Professionals: how to keep them honest?

Reports of dishonesty among professionals, such as doctors and researchers, are surging. Every day, it seems, new stories emerge of doctors who fatten their profits through unnecessary procedures, or who are paid by pharmaceutical companies to push new drugs. The Chief Medical Officer of the American Cancer Society describes American health care today as “a subtle form of corruption”. The corruption has also spread to many other fields: recent reports document rising incidents of outright fabrication of academic research results, and more pervasively, a widespread tendency to “torture” data – to use technically legitimate statistical analyses to get results that are statistically significant but not necessarily valid.

This probably didn’t happen so much in the past. Doctors and researchers used to be shielded from outside pressures and incentives, and primarily influenced by their peers. They were part of tight communities with strong values; their reputations – and success – depended in upholding those values. There wasn’t much confusion about right and wrong. Both moral and material incentives encouraged focus on the pursuit of truth and social benefit.

But things have changed. Professional communities are increasingly penetrated by the outside world. There is more chance to make money and reputation by impressing the general public: superstars are viewed on TED Talks and written up in popular media. At the same time, those outsiders demand new levels of openness: they don’t automatically take the word of doctors or scientists or teachers that they know what they’re doing. All kinds of objective measurements have been put forward to prove professional worth: ranking systems for universities, hospitals, schools, professors. Those who score high may make a lot of money.

Thus for professionals, motivations are confused. They are no longer bound in a relatively unified community that understands them in depth. There is tremendous incentive do things that look good in the metrics or in the press, whether or not they advance truth or justice. As a professor, I hear my young colleagues talking in the annual meetings about how many publications they can get out of a single study, rather than how they can deepen their findings. They measure results in part by whether they will get attention in the press. Once they’ve found a good result, there’s neither material nor moral incentive to query it: they want to get it out to a publication as fast as possible so it will count on their metrics. Some people, inevitably, are pushed close to the edge, torturing data and ignoring annoying nagging questions in their minds; a few are pushed over the edge, fabricating results.

What to do?

The road back to the old order is probably closed. Professionals can’t just keep each other honest. There are too many cross-cutting temptations and incentives. Moreover, the clients don’t really want that: they want a voice in professionals’ deliberations. In every part of society, there is less public deference to experts. People are less willing to just let their doctors prescribe or their teachers set curriculum; they want to discuss it and have their say.

Government regulation can at best deal with only a tiny part of the corruption: even the most dictatorial states can catch no more than a fraction of wrongdoing. Government is effective only when most people want to do the right thing.

The only way forward is a big change in mindset: for professionals and their clients to come together around a shared sense of purpose. Right now it’s a tug of war: in the past professionals did things their way, telling clients to trust them to do the right thing; now clients want it their way, wanting to shape outcomes and processes. The only way that will work is for the parties to try to build action in concert.

Doctors can't just tell patients what to do: they need to enlist them in a shared to maintain health. To do that, they need to discuss options and purposes, to listen closely to what the patients need, to make sure there is a common understanding of a course of treatment. With that kind of collaboration, diabetics, for example, are much more likely to take their medicines and maintain their weight. And doctors are more likely to be focused on the "right" things.

Similarly, teachers can't just set curriculum and expect to be paid what they think they're worth; they need to justify their worth to parents and communities, to win support. This can be painful and difficult, involving dealing with narrow perspectives and ideological conflicts; but it's the only long-term way to create a responsible system of education in which teachers are motivated to do the right thing.

This is a big change. Some small steps have been taken: some change in the way doctors talk to their patients, some improvement in the availability of information that patients or other clients, some increased education, some development of public debates. But we’re still far from a state in which clients and professionals really work together, both playing their part in maintaining core values.