Abstract
The prisoner’s dilemma was originally framed by Merrill Flood and Melvin Dresher 1 at the RAND Corporation, and given its famous name by Albert Tucker. 2 It is a problem analyzed in game theory where a sub-optimal situation is maintained because each player is forced to play a dominant strategy.
Two members of a criminal gang are held in separate rooms. The prosecutors do not have enough evidence to convict them unless one of them betrays the other.
If A betrays B but B remains silent, A will be set free while B will serve three years in prison.
If A and B betray each other, each of them will serve two years in prison (worst outcome).
If A and B both remain silent, each of them will serve only one year in prison on a lesser charge (best outcome).
Although the third option leads to the best outcome, the dilemma predicts that neither player will choose this option. Because of the potentially higher reward for betraying a partner, purely rational self-interested prisoners will betray the other. The paradox is that despite the possibility of a better outcome if both parties were to remain silent, both parties end up worse off when they pursue individual reward. The prisoners, while aware of this mutually beneficial solution, are in a dilemma because each is unable to ascertain if the other will betray him/her. They are stuck in a Nash equilibrium. 3
In a real-world application of the prisoner’s dilemma, we look to the cigarette industry. Cigarette advertising was banned on television by the US government in 1971, raising expectations that cigarette companies’ revenues would fall. Instead, revenues rose because the number of smokers remained relatively constant, 4 even though cigarette companies did not have to spend on advertising. Advertising’s main effect was influencing smokers’ brand preferences, not increasing the total number of smokers, as mistakenly believed (i.e. the companies that spent the most advertising got a larger share of the smokers). Hence, this was a case of cigarette companies being caught in a prisoner’s dilemma, until an external force unbalanced the Nash equilibrium.
Medical sponsorship in knee replacements
Trends in medical sponsorship bring attention to another industry that is confronted with the prisoner’s dilemma. We will use knee replacements to illustrate the conflict, keeping in mind that this description is equally applicable to other medical sponsorships. The main factors displacing the number of knee replacements are the population size and its demographic. The numbers should otherwise be relatively constant, assuming that there are well-established indicators as to when a knee should be replaced. Yet, another prominent factor has surfaced that exercised its influences on the numbers. Companies sponsor doctors who use their implants in educational events. This transaction imposes implicit expectations for surgeons to preferentially use the sponsored brand. In trying to maintain or increase market share, the competing companies resort to sponsoring more doctors. This results in a significant expenditure just to maintain market share. This expenditure is then passed on to the customers (patients receiving the knee replacements) by increasing the cost of their implants. This effectively means that patients are paying for the sponsorship of the doctors. The apparent solution of banning sponsorships (just as the US government banned cigarette advertising) should benefit the patients as the cost of implants are reduced due to diminished company expenses and a competitive marketplace.
A second prisoner’s dilemma?
If the problem was so simple and the solution so obvious – putting a stop to sponsorship – why has this not been done? As it turns out, hospitals are caught in a prisoner’s dilemma of their own. Removing sponsorships would add significant capital to fund education and teaching. Without the means to do this, the sub-optimal solution would be to continue the status quo. With doctors attesting to their continued education by attending meetings and conferences (CME is a key KPI in many institutions), patients hope that better-trained and educated surgeons translate to more successful surgeries. On the surface, this looks like a win–win situation. However, this is a logical fallacy. The argument made that issuing sponsorships to educate the doctors improves the quality of the surgeries is less persuasive given that knee replacements are a mature and stable technology.
The fallacy lies in the fact that there are surgeons who use sponsored knee replacements, despite the availability of registry data to distinguish the well-performing knee replacements from the poorly performing ones. This offsets many of the advantages in educating the medical community.
Why it has suddenly gotten worse
With effect from January 1, 2018, sponsorship to third-party educational events was banned in Asia, USA and Europe. 5 A third party refers to someone not directly involved in the transaction.
As a result, companies have turned to organizing their own educational meetings. These “first party” meetings organized by the manufacturers share information biased in their favor to the medical community. An example would be a manufacturer of medical devices who highlights the advantages of their devices and downplays the disadvantages. This is comparable to gaining subjective information about products from the cigarette companies.
A possible solution
Despite the obvious misgivings of this situation, a resolution is possible. The long-term goal must be revised so that the best-trained doctors are using the best-performing implants. Hospitals, not industry, should bear the additional training cost required to keep doctors up to date. If necessary, training fees could be factored into surgical cost to patients. The resulting training and information offered by hospitals would increase objectivity and reduce biasness compared to meetings organized by implant companies. Additionally, a doctor not reliant on industry sponsorship would be free to use the best performing and most durable knee replacements. Another incentive would be to lower implant costs as medical device companies no longer need to sponsor educational meetings. This change would offset any increased cost to the hospital, and possibly result in the unchanged overall costs to the patients.
By tapping the registry data, the use of implants should result in knee replacements with better survival and lower need for surgical revisions in the long term. This improved longevity of the implants would drive total cost down even further, and result in happier patients. Ultimately, the outcomes of this solution can and should benefit the patients. This was our primary motivation in enduring the long and hard training and this is why we became doctors in the first place. To realize the optimal benefits, we must both see and follow the right path that truly leads to a win–win situation.
