Politica sanitaria: copiare quello che funziona altrove

Affordable Excellence: The Singapore Health System by William A. Haseltine

E’ importante conoscere la storia del sistema sanitario migliore del mondo…

… Affordable Excellence tells the story of the Singapore healthcare system, how it works, how it is financed…

Il costo è minimo…

… Singapore spends less on healthcare than any other high-income country, both as measured by fraction of the Gross Domestic Product spent on health and by costs per person…

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Singapore: 50 anni di boom economico…

… In just 50 years, Singapore transformed itself from a low-income country to one that has one of the highest per capita incomes in the world…

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Prima lezione: nella politica sanitaria la path dependence è fortissima, tornare indietro è difficile. Per questo programmare è molto utile (e un dittatura illuminata è avvantaggiata)…

… One point that emerges clearly: decisions made early on affect the course of later history. Once begun, it is very difficult to revise health finance and delivery systems, as such decisions profoundly affect the lives of individuals and economies…

Oggi i sistemi sanitari sono essenzialmente di tre tipi…

… To finance healthcare, should countries adopt a mixture of private and public insurance as does the United States, the state approach to healthcare finance and operations as in the United Kingdom, or the public–private partnerships of Germany and Japan?…

Singapore, al contrario, punta sulla responsabilità personale del cittadino…

… an entirely different approach be taken, that of Singapore, where emphasis is placed on individual responsibility supported by an enabling state…

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L’invecchiamento della popolazione porterà la discussione sulla sanità al centro del dibattito politico…

… The world's most developed countries are facing a crisis of confidence in their healthcare systems. Costs are rising…

Singapore insegna la programmazione. Al momento la sua sanità è programmata per i prossimi 30 anni…

… Singapore is relatively unique amongst governments in its ability to plan for the future. In the past, the government has planned and successfully executed, over a 30-year period… Today, the emphasis is on planning for the coming demographic crises…

Gli USA spendono molto? Singapore propone un modo per calmierare i costi…

… In the United States, healthcare accounts for almost 18 percent of the GDP and is rising. Most developed economies are facing twin demographic problems… The Singapore system offers a guide to controlling costs…

Il problema degli USA sono le assicurazioni private?

No, esistono anche a Singapore, nella sanità meno costosa che garantisce a tutti l’eccellenza.

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Ma le obiezioni alla proposta di copiare non mancano: Singapore è un caso unico: sono in pochi, sono una dittatura illuminata…

… In writing this volume, I have often been told that Singapore is unique and lessons learned are not applicable elsewhere… Others believe only a government with a long tenure in power (Singapore's ruling People's Action Party has been in power since independence in 1965)… Some even go so far as to describe Singapore as a dictatorship… such a healthcare system can only be imposed by a controlling government…

Per quanto l’obiezione sia ficcante cio’ non ci esime dallo studiare cio’ che funziona.

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In effetti le tre condizioni cardine per costruire “il sistema sanitario nazionale migliore del mondo” non sono ubique…

… They are long-term political unity, the ability to recognize and establish national priorities, and the consistent desire for collective well-being…

Sulla sanità pesano mille variabili…

… Health would be affected by almost every aspect of life in an urban setting: housing, water supply, food supply, air quality, waste disposal, road traffic, parks, tree planting, and more…

La complessità è tale che stabilire delle priorità è l’operazione più importante.

All’inizio Singapore si occupò con successo dei bisogni minimi, quelli tipici del terzo mondo…

… Wisely, the initial focus in Singapore was on public health: putting proper sanitation procedures in place, controlling infectious diseases, all successful efforts. Early initiatives were launched to provide clean water, develop a vaccination program, and guarantee access to basic medications, clean food, and more…

Ma forse bisogna gettare un’occhiata più generale sul paese per coglierne al meglio le caratteristiche.

Singapore e Hong Kong: differenze tra le due tigri…

… A competitive, winner-takes-all society, like colonial Hong Kong in the 1960s, would not be acceptable in Singapore…To even out the extreme results of free-market competition, we had to redistribute the national income…

Il sistema pensionistico…

… One important solution Lee and his ministers found was the Central Provident Fund (CPF). It was set up during British colonial rule as a compulsory savings program for workers to build a nest egg for retirement… The CPF has become one of the key pillars supporting social stability…

I contributi obbligatori:

… Mandatory contribution rates have risen over the years and now stand at 16 percent of wage for employers and 20 percent for employees. After age 50, the rates decrease…

La parte privata della pensione resta notevole…

… it helps control costs by instilling in patients a sense of responsibility about their spending—after all, it is their money to save or spend…

Donne e istruzione…

… Specifically, women's health education was deemed essential to the future of the country…

La responsabilizzazione è al centro di tutto…

… If anything may be identified as the guiding philosophy behind Singapore's success, it is Lee's conviction that the people's desire to achieve and succeed must never be compromised by an overgenerous state. The government made certain that Singaporeans developed and retained a sense of responsibility…

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Il sistema sanitario è molto capillare…

… An early move was to bring primary care services closer to the people by developing a network of satellite outpatient dispensaries and maternal and child health clinics….

Il singolo contribuisce sempre alla spesa sanitaria che lo riguarda: chi paga apprezza (e controlla)…

… The ideal of free medical services collided against the reality of human behaviour, certainly in Singapore. My first lesson came from government clinics and hospitals. When doctors prescribed free antibiotics, patients took their tablet or capsules for two days, did not feel better, and threw away the balance. They then consulted private doctors, paid for their antibiotics, completed the course, and recovered….

La prevenzione ha un ruolo importante, così come la promozione di certi stili di vita salubre.

Il conto individuale sanitario è al centro di tutto…

… the Plan announced the creation of Medisave, Singapore's individual medical savings plan…

Serve per pagare l’assicurazione sanitaria, l’ospedale e i tickets…

… Workers contribute a certain percentage (set by the government) to their individual accounts, as do their employers. The money can then be used to pay for health services as well as health insurance plans… Medisave enables patients to pay their share of their healthcare bill…

Scaricare gran parte della spesa sul cittadino contribuisce a controllare i costi…

… It has also had the effect of keeping national healthcare costs low by shifting a large portion of expenses to individuals and their employers…

I 5 obbiettivi:

1. promuovere la salute,

2. promuovere la responsabilità individuale,

3. assicurare servizi di eccellenza,

4. creare competizione nell’offerta dei servizi,

5. regolare la concorrenza per combattere le posizioni di rendita.

Franchigie e i tickets sono il cuore del sistema: per ogni dollaro tirato fuori da terzi, il provato deve versare la sua quota…

… making patients pay directly a part of their healthcare expenses, excessive demand for services could be mitigated and overreliance on state welfare or third-party medical insurance…

Anche per questo vengono incentivate fiscalmente solo le assicurazioni che ne fanno largo uso…

… To avoid overreliance on comprehensive insurance programs that provided first-dollar coverage, the government incentivized the purchase of health insurance schemes with features such as deductible and co-payment components and guaranteed renewals by restricting the use of Medisave to only plans that met these requirements. Insurance plans that provided first-dollar coverage were viewed as playing a major role in raising costs in countries where they are readily available…

Lo stato fissa rigorosi pacchetti sanitari standard in modo da rendere trasparente l’offerta e la relativa concorrenza…

… The basic package had to be affordable and be provided by hospitals receiving government subsidies…

I pacchetti vengono revisionati di frequente…

… The package should be reviewed frequently to reflect, among other things, the purchasing power of Singaporeans and productivity increases in medical science…

Infatti, il problema della competizione sanitaria è sempre lo stesso…

… patients rely on doctors for advice and are themselves generally unaware of better or competing alternatives…

Il problema dell’offerta confusa…

… Oversupply or overabundance of choices would in turn drive healthcare costs up rather than keep them in check…

La sanità è un bene particolare: di fronte alla confusione il consumatore tende a spendere in modo eccessivo per mandare segnali a terzi: “io sono un tipo che si prende cura dei suoi cari e di se stesso!”.

Trasparenza, prezzi sul web e offerte omogenee dissipano la confusione…

... One step the Ministry of Health has taken to stoke competition is to provide price transparency by publishing the hospital bills for common illnesses on its website…

Singapore: capitalismo calibrato…

… I view Singapore's chosen approach to the healthcare market as a kind of highly-calibrated capitalism…

Esistono anche ospedali pubblici con lo scopo di tenere a bada i cartelli del privato…

… This approach is seen in the fact that it funds public hospitals and other care facilities but also encourages the participation of private hospitals and clinics…

L’intervento pubblico è importante in molti ambiti del sistema sanitario. Ecco un breve elenchino…

… Situations that might demand government action included preventing an oversupply of healthcare services, moderating demand, and creating incentives to keep costs down… For example, over the years, intervention has included creating and adjusting medical savings programs, sponsoring insurance programs, providing subsidies to hospitals and polyclinics, determining the number of beds and their distribution in public hospitals, funding new medical schools, regulating the number and type of doctors who can practice in the country, and regulating and limiting the type and number of private insurance programs available to Singaporeans…

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Ma vediamo più da vicino gli esiti brillanti che ha fatto registrare questa impostazione…

… By most common measures, the nation has achieved noteworthy outcomes in all areas of healthcare. It has increased the life expectancy of its citizens; increased infant survival rates, and achieved one of the lowest under-five mortality rates in the world. Singapore's cancer survival rates are similar to Europe's, while its cardiovascular disease death rate is half that of the rest of the Asia Pacific region…

Aspettativa di vita, mortalità infantile, mortalità neonatale, diabete, cancro, malattie infettive… il sistema sembra reggere senza fatica il confronto con quelli occidentali più avanzati.

Ma i risultati diventano da record se analizziamo i costi…

… A quick look at cost comparisons with other nations brings the point home… The United States, for example, spends almost 18 percent of GDP on healthcare. Singapore, on the other hand, spends slightly under four percent of GDP. The government's expenditure for healthcare has been slightly under one percent, far less than other most developed countries… Singapore's Healthcare Expenditure… less per capita than any other high-income economy…

La soddisfazione dei clienti…

… Not only does Singapore perform well in terms of achieving world-class outcomes, the quality of care as experienced by consumers is also one of the system's highest accomplishments. The Ministry of Health regularly conducts “Patient Satisfaction Surveys”…

Qualche esempio più specifico in tema di costi…

… the cost of an angioplasty in the United States is almost 83,000, while in Singapore the cost is about 13,000. A gastric bypass in the United States is almost US70,000, while in Singapore the cost is 15,000… Singapore's per capita expenditure was just over US2,000 in 2009…

Record!…

… Figures on government-only expenditure for the world's healthcare systems also show Singapore as the leader in keeping costs under control… Per capita studies reveal that in 2008, the government spent over 600 for care, while the United States spent almost 3,500, the United Kingdom over 2,600, Japan about 2,300… Singapore government expenditure as a percentage of total government expenditure was around eight…

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Certo, questi risultati possono essere ottenuti anche grazie ad alcuni vantaggi. Infrastrutture…

… Along with its excellent system of medical care, Singapore has developed an infrastructure that helps support healthy living and general wellness…

A Singapore, per esempio, non esiste campagna: tutto è una grande città omogenea! Il che, per molti versi, facilita le cose.

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e adesso, qualche considerazione conclusiva.

Il problema USA sono le assicurazioni private? Non si direbbe visto che le ha anche la "miglior sanità al mondo" è finanziata dai privati.

Dubbi sul successo di Singapore: S. è un piccolo stato. S. è una dittatura. Quel che lì funziona altrove non funzionerà.

Singapore ci insegna la strada: prima lo sviluppo economico e poi la sanità d’eccellenza.

Medisave: conto individuale sanitario. Serve per pagare gli ospedali e le assicurazioni. Il contributo privato al finanziamento del sistema è sostanziale per responsabilizzare i cittadini e tener sotto controllo i costi.

L’intervento pubblico è basilare e la sua funzione è chiara: calmierare ma soprattutto ordinare la concorrenza.

Di fronte alla confusione e all’incertezza il consumatore di sanità tende a spendere in eccesso per segnalare il fatto che si prende cura di sè e dei propri cari. Un’offerta ordinata neutralizza questo bias.

Anche a questo scopo esiste un pacchetto di base ben preciso e dei pacchetti standard messi insieme a livello governativo che le assicurazioni devono offrire potendo concorrere solo sui prezzi.

Costi. Gli Stati Uniti hanno un servizio sanitario tra i più costosi al mondo, spendono il 18% del PIL per curarsi. Quasi 7.000 dollari a testa, e di questi 3.500 ce li mette lo stato. Il 52% della spesa resta sulle spalle dei privati i quali devono rivolgersi alle assicurazioni. Nei più avanzati paesi europei la sanità è socializzata, forse è poco innovativa ma costa molto meno: solo un 8/9% del PIL, circa 3.000 dollari a testa di cui 2600 ce li mette lo stato attingendo alla fiscalità generale. Il carico della spesa sui privati è solo un residuale 14% (contro il 52% degli USA!), le assicurazioni sono così ridimensionate. Ma il divario nei costi è dovuta alla presenza massiccia delle assicurazioni e alla loro azione di lobbing? Prima di rispondere occorre farsi un giro a Singapore, ovvero "il paese con la Sanità migliore del mondo". Lì il carico sui privati (e quindi l’affidamento alle assicurazioni) raggiunge il 65%, ben oltre quello USA. I livelli qualitativi garantiti sono di eccellenza - sopravanzano sia gli USA che l'Europa - ma soprattutto i costi del servizio sono estremamente compressi: giusto 2000 dollari a testa, il 4% del PIL (in Europa è il doppio!).

La scommessa come bussola

Il miglior modo per prendere le decisioni è essere informati e il miglior modo per informarsi è conoscere quello che gli altri sanno. Robin Hanson parte da questo assunto per proporre una soluzione che corregga gli errori decisionali più comuni. Il suo saggio si intitola “Decision Markets”.

Agire sulla testa delle persone è decisivo:

… The human part of any large intelligent system is by far the most intelligent part. As long as this remains true, the biggest system advancements will come from aids that fill big holes in human abilities, rather than from artifacts that stretch engineers' abilities. Consider Post-it Notes or, better yet, plain paper notepads. These probably seemed like trivial ideas, but they turned out to be terribly useful…

Condividere le informazioni non è facile come si pensa: chi deve offrire info non sempre ha i giusti incentivi  e chi deve ottenerle spesso è riluttante poiché teme di guastare i suoi pre-concetti:

… Consider, for example, a clearly important policy question such as, How would crime rates change if more citizens could legally carry hidden guns?… I suspect that the existence of such divergent opinions reflects the fact that we suffer from a serious failure to share information… The real problem is not finding more words, but judging who really knows about the topic and whether these experts are saying what they know. We are in many ways bit-full, yet information-poor…

Che fare? La proposta:

… I suggest that speculative markets are a neglected way to help us find out what people know. Such markets pool the information that is known… Speculative markets are decentralized and relatively egalitarian, and they can offer direct, concise, timely, and precise estimates in answer to questions we pose. These estimates are self-consistent across a wide range of issues and respond quickly to new information. They also seem to be cheap and relatively accurate…

Per capire come funziona, torniamo al problema delle armi:

… Imagine that we created markets where people could bet on future crime rates, conditional on allowing or not allowing more hidden guns. That is, if the market prices predicted that murder rates would be 10 percent higher should a certain hidden-gun bill pass, then anyone who thought this estimate too high could easily identify a particular profitable trade… if market prices said that crime rates would be 10 percent higher given more hidden guns, most nonexperts would accept this estimate as our "best answer" or as a neutral "consensus."…

L’incentivo all’onestà intellettuale è palese:

… Speculators, in turn, would have a clear incentive to be careful and honest in contributing what they know and in judging what advocates know… speculators must "put their money where their mouth is."

C’è pur sempre bisogno di un terzo:

… Next, you must choose some particular trusted third party who will finally declare a murder rate M within [0,1] and determine whether bill B passed…

E i rischi di sabotaggio?

… Finally, you have to decide how much to subsidize this market. If interest in your topic is strong enough, simply creating these markets might induce people to trade in them. Failing that, sufficient interest might be induced if someone committed to make a policy choice based on the market estimate… You can also safely and directly subsidize a market to induce more participation…

Abbiamo fatto le esempio del nesso tra armi e crimini, in realtà le materie dove gli speculatori potrebbero dire la loro sono parecchie:

… Murder rates-with or without capital punishment? • Average mortality rates-with or without national health insurance? • Health-care spending-with expanded or curtailed use of health maintenance organizations? • Employment change-raise minimum wage or rescind NAFTA? • Global sea-level and temperature changes-impose or not impose a carbon dioxide tax? • Military casualties-with a Republican or a Democratic president? • Stock prices-with a Republican- or Democrat-controlled U.S. Congress? • World per capita food consumption-raise or lower average tariffs? • Student test scores-with or without school choice or voucher reform? • Future national economic growth-raise or lower interest rates, or with or without an education subsidy?…

Ma le speculazioni di mercato hanno esiti affidabili?

… decades of research on the efficiency of financial markets have found little price-relevant information that is not reflected in market prices… Any inefficiencies seem to be weak and to go away with publicity, because they represent a profit opportunity. If you think the current price is too low, you expect to profit by buying now and selling later, and buying now will raise the price… For example, orange juice futures prices have been shown to improve on government weather forecasts… Also, markets where traders can bet on election results predict vote totals better than opinion polls…

Chissà come mai ma quando in ballo c’è il nostro denaro molti bias cognitivi si dileguano e la qualità delle scelte migliora sensibilmente:

… while most traders tended to suffer from cognitive biases such as expecting others to agree with them, the most active traders were not biased this way-and active traders set the prices. Speculative markets thus seem to induce the real experts to self-select and participate more…

I mercati devono essere sufficientemente “densi” per funzionare, in questo senso le sperimentazioni messe in campo al momento sono abbastanza incoraggianti:

… Older economics writings sometimes give the impression that speculative markets will not function unless you have thousands of traders frequently trading millions of dollars worth of goods. Recent Web markets, however, clearly show that markets can be much smaller and slower than this…

Con il web i costi della “speculocrazia” si abbassano notevolmente e l’istituto della “scommessa” migliora la sua fama man mano che nei vari campi emerge la sua utilità sociale.

…  Until the last few centuries, the cost of simply handling trades was enough to sharply limit the number of speculative markets that could be made widely available. Yet today, ebay.com routinely sells $10 items by having a handful of people bid a few times each over a period of a week… More important, most speculative markets are now illegal. The short history of financial market regulation is that everything was once illegal until limited exemptions were granted for specific purposes… Gradually, exceptions were granted for what came to be seen as worthy purposes, such as teaching people about horses (horseracing) or raising state revenue (lotteries)… Stocks were allowed for the purpose of capitalizing firms… insurance was allowed to let individuals hedge risks… commodity futures and financial derivatives were allowed to let firms hedge more risks…

Una via per testare i “Decision Market” potrebbe essere quella di consigliarne l’adozione all’interno delle corporation:

… how can we test prototypes if IA markets are generally illegal? Well, there is one plausible loophole (besides offshore gambling), which I have saved for those of you who are still reading this far: internal corporate markets…

E in effetti qualcuno già traffica con questi strumenti:

… several companies, including Hewlett-Packard and Siemens, have begun experimenting with real-money internal speculative markets for estimating things such as future sales…

Meglio essere temuti o amati? SAGGIO

Meglio essere temuti o essere amati?

Nicolò Machiavelli non ebbe dubbi: se siete un politico molto meglio per voi essere temuti.

Per motivare questa risposta scrisse il suo capolavoro, “Il Principe”. In sintesi: se siete temuti conviene a tutti darvi il rispetto dovuto, se siete amati, nel momento in cui non converrà più, il rispetto dovuto vi verrà negato. L’uomo è un egoista che sa fare i suoi calcoli, il politico, a maggior ragione, deve far con cura i suoi.

Peter Turchin invece è uno storico. Il compito che si è proposto è quello di illustrare la storia degli imperi confutando Machiavelli: l’altruismo è il vero motore della politica e della guerra.

Prendiamo la I guerra mondiale, tutti sanno come iniziò ma è bene ricordarlo:

Serbian nationalist Gavrilo Princip rushed to a car in which sat Archduke Franz Ferdinand, heir to the Austro-Hungarian throne, and his wife, Countess Sophie. Princip shot two times, hitting Sophie in the stomach and Franz Ferdinand in the neck. After accomplishing his mission, Princip swallowed a capsule of cyanide, but the poison was defective and only made him vomit… (he was too young for the death penalty)…

Insomma, un kamikaze che sacrificò la sua vita per la causa in un gesto estremo di altruismo.

Un gesto che scatenò una catena di comportamenti inspiegabilmente altruistici: gran parte delle popolazioni europee desiderava la guerra ed era pronta al sacrificio, ma non a parole bensì nei fatti.

Certo che se uno si fa un’idea della Grande Guerra leggendo “Un anno sull’altipiano” (è il mio caso), pensa ad una grande truffa seguita da una mattanza: i poveri soldatini usati come carne da cannone dai generali. Ma questo quadro impedisce di vedere il fenomeno più macroscopico: il volontariato entusiasta di migliaia di giovani che morivano per la Patria:

… One month after the assassination of Franz Ferdinand, and using it as a pretext, Austria-Hungary declared war on Serbia. Russia, who was tied by a defensive treaty to Serbia, began mobilizing, which was treated as a hostile act by Germany. On August 1, Germany declared war on Russia, which dragged into the war Russian allies France and England. World War I had begun… Patriotic crowds demonstrated for war in Vienna, Berlin, and London. More tellingly, all over Europe hundreds of thousands volunteered for the army… In the British Empire, for example, there was no need to introduce conscription until 1916…

Ecco allora quel che per Turchin conta e che Lussu passa un po’ troppo sotto silenzio:

… The willingness of the British, the French, and the Germans to fight for their country is only one of the many striking examples of the human capacity to sacrifice self-interest for the sake of a very broad common good… the willingness of Gavrilo Princip to murder Franz Ferdinand even at the expense of his life, or the eagerness with which Palestinian suicide bombers sacrifice themselves to inflict horror on the Israelis, falls into the same category. The “common good”… The capacity to sacrifice self-interest for the sake of common good is the necessary condition for cooperation…

Lasciamo perdere Lussu dal quale – essendo uomo di ideologia – è lecito aspettarsi certi silenzi; ma Machiavelli? Machiavelli è uomo di scienza, anzi, fondatore della scienza politica. Come puo’ lui spiegare fenomeni del genere? Ci interesserebbe poco il suo caso particolare se non fosse che la scienza politica moderna ha fatto di questo studioso il suo nume. E infatti l’impasse riguarda tutta la scienza politica moderna e il paradigma della scelta egoistica e razionale. Gli antichi sembrano fare meglio dei moderni sul punto:

To ancient and medieval thinkers such as Aristotle, Thomas Aquinas, and, above all, Ibn Khaldun, it was obvious that it was cooperation that provided the basis of social life. Beginning in the early modern period, however, this certainty was gradually abandoned by most influential social thinkers. By the end of the twentieth century, the “rational-choice theory,” which postulated that people behave in entirely self-interested manner, became the dominant paradigm in the social sciences… If people are motivated entirely by self-interest, the only forces that matter are rewards and punishments…

Alla domanda canonica (“meglio essere temuto o amato?”) Machiavelli aveva capovolto la risposta della saggezza antica reputando la paura più forte dell’amore. La risposta classica risuona chiara nelle parole di un Santo guerriero, Luigi IX:

Louis IX ( 1226-70) before his death. When he fell ill, he said to his son and heir, “Fair son, I pray that you make yourself beloved of your people; for truly I would rather that a Scot should come from Scotland and govern the kingdom loyally and well than that you should govern it ill.” The people of his time clearly agreed with this sentiment, and Louis was canonized in 1297…

Si noti che nell’azione concreta Luigi fu uomo di successo mentre Machiavelli un politico mediocre e con parecchi fallimenti:

St. Louis was no great shakes as a political thinker, he was a remarkably successful practical politician… France became the hegemonic power of Europe, famous for the quality (and quantity) of its fighting men, the learning of its university, and the beauty of its Gothic cathedrals. The reign of St. Louis was the golden age of medieval France… By contrast, Machiavelli was ultimately a failure as politician… He played an important role in the successful subjugation of Pisa by the Florentines in 1509. However, in 1512, the Spanish troops attacked… after only a brief struggle the Florentine militia, recruited by Machiavelli, broke and ran away. Florence surrendered without further resistance, and the Spanish installed the new government headed by the Medici, who had been chased away from Florence 18 years earlier. Soderini was forced to resign and went into exile, and Machiavelli was dismissed from his post and banished. He withdrew to a small farm that his father left him, and there wrote the book that made him famous. The Prince (1513) was addressed to Lorenzo the Magnificent de Medici, and Machiavelli’s stated desire was to be reinstated in the government. His plea, however, remained unanswered, and he was forced to rusticate for the rest of his life….

Come teorico invece Machiavelli svetta, la sua idea dell’uomo egoista si è tramandata fino a noi attraverso una lunga catena di studiosi prestigiosi che l’ha sposata:

The main premise of the argument in The Prince is that all people behave all the time in a completely self-interested manner…  In Leviathan, Thomas Hobbes (1588-1679) assumed that in the “state of nature”—in the absence of the state keeping order—society would fall apart and degenerate into the war of all against all… David Hume ( 1711-76) wrote, “Political writers established it as a maxim, that, in contriving any system of government ... every man ought to be supposed to be a knave and to have no other end, in all his actions, than his private interest.”… Bernard Mandeville (1670-1713) in The Fable of the Bees: Private Vices, Publick Benefits: “Thus every Part was full of Vice, yet the whole Mass a Paradise.”… 1980s and 1990s—“greed is good”?… In his master-piece The Wealth of Nations, Smith wrote, “It is not from the benevolence of the butcher, or the baker that we expect our dinner, but from their regard to their own interest.”… During the twentieth century, the ideas of Mandeville, Smith, and many others have been developed and systematized into what is now known as “the theory of rational choice.”… In principle, the utility function could be almost anything, but in practice almost all applications of the theory in the mainstream economics equate utility with material self-interest…

Tutti costoro hanno ben poco da dirci sull’innesco della I guerra mondiale e sul fenomeno del volontariato che seguì:

There is, however, one area where the rational choice theory fails utterly-in explaining why people cooperate. Take volunteering for the army when your country is attacked… the cost of enlisting you bear directly, whereas the benefit is shared equally among everybody… Your participation, or not, in the army of millions is not going to make any appreciable difference to the outcome of the war…

C’è chi pensa di cavarsela facendo osservare che comunque la coscrizione obbligatoria ebbe un ruolo centrale. Ma tener conto di questo sposta solo il problema, non lo risolve:

What about forcing people to cooperate? For example, we might establish firing squads that would go to towns and villages and shoot everybody who fails to volunteer. When faced with a choice of being shot here and now, or joining the army and taking one’s chances, the rational agent would of course “volunteer.” But who will constitute the enforcement squads? Certainly not rational agents. Participation in the enforcement squad is personally costly (you might get killed by rioting draft evaders), whereas the benefit (getting an army together and resisting the invaders) is again spread evenly among all…

Ma l’imbarazzo che genera la cooperazione umana coinvolge anche i biologi evoluzionisti fautori del gene egoista:

… AT THE SAME TIME THAT THE social scientists were perfecting the theory of rational choice, biologists were doing the same for the theory of evolution by natural selection, reaching very similar conclusions. The biological counterpart of utility is “fitness”—the expected number of viable offspring contributed by an organism to future generations…

Per l’evoluzionismo la socialità è una pietra d’inciampo sin dai primordi. Un conto è quella delle api (formiche…), tutte sorelle tra loro perché generate da un’unica regina, un conto è quella umana che s’instaura tra estranei:

… beginning with Charles Darwin himself, there was one puzzle that bothered evolutionary biologists—how could sociality evolve. Take the beehive. If you try to plunder its honey, you will be immediately confronted with an angrily buzzing swarm of bees. If you do not have protective clothing, you will be stung many times. A bee cannot withdraw its barbed sting from the skin of the victim, so the inevitable result of its attack is that the sting is torn out of its abdomen, and the bee dies. Thus, its defense of the hive is a true act of self-sacrifice… wasps, ants, and termites, do something even more puzzling—they give up their ability to reproduce…

Chi si concentra sulla parentela riesce a dar senso a gruppi coesi ben più piccoli di quelli che osserviamo all’opera nella storia:

… British biologist William D. Hamilton advanced the theory of kin selection. We know that all bees in a hive are sisters and, due to a quirky genetic makeup of Hymenoptera (a group that includes wasps and ants), a bee shares three quarters of her genes with any of her hive mates….

Altri puntano sul “finto altruismo”, ovvero l’altruismo che si aspetta un ritorno, ma l’altruismo osservato nell’uomo va ben al di là, si esplica anche con estranei che non incontreremo mai più:

… The second important strand in evolutionary research that has a bearing on human sociality is the idea of “reciprocal altruism” developed by the biologist Robert Trivers and the political scientist Robert Axelrod… but when a Frenchman enlisted in the army in 1914, the vast majority of his 40 million countrymen and women had no blood relation to him whatsoever. Hamilton’s insight does not really help us understand human “ultrasociality”… What about reciprocal altruism? Does this help us understand how we can solve the collective-action problem involving many people? Unfortunately not…

Anche Richard Dawkins nel suo capolavoro “Il gene egoista” ammette il fallimento:

… In the final analysis, although they made valuable contributions to the debate, sociobiologists failed to explain human ultrasociality In the last chapter of The Selfish Gene, Dawkins himself acknowledged, “Kin selection and selection in favor of reciprocal altruism may have acted on human genes to produce many of our basic psychological attributes and tendencies. These ideas are plausible as far as they go, but I find that they do not begin to square up to the formidable challenge of explaining culture, cultural evolution, and the immense differences between human cultures around the world.”…

Di fronte all’impasse c’è chi rimuove, chi invoca una deriva di comportamenti irrazionali e chi molto più semplicemente ritiene ricorre al concetto di “massa manipolata” dal machiavellismo dei potenti. Si tratta di soluzioni di comodo per andare oltre:

Anomalies such as, for example, World War I were generally ignored. Some scientists tried to explain such instance of mass cooperation away. Perhaps enlisting in the army was an atavistic cooperative impulse, which evolved by means of kin selection when primordial humans lived in bands of relatives, and now was somehow triggered by nationalistic war propaganda. In other words, volunteers behaved in truly irrational fashion, both in the technical and common senses of the word; they were somehow “fooled.” Or perhaps they were purposefully fooled—manipulated by the Machiavellian…

Cominciamo a dire che allo stato attuale almeno una cosa è certa: gli altruisti – quelli autentici, quelli che consentono di fare guerre devastanti come di salvare gli sconosciuti – esistono. Lo sappiamo non solo perché abbiamo studiato la storia ma anche grazie ad una mole notevole di sperimentazione sul campo. Machiavelli è confutato di fatto, si tratta solo di elaborare una teoria. Nella società umana egoisti e altruisti convivono, laddove si riscontra il giusto mix emerge una società vincente

… THE BEHAVIORAL EXPERIMENTS USING THE public goods and the ultimatum games decisively prove that Machiavelli’s self-interest premise was wrong. It is simply not true that all people behave in entirely self-interested manner… Furthermore, different societies have different mixtures of self-interested and cooperative individuals.

Gli altruisti non si limitano ad essere tali, sono anche moralisti e godono nel fustigare chi viola le norme sociali a cui loro sacrificano i loro interessi più immediati:

… Self-righteous moralists are not necessarily nice people, and their motivation for the “moralistic punishment” is not necessarily prosocial in intent. They might not be trying to get everybody to cooperate. Instead, they get mad at people who violate social norms…. A recent experiment, conducted in Zurich by Fehr and colleagues, confirms that emotions play a strong role in moralistic punishment. The new twist was that the researchers scanned brain activity of the subjects who were contemplating whether to punish a cheater. The brain scan showed that when a player was deciding on punishment, a spike of neural activity occurred in the region of brain known as the caudate nucleus. The stronger the nucleus fired, the greater was the fine imposed by the subject on the norm violator. The caudate nucleus is known to be involved in the processing of rewards…

Ma oggi abbiamo anche una teoria soddisfacente dell’altruismo. Va sotto il nome di “selezione di gruppo”. In embrione era già nella testa di Darwin quando rifletteva sull’incoerenza tra evoluzionismo tramite selezione naturale e socialità dell’uomo:

… “Selfish and contentious people will not cohere, and without coherence, nothing can be effected. A tribe possessing ... a greater number of courageous, sympathetic, and faithful members, who were always ready to warn each other of danger, to aid and defend each other ... would spread and be victorious over other tribes.”… The mechanism, proposed by Darwin, is now known as “group selection”

In poche parole, così come l’individuo è il veicolo dei geni e a tutti i geni in esso conviene che quell’ individuo sopravviva, allo stesso modo il gruppo è il veicolo dell’individuo e ad ogni individuo presente nel gruppo conviene che esso sopravviva quando lotta con gli altri gruppi. In questo senso gli “egoisti” presenti in un gruppo hanno interesse a “coltivare” il giusto numero di “altruisti” poiché sono estremamente preziosi nel conflitto tra gruppi. Nella lotta intragruppo, infatti, l’egoista potrebbe facilmente battere l’ingenuo altruista ma ora capiamo bene che non è sempre nel suo completo interesse farlo visto che la cosa lo sporrebbe poi a conseguenze deleterie nella lotta intergruppo. Agli altruisti viene così offerta  fama, reputazione, carisma, e quindi anche occasioni riproduttive: è vero, ne muoiono tanti perché si sacrificano nella lotta intergruppo o soccombono per ingenuità nella lotta intragruppo, ma si riproducono anche in tanti per le maggiori occasioni riproduttive offerte dall’aura di cui godono. Inoltre, l’altruista genuino ha molte più possibilità di godere del trattamento privilegiato visto che essendo tale non rischia di essere smascherato.

Per vedere il meccanismo della soluzione di gruppo all’opera forse è meglio concentrarsi sulla relazione gene-individuo (l’individuo è una collezione di geni):

… in Dawkins’ own book he discusses at least three distinct units of selection. These units are the gene (which is reflected in the very title), the individual, and the group of relatives (Hamilton’s kin selection). Individuals, after all, are not unitary, structureless “atoms” (despite the name—individuum—meaning “undividable”). They are made up of organs, tissues, and cells, and each cell contains many genes. It might be in the common interest for genes to cooperate to ensure the cell’s proper functioning, but there could also be incentives for selfish genes to free-ride on this collective effort. Similarly, cells usually cooperate to promote the survival and reproduction of the organism, but at times this cooperation breaks down, and a bunch of knavish cells begins to increase at the expense of the cooperative ones. We know this as cancer…

In che modo vengono “coltivati” gli altruisti che consentono l’ “ultrasocialità” umana? Attraverso quella roba che chiamiamo “cultura”, una specialità dell’uomo. La cultura inoltre si trasmette molto più velocemente dei geni e quindi consente la rapida formazione di gruppi coesi e allargati. Gruppi coesi e allargati consentono sia la caccia al mammuth che i genocidi:

… Empirical examples of group selection in nature are rare. Humans, on the other hand, are unique in the biological world in their capacity for thought, communication, and culture… Probably the most important difference between humans and other organisms is the unique importance of cultural transmission of behaviors in humans…. What makes cultural transmission really distinct from genetic inheritance is that people can learn from other people, not only from their parents. Young people adopt certain behaviors by imitating a particularly successful or charismatic individual in their tribe. They are also taught many things by the tribal elders, from catching fish to telling the truth… Unlike chimps, however, who enjoy eating meat but can capture only small prey, our ancestors learned how to hunt large game in the savannas of Africa. Humans eventually learned (perhaps too well) how to kill large mammals… Even more importantly, as humans got better at hunting large game, they also got better at killing other humans.

Dallo studio dell’uomo ricaviamo che la violenza è stata in passato lo strumento più efficiente per sopravvivere. La selezione naturale ha operato prevalentemente attraverso la guerra, è chiaro che in un simile contesto l’altruismo era sinonimo di vittoria: 

… warfare (that is, any kind of organized fighting, from several chimps waylaying and killing a member of a different band to trench warfare involving millions during World War 1) became the most important force of group selection. Several kinds of evidence show that early humans practiced extensive warfare. For example, we know that interband warfare is very common among the chimps, our closest evolutionary relatives… The anthropologist Lawrence H. Keeley presents evidence that somewhere between 20 percent and 60 percent of males in these societies die in wars…

Nella storia i moralisti vincono facile sui familisti: formano gruppi più ampi e potenti, sono pronti al sacrificio e danno il meglio di sé nella lotta al nemico comune:

… Kin groups consisting of familial moralists would be able to achieve a higher degree of cooperation, and greater fitness, than groups consisting of those who cooperate with relatives, but do not punish uncooperative ones. As a result, familial moralism will spread through the population… Now suppose that a cognitive mutation arises in a population of familial moralists. Instead of limiting cooperation (and punishment of noncooperators) to relatives only, these mutants also—“mistakenly”—cooperate with unrelated people they know, friends… think how readily kinship terms enter our discourse when we want to promote cooperation—a band of brothers, the father of a nation, or our motherland… groups containing moralists acquired the ability to raise larger war bands, because they were not limited to relatives…

In tutto questo la cultura è centrale per tre motivi: da un lato consente di venerare gli altruisti che sono la forza del gruppo ma dall’altro consente di “riconoscersi” nel momento in cui il gruppo assume dimensioni tali da trasformarsi essenzialmente in una collezione di estranei non imparentati tra loro. Oltre a cio’, la cultura consente di estendere il gruppo più rapidamente visto che la trasmissione culturale non soggiace ai tempi biologici della trasmissione genetica, in questo senso, poiché la cultura ha anche un suo contenuto pratico, è la cultura migliore a prevalere. Ebbene, la cultura religiosa è particolarmente adatta ad assolvere a queste funzioni: 

… Thus, group-level selection favored the spread of true moralistic behaviors. At the same time, within-group (individual) selection against the moralists was extremely weak, because after the moralists tip the group over to a cooperative equilibrium, punishments become so infrequent that they hardly impose any costs on the moralists…. If a moralistic individual turned out to be a very successful hunter or a particularly charismatic person, he or she would be emulated by the young members of the group. The moralistic behavior, then, will rapidly spread within the group… Moralism in the form, say, of a religious commandment from Muhammad can spread rapidly to other groups…

Nella trasmissione culturale rileva anche il contenuto della cultura (che non è solo mero segnale), cosicché i vincitori non solo esportano la loro cultura ma importano cio’ che di buono hanno le culture perdenti creando così la contaminazione più “adatta” a passare la selezione.

… The Romans did not wear pants, but any German foolish enough to imitate that aspect of the Roman cultural package would not survive the next winter, never mind the next night out partying with the guys. On the other hand, the Romans had discipline and fought in close ranks. When the Germans imitated this particular cultural practice, they found that it worked for them, too…

Particolarmente interessante è la funzione del “riconoscimento”. Finché il gruppo è piccolo basta il faccia a faccia. Ma dopo… anche i nostri cervelloni sono insufficienti.

… WHEN HUMANS EVOLVED THE ABILITY to cooperate with unrelated individuals, they relied on face-to-face interactions and memory to distinguish friends and acquaintances from the enemies or untrustworthy individuals in the group… we cannot remember everyone on Earth… As the size of the group increases, the number of relationships to remember explodes… humans live in the largest groups, and have the largest brains, but a limit is inescapable. “The figure of 150,” estimates the British anthropologist Robin Dunbar, “seems to represent the maximum number of individuals with whom we can have a genuinely social relationship… 150 is very close to the average size of villages in hunter-gatherer societies…

La soluzione sta nel pensiero simbolico. La cultura è essenzialmente simbolo più che contenuto:

… Evolution had to find another way for humans to distinguish between those with whom to cooperate and those who should be killed… The distinctly human ability to invent and manipulate symbols was an important aspect of evolution of ultrasociality. In fact, as the Russian psychologist Lev Vygotsky (1896-1934) and his school argued, all higher forms of human cognition have social origins…. One example of a symbol representing a social group is the totem of American Indians. As the great French sociologist Emile Durkheim recognized almost a century ago, the totem is “the symbol of the determined society called the clan… Another example is the standard of a Roman legion, called the Eagle. The Eagle was a sacred emblem of the legion…

Il simbolo è un segno di riconoscimento immediato comunque facile da falsificare, ecco allora che la padronanza di una simbologia e la passione con cui la si adotta equivale ad un giuramento di fedeltà al gruppo. Per questo alcuni cerimoniali sono particolarmente impegnativi per chi vi si sottopone Chi poi arriva a considerare quel simbolo inventato alla stregua di una “realtà fattuale” è un membro particolarmente affidabile della comunità. Anche questa funzione è assolta in modo splendido dalla religione:

…Because of our psychological makeup, we tend to think of social groups, such as nations, as more real than they are “in reality.”… The capacity for symbolic thinking was the last great evolutionary innovation that made possible human ultrasociality. People now did not need to know personally another individual in order to determine whether to cooperate with him, or treat him as an enemy. Particularly good diagnostic features are religious observances and ritual actions…

Ma per comprendere il meccanismo non c’è bisogno di risalire alle pratiche religiose di qualche tribù amazzonica, basta un incontro tra cultori hip hop in Zimbawe:

… “It’s 1992 and I am sitting in a bar in Harare, Zimbabwe,” wrote Patrick Neate in Where You’re At, “when a guy walks in wearing a Lakers vest and Chipie jeans, his hair is neatly dreaded and he walks with a rolling ease of the B-boy swagger. He clocks my Karl Kanis and second pair of Air Jordans and comes straight over. ‘Yo, my brother, wassup?’” Here were two complete strangers, one a Zimbabwean black kid, another a white kid from Chippenham, U.K., but they instantly recognized each other as being “us,” members of the same hip-hop subculture—from they way they dressed, the way they walked or even sat, the way they were “blunted.”…

COMMENTO PERSONALE

Un libro estremamente proficuo per comprendere le dinamiche che connettono altruismo ed egoismo: gli altruisti ci fanno prosperare in tempo di guerra (vedi il kamikaze di Mishima), gli egoisti in tempo di pace (vedi il macellaio di Smith). Se dobbiamo produrre beni pubblici viene buono l’altruista, se dobbiamo produrre beni privati viene buono l’egoista. [Attenzione: sia il bene pubblico che il bene privato beneficiano i terzi, la differenza è che nel caso del bene pubblico il beneficio è intenzionale, nel caso del bene privato è non-intenzionale. Senza l’altruista, l’egoista si estingue, senza l’egoista, l’altruista s’immiserisce. Oggi che viviamo una pace prolungata (e quindi prevale la necessità di beni privati) il mix ottimale dovrebbe spostarsi ulteriormente a favore dell’egoismo (meno predicatori moralisti, più imprenditori dinamici) anche se la storia riserva sorprese e una piccola quota di altruisti è meglio tenersela cara.

War and Peace and War: The Rise and Fall of Empires di Peter Turchin