George Bernard Shaw on doctors and asymmetric information

I’ve known that George Bernard Shaw had a thing or two to say about conflicts of interest in the medical profession, about how doctors have a direct pecuniary interest in providing you with services (for which they charge a fee) rather than in keeping you well (in which case they don’t).

GBS was an early pundit on the problem that now goes by the name of asymmetric information.   Nevertheless I hadn’t been prepared for such a blast from his first para.

It is not the fault of our doctors that the medical service of the
community, as at present provided for, is a murderous absurdity.
That any sane nation, having observed that you could provide for
the supply of bread by giving bakers a pecuniary interest in
baking for you, should go on to give a surgeon a pecuniary
interest in cutting off your leg, is enough to make one despair of
political humanity. But that is precisely what we have done. And
the more appalling the mutilation, the more the mutilator is paid.
He who corrects the ingrowing toe-nail receives a few shillings:
he who cuts your inside out receives hundreds of guineas, except
when he does it to a poor person for practice.

Read a whole lot more if you want here.

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Andrew Leigh
17 years ago

Nicholas, there’s an interesting proposal that Grassley & Baucus have put up in the US. I don’t think it goes as far as you’d like, but I’d be curious on your views about it nonetheless.

17 years ago

Shaw had a horrendous and long drawn out experience with a diseased foot which began from lacing up one of his shoes too tightly & ended with surgery for necrosis of the bone and marriage to the lady who nursed him – I’ve often wondered if Stephen King got the idea fro the plot of Misery from this episode.

17 years ago

There are probably more effective ways for the US government to spend the money:

Norman Swan: What do you think about the Australian situation which you know a little bit about? We’ve been doing some of the things that you’ve been advocating for many years such as academic detailing. Do you want to just describe academic detailing?

Jerry Avorn: Sure. I’m a huge fan of the National Prescribing Service in Australia because I think it is probably an international model for trying to get information to doctors in a way that will improve prescribing and not just get them to sell more product for a given company. The academic detailing approach which we actually helped to get Australia started with I developed with colleagues at Harvard back in the 1980s and it essentially says let’s get word out, not just from the companies to doctors about what to prescribe, but from some neutral source that just is in favour of evidence based prescribing, in favour of just rational drug use. And in many countries that’s the government and so what I’ve been delighted to have seen Australia –

Norman Swan: Just before you go on, and what you’re essentially doing is using the same techniques that the pharmaceutical industry uses which is a representative arriving at the surgery and detailing in the case of the pharmaceutical industry their latest drug but in your case, detailing evidence based prescribing.

Jerry Avorn: Exactly, what we noticed and I guess what got me started on this whole effort back in the late 70s even was that we and academics we may know the answers and we not have any particular commercial axe to grind but we are lousy communicators. Whereas the drug companies are terribly good at getting into our faces and changing our behaviours and our way of thinking but they’re only doing it to sell products. So the insight, if you can call it that, that I had back in the late 70s was what if we could combine that wonderful interactive behaviour change strategy that the companies are so good at but put that in the service of just communicating the facts and the optimal prescribing ideas that a medical school would recommend.

Norman Swan: It’s expensive, it’s about over $100 a visit probably to do and does it change behaviours, is it worth the money?

Jerry Avorn: We know from our studies and from those actually in many settings in the world that have done this that not only does it save money it actually pays for itself. Because if you get a doctor to understand better when to use a drug for heartburn, or for blood pressure, or for depression, if you can really teach them that lesson he or she will use that for the rest of their practice and that one visit will make a big dent in how they prescribe for ever.

I think Australia is real important, it has probably the best National Academic Detailing program in the world and Australian model for many, many countries that are out there.

Norman Swan: Jerry Avorn is Professor of Medicine at Harvard Medical School. And you’re listening to the Health Report here on ABC Radio National.

Drug companies’ objective is to maximise their sales. The health system’s objective should be to treat according to best evidence. These are not at all the same thing.

The full transcript for this Health Report program (12 June 2006) is at

Damien Eldridge
Damien Eldridge
17 years ago

Eric Rasmusen discusses another quote from George Bernard Shaw to do with Economics in the introduction of the following book:

Rasmusen, E (2005(?)), Games and information: An introduction to game theory (fourth edition), Basil Blackwell, Great Britain(?).

This book is available online at the following website: .

The following quote comes from page 4 of the above book:

“Intelligent laymen have objected to the amount of mathematics in economics since at least the 1880s, when George Bernard Shaw said that as a boy he (1) let someone assume that a = b, (2) permitted several steps of algebra, and (3) found he had accepted a proof that 1 = 2. Forever after, Shaw distrusted assumptions and algebra. Despite the effort to achieve simplicity (or perhaps because of it), mathematics is essential to exemplifying theory. The conclusions can be retranslated into words, but rarely can they be found by verbal reasoning. The
economist Wicksteed put this nicely in his reply to Shaw’s criticism:

`Mr Shaw arrived at the sapient conclusion that there “was a screw loose somewhere”

Jim in Oslo
Jim in Oslo
17 years ago

That is unbelievable. An economist wrote that in 1885! I was just arguing with an economist friend recently about that very question. My issue (coming from a political background) is that symbolic logic, while helpful in many circumstances, tends to obscure questions of quality and interrelation. There are people in the World Bank, for example, who obsess over ‘social capital’, trying to show that an x increase in social participation will result in y effect for society. To simplify such a complex situation is insanity. Every time the term social capital is mentioned you can faintly hear a sociologist’s teeth grinding somewhere in the distance !