A major event that changed the way I see the world occurred in 1995 when I read Robert Wright’s The Moral Animal: Why We Are The Way We Are: the New Science of Evolutionary Psychology. The book was so good that I immediately gobbled up Nonzero: The Logic of Human Destiny when it was published by Wright in 2000 and then The Evolution of God when it was published in 2009. In the midst of the span between Nonzero and The Evolution of God I found a copy of Wright’s first book from 1988 which was out of print, Three Scientists and Their Gods: Looking For Meaning in an Age of Information.

Robert Wright is not a traditionally religious man which raises the question of why he is interested in why we are moral animals looking for our God or Gods and inventing them if necessary to fill a need. Wright calls himself an atheist, or if it seems more acceptable, a secular humanist. I was delighted when I learned that like me and the famous sociobiologist E.O. Wilson who was one of the three scientists in his first book, Wright was raised by parents who were Southern Baptists. It was through my reading of Wright that I developed an interest in how these powerful forces of “nature and nurture” that drive our individual behavior affect how we live together. More practically I began to wonder and think about how these realities of behavior either contributed to or compromised my ability to be a physician who could work in a complex organization with other professionals in the pursuit of a mission. Wright begins Chapter 9 of The Moral Animal entitled “Friends” with a quote from Charles Darwin’s The Expression of the Emotions in Man and Animals (1872).

[I]t is not a little remarkable that sympathy with the distress of others should excite tears more frequently than our own distress; and this certainly is the case. Many a man, from whose eyes no suffering of his own could wring a tear, has shed tears at the suffering of a beloved friend.

We saw a perfect example of this reality when Senator Lindsey Graham responded to the plight of his dear friend and colleague John McCain, and it was not that long ago that McCain expressed the same remorse for the suffering that Ted Kennedy was enduring with dignity. We all know that shared grief and empathy is easy with kin or close friends, but most of us are also capable of the same feelings for people we have never known and could easily avoid without any sense of guilt and with no ill feelings about our disinterest from anyone we know. I have a friend in New London who after she had been successful in business decided on her sixtieth birthday that she was going to find a village in Africa that she could help. Over the next decade she made 26 trips to Ghana where she identified a community that she thought she could help. She began the work with a program of “micro investments” giving the people chances to build businesses and improve their own lot. She did not have the resources of a Bill Gates or an Oprah Winfrey, but she did use what she had to build a non profit that has transformed the lives of many in a place far away. How do you explain such altruistic behavior?

It almost seems wrong to try to analyze and understand the origins of these urges to “do good” for people that we do not know, but I believe that reminding ourselves of the reality and learning more about it so that the same forces can be used to find common ground and make progress on the problems that challenge us in a small world and a divided country. Perhaps a deeper understanding of what determines what we do could help us make a difference in a variety of areas. Strategies to improve healthcare, income inequality, and climate change begin to look somewhat similar when you search for reasons why to care enough to try to do something.

I was deeply moved by the words and actions of Shelley Moore Capito, Lisa Murkowski, and Susan Collins when they had the political courage to kill the idea of “repeal without replace.” All three dared to disappoint their colleagues and leaders because to be silent and to go with the majority meant that many people would suffer. Capito said it best, “…I did not come to Washington to hurt people.” All three are hoping that their actions will lead to a better outcome. I believe that their unwillingness to vote for the BCRA or for “repeal without replace” was an expression of complex feelings that are a starting point on the road to a bipartisan creation of a widely acceptable set of compromises and joint experiments that in time could lead to a workable mechanism to fund universal coverage.

At the core of the opportunity is the reality that true achievements and improvements in the complex collective problems of society are made through the exercise of what people like Wright, E.O. Wilson, Robert Trivers, and Robert Sapolsky call reciprocal altruism. You may understand the concept but there is benefit to looking more closely at it in the context of the current healthcare debate. It is more complex than just “I help you and then you help me and together we have a win-win.” Social scientist have given the issue a lot of thought and from game theory, using mathematical analysis of “games” like the “prisoner’s dilemma” and concepts of “tit for tat” a useful set of ideas have been described. All of these ideas require trust and a willingness to resist those who are self serving. Our president’s assertion that he and his agents, principally Tom Price, Secretary of HHS, and Seema Verma, the Administrator of CMS do have the ability to kill the ACA or as the president euphemistically says, “Let it die.” That would be a strategic error that would surely undermine any chance of bipartisan cooperation and would drive the wedge that divides us deeper than even Mitch McConnell’s promise to defeat or overturn anything that President Obama would do.

Some authorities trace reciprocal altruism to our days as “hunters and gathers.“ I think we can see it in our own history when Farmer Brown helps Farmer Jones raise his barn and realizes that the next time his crop fails he can be sure that Jones will be willing to help him and his family make it through the winter. My neighbor who does not have lakefront property uses my dock to park his ski boat and then reciprocates by taking my granddaughter out to wake surf when she visits. I am sure you have your own examples of the process. How does this relate to a bipartisan effort to “repair and improve” what we have learned with the ACA?

To try to answer that question let’s look at a schema that describes the rules of reciprocal altruism. There is a nice summary of the work of Stephens in the Wikipedia discussion that serves our purpose nicely which I have modified just a little.


Christopher Stephens from the University of British Columbia published a set of necessary and jointly sufficient conditions in 1996 for reciprocal altruism:

  1. The behaviour must reduce a donor’s fitness relative to a selfish alternative;
  2. The fitness of the recipient must be elevated relative to non-recipients;
  3. The performance of the behaviour must not depend on the receipt of an immediate benefit;
  4. Conditions 1, 2, and 3 must apply to both individuals engaging in reciprocal helping.
  5. There are two additional conditions necessary for reciprocal altruism to evolve. There must be a mechanism to detect cheaters, and there must be many many times that the process is used.


OK, that may be a little abstract but let’s take them one at a time. Condition 1 describes a “donor.” In the ACA I would say that is a combination of taxpayers, individuals forced by mandate to buy insurance, and employers. In the moment their generosity or participation “reduces their resources” or costs them money relative to the alternative of not participating. Condition 2 is easy. The beneficiaries of the ACA are better off than they were, and better off than those unlucky enough to live in “red states” that did not expand Medicaid. Condition 3 is also easy. How often do we hear about people who feel cheated by the fact that they see no personal benefit in the tax dollars they lose today to pay for some deadbeat’s healthcare. Condition 4 says that we are all in the same process and if fortunes change we can expect to be recipients of what we are making possible for everyone. Condition 5 advocates that there be no cheaters and a lot of activity. Both of these concepts are also reflected in the mandate and the attempt at inclusiveness of a large population in the ACA. The more people who are involved in a process that is considered to be beneficial and is basically fair and equitable, but monitored for cheaters, the more secure it becomes as an important part of our lives together. Social Security might be a good example of both of these concepts.

When trying to promote a bipartisan process these principles that we all accept in our culture need to be identified along with empathy for those who in the moment need help. We must  realize that just a diagnosis and a few unforeseen pieces of bad luck separates “recipients” from “donors.” One of my senior residents once pointed out to me that we all look pretty much the same in a hospital johnnie. That is just the sort of observation that holds a truth that we often try to avoid.

Bipartisanship will also require that we understand what is important to everyone so that we can find common objectives. Working together to lower the expense of care and mutually developing strategies to reduce waste are areas where initial common ground is possible. A willingness of progressives to look at the rapid growth of the expense of entitlement programs is also a consideration of the type of compromise that will promote a bipartisan conversation. I think there is reason to hope for a renewed effort from our Senators. There are at least three who have shown the courage to act in the defense of what has been accomplished. They deserve our support and our encouragement. Perhaps through their example a bipartisan majority may evolve that sees the wisdom of exercising the principles of reciprocal altruism to guarantee that we will all get the care we need.