This post was inspired by my pastor Bob Hurst’s sermon last Sunday, built around the instruction not to fret over how some evil-doers never seem to get what they deserve. As my mother put it, “life’s not fair” (subtext “quit whining and get over it”). Bob did a lovely riff on this timely theme, including the pitfalls of punishments and rewards, and managed to work in Bernie Madoff to boot. No sermon on evildoers is complete without Madoff!
As a pediatrician and a parent, I realized years ago that the whole carrot and stick bit was pretty worthless when it came to teaching kids important things like honesty, respect, and courage. The research literature backs that up at every turn—for both adults and children, punishments are one of the least effective tools at producing desired behaviors, and rewards twist them up terribly. In any activity requiring higher order thinking, an external reward diverts attention from the good action itself. The result is cutting corners to check off boxes (e.g., No Child Left Behind) and a loss of internal motivation. Punishments create ripe soil for more sneakiness, among other problems.
Some writers take this so far as to imply human choices aren’t influenced very strongly by punishments and rewards, but that has always bothered me. It seems obvious that behavioral modification works sometimes, and I’ve never seen a really good explanation why. During my sermon-induced meditation on evildoers, I suddenly figured it out. Rewards DO work—but only to stimulate wrong-doing. Punishments DO work—but only to inhibit doing good. Let me explain.
When drug companies reward doctors for listening to their false advertising, we get the wrong-doing of thoughtless prescriptions. When we give so-called incentives for doctors to perform in certain ways, we get medicine distorted by box-checking and overshadow the best incentives—satisfaction at helping patients be healthier, and pride in good work. When we pay subspecialists huge fees to do procedures, we get lots of unnecessary procedures. If a person requires an external reward, separate from the good action itself, performance will ultimately deteriorate. I know someone is going to say doctors won’t work for free, so I’ll try to nip that in the bud. Read Daniel Pink’s “Drive” for details. As long as salaries are perceived by employees as subjectively reasonable, so that they do not feel disrespected or taken advantage of, more money doesn’t produce better work.
As for punishment, when corporate insurers issue forth their spin doctors to scare physicians and the public about universal healthcare, they are often successful in getting folks to oppose it or at least to just keep their mouths shut. That explains why I hear, over and over, “well, I know Medicare for All sounds good, but. . . ”. After the “but”, insert every variation of propaganda you can think of—this isn’t the time, it’s socialized medicine, government can’t do anything right, we need competition across state lines, etc. Follow the money and you’ll find out where each sound bite came from.
The Bible passage about fretting encourages us to quit worrying about wrongdoers who seem to get a free pass. We are also advised not to think about whether we will get rewarded for doing good. I agree. But the consequences of doing ill or good have never fallen specifically on any one person’s head—the karma of justice is not that targeted. Allowing private insurers to keep doing wrong is clearly hurting every one of us.
So I looked up “fret” in the dictionary and found another, older meaning of the word I’d forgotten—“to wear away” at something, as by constant rubbing. When I get discouraged that advocacy for national health insurance is taking too long and I’m not seeing results, I remember that water, over time, can wear away the hardest rock. We can never remove all the incentives in the world to do wrong—it will always require determination and courage to keep fear from deterring good work. Let’s fret a little more and a little harder. Medicare for All—everybody in, nobody out.