Sunday, August 4, 2019

Is public philanthropy evil?

That lobotomies were not a good way to treat mental illness was known by 1941, yet lobotomies continued for thirty more years, mostly in public asylums.  Here's why:

Because superintendents [those managing publicly funded asylums] received federal funding based on the number of committed patients rather than offering effective medical care, treating patients was a secondary matter.  
[these superintendents]... sought low-cost treatment options. The lobotomy provided such an opportunity. Unlike the therapeutic or hydro and shock treatments available (all of which are still used today), the lobotomy was comparatively cheaper and did not take years to complete. It also frequently made difficult patients more docile and easier to manage.
In contrast, private asylums, which also faced overpopulation issues and treated the same patient demographics as public asylums, were funded by philanthropic donors and the patients’ legal caretakers. When patients failed to improve, were mistreated, or not offered sufficient quality of care, an asylum risked its profitability. Accordingly, using erroneous or excessively harmful treatment methods like the lobotomy would be detrimental to their bottom line.

QUESTION:  how would you better align the incentives of superintendents with the goals of patients (and their caretakers)?



  1. Link funding to health outcomes (evidence-based) over regulatory-compliance outcomes (process-based)

  2. Let the funding be dependent on improved patient outcomes rather than number of committed patients. This way, they are forced to provide effective medical treatments to the patients.

  3. As long as incentive structures reward patients admitted, there is no incentive to treat patients in a way that helps them permanently and keeps them from returning. Incentivizing a reduction in number of patients who return for further treatments would help caretakers focus on helping patients in a longer-term manner.

  4. Change the performance evaluation metrics to one which includes ensuring effective treatment outcomes as opposed to leveraging the incentives on the number of committed patients.

  5. It would be best to link incentives to patient outcomes. In case the patient is too sick to report improvements, caretaker feedback should be used as a metric instead