Let’s assume there is a thing that all would agree is, in context, a Good Thing(tm) that someone in your situation would want.

Do you want the thing, or do you want the symbolic representation of the thing?*

This sounds like an easy question; obviously you want the thing! Alas, it is often not that simple. Even when the thing itself would be most valuable, often the symbolic representation of the thing is what is in demand and gets produced.

One of MetaMed’s biggest mistakes was not realizing that this applied to health care. As Robin Hanson put it, health care is not about health: The system is more concerned with making sure everyone is able to signal, to others and to themselves, that they care deeply and that they are doing everything they can. This drives people’s decisions strongly enough to usually dominate decision making when the stakes are high. The actual health effects of the decisions involved are often a secondary concern, and the costs a distant third. The risk of not doing the standard thing, or what your doctor told you to do, looms larger than the fact that you believe that the decision is wrong; if you go against that advice, then you are not doing the responsible thing, you don’t care for yourself or your loved ones, and everything that happens to you after that is your fault.

Unsurprisingly, this leads to some very poor decisions when looked at in terms of what has a positive impact on the people’s health. And of course, everyone involved being afraid of being sued (far beyond the statistical danger of actually being sued) every time they deviate from the standard of care makes this that much worse.

MetaMed’s central thesis was that people cared enough about their health that if the information on how to save their life was available to them, they would have to buy it, and they would be willing to pay at least a small fraction of what that information was worth.

This theory was tested, and was conclusively falsified. Or rather, the following was conclusively falsified:

If a person is convinced that information could become available that might save their life, that person will often be willing to buy that information for a small fraction of what that belief implies the information is worth to them.

The experiment was not a randomized controlled trial, nor was the sample size all that big, but the data was clear and conclusive: A non-zero number of people will do this, but the vast majority of people will not.

Two points of failure are being explicitly excluded here.

The first is: Did we actually have that information? I would argue that we did, and believe we very much did right by those who hired us in terms of getting them the information they needed and/or requested, but of course I am biased, and we will never know for sure.

The second is: Did we manage to convince people that we had or could acquire this information? Our success rate on this was not all that high; certainly the majority of people who considered this hypothesis rejected it, most of them doing so quickly. Like any good start-up, and many bad ones, we did not let this stop us, and we kept pitching. Eventually we found a decent number of people who we did convince. We should have been able to do this more often, and were improving at it, but that is another story.

The important thing is that while it was only a fraction of the people we attempted to convince, many people explicitly said that they believed we had or could acquire this information in exchange for money, and I have no reason to doubt them. We have a sample size well into the triple figures of such people.

The majority of them did not buy. Of those who did buy, the majority of them chose a project far smaller than their problems justified, and intensely haggled to make that size as small as possible.

Then, in the end, many were dissatisfied because we had given them the thing rather than the symbolic representation of the thing. In one case, the person went so far as to show us the symbolic representation of the thing that the person was hoping to buy – a very colorful and nicely formatted informational packet that did not contain the information this person needed to deal with their very serious health problem, in part because the packet was completely out of date.

It took us over a year, and over forty cases, to realize that when we delivered a report, it was not being evaluated on the basis of whether the information would improve health outcomes. It was being evaluated on the basis of whether it looked like an expensive report should look, and whether it looked like they had ‘gotten their money’s worth’ in terms of the work that was visible. The work that was visible, of course, was mostly distinct from the work that could make them healthier.

Over time, we moved from spending almost all our time and effort into helping find ways to improve people’s health, and inventing a system to make that happen efficiently without wasting money on other things, to figuring out how to make people feel listened to and show them (ideally grey-haired and well-credentialed) doctors that spoke with proper authority and confidence, and then give them reports that were laid out as beautifully as possible and looked expensive and professional, and do that as efficiently as possible so we could deliver our actual research payload that might actually help them. Everything depended on convincing the right people that we were capable of presenting the proper symbolic representations, so we could get continued funding for our operations and improve our symbolic representations in the hopes of finally being able to get more sales at the now much higher price point that was necessary in order to deliver the symbolic representation of our product, without which our product would never get to help anyone, as well as also deliver the actual product.

We had a bunch of people who care very deeply about helping and making sure the product actually works, and were deeply concerned about every minute spent on anything else, so the temptation was never there to only deliver the symbolic representation and stop actually helping people. I think that people who would have been capable of that would have never founded MetaMed in the first place! But that is the natural outcome of such a process after enough rounds of selection pressure: Only the symbolic representation remains.

A number of the products and services we attempted to buy, or which others attempted to sell to us, had either gone through this process or had skipped it entirely by never being real in the first place. Instead, they existed so that people could tell themselves they were doing a Responsible Business Thing that businesses needed to do, rather than working to get the benefits that thing would provide if it was actually done. Most times we hired people from outside the core team to complete key tasks, and those tasks could not be fully and explicitly specified, those tasks did not actually get done. Instead, the people involved did things symbolically representative of the task, and billed us or collected their salaries continuously until we realized the things involved never got done. When we then investigated, it became clear the decisions being made did not make any sense if one was looking to help a company succeed; they only made sense in terms of what would superficially look like doing the job if not examined too closely, or would be vaguely associated with the job getting done if one never thought about how things would physically progress from point A to point B.

Michael Vassar speculates that this has overtaken giant sections of the economy, and that many or even most products and services are symbolic representations of themselves first and the product or service itself second or not at all. I certainly find examples of this all around me. This last week, my wife and I went on vacation to a place that charges quite a bit of money for things that I see no value in, but which she enjoys greatly, and I believe that what she enjoys is that it symbolically says “Vacation” to her. I see the actual thing, and so I do not get it. That is fine. I am not the target (a powerful mantra!). Sometimes, what one needs are not expensive wines but expensive wine bottles. Other times one wants the wisdom, or lack of wisdom, to know the difference.

*The problem with talking about this topic is that I realized that every time I wanted to talk about the details, it would involve accusing someone of fraud or at a minimum completely missing the point, and be at least deeply insulting if not fighting words or grounds for a lawsuit. Thus, the motivating example of this post is completely missing, and a lot of details are being left out that would make this a lot easier to grok. But I’d rather post it this way than not post at all.