1. Problems with health-care provision

Markets can be expected to work well when (among other things) (1) there are many buyers and sellers and hence no monopoly power or room for bargaining; (2) buyers and sellers are able to make an informed assessment of the properties of the commodities and services they buy and sell; and (3) buyers and sellers are able freely to exchange or not, as they prefer. None of these three conditions is satisfied by health-care markets. The number of providers is limited. In rural areas, there may be no feasible alternative to the local clinic (if indeed there is one); and even in good-sized cities, it may be difficult to find any physician who will take one as a patient. Medical interactions are fraught with information asymmetries (Arrow Reference Arrow1963). Patients know more about their symptoms than providers, who in turn often know more about the advisability of treatments than patients or insurance companies do. Buyers and sellers are often not freely able to make the exchanges they prefer. When unconscious accident victims are wheeled into the emergency room, they cannot choose their physician, and, owing to their professional duties, physicians in the emergency room cannot choose which patients to treat. Because of the urgency of health needs, individuals are often unable to shop for providers, and even when they can choose among providers, they very often lack the information they need to protect their interests. So, it would not be surprising if markets in health care, unlike markets in house painting, were inefficient.

A serious problem with market provision of health care further diminishes efficiency. Owing to the urgency, expense and unpredictability of health-care needs and costs, people will seek to insure themselves against the costs of injury and disease and of their treatment. Saving in order to be able to pay the costs of unanticipated illnesses is scarcely feasible, and it would be extremely inefficient. Insurance is the obvious solution, and in a free market, entrepreneurs would sell insurance, which would enable individuals to pool their risks. However, as I will detail below, owing to problems such as adverse selection and moral hazard, private health insurance is inefficient. Mitigating the inefficiency is challenging; and every health-care system across the globe has to make some undesirable compromises.

In addition to the inefficiency of market provision of health care, which, because of the scale of health-care costs, is itself a major moral problem, there are also problems of equity, choice and compassion (Daniels Reference Daniels1994; Kamm Reference Kamm, Murray, Salomon, Mathers and Lopez2002; Brock Reference Brock, Tan-Torres Edeger, Baltussen, Adam, Hutubessy, Acharya, Evans and Murray2003; Menzel Reference Menzel2012). Health-care costs can easily bankrupt uninsured individuals, and the costs condemn to death others whose resources are even more limited. Insurance may be unaffordable for the poor. Moreover, to make an unregulated insurance market feasible, insurance companies have to take steps to limit the impact of adverse selection and moral hazard by charging higher premiums to those with worse health prospects, by refusing to insure them altogether and by complicating policies with substantial deductibles and co-pays.Footnote ² As a consequence, many of those who are poor or who are ‘bad risks’ with ‘pre-existing conditions’ will be unable to purchase insurance. Whether because of poverty or pre-existing conditions, a large portion of the population will have very limited choices about how to protect themselves from medical harms or the financial stress or ruin due to illness. Moreover, the avoidable suffering and death of those who cannot insure themselves in a private market health-care system presumably weighs on the rest of the population – unless they can learn callously to avert their eyes.

Supplanting the health-care market with centralized government-provided or government-regulated health insurance and public health measures mitigates many of these problems. Universal health insurance eliminates adverse selection with respect to the conditions it covers, although adverse selection can return with lesser vehemence if there are markets for supplemental insurance. Government regulations in the form of licensing and medical review boards diminish the frequency of cases in which health-care providers enrich themselves by exploiting their greater knowledge of which tests and treatments are appropriate for their patients. But there is no way to eliminate completely the informational asymmetry or the risks of exploitation it creates.

Public provision of health care does not help with the moral hazard that insurance creates – both ex ante, in diminishing the incentives to protect one’s own health, and ex post, in diminishing the incentives to economize on treatment (Finkelstein et al. Reference Finkelstein, Arrow, Gruber, Newhouse and Stiglitz2015). The ways to cope with moral hazard are the same whether individuals purchase health insurance privately or whether there is universal state-provided health insurance. In both cases, deductibles and co-pays encourage healthy behaviour and discourage overuse of health care. However, they are far from a solution. They create costly paperwork for insurers, providers and patients. They are much more burdensome for those who are poor than for those who are relatively affluent. If co-pays and deductibles are low, they do little (apart from creating paperwork). If they are high, they partly defeat the purpose of the insurance by leading those who cannot afford them to avoid seeking health care, except in catastrophic circumstances. Treatment protocols, whether issued by the government or by an insurance company, help to limit moral hazard, but unless the insurer refuses to reimburse treatments other than those prescribed by the protocols, the moral hazard will not be greatly diminished. Coverage limits are a straightforward and potent means to address moral hazard, but they are either inflexible, depriving everyone of more expensive treatments (apart from those who can pay out of pocket), or they depend on gatekeepers who are charged with making life and death decisions, often without anything like the information required. Since the affluent can pay out of pocket, coverage limits also turn out to be less egalitarian than may initially appear.

Moreover, specifying the coverage limits – that is, detailing what health insurance will and will not pay for – makes insurance policies complicated and hard for individuals to evaluate. Note that coverage limits are less politically fraught if they are imposed by private insurance companies rather than by the government. No public official wants to be in the position to tell you that it is time to turn off your uncle’s ventilator. Better to let the government play ‘good cop’ to the ‘bad cop’ played by insurance companies.

Most of the ways of coping with the moral hazard problem, whether imposed by private insurance companies or by the health authorities, disadvantage the poor. The poor have a more difficult time paying deductibles and co-pays, and they may be effectively deprived of non-catastrophic health insurance and of the treatments that insurance would have paid for, but for the deductibles and co-pays. Treatment protocols and coverage limits are less obviously inegalitarian, but unless payment out of pocket is forbidden, they limit the choices of the poor considerably more than they limit the choices of the affluent.

2. Incentives and inequalities in health-care provision

The difficulties in allocating health care are all tied to misaligned incentives for individuals. Those who anticipate needing to make insurance claims have a stronger motive to purchase insurance than those who expect to remain healthy. This adverse selection is individually rational, but it undermines private health insurance. Similarly, in pursuit of their interests, the choices of the insured manifest moral hazard: those with insurance have a weaker monetary incentive to avoid making claims or to economize on health care than those without insurance. Informational asymmetries – that is, the greater knowledge providers have about what their patients need than their patients have – make it possible for unscrupulous providers to enrich themselves by employing remunerative clinical strategies that are not in their patient’s interests. Actions aimed at correcting these various misdirected incentives tends to raise costs, limit access and increase inequality.

An apparently trivial, but crucial insight of economics is that people respond to incentives – that is, to the costs they anticipate incurring and the benefits they expect to receive from their choices. If some individual or organization offers to pay people to do something or threatens to charge them if they don’t, then, ceteris paribus, they do it. This is not rocket science, but it has launched heavier payloads than rockets ever have. The trivial insight that people respond to incentives suggests a somewhat less obvious thought: instead of mandating outcomes by directives and threats, it may be possible to design markets or other institutions so that when individuals pursue their own interests, they willy-nilly bring about the favoured outcome. Put the magic of markets to work. For example, the US sulphur emission allowance market proved to be an effective method to limit acid rain without directly mandating the behaviour of individual firms.

This strategy has had limited success with respect to health care. It is stymied by the asymmetries in information that give providers incentives to exploit their patients (or the insurers of their patients), by the logic of moral hazard, by the deep concern many people have about the fairness of the resulting distribution of health care, and by the compassionate unwillingness to abandon to death or suffering those who have exhausted their entitlements to health care and who are unable to purchase more.

Discouraging choices that undermine the health-care system by increasing their cost winds up increasing inequalities. In his 1983 book, Spheres of Justice, Michael Walzer argues for a pluralistic view of equality, in which there is equality in the sphere of politics but cross-cutting uncorrelated inequalities in other particular social domains such as business, health care, sports or education. Some individuals are better at chess than others, while the latter are better cooks or musicians. Walzer’s egalitarianism does not call for levelling these differences. Egalitarians should instead prevent any of the domains in social life from establishing a hegemony that imposes its inequalities on the other domains.

Walzer’s vision of pluralistic egalitarianism expresses an aspiration rather than a description of any existing society, let alone the USA as it was when Walzer published Spheres of Justice or as it is now. In modern capitalist societies, inequalities in wealth imply inequalities in political power, and they are correlated with and responsible for inequalities in many other social domains, from vulnerability to criminal prosecution to access to health care. Whether or not Walzer’s pluralistic ‘complex’ equality captures everything that an egalitarian wants, it is an attractive vision of how egalitarian ideas could be realized in a diverse society in which differences among people are ubiquitous and welcome, provided that they are not systematic and do not subordinate one individual to another.

Walzer argues that health care should be distributed according to need, not according to wealth. But insulating health care from inequalities in wealth is hard to do. Designing a health-care system so that financial incentives line up to motivate the actors to bring about an efficient outcome seems bound to imprint the distribution of wealth on to the distribution of health care.

3. Non-financial incentives

There is a further possibility to explore. Although economists conceive of costs ultimately as the most advantageous of the opportunities individuals forego in choosing as they do, economists typically simplify and conceive of costs and benefits in monetary terms. If everything had a price, then all costs and benefits would have monetary equivalents. The cost of taking an extra hour of sleep by calling in late may be estimated by the loss of wages. The benefit of the greater quiet and comfort a new window provides can be estimated by its cost. In quantifying incentives, it is obviously convenient to focus on monetary costs and benefits. They are salient, comparable and measurable.

But not everything has a price. There are many costs and benefits that are not monetary and that are hard to measure in monetary terms. What is the monetary equivalent of the costs of ‘broken-window’ policing, which include the humiliation thousands have experienced of being arrested and handcuffed for jaywalking? What is the monetary equivalent of the smile on your aged grandfather’s face when you visit him? Many of the costs and benefits in health care have no clear monetary equivalent. How much is pain relief worth?

A visit to the doctor does not have only monetary costs. It is time consuming, and it may be uncomfortable, frightening and embarrassing. Although perhaps harder to manage and measure, these costs, just like money, may be incentives that those designing health policy may use to influence people’s choices and to shape the distribution of health care.

Sticking to monetary incentives is convenient. In many contexts, money is more potent than other benefits and burdens that policymakers can control. Moreover, the monetary cost imposed on an individual will typically be a gain to someone else, unlike the cost of standing in line or filling out a form, which is ordinarily a pure loss. But focusing exclusively on monetary incentives and costs is short-sighted and perpetuates inequalities. It may be too expensive to create strong monetary incentives to lead people to make one choice rather than another. In addition, since a given monetary reward or cost motivates those who have little wealth more strongly than those with more wealth, policies that rely exclusively on monetary carrots and sticks may have different effects on different sub-populations. These differences may raise questions of fairness, especially when policies attempt to direct people’s behaviour by imposing costs. Moreover, focusing exclusively on money, encourages the cynical and destructive view that everything is fungible with money. As Richard Titmuss (Reference Titmuss1971) argued, seeing actions such as donating blood as equivalent to writing a cheque for the monetary cost of a pint of blood can undermine the value individuals place on the donation.

Is there any way to put non-monetary incentives to work to improve the efficiency, fairness, compassion or the range of choice provided by a health-care system? This is the question that those discussing the use of ‘ordeals’ in health care raise, albeit in a one-sided way, because they focus on non-monetary costs without a similar emphasis on non-monetary benefits. As the example of blood donation illustrates, non-monetary incentives can be potent instruments of public policy.

4. Carrots and sticks

There are so many non-monetary costs and benefits of health-care policies that it would be surprising if none of them could be used to improve the efficiency, fairness and compassion of the health-care system, while expanding rather than limiting the choices available to the individuals served by the health-care system. Ordeals are non-monetary costs. They make some choices less attractive not by imposing financial costs, but by imposing burdens such as waiting or filling out forms. Ordeals are diverse, and some of the costs they may impose, such as the stigma of going to a free food pantry or applying for welfare, have different implications for inequalities than do others, such as waiting time. Ordeals can operate at different ‘sites’ in the health-care system and can be imposed on different agents. Many of the ordeals that patients, providers, insurers and others experience are not intentionally imposed in order to control their behaviour. For example, providers face ordeals consisting of the paperwork involved in seeking payment from individuals, insurance companies and the government. These ordeals are substantial, and they may lead physicians to refuse to treat some groups of patients because of the hassles attached to filing claims or to extracting payment from the individuals. In this case, the ordeals also imply monetary costs, as physicians or clinics hire staff to cope with the task of filing claims. They are ordeals, but unlike the ordeals with which this essay is concerned, they are not imposed in order to change the behaviour of providers so as to improve the functioning of the health-care system. (They do, of course, change the behaviour of providers, but, unless by good luck, not in desirable ways.)

It is unhelpful to separate ordeals – that is, non-monetary costs – from non-monetary benefits, if for no reason beyond the fact that what matters to behaviour is likely to be the difference between the non-monetary costs and benefits of the alternatives, not their absolute levels. The half-hour wait to see Dr X is not much of an ordeal when there are two-hour waits to see her competitors. Focusing on ordeals may also tend to discourage a concern with non-monetary incentives, because ordeals impose costs on people.

Because the costs that ordeals impose are not monetary, ordeals may be better able than financial costs to avoid exacerbating inequalities in the health care of rich and poor. Unlike out-of-pocket costs, deductibles and co-pays, which are less burdensome to those who are more affluent, ordeals such as waiting lists may be no more or even less burdensome to the poor. If it costs time, or stigma or persistence to achieve some outcome, then achieving that outcome will be less burdensome to those who have greater endowments of time or persistence or who have a greater tolerance for stigma. The poor are not always better endowed with these. Waiting may cost a worker her job. Someone who is sufficiently affluent may be able to pay someone else to spend days on the phone badgering insurance underwriters to cover some treatment. But if costs are not monetary, there is at least the possibility (which legislation can support) that they will not weigh more heavily on the poor than the rich.

For an initial example illustrating both the importance of non-monetary incentives and the difficulties of putting them in place, consider the following largely positive aspect of provider and patient interactions which monetary incentives are unlikely to elicit. The character of these interactions is of great importance both to the patient’s prognosis and to the provider’s efficacy and job satisfaction. Physicians who get to know their patients well will be less inclined to think of them ‘pigeons’ or ‘marks’ whose ignorance of medicine makes them lucrative sources of revenue. In limiting exploitation, the personal ties between provider and patient are also likely to lower total costs, because providers who do not exploit their patients prescribe less costly tests and treatments. Moreover, knowing their patients better, providers will need to carry out fewer tests. For similar reasons, stronger ties between patient and provider will tend to improve care.

On the other hand, knowing their patients better may make it easier for unscrupulous providers to exploit them, or patients may be less willing to discuss embarrassing health problems with a provider who is also a friend than with an impersonal clinic employee.Footnote ³ In a less personal relationship, the provider may be better able to make hard choices and to avoid wishful thinking.

Although the affective connection between provider and patient cannot be imposed, the health-care system can nurture these connections or weaken them, and it can offer protections against unrealistic treatments born of desperation and of caring too much. The depth, frequency and effects of affective connections between providers and patients depend on how often and for how long providers see patients (and whether they spend that time interacting with patients or typing on a computer terminal). The length and quality of the interactions depend on the length of appointments, on whether there is continuity in the relations between health-care providers and their patients, on whether a physician has a scribe or needs to enter data directly, and on whether providers work in teams. The continuity of a patient’s relationship to caregivers will be harder to maintain in a mobile population, but the structure of health care still has an effect on the connections between providers and patients. In drop-in ‘urgent care’ centres, patients may rarely see the same doctor or nurse practitioner twice. If visits to such centres come to replace visits with one’s own physician, the bond between patient and provider will weaken. Similarly, it is more efficient to be seen in the hospital by hospital physicians rather than one’s own doctor, but the interactions with hospital doctors are typically impersonal. Competition between insurance plans, each with its own ‘in-network’ physicians, can lead patients to change physicians regularly as the relative costs of different insurance plans shift.

As is implicit in this example, some features of health-care systems are influenced more strongly by non-financial incentives than by monetary incentives, and those features themselves may wind up constituting ordeals or positive non-monetary incentives that may be helpful or unwelcome. It is difficult to construct a health-care system so as to exploit and control less tangible incentives such as those grounded in the affective connection physicians will normally (though not invariably) develop with patients whom they get to know well.Footnote ⁴ In addition to the benefits already discussed, the medical professions are more satisfying if providers are helping known people rather than bodies with name bracelets, who flit into the office or clinic and then leave with instructions for tests or treatment, never to be seen again.

One might mistakenly take the non-monetary incentives with which this essay is concerned to be what Sunstein and Thaler call ‘nudges’. Since Sunstein and Thaler call almost anything a nudge that influences choices, apart from overt coercion and economic costs, it is easy mistakenly to identify non-monetary incentives as nudges. However, what Sunstein and Thaler are concerned with is a sort of deliberative jujitsu, whereby shortcuts and foibles in rational decision making are put to work to improve upon poor choices that individuals make owing to similar shortcuts and foibles. Unlike nudges, ordeals are not designed to remedy cognitive foibles, and they do not operate by taking advantage of limitations or short-cuts in rational decision making. Ordeals are imposed on rational agents, and they aim to change people’s behaviour by making some alternatives more advantageous or less advantageous than they otherwise would be. However, distinguishing non-monetary costs and benefits from nudges does not preclude combining them.

5. Taming moral hazard

I suspect that non-monetary incentives may be especially useful in counteracting moral hazard, and in this section, I shall focus on this use of ordeals. This discussion should be applicable to both market and state-run health-care systems, since moral hazard is a serious problem for both.

Ex ante moral hazard is automatically subject to substantial non-monetary costs. The risk of lung cancer or a heart attack is a powerful reason not to smoke and the risk of brain injury is a powerful reason to wear a motorcycle helmet, even if one has comprehensive health insurance that will cover the costs of treatments. These are, as it were, natural ordeals that greatly limit the importance of ex ante moral hazard with respect to health care.

On the other hand, ex post moral hazard is a huge problem. Imagine the cost, if everyone who complained of a headache were sent for an MRI. Even though MRIs and other tests come with some burdens attached, if insurance is paying, why settle for anything less than the very best in diagnosis and treatment? If one clinical strategy has a one in ten thousand chance of death while another has a one in a million chance and the bill goes to the insurance company, why choose the first?Footnote ⁵

To illustrate both the severity of ex post moral hazard problems and the role that non-monetary incentives can play in diminishing the problems and enhancing fairness, consider the following simplified hypothetical example. Suppose that there are two treatments for some moderate health problem, a platinum treatment and a bronze treatment. The treatments lead to full recovery respectively 99% and 97% of the time. However, the bronze treatment succeeds rarely among individuals who have nerve complications, which are experienced as tingling in the limbs, while the platinum treatment is virtually certain to work among those with tingles. These tingles cannot be detected by others. Only the individual knows if she has them. Without treatment or when the treatments fail, individuals gradually lose their ability to walk. Both treatments also have some unpleasant temporary side effects, which are somewhat worse in the case of the bronze treatment. Neither the health problems nor the treatments pose risks of death. If the bronze treatment is tried and fails, the platinum treatment is ineffective.Footnote ⁶ The platinum treatment costs $100,000, while the bronze treatment costs $10,000. Without insurance, many of those afflicted with the disease would be unable to afford either treatment. Only a minority would choose the platinum treatment, both because few can afford to pay $100,000, and because many among those who could fork out $100,000 (and who have no limb tingles) would rather save their money and take the chance that the cheaper alternative will work.

If insurance covers only the cost of the bronze treatment, then the percentage of those afflicted who choose it will grow even larger, because it is now in effect cheaper both absolutely and relative to the platinum treatment. If, on the other hand, insurance also covers all or nearly all the cost of the platinum treatment among those with limb tingling, many individuals would falsely claim that they have tingling in their limbs and would request reimbursement for the platinum treatment. After all, the only thing better about the bronze treatment is the much lower cost, which comprehensive insurance makes irrelevant to individual treatment choices. A high deductible or co-pay would lessen the moral hazard to some extent, but it would also make the platinum treatment largely unaffordable for those who are poor.

Whether both treatments or only the bronze is covered, with or without co-pays, the allocation of health care is unsatisfactory. Even in an affluent society, the platinum treatment should be going only to those with tingling in their limbs. If insurance covers only the bronze treatment then some people who should be receiving the platinum treatment are not getting it, while if insurance covers both treatments, resources are being wasted on very small reductions of risk. Of course, there will be some individuals with integrity (and no tingling), who pass up the chance to have insurance pay for the expensive treatment. But if both treatments are covered, the result will be very costly. Moreover, the distribution will be unfair, with only the honest receiving the inferior bronze treatment.

Can health-care policy employ non-monetary incentives, including, but not limited to ordeals, to cope better with ex post moral hazard in a case such as the one just described? The platinum treatment should be reserved for those whose prognosis with the bronze treatment is poor. Doing so would attenuate the connection between wealth and the platinum treatment, and it would mitigate overall inequalities. To accomplish this, non-monetary benefits can be offered to patients, caregivers or even insurers, or ordeals can be imposed on them. The main non-monetary benefits consist of commodities and services that are not readily fungible in cash, including public praise and honours, and, in this context, health improvements. Although not an exhaustive list of the way ordeals work with respect to health care, they typically impose costs on individuals in the form of (i) time, (ii) convenience, (iii) comfort, (iv) bureaucratic hassles, (v) risks, (vi) embarrassment, (vii) social stigma and (viii) all of the many disadvantages of illnesses. Some of these methods of influencing behaviour come close to direct coercion, but ordering people to behave in a certain way and threatening them with sanctions if they don’t does not count as imposing an ordeal. In general, ordeals for providers or insurers are less likely to aggravate inequalities than ordeals for individual patients. The ordeals of illness are more often harms to be minimized than opportunities for improving efficiency and fairness. Similarly, it will be hard to justify the imposition of significant risks in order to improve health-system performance. For those who hope to use non-monetary benefits and costs toward egalitarian ends, ordeals that cost individuals embarrassment or social stigma in order to receive some health care will be unattractive unless those whom they disadvantage are among those who are already privileged. That leaves as non-monetary means of altering behaviour to improve health system performance interventions with respect to convenience, comfort, hassle and waiting time.

Although we should not forget about non-monetary benefits, let’s begin by considering what ordeals might help address the moral hazard that results if insurance covers the cost of the platinum treatment for those with tingling limbs. The simplest ordeals would make it more time-consuming and inconvenient to have the platinum treatment, so that it is worth the trouble only for those who need it to reduce their risks. Individuals might have to endure unpleasant interviews with insurance company investigators suspicious of people’s claims to experience limb tingles. Insurance companies can make life miserable for caregivers seeking reimbursement for providing the platinum treatment. They might, for example, require whatever evidence providers can produce that individuals have tingles in their limbs. Doctors who rarely use the bronze treatment might find that more of their special requests to insurance companies are turned down. Supplies of the platinum treatment might be limited, creating a long wait for the treatment, which would make it advantageous for those without tingles to settle for the bronze treatment now rather than waiting for the platinum treatment, or for physicians to be less willing to prescribe the platinum treatment. If it were impossible for those with the resources to jump the queue, the affluent would not be favoured.

But one should not focus only on the imposition of ordeals and ignore the effects of removing existing ordeals and providing other non-monetary benefits. Indeed, other things being equal, it is more efficient and shows greater concern for those who are ill to take action to make the bronze treatment more attractive rather than making the platinum treatment more troublesome. For example, the bronze treatment might be carried out in newer and more comfortable or more conveniently located clinics or hospitals. Patients choosing the bronze treatment could be praised. They could have better food or more attentive treatment in the hospital. Procedures for seeking insurance reimbursements could be streamlined. By making the cheaper alternative more pleasant or convenient, one removes a reason why people prefer the platinum treatment. One can also put solidarity and public spirit to work. In a state-run system, one can make the case that the inefficient use of resources in one person’s treatment leaves fewer resources to treat others. Those who choose the platinum treatment, who have no limb tingles, are preventing others from receiving important care in order to secure a smaller benefit to themselves. Publicizing this fact in a society in which citizens care about one another and identify with one another attaches a powerful non-monetary benefit to choosing the bronze treatment. Or, if one prefers to think in terms of ordeals, it imposes an ordeal of guilt and shame on those choosing the expensive treatment when with high probability they would be cured by the bronze treatment. But, crucially, on the bright side, it imposes an ordeal not by making the circumstances of some patients worse, but by improving the circumstances of getting care that others experience. On the dark side, depending on the level of social trust and solidarity, it may impose shame on all those who ask for the platinum treatment, even if they all have limb tingles.Footnote ⁷

The affective states of individuals that make non-monetary incentives effective can be distinguished from one another in several different ways:

1. (1) Some, such as accepting a duty to save resources for others, rely on moral commitments, while others, such as waiting time or food quality, depend on narrow immediate self-interest

2. (2) Some rely on acceptance of social norms, such as taking one’s turn, while others depend on factors that are relatively independent of norms.

3. (3) Some rely on largely unalterable facts about individuals, such as displeasure about standing in line, while others depend on labile preferences or aversions.

4. (4) Some have a relatively uniform effect on individuals regardless of culture, age, gender, such as greater attention from providers, while other non-monetary incentives, such as standing in line or communicating via email have different influences on different individuals.

These contrasts concerning the affective factors that make non-monetary incentives efficacious overlap with one another. For example, those that are most stable are also likely to be those that are least dependent on differences among individuals.

These contrasts among the affective bases of non-monetary incentives present institutional architects with great opportunities and at the same time, great complexity. The differential efficacy of different incentives on different subpopulations may pose ethical conundrums. For example, in my fable above, relying on integrity and social norms of solidarity could result in the less scrupulous and less public-spirited exploiting those who are more ethical and more concerned about their fellows. And, of course, that exploitation might itself have further unfair consequences. Making the beds in the bronze-treatment wards more comfortable and the food better, carries few such risks.