cloaked their misdeeds. When pious men committed crimes, went the thinking, godlessness was to blame - ‘secularism in its worst form!’ In a Section titled ‘Accountablity,’ the tract explained why the Fellowship should not be held accountable for the actions of its individual members.... ‘Persisting in the accusation of collective guilt immobilizes a society,’ advised the tract. Perhaps, but the Fellowship denied the very concept of guilt for the powerful. That was a legalistic notion, an encroachment on God’s sovereignty.... (P 220)

We’re all sinners, and thus shouldn’t judge those whom God places in authority. (P 241)

The "Divine Right" Extends Even to Dictators

The Family’s support of powerful, unaccountable leadership is suggested by how it tolerated, and sometimes supported vicious dictatorships.

Understand Abram’s weirdly ambivalent relationship with fascism.... (P 124)

In Frankfurt, Abram claimed, God personally revealed to Abram a key man to quietly help manage the internal affairs of Germany’s elite: Dr Otto Fricke, an austere German churchman with an uncomfortable past. ‘You are God’s man for this hour in Germany,’ Abram told him. Had Abram asked about Fricke’s role in Germany’s previous hour, Fricke would have begged off explaining his activities during the Third Reich. As a radio preacher, he’d been recruited by Goebbels to propagandize,.... (P 159)

Coe counseled a Haitian senator and then Haiti’s ambassador to the United States, easing both into commitments to a Christ-led nation, with the understanding the Christ Coe preached led not toward the socialism that tempts any bitterly poor people but toward an economics of ‘key men’ who would share their wealth as God instructed them. Senators Frank Carlson and Homer Capehart, both members of the Foreign Relations Committee, did the follow-up work, leading a Fellowship delegation of twelve businessmen to instruct the Haitian parliament in prayer cell politics. Francois ‘Papa Doc’ Duvalier, who would declare himself president for life but also the nation’s official ‘Maximum Chief of the Revolution’ and ‘Electrifier of Souls’ - he was the weirdest and most vicious dictator in the Western Hemisphere - impressed the senators with his spirituality.

Not only did South Korea hold a prayer breakfast, but its dictator, General Park Chung Hee, tried to use the Fellowship to channel illegal funding to congressional candidate’s of [President Richard] Nixon’s selection. (P 216)

In 1968, Abram declared [Indonesian dictator] Suharto’s coup a ‘spiritual revolution,’ and Indonesia under his rule an especially promising nation, hope for the future in Abram’s later years. (P 245)

The family also had cordial relationships with South Vietnamese leader General Nguyen Van Thieu (P 248) and Filipino dictator Ferdinand Marcos (P 249)
 
Summary
 
Sharlet's book suggests how the Family's increasing influence has led to the infiltration into the general society of the notion that all current leaders, including and particularly corporate CEOs, have a "divine right," and can thus not be held accountable by mortal men, even though that notion, if expressed this clearly, would seem ridiculous to a vast majority of the population.  It is possible that the major reason that most health care leaders have become unaccountable is some sort of subconscious acquiescence to the notions of economism (as discussed here), and promulgated by the Family.  However, this acquiescence then is largely by people who would likely reject the bizarre religious beliefs that underpin these notions if those beliefs and their origin were made clear.
 
All those who do not believe that all earthly leaders are divinely chosen need to challenge the leaders chosen by human to be accountable to humans. 
 
As a society we need to wake up from our dazed acquiescence to ideas that border on crazy.  We need to challenge rote justifications and talking points for that which makes no sense, but serve to make the powerful more powerful.

The Golden Calf Explains How Economism Lead to the Divine Right of CEOs

Our fellow blogger (on Hooked: Ethics, Medicine and Pharma), family physician and bioethicist Dr Howard Brody, has written a book on economic ideology that helps explain some of the issues we frequently discuss.

Dr Brody's book, The Golden Calf, is about how the social science of economics has been taken over by an ideology he and others call "economism." 

Economism

Economism consists of these major ideas:

• "'The economy' is a separate and distinct sphere of society."  This means that economic planning can be independent of consideration of the rest of society.
• "Even if only a part of society, the economy is the primary part."  Thus economic planning, thinking, policies etc take precedence over other planning, thinking, policies, etc.
• "People are, at core, economic beings.  The laws of the marketplace describe virtually asll of their behavior and the reasons for it.  People are beings of economic exchange, driven first to make money and then to spend on the goods obtainable in the marketplace."  So all other human thought, values, emotions, etc are less important.  The answer to the question, "what does love have to do with it?" is nothing.  Neither does honesty, morality, or ethics have to do with it.
• "Economic calculation is the best way to understand, value, and manage human life.  It is appropriate that every aspect of our lives be thought of and analyzed in terms of economic calculations."  This essentially asserts that economists, economic thinking, and the marketplace should rule the world. 
• "The economy, above all else, must be managed solely with an eye towards its own technical requirements - that is, what economists study.  There ought to be no interference from politicians, or policymakers, or moralists, or anyone else."  Thus, not only should greed be considered good, but greed ought to be enacted into law. 

Economism's Prescription for Health Care

Stated so baldly, economism may seem absurd.  However, it is easy to see its influence.  For example, Dr Brody explained how economism would state:

what sort of health system the U.S. ought to have. It would be one that is governed by the laws of the market, and that treats all aspects of health care as consumer goods. How much any person 'needs' health care would be determined by one thing only - what that person is willing to pay on the open market. Anything else would be denounced as illegitimate interference with the market by politicians, policymakers, and other do-gooders.

This, of course, corresponds very well with a lot that is said about health care by its current leaders. How often have we heard about the health care market, and how the only way to improve health care is market-based reforms? (Look here).  How often have we heard leaders of hospitals refer to their "industry?" How often have we heard of patients as consumers, and doctors as providers? The list can go on.

The problems are that economism does not provide good tools for prediction or management of the economy. Worse,

If we want to live in a society that reflects basic human values, including acceptable moral rules, economism is a very poor guide. Yet economism is blind to its own deficiencies. it claims to be able to tell us the definitive answer to any problem in any aspect of human life, and accuse us of being irrational if we disagree with its proposals. If a powerful elite takes over control of a society, wedded to economism as their belief system, then the results for that society could be disastrous.

The origins of economism provide an explanation for a phenomenon we have often seen in health care, the lack of accountability of health care leaders, which we sometimes have described as CEO exceptionalism. We have noted how health care leaders almost never seem to need to take responsibility for their organizations' misbehavior and its outcomes, (look here) and in fact can command ever increasing compensation, no matter how badly they or their organizations do.

The Religious Origins of Economism
To understand this explanation, first note that Dr Brody suggested that economism is not a science. It did not arise out of an effort to use logic and reason to explain evidence. Instead, it seems to have come from two strains of religious thought that got translated into economic terms.  Dr Brody suggest that while it may make sense to think of economism as an ideology, it functions more like a religion, so that viewing economics ruled by economism as a social science would be a very big mistake.

The first strain was the Protestant evangelism found in England in the 18th century. Evangelicals of that time

regarded poverty as part of a divine program. Evangelicals interpreted the mental anguish of poverty and debt, and the physical agony of hunger or cold, as natural spurs to prick the conscience of sinners. They believed that the suffering of the poor would provoke remorse, reflection, and ultimately the conversion that would change their fate [in the afterlife]. In other words, poor people were poor for a reason, and helping them out of poverty would endanger their mortal souls.

Thus, people who fail in the marketplace of life are sinners. Markets should not be regulated to prevent such failure, because doing so would prevent their still possible salvation.

On the other hand, the Puritanism of the 17th and 18th centuries, and its 19th century evolution in the US

was creeping up on the idea, not only that material wealth and worldly success was a good thing in the eyes of God, but that seeing oneself become successful and wealthy was the strongest possible sign of God's grace and one's status among the Elect.

Things then got more extreme.

The moderate idea that those who enjoy material wealth in the earthly life may have been especially favored by God seems gradually to have morphed into the extreme idea that God wishes us to bestow on the super-rich our adulation and unquestioning allegiance.

So,

For example, Reverend Russell Cornwell's lecture called 'Acres of Diamonds' proved so popular after he first wrote it in 1870 that he was called upon to give it six thousand times over the next quarter century. He preached: 'I say you ought to get rich, and it is your duty to get rich.'

Thus,

We have been conditioned to believe that wealth is an infallible sign of God's favor.

Here is the religion behind CEO exceptionalism, lack of CEO accountability, outrageous CEO compensation, the imperial CEO. CEOs can become extremely wealthy, and "wealth is an infallible sign of God's favor," generating the notion of the divine right of CEOs.

Summary

No wonder that we have yet to see any logic or evidence to support CEO exceptionalism. Instead, we have seen logical fallacies used to support lack of CEO accountability and immense CEO compensation. The wealth of our leaders cannot be addressed with logic and evidence if it is a sign of God's favor.

Thus, anyone whose religious beliefs are perfectly compatible with 18th century English evangelism and 17th through 19th century British and American Puritanism and its aftermath might be happy with the divine right of CEOs, and with economism in general.

However, Dr Brody makes the powerful point that economism functions like a religion, and at best is an ideology, not scientific paradigm. Anyone who is uncomfortable with the religious beliefs that underlie it ought to be very uncomfortable with its precepts, as should anyone who believes that economics or health care should be based on evidence and logic.

Specifically, in health care and in the larger economy, anyone who does not believe that rich CEOs are especially favored by God should question why they should be so rich, and why they should be so unaccountable.

Dr Brody has written a powerful and important book which goes a long way to explain the irrationality that has infected health care. People of all, or of no religious beliefs should pay attention.