In Wealth of Nations first published in 1776, Adam Smith stated that “it is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest. We address ourselves, not to their humanity but to their self-love, and never talk to them of our necessities but of their advantages.” In contrast, in Theory of Moral Sentiments published in 1759, Smith stated, “however selfish man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others, and render their happiness necessary to him, though they derive nothing from it except the pleasure of seeing it.” The two seemingly contradictory statements published approximately twenty years apart were foundational to economics and biology. Whereas the first description of human nature was incorporated into the model of homo economicus, the second description influenced Charles Darwin’s conceptions of evolution and natural selection as evidenced in his statement, “In however complex a manner this feeling [sympathy] may have originated, as it is one of high importance to all those animals which aid and defend one another, it will have been increased through natural selection; for those communities, which included the greatest number of the most sympathetic members, would flourish best, and rear the greatest number of offspring.” Darwin’s statement is also more consistent with empirical observations – at least on the macro level – as humans everywhere engage in collective actions in many different domains, at all scales, and in all known human groups. We innately become part of groups and possess a strong propensity towards reciprocal aid, voluntary associations, and the self-organized management of commons.
Humans are organized in a seemingly infinite variety of structures with group sizes ranging from a few to a few million and relationships ranging from individualistic to hierarchical. Nevertheless, within this variation, overarching patterns of cooperation that emerge. One model that clusters this variation is the Culture theory initially developed by Mary Douglas. In this model, the group dimension (x-axis) describes how much horizontal bonding, mutual commitment, or constraints there are in the group and the grid dimension (y-axis) describes the amount of vertical hierarchy, control, and authority. The two dominant paradigms of civilization are the individualistic and the hierarchical paradigms. In individualistic groups (low grid-low group), people have little obligation to one another, group members enjoy their differences more than their similarities. They seek to avoid central authority and competition is the main form of control in these groups. The mechanism of the invisible hand in the form of price signals enables the self-interested and self-loving butcher, brewer, and baker to align behaviors. The downside of individual freedom and lack of external constraints is that the group becomes less effective in handling external force, adapting to threats, or mobilizing long-term resources. In contrast, hierarchical groups (high grid-high group), develop institutions and laws that both regulate individual action and provide for social members. Power and responsibility are organized in a chain of command. These groups have an organizational glue in the form of social norms, codes, ethics, and morality to scale, and can include millions of agents as leadership can demand individual sacrifice in the best interest of the group. Historical empires, nations, and modern-day corporations are archetype hierarchical systems.
The early models of grid-group theory as constructed above implies a level of staticity. It implies that collectives are either individualistic or egalitarian or hierarchical and all of its members maintain that paradigm. Nevertheless, in real life groups, it is never an either-or, but rather a distribution of subcultures at all scales and levels. Each culture is defined in contrast to another culture. Ideally, this leads to a well functioning dynamic equilibrium but the system is always in danger of devolving into competing paradigms that fail to integrate subcultures. In my opinion, the fragmentation and dysfunction of the United States healthcare system can partly be explained by a mishmash of values within the ecosystem. The dominant industry culture of individualism and hierarchy compete against each other and purport mission statements adhering to a value system of egalitarianism. An industry of largely individualistic stakeholders such as insurance companies, hospitals, pharmaceutical companies, and physicians groups operates under the hierarchy of the government but is guided by egalitarian values of equality and fairness of care, compassion for the sick, and partnership with patients. The conflict arises when these values directly conflict and there are no mechanisms in place to integrate subculture values within the dominant framework. How can we integrate the commercial aspirations of individualistic organizations with values of equality of access within the cost containment needs of the government? How can physicians or hospitals, incentivized by volume of services, contain cost or not overtest or overtreat? How can pharmaceutical companies developing therapies for profit provide medications to the poor? How can profit motivated insurance companies insure patients with pre-existing conditions?
Published nearly a decade in advance of Darwin’s theory of evolution, Tennyson wrote the now classic line, “nature, red in tooth and claw” in reference to the violent and cold-blooded natural world, in which predatory animals, without sentiment, kill and devour their prey. Subsequently, Darwin’s metaphors such as the “struggle for existence” and “survival of the fittest” gained prominence and were adopted as the justification of nature and society being innately competitive. However, empirical evidence shows that humans are a social species with a strong predilection for group bonding and cooperation. Although historically, the theoretical ranges of human cooperatives range from individualistic and fatalistic groups to hierarchical and egalitarian groups, there is lots of room within these ranges for constructs that have a varying distribution of cooperative paradigms. As the country looks to solve the triple threat of poor outcomes and inadequate access with ever-increasing costs, it will be advantageous to move past the false social construct of exclusive competition and consider distributive models of cooperation such as the Culture Theory.