Cipolla’s banditry among medical professionals

                  Cipolla’s banditry among medical professionals

                                                             Dr. KS Dhillon

Introduction

Doctors are supposed to be intelligent people. Students with best grades at the end of high school are selected to enroll in medical schools. After 5 to 6 years at medical school, they undergo several years of Houseman and medical officer training before they can go into general practice. Those who get selected for postgraduate training spend another 4 years as postgraduate trainees. After getting the postgraduate diploma or degree the specialist spends several years horning the specialty skill. After more than about 15 to 20 years of training, a doctor becomes a consultant in his specialty, either in government or private sector.
This highly educated and skilled doctor is supposed to be very intelligent. The question is whether this assumption is true?

Types of human beings

Cipolla (1) a professor of economic history at the University of California at Berkeley, USA, believes that there are basically four types of human beings i.e ‘the helpless, the intelligent, the bandit and the stupid’. According to him an intelligent person’s action brings gain to both parties, a helpless person’s action brings loss to himself and gain for the other party. A bandit is a person whose action brings gain to himself and a loss for the other party and a stupid person is one whose action brings loss to other parties while bringing no benefit or causing loss to himself.
Most humans do not behave consistently all the time. They behave intelligently under certain circumstances and under different circumstances, the same person can be helpless. However, a stupid person, on the other hand, is perfectly consistent in his behavior all the time in every endeavor.
A bandit's actions are rational and predictable whereas those of a stupid person do not conform to the rules of rationality. A bandit wants to take away something for his gain which causes a loss to another person.
It is not possible to organize a defense against stupid behavior because the actions of a stupid person are unpredictable, erratic and irrational.
Cipolla believes that ‘non-stupid people always underestimate the damaging power of stupid individuals’ and that non-stupid people tend to forget that dealing with stupid people under any circumstance turns out to be a costly mistake. Often people believe that a stupid person will only harm himself but that is not true. Stupid people cause harm to society in general.
In which category does a doctor fall?

Conflicting and irrational behavior among medical professionals

In the last few decades, there has been an unprecedented interest, among doctors, in newer medications to treat diseases. This interest has been generated by the pharmaceutical industry and not by unprecedented new discoveries. There exists a widespread conflict of interest in the relationship between physicians and the pharmaceutical industry.
In 1999 Merck introduced a new Cox-2 inhibitor, Rofecoxib (Vioxx), as a safe and efficacious alternative to other non-steroidal anti-inflammatory drugs (NSAIDs) for treatment of osteoarthritis. Krumholz et al (2) were able to access Merck’s documents as a result of a tort ligation which showed startling conflicts of interest. In 1996-97, a Merck sponsored study revealed that Rofecoxib reduced urinary metabolites of prostacyclin in healthy individuals by half. Prostacyclin and its analogs are potent vasodilators and they possess antithrombotic activity. At the request of Merck, the authors altered the manuscript to say that ‘Cox-2 may play a role in the biosynthesis of prostacyclin’ instead of saying that the biosynthesis of prostacyclin synthesis was reduced by Rofecoxib (2). Despite the fact that Merck knew of the cardiovascular side effects of Rofecoxib, Merck in its new drug application to FDA in 1998, presented interventional studies that were ‘generally small, had short treatment periods, enrolled patients at low risk of cardiovascular disease, and did not have a standardised procedure to collect and adjudicate cardiovascular outcomes’ (2).
In January 1999, Merck launched its Vioxx gastrointestinal outcome research (VIGOR) study, involving over 8,000 patients to show its gastrointestinal (GI) safety compared to Naproxen in the treatment of rheumatoid arthritis. In this study, the first non-endpoint safety analysis of Vioxx showed a ‘79% greater risk of death or serious cardiovascular event’ in one treatment group compared with the other (2). Despite this finding, the safety monitoring board, which had some members on the board with conflicts of interest, allowed the study to continue till its GI endpoint. The study showed that Vioxx was not more effective than Naproxen in the treatment of Rheumatoid arthritis but the GI adverse effects were reduced by half. The outcome of the VIGOR trial was published in the New England Journal of Medicine in Nov 2000. The authors concluded that the incidence of myocardial infarction was lower in the Naproxen group but the rate of death from cardiovascular causes was the same in both groups (3). Only 5 years later, in Dec 2005, an editorial appeared in the same journal expressing concern, after more data was available from a tort litigation, that there were inaccuracies and deletions in the data regarding the cardiovascular risk of Vioxx, submitted to the journal in the original VIGOR manuscript (4). In fact, Mukherjee et al had in 2001 raised the ‘cautionary flag’ that the ‘annualised myocardial infarction rates for Cox-2 inhibitors (Vioxx and Celebrex) were significantly higher than that in the placebo group’ (5).



Merck, however, continued to investigate the use of Vioxx for other indications. In Feb 2000 the Adenomatous Polyp Prevention on Vioxx (APPROVe) trial began, to evaluate the reduction of risk of recurrent adenomatous colorectal polyps. It was a randomised, single blinded, placebo controlled trial. The study was terminated in September 2004, three months before the completion date because of increased incidence of myocardial infarcts and ischemic cardiovascular events (6). Five of the authors of this study were Merck employees and the remainder who received consultancy fee asserted that the increased risks of cardiovascular events were seen only after an 18 months period. Further analysis of the data after publication showed that a flawed methodological approach was the reason for this conclusion (3). In 2006, more than a year after the publication of the APPROVe study in 2005 in the New England Journal of Medicine, a correction was published in the same journal to remove the statement that the increased risk of cardiovascular was apparent only after 18 months (7).
There were glaring failures of the peer review process of the medical journals. Flaws, mistakes, and inaccuracies of Merck sponsored Vioxx publications escaped the peer review process of the New England Journal of Medicine which published both the VIGOR and the APPROVe studies. Articles favoring Vioxx, some of which were ghost written, appeared in several journals including the Annals of Internal Medicine and the journal Circulation (3). Conflicts of interest were obvious but there was little outrage among the academics in this Vioxx saga which was ‘bad news for the industry, academics, journals, and the public (3). In September 2004 Vioxx was withdrawn from the market while litigations and settlements between Merck and consumers were ongoing (8).
In fact, before the APPROVe trial began in early 2000, a Pfizer sponsored trial, the adenoma prevention with celecoxib (APC) trial had begun recruiting patients in November 1999. It was a large randomised controlled study to assess the effectiveness and safety of a Celecoxib 200 mg twice a day, Celecoxib 400 mg twice a day and placebo in reducing the incidence of colon and rectal polyps. After the findings of the APPROVe trial were known and the withdrawal of Vioxx in 2004, APC data and safety monitoring board, and the steering committee of APC requested a reassessment of data on cardiovascular safety by an independent committee. Based on the findings of the independent committee the use of Celecoxib in the remaining patients in the trial was stopped. The review of available data showed that there was a dose related increase in the risk of cardiovascular events including deaths from myocardial infarcts, stroke and heart failure in patients on Celecoxib (9).

How would Cipolla categorize such medical professionals involved in these studies and these publications and not to forget the peer reviewers of the leading medical journals in the world? Without a doubt, Cipolla would classify such medical professionals as bandits, who do things for personal gain and harm the poor patients who seek treatment, from the so called ‘highly educated and respected professionals’.

The most scandalous failure of the peer review process was the case of Scott Ruben, a Professor of Anesthesiology in Boston, USA. He allegedly published 21 fraudulent articles, based on fabricated data, in leading peer review journals, including Anesthesiology, Anaesthesia and Analgesia, and the Journal of Clinical Anaesthesia, among others, over a span of 13 years. The publications promoted the use of drugs such as Celebrex, Vioxx, Ketorolac, Oxycodone, and Pregabalin, mainly in patients undergoing orthopedic surgical procedures, while he had ties with the pharmaceutical industry (10). In Feb 2010 he pleaded guilty to one count of health care fraud and the US Attorney’s Office announced in June 2010, that Ruben was sentenced to 6 years in prison followed by 3 years supervised release and a $5,000 fine, restitution of $361,932 and forfeiture of $50,000 (11). This effectively ended his career as a doctor.
Such scandalous behavior can only be described as doltish or stupid. Surely it can not be described as intelligent behavior.

Gifts, free lunches, and the pharmaceutical industry

Something is amiss in our healthcare system, which is highlighted by a complex, controversial and maybe unhealthy pervasive interaction between doctors and the pharmaceutical industry. This relationship starts in the medical school and continues through postgraduate training and last the lifetime of a physician (12).
Moynihan has registered 15 forms of entanglement between the doctor and the pharmaceutical industry, ranging from trivial gifts (pens, pads), free meals, travel and accommodation expenses for ‘educational’ meetings, entertainment, trips, speaking honoraria, consultancy fee, and ghost writing of publications to name a few. Even medical journals and many medical societies interact and depend on corporate sponsorship (13). This entanglement between doctors and industry is very widespread. Studies show that 80 to 90% of the doctors around the world regularly meet drug representatives and studies have also shown that the prescribing behavior is influenced by gifts however trivial they are (13).These interactions lead to a greater use of newer more expensive drugs and less use of generics despite lack of evidence of the superiority of one over the other. It also leads to irrational and incautious prescribing behavior (12).  Continuing medical education (CME) tops the list of ways in which the pharmaceutical companies interact with the doctors. In the US, close to a billion dollars annually are spent by pharmaceutical companies on CME for doctors (12).
The Pharmaceutical companies claim that the cost of drugs is high because of the high cost of research and development (R&D). Such claims appear to be untenable. Large drug companies apparently spend between 15% to 17% of their income on R&D. The actual figures are not disclosed by the companies (14). However, after deduction of corporate tax, the actual cost for R&D should be lower. In the US, a major part of the initial research is done by academic centers, the government and other public and nonprofit organizations. The National Institute of Health (USA) in 1995 found that 16 of the 17 key scientific papers that lead to the discovery and development of the five top selling drugs were from outside the pharmaceutical industry (14). Most of the new drugs entering the market are modifications of older drugs which are already in the market (called the ‘me-too’ drugs) (14).
More money is spent by pharmaceutical industry on marketing than on R&D. Up to about 36% of the big pharmaceutical company’s budget is spent on marketing and distribution and this can be as much as 12 to 15 billion dollars annually according to some estimates (14). Here is where the expenses for the entanglement between doctors and industry come from. In the USA there were 88,000 sales representatives, according to a 2002 estimate, who were paid about 7 billion dollars a year to promote drugs directly to doctors in the hospitals. This raises a question as to whether doctors really need to be educated about the use of the drugs by these representatives when all the information is readily available on the web at the touch of a button. It is not so much about the information the doctor receives from sales representatives but it appears to be more about the gifts, free lunches and other inducements which influence doctors prescribing behavior. CME meetings are also a major platform used by the industry to advertise their products to doctors.
Intelligent individuals do not exhibit such prescribing behavior because such behavior brings benefit to the doctor but not the patient. Such behavior would probably fit the definition of a banditry.


 The influence of the industry does not end here but extends to other areas of medical practice. Doctors in their daily practice have to make clinical decisions about the most appropriate way to handle specific clinical circumstances based on valid scientific evidence and critical evaluation of the evidence. Such decisions can sometimes be difficult due to time constraints and the extensive volume of scientific literature available in a given field. Clinical practice guidelines can fill the void by providing the best available evidence, which will fulfill the needs of most doctors when they are faced with decisions about the most appropriate healthcare intervention.

Doctors and clinical guidelines

Clinical practice guidelines are ‘systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances’ (15). In clinical practice these guidelines ‘influence patient and physician decision about health care intervention…’, hence they should be based ‘on valid scientific evidence, critical assessment of that evidence and objective clinical judgment’ (1). Practice guidelines were first proposed by the Institute of Medicine in 1990 (16). Since then the number of clinical practice guidelines (CPGs) has grown rapidly. Currently, the US national guideline clearinghouse contains 2,564 individual guideline summaries on various topics (17). These guidelines have to be updated on a regular basis to remain relevant.
Clinical guidelines must be based on the highest level of evidence with the elimination of financial or other bias and they should not become a ‘marketing tool for device and pharmaceutical manufacturers’ (18). When the biomedical and pharmaceutical industry and medical experts with affiliations to the industry, are involved in the development of clinical practice guidelines there can be conflicts of interest which may not be in the best interest of the patients and the health care providers.
In 2011, Norris et al did a systematic review of conflict interest in clinical practice guidelines development to ‘describe the extent of conflict of interest (COI), both financial and intellectual, in clinical practice guidelines (CPGs) and to examine the effect of COI on recommendations within CPGs’ (19). Their review included studies where there was a prevalence of conflict of interest, industry relationships, funding, or sponsorship in CPGs or among guideline panel members and authors, or there was the effect of such conflicts on guideline recommendations. They were only able to identify 12 studies which met the criteria and this reflects the paucity of studies on this topic. However, their review found ‘a high prevalence of non-disclosure of COI among authors across a variety of clinical specialties’, and where there were disclosures a high percentage of CPG authors reported COI (19). The authors recommended that users of CPGs ‘need to critically appraise CPGs considered for implementation, read disclosures and consider how they may have influenced recommendations, and seek to move forward research on unanswered questions’.
Other studies have also found conflicts of interest in the development of clinical practice guidelines. Bindslev et al, in a study on conflicts of interest in the development of clinical practice guidelines, found that disclosures were rare and conflicts of interest were common (20). Choudhry et al in a survey of 192 authors of 44 CPGs found that there was considerable interaction between CPG authors and the pharmaceutical industry (21).
The development of clinical practice guidelines can be a very sensitive issue, especially when the guidelines are created by a reputable state agency. The US Congress in 1989 created the Agency for Healthcare Policy and Research (AHCPR) after John Wennberg’s research showed practice variation in the medical field and RAND studies showed a widespread inappropriate use of common surgical procedures. The AHCPR was tasked with research on the outcome and effectiveness of treatment. One of its tasks was to produce clinical practice guidelines based on ‘review and synthesis of available research, analysis of practice variations and patient outcomes’ (22). Such research was conducted by Patient Outcome Research Teams (PORTs). One of the reasons for the near demise of such a useful agency was the result of conclusions of the PORT on low back pain. The PORT on back pain concluded that there was no evidence to support spinal fusion surgery for low back pain and that such surgery was frequently associated with complication (22). The North American Spine Society attacked the literature review and initiated political lobby which resulted in ‘rechristening’ of AHCPR to the Agency for Healthcare Quality and Research (AHRQ) and the new agency withdrew from developing clinical practice guidelines (15).
Why do medical professionals participate in such deception? The answer appears to be a personal gain at the expense of others, which Cipolla describes as banditry.

Physician Prescription Behavior (PPB)

There is no doubt that the physician can do a lot of harm to the patient if his/her prescribing practices are influenced by the pharmaceutical industry. Waud (23) did not mince his word when he said " [f]rom the press, one can get an idea of what it costs to buy a judge or a senator - generally, thousands of dollars. But you can buy a physician for a pen or some pizza and beer for a departmental meeting."Colette DeJong et al (24) did a study to answer the following question: ‘Is the receipt of pharmaceutical industry-sponsored meals by physicians associated with their prescribing the promoted brand-name drug at higher rates to Medicare beneficiaries?’ They did a cross-sectional study of 279,669 physicians and found that ‘receipt of industry-sponsored meals was associated with an increased rate of prescribing the promoted brand-name medication to Medicare patients’. Ninety-five percent of payments were in the form of a meal with a mean value of less than $20. When more meals were received and the meals cost more than $20 there were relatively higher prescribing rates.
Ashley Wazana (25) did a literature search to identify ‘the extent of and attitudes toward the relationship between physicians and the pharmaceutical industry and its representatives and its impact on the knowledge, attitudes, and behavior of physicians’. He found that ‘physician-industry interactions appears to affect prescribing and professional behavior’. He also found that physician interactions with pharmaceutical representatives were generally endorsed. Meetings with pharmaceutical representatives are often associated with ‘requests by physicians for adding the drugs to the hospital formulary and changes in prescribing practice’. Continuing medical education (CME) sponsored by drug companies preferentially highlighted the sponsor's drug(s) compared with other CME which is not sponsored by drug companies. Higher rates of prescription of sponsor’s medications were associated with attending sponsored CME events and accepting funding for travel or lodging for educational symposia. Attendance at presentations given by pharmaceutical representative speakers at such symposia was also associated with nonrational prescribing (25).
In 2004 the pharmaceutical companies in the United States spent about US$57.5 billion, or 24.4% of their revenue, on promotion (26). Why would pharmaceutical spend so much of their budget on drug promotions if they can not get significant returns? Obviously, their promotions have a significant influence on medical professional's prescribing behavior. Why would doctors not prescribe what is good, safe and cheap for their patients?The answer appears to be a personal benefit which would come under Cipolla’s definition of a banditry. Why would medical professionals fall for such cheap rewards and why can they be bought for a ‘pen or some pizza and beer’ as Waud (23) succinctly put it. That would be due to stupidity.

Surgery and the medical device industry
There is a close relationship between the surgeons and the multi-billion dollar medical devices manufacturing industry. The physician-industry interaction has led to increasing conflicts of interest with diminishing scientific objectivity. New implants are being introduced into the market at a very rapid pace over the last few decades. The design and introduction of new implants into the market is the result of industry physician interaction which is often tainted with conflicts of interest. The new implants provide financial rewards for the industry and the surgeons involved, but unfortunately, the patient becomes the victim of these innovations. Many surgeons are swayed by industry sponsored opinion leaders who travel around the world as guest lecturers. Many of these implants are introduced into the market without adequate laboratory testing and clinical trials.
Despite excellent results with traditional hip replacements, new prostheses with fashionable design features and with theoretical superior performance continued to be launched into the market without extensive clinical testing.
Many hip and knee prosthesis introduced into the market have had early failures. The saga of metal on metal hips with a disastrous outcome is still fresh in many people's minds.Despite the previous failure of metal on metal prostheses and the known toxicity of metal ions that result from wear, new designs for metal on metal resurfacing hip continued.
A systematic review by Person et al (27) showed that in England and Wales, 24% of all hip replacement implants available to the surgeons have no evidence of their clinical effectiveness.
Not only for the hip and knee, newer implants are being introduced by device companies for the spine, and most other joints in the body, which are being aggressively promoted by doctors to their patients.
This symbiotic relationship between medical professional and the devices industry is necessary but when it is poorly regulated it causes tremendous harm to the patients. However, it brings a lot of financial benefits to the players on both sides at the expense of the patients. Such behavior among the medical professionals would be classified under the category of banditry. However, there are other doctors who will do irrational things such as using untested implants because their peers do it and they don’t ‘want be left behind’. This would be classed as doltish or stupid behavior.

Unnecessary invasive procedures and surgery

There are several definitions for unnecessary surgery. Stahel et al (28) have defined it as ‘any surgical intervention that is either not needed, not indicated, or not in the patient’s best interest when weighed against other available options, including conservative measures’. L L Leape (29) has defined an unnecessary operation as ‘one that is useless’, one that ‘does not benefit the patient’, one that ‘does not do what it purports to do, or at the most, carries benefits so small that they are outweighed by the costs in terms of risks, morbidity, disability, and pain’ and ‘the patient is not better off’.
One wonders why do surgeons do unnecessary invasive procedures and surgery. Two possibilities exist, one is that they do it out of ignorance and the other is that they do it deliberately. Those who do it deliberately are unscrupulous individuals who out of greed perform surgery on unsuspecting victims (29).
As far back as the 1950s, Dr. Paul Hawley, the Director of the American College of Surgeons (ACS), stated that “the public would be shocked if it knew the amount of unnecessary surgery performed (…)” (30). The growing numbers of unnecessary surgeries became a concern for the American Medical Association (AMA) which in 1976 called for a congressional hearing on unnecessary surgery. They claimed that there were “2.4 million unnecessary operations performed on Americans at a cost of $3.9 billion and that 11,900 patients had died from unneeded operations (…)”(31). That was 41 years ago, one wonders what the figures would be now.
Until now (2017) there appears to be no change in the behavior of doctors as far as unnecessary surgery is concerned. High quality multiple clinical trials show that spinal fusion for back pain does not improve long term outcome as compared to conservative treatment (32,33), yet the number of spinal fusions continues to rise dramatically in the USA (34).
Another good example is arthroscopic partial meniscectomy, one of the most commonly performed surgical procedures in the world (35). In the United States, about 700,000 arthroscopic partial meniscectomies are done every year despite the fact that high level (level I) evidence shows that this operation is no better than a sham operation (36). No operation should be considered as routine and safe considering the possibility of morbidity and mortality which can be associated with any surgery.
Pharmaceutical drugs undergo ‘strict’ scrutiny of testing for safety and feasibility in phased trials followed by prospective randomized controlled trials prior to approval by the Food and Drug Administration (FDA) (34). However, for surgical procedures, no such regulations exist.

A lot has been written in recent years about economic motivation for invasive procedures and surgeries. Physicians in private practice have been characterized as "income maximizers" (29). There is evidence that patients in fee for-service systems have more operations overall than those in prepaid plans and this has widely been accepted as evidence that economic motivation leads to increased provision of services including invasive procedure and unnecessary surgeries (29). Provision of a service is known to enhance income and it does influence a physician's decision. A rapid proliferation of endoscopic procedures in recent years suggests that this phenomenon is not confined to those who wield the scalpel alone (29).
In 1969, Lewis (37) showed a link between surgical utilization to the availability of both beds and surgeons. He came up with 'a medical variation of Parkinson's Law: patient admissions for surgery expand to fill beds, operating suites and surgeons' time". There are others who have found a strong relationship between bed supply alone and surgical utilization.
There was a landmark Study of Surgical Services in the United States in
1975 which reported an almost linear relationship between the number of
surgical specialists and the number of operations performed per 10,000
Population (38). A logical analysis will support the belief that an underemployed surgeon will create more work and hence more unnecessary procedures.
Cipolla would classify this senseless indulgence in unnecessary surgeries which is going on around the world for financial benefits as banditry.
Those who do unnecessary surgery out of ignorance should be classified as doltish or stupid. When there is groundbreaking research published we should not be ignorant about it.

The list of actions of medical professionals which reflects banditry and doltish behavior is long and it is difficult to provide a comprehensive list of such actions. More important than the list, is the question as to why such behavior exists among ‘intelligent’ professionals.

Why banditry among professionals?

‘Whoever loves money never has enough; whoever loves wealth is never satisfied with their income. This too is meaningless’. Ecclesiastes 5:10

The ancient Greek philosopher Aristotle, said that money cannot bring true happiness and fulfillment in life because it is only an ‘instrumental good’ i.e it is good only for what we can get (buy) with it. Nothing is wrong with the desire to have more money to meet our needs. What is bad is an excessive desire (greed)  for money.

Psychologist Harvey A. Kaplan defined greed as "the selfish desire
to acquire for the sake of acquisition without regard for others."(39). In other words, greed is a selfish desire for more than one needs or deserves. Others have defined it as an ‘excessive love or desire for money or any possession’.
There is a point up to which the pursuit of wealth and belongings is a normal, healthy behavior. Such pursuit of materialism to a degree is necessary to generate economic growth. It is okay to care about money and possessions, but caring too much about them is tantamount to greed.
 A greedy person, however, gets very attached to his things and his money and continues to desire more of the same in an excessive manner. Greed generates anxiety and restlessness when we long for some possession, and we hope that once we attain it, we will be at ease and be satisfied. However, that does not happen when we are greedy. We believe a bit more would be better and a vicious cycle is established. It is well known that a person suffering from greed is usually not satisfied by his acquisition, and he always wants more. Medical professionals often resort to performing unnecessary investigations, procedures, and surgeries as well as dishonest billing to increase their income, without regard for the erosion of professionalism that results. Greed becomes the precursor of banditry.


Human beings manifest materialism to different degrees, some people acquire just enough for creature comforts for personal satisfaction and do not harm others but there are others who are so obsessed with materialism that they become toxic and socially destructive.
Psychologists have, for some time now, recognized the existence of an increasingly visible and widely destructive phenomenon in the society which is created by a ‘passion for selfish gratification in the amassing of wealth, and the worship of money, through fraudulent and deceptive tactics’ (40).
Arthur Nikelly describes it as a "pleonexic personality disorder’ and he proposed the following criteria for the diagnosis of this disorder:
‘Lack of a sense of boundaries .... Increasing wealth becomes a race without a finish .... a morbid quest for money that defies the rules of reason .... Disregard of how financial transactions affect others .. . . lacks an
understanding of what is more essential in life. Judges self by possessions, not by accomplishments. Emotionally detached .... Inane competition to surpass adversaries’ (41).

We see more and more greed around us with the passage of time. But why? What are the triggers of personal greed? Several reasons have been postulated (42).

1. ‘Insecurity and Modeling of Materialism’

Many studies show that emotionally and/or financially insecure people turn to acquisitions as a solution to their insecurities. They develop what is known as "materialistic value orientation, or an MVO’. Growing up in ‘unfortunate social situations’ such as neglect in childhood by family, threats of death, and experiences of poverty can lead one to adapt by becoming more materialistic. In layman’s term, it can be summed up as ‘an unhappy childhood may produce a materialistic adult’. Cultures which over-value material acquisitions also have a great influence on making someone more materialistic.

2. Mental Disturbance

Preoccupation with the material acquisition is known to be associated with mental disorders in some individuals. Studies show that adolescents who are highly materialistic often have ‘depression and anxiety, conduct disorders, narcissism, drug use, and personality disorders’. They avoid friendship and intimate relationships and are usually less empathetic. They like to compete and are less cooperative. An element of insecurity in such people pushes them to be more materialistic so that they can prove they are successful.

3.Fear of Death

Money has now been labeled as a new ideology of immortality (43). There has been an increasing interest in the ‘purchase of luxuries under salience conditions’ (44). Mortality salience increases one’s expectations for more material wealth and also increases an individual's greed for money. Money and other possessions somehow help humans distance themselves from the realization that we are destined for death.  There is evidence which suggests a direct link between death anxiety and materialism. Material acquisitions seem to provide a sense of security against ‘existential insecurity and sense of mortality’ (45). We aspire to survive beyond our death by acquiring lots wealth and property which can be passed on to our heirs who continue to enjoy the wealth and possessions. In this sense, we continue to live after our demise. Those who are more fearful of death are more greedy and they have a greater desire to acquire more.

4.Fear of Loss

Fear of losing what one has acquired is another trigger for greed. This is closely related to fear of death. The desire to acquire more is a hedge against loss. This has been eloquently explained by Professor David Levine who said "greed expresses the fear of loss, and the effort to defend against it. The greedy person is constantly aware of the threat of loss, and because of this is driven to attempt to take from others lest they take from him first." (46).

Conclusion

Now to answer the question whether the highly educated and skilled doctor is intelligent or not. If intelligence is measured by one’s ability to find and solve problems or by the use of psychometric instruments such as I.Q. test, it is likely that many medical professionals will be classified as intelligent people. However, if Cipolla's classification of an intelligent person is used then many doctors will not make the mark to be labeled as intelligent. Cipolla’s definition of an intelligent person is one who, with his actions tends to create advantages for himself and also creates benefit for others.
However as we have seen in the foregoing discussion, many doctors cannot be classified as intelligent. They more likely fall under the category of bandits or in some circumstances under the category of stupid people.

References

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