Spreading Altruism as a Public Health Effort
The core conflict in a game of NPD is that if the participants decide to act on the basis of their rational self-interest, they would all be worse off than if they had not followed their rational self-interest. Real life examples of individuals not acting out of rational self-interest are plentiful. For instance, individuals often vote in general elections even if their self-interest dictates that they are better off not voting. For US presidential elections, an individual’s vote would make minimal difference to the eventual outcome and casting votes often entail long waits. Yet, 59% of registered voters voted in 2012 presidential election (FairVote). Turnout in the 2005 Iraqi parliamentary election—the first in the history of Iraq—was estimated at 70% even though insurgent groups threatened violence. From the point of view of rational self-interest, individuals should not be voting voluntarily. The same altruistic behavior occurs with regard to voluntary recycling. In 2012, 34.5% of all US households recycled. The majority of these households are in municipalities that do not mandate recycling (EPA). Rational self-interest does not always dictate our choices. We often pursue a course of action that is not in our best interests guided by considerations such as the well-being of others.
The global monitoring approach to solving the problem of antibiotic resistance depends on extensive surveillance of appropriate drug use at the clinical and pharmacy level, a combination of proper carrots and sticks to incentivize nations to participate, and a sufficiently objective and resourceful organization to implement the consequences of cooperation and defection by signatories. Given the slim chance that such a system can exist, it is wise for us to explore a possibility that has been largely ignored: that is, encouraging individuals to act not just in their rational self-interest but also the interests of other individuals including future and distant people. Dan Ariely has done extensive research into the psychological mechanisms at work when one decides whether or not to cheat (Ariely 2012). What he has uncovered is that most subjects in his studies do not base their actions on a simple cost-benefit analysis in the face of an opportunity to cheat. In one study, Ariely et al. provide their subjects with a matrix of simple mathematical questions. After a short period of time, the subjects report how many questions they have solved and they are paid accordingly. In one variation, the subjects’ answer sheets are shredded by the subjects after they have had a chance to check their answers. There is no way the experimenters can tell if the subjects were lying about the number of correct answers they had on their sheets. In experiment after experiment, Ariely et al. observe that the majority of subjects lie about how many answers they get right by only a small margin when they could easily have lied to a greater degree and receive more money. (They determine the subjects regularly lie by comparing the subjects’ reported number of right answers with their control group whose answers are checked by the experimenters.) One of the key conclusions that Ariely et al. draw is that the degree of cheating and propensity to cheat is determined by our perception of ourselves as morally decent people. Cheating a little allows us to benefit from our transgressions while letting us retain the sense that we are still good people. In other words, for most of us, the sense of moral self-worth trumps simple rational self-interest.
Indeed, moral decency plays a significant role in one’s decision to cheat. Ariely et al. discovered that if subjects were exposed to a “moral reminder” prior to reporting their answers, their propensity to cheat decreases. Ariely et al., for instance, ask one group of subjects prior to an opportunity to cheat to try to list the Ten Commandments and another group to list ten books they read in high school. The Ten Commandments group cheated less while the other group did not behave differently.
Ariel’s insights into the psychology of cheating can perhaps help us craft a global public health effort to encourage individuals to think about the well-being of future and distant people when it comes to the use of antibiotics. Such an effort might include an emphasis on the impact antibiotic usage has on other people. Perhaps we can use moral reminders in the form of signing an education form that highlights the externalities of antibiotics prior to receiving care (on a par with consent forms). Likewise, a public health campaign to educate the public on the virtues of good antibiotic stewardship can help create a culture of viewing the cavalier use of antibiotics as morally dubious. Such a campaign can model itself on other attempts to encourage altruistic behaviors. In the United States, for instance, we value and celebrate the virtues of democratic elections, and there are subtle and not so subtle efforts to instill in citizens a sense that voting is important and morally admirable. We teach elementary school children about the electoral process and the importance of voting. States and municipalities ensure that voting in an election is relatively easy, recent efforts by some states to limit participation in the form of voter ID laws notwithstanding. Voters get little “I Voted” stickers to show off their participation. The swearing in ceremonies for many immigrants often take place in historically significant places emphasizing the value of a liberal democracy. These subtle efforts all contribute to a climate in which individuals feel a sense of duty to participate in a democratic political system even when it is not in their rational self-interest to do so. Our value for voting is so ingrained that we hardly notice the mechanisms that went into its cultivation in our political and cultural psyche.
Antibiotic-resistant pathogens represent a serious threat to our well-being. The typical solutions take for granted that individuals will always act as rational selfinterested agents. As such, like any NPD, cooperation can only come about by aligning individuals’ interests with public health interests with the use of incentive and punishment. Nonetheless, given the scope of the problem and the level of logistical challenges involved, such a solution is unlikely to materialize. Perhaps a more promising approach is to encourage individuals to act not on the basis of rational self-interest via a broad educational campaign that stresses and celebrates the importance of altruism. Parents, for instance, might feel the moral nudge not to demand antibiotics for their children’s ear infections (that would likely clear up on their own). This nudge might be on a par with our attitude toward littering: even though one can likely get away with doing so, there is a sense of internal shame that often leads one not to litter. This internal policing is a product of successful public service campaigns that fosters the communal values. It is certainly a challenge to create a culture where thinking of our collective interests comes naturally but our success in urging one another to cooperate (from voting to recycling) gives us some hope that teaching altruism might not be entirely a pipe dream. Adding moral education as a component of public health effort has not been seriously explored.
Given the gravity of antibiotic resistance and our limited options, perhaps it is time to explore altruism as a solution to our shared woes.
-  One of the most startling experiences a traveler might encounter in a foreign country is the realization that our disdain toward Uttering is not universally shared. It is a stark reminder that our ownattitude toward littering is the result of carefully crafted public campaigns.
-  The evolutionary biologist Richard Dawkins first introduced the concept of a meme in his 1976book The Selfish Gene (2016). Dawkins notes that natural selection can occur in an infosphere aswell as a biosphere. The unit of transmission would be a meme (which is the information analogyto a gene). “Releasing” an altruism meme that combats antibiotic-resistant pathogens via the prop-