Bryan Caplan  

I Refused to Shake His Hand

Krugman's Tin Ear... Downgraded into Bankruptcy?...

I truly need a vacation from my vacation.  After my kids were diagnosed with bronchitis, I decided I probably had the same ailment.  I'm a member of Kaiser, but since I'm out-of-state, my only in-plan option in California was to go to Kaiser's Urgent Care facility and queue for a doctor.

If I'd been on Candid Camera, opponents of immigration would have overflowed with Schadenfreude.  At last, Bryan Caplan gets his come-uppance, sniffling and coughing in the waiting room while the nurses call out scores of Hispanic surnames!  But even in my fragile state, this economically illiterate analysis did not tempt me.  If Kaiser had fewer Hispanic customers, it would have fewer facilities and fewer employers, and there's no reason to think my wait would have been any less.  Indeed, if there were more Hispanic immigration in the middle of the Arizona desert, perhaps I could have seen a doctor six hours earlier during my drive back from Phoenix.

First-hand experience with the Los Angeles medical system didn't teach me anything new about the economics of immigration.  But I did learn something about the economics of health care.  As you may recall, my colleague Robin Hanson argues that medicine is more about "showing that you care" than actually curing people.  My experience in SoCal Kaiser's Urgent Care facility gave me a striking tidbit of confirmation: When the doctor finally got to me, he tried to shake my hand!

So what?  Well, if the doctor's main goal were to prevent the spread of contagious disease, he wouldn't want to needlessly touch me, would he?  Shaking hands is a great way to give me the diseases of his previous patients, and a great way to give my disease to his subsequent patients - especially considering doctors' irregular hygiene.  But offering your hand is a classic way to "show that you care."

After five days of illness, though, I was in no mood for such nonsense, so I politely refused to shake the doctor's hand.  I'm happy to spend two hours in an Urgent Care center to get my health back.  But two hours for a stranger to express phony sympathy, and expose me to a germ cocktail?  No thanks! 

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COMMENTS (17 to date)
Lord writes:

If their intent was to show you they cared they wouldn't put you through hell when it came to payment, though Kaiser is better than most in this regard.

Jody writes:

If Kaiser had fewer Hispanic customers, it would have fewer facilities and fewer employees, and there's no reason to think my wait would have been any less. Indeed, if there were more Hispanic immigration in the middle of the Arizona desert, perhaps I could have seen a doctor six hours earlier during my drive back from Phoenix.

Bryan, you've misunderstood the illegal immigration criticism / health care criticism.

The argument is
a) illegals pay no (or much less than they should) taxes and
b) make use of public services (such as legally mandated emergency room care).

As such, the illegals are free-riding on the provisioning of services by legal immigrants / citizens.

In your description, you suppose no free-riding (everyone is paying as customers) thereby missing the point. More generally, you have have rebutted a congestion argument instead of a free-rider argument.

shecky writes:

I thought Kaiser services were usually rendered to members only. Perhaps all those Hispanic surnames referred to Hispanic members rather than specifically illegal immigrants, referring to Jody's argument. If this is the case, legal status is irrelevant.

My experience with Kaiser is that if they do accept non members in urgent care facilities, they are not doing it without compensation.

If one is referring to immigration in general, I suppose in other parts of the country, one might hear more white European surnames. Of course, they were immigrants, too, at one point, so they may be the ones clogging up the urgent care facilities there. So it follows, immigrants do, in fact use up resources eventually.

FWIW, there are independent urgent care centers oriented to taking care of minor medical needs that are cash based and very reasonably priced, aimed at travelers, uninsured, the impatient (as waiting times are drastically less), and yes, illegal immigrants. Insurance plans such as Kaiser often reimburse, though it's the responsibility of the patient to do that work.

RL writes:

Standard recommendations--not necessarily enforced, of course--is for physicians to wash their hands both before AND after seeing each patient; the idea is to do it in front of them, precisely to allay the concern Bryan properly has.

It IS strange, though, to imagine not shaking hands with a person who will subsequently, presumably without objection, do a detailed physical examination of your body. Did Bryan ask that the stethoscope head be sterilized?

You can always request the physician seeing you to please wash their hands before you shake them.

j writes:

You may adopt the robes of Chinese scholars, with wide and long sleeves that hide their hands, and learn to kowtow politely.

David J. Balan writes:

Showing that he cares is a legitimate thing for a doctor to do, and an offered handshake is a quick way of doing that. It only has a health downside if he hadn't washed his hands before you and/or wasn't going to wash his hands after you, and even if he hadn't, it's not clear what the handshake adds in terms of risk given that he's going to be touching you and later patients in a lot of other places anyway. Of course, you have no way of knowing whether he did/will wash his hands, so maybe it still makes sense for you to refuse, and he knows that you have no way of knowing, so maybe it makes sense for him not to offer and to give you a big smile instead, even if he knows that he did/will. But it doesn't seem to me like the doctor did anything really egregious.

Dr. T writes:

The physician did nothing wrong by offering to shake your hand. After all, he was going to examine you, and you already had the virus. He would not be spreading disease as long as he washed his hands before touching things that other patients would touch and after examining you.

I Kotlicky writes:

I'm going to voice an objection here - a doctor shaking hands with a patient doesn't absolutely spread disease - do you not wash your hands either? that's MUCH more critical for your hygiene than the doctor watching his.

You were in a waiting room with a dozen coughing patients - I'd be much more worried about the possibility of something airborne than the contact with the doctor - even if it IS on your hand, you can still wash it off and not get sick.

By shaking your hand, it isn't saying that his only purpose is to allay the sick, not cure them; it is an economic decision that the benefits of creating that "trust" are greater than the rather MINOR risk of transmitting contact infection.

If you were coming in with a bleeding hand, I don't think he'd try to shake it.

If you don't trust your doctor, you won't do what's necessary to cure yourself.

Honestly, some of this utter cynicism is a little off-putting, Bryan.

guthrie writes:

Jody, look at what Bryan said. He said 'opponents of immigration' not '*illegal* immigration'. The problem with many 'anti-illegal' arguments is that they tend to devolve from the 'free-rider' position into congestion and 'anti-immigration' arguments. The post 'Immigrant in my basement' deals with this and in the rather lively and interesting discussion that follows, you can see some of those who start out opposing 'illegal' immigration, change over the posts to opposing 'immigration' in general.

And did any of you guys read the link Bryan posted about doctors' irregular hygiene? Most of you seem to presume Bryan's doctor had washed his hands before seeing him, or, if he didn't, it wasn't much of a problem. The linked article begs to differ both counts. It may be a little off-putting, but if you were in Bryan's shoes knowing what that article said, I'm thinking you'd have a little more sympathy with what he did!

Jody writes:

Guthrie: Jody, look at what Bryan said. He said 'opponents of immigration' not '*illegal* immigration'.

So you agree then that Bryan was knocking down a strawman (or at least one of the weaker and rarely offered arguments)?

FWIW, I agree with you that the hygeine part was overlooked by other commenters. Grouped together iatrogenic causes of death (of which poor hygeine is one cause) is perhaps the largest killer.

I didn't comment on that because I actually agreed with Bryan's hygeine rationale. I differ in practice as out of politeness, I'll shake anyone's hand. But depending on the situation I will seek out the first opportunity to wash my hands afterwards (e.g., situations depend on probability of disease exposure and how easy it is to find an opportunity to wash my hands). As this is de minimis (I'm doing it several times a day anyways), it seems like a better solution.

It's good practice in other situations beyond the doctor's office (a high disease exposure probability event) as well. For example at my mother's funeral, my extended immediate family (brother and our spouses and our father) shook hands with a large number of people which implies a high likelihood of getting some bug on our hands. Afterwards, only my wife and I washed our hands before eating (others said they were too worn out when we chided them) and only my wife and I avoided falling ill immediately afterwards.

guthrie writes:

Jody, thank you for your comments!

Actually, no, I wouldn't agree with your characterization. I understand Bryan's position is that there should be no restriction to immigration, thus ending much of the free-rider problem because all immigrant workers would be free to be paid (and have their pay deducted) legally. He gets a lot of flack for that position as such, and it seems he is addressing those who take issue with him here. I don't see that as a strawman.

And my own FWIW, I, too, will shake anyone's hand... and can relate to your funeral story as well. Last year at my wife's grandmother's funeral, I didn't wash my hands after all those greetings, and was devastated by the flu for a week. Lesson learned!

Marc Resnick writes:

Even if you assume there is a non-zero probability of catching a disease from a hand offered as a social grace, it is still an economically rational decision.

There are benefits in terms of social interaction (having the doctor like you), self-perception (seeing yourself as a personable individual), cultural conformity, etc.

There are costs in terms of the negative consequences of catching the disease, which is probably no worse than a cold but could be something worse.

For myself, I think I would rather shake the hand and take my chances. I have a robust physical constitution but a shaky self-perception of sociability.

Snark writes:

How ironic that, having originated as a gesture of peace by demonstrating that the hand holds no weapon, the handshake actually wields one the deadliest weapons known to man (bacteria).

I find it interestinting, however, that Bryan has previously commented on this subject. I’m beginning to suspect his “cost-benefit analysis” approach towards shaking hands is a clever attempt to disguise what may be OCD.

Peter Schaeffer writes:

A few years ago, the Heritage foundation showed that each low skill immigrant family generates around $10K in tax revenue and imposes a $30K tax burden. Given the per-capita cost of health care and education, these numbers appear to be low, if anything.

Obviously, low skill immigration is a losing proposition for the American people and makes our nation poorer. Clearly, legal low skill immigrants are worse than illegal immigrants, precisely because they can (and do) consume more public services.

Since the losses imposed by low skill immigrants must be paid for by other taxpayers, their is nothing libertarian about advocating Open Borders. Indeed, Open Borders is essentially a statist scheme to tranform America into a nation of ever greater inequality for the benefit of the few who benefit from cheap labor.

Any real liberatian would oppose such a idea (as Milton Friedman did). The fact that any number of so called libertarians continue to advocate Open Borders, in spite of obvious negative facts, shows that the real committement is to mass immigration, not libertarian ideals.

scineram writes:

Friedman did not.

The Cupboard Is Bare writes:

There's nothing wrong with refusing a handshake or walking out if you think the doctor is sick.

On the recommendation of a friend, I went to a new doctor for an annual physical. When the doctor entered the room, I saw that she was wearing latex gloves (I found that reassuring). She offered me her hand, and I shook it. As we began to talk, I noticed her head sounded rather stuffy, but I decided that it could just as easily have been allergies. After all, what doctor would examine a healthy patient when they themselves were sick.

She was in the process of examining me, when she began to have a sneezing/coughing fit. She pulled a dirty tissue out of her sleeve to wipe her nose and then ran out to the hallway until the spasm subsided. It was then that I realized she was really sick. Quite frankly, I wanted to run out of the room, but I was so flustered by what had just happened that I stayed (never again).

So, basically, I entered the office a healthy person and left with a virus that made me sick for two weeks.

Peter Schaeffer writes:


From "Look to Milton Open borders and the welfare state.
" (

"A decade ago, Nobel prize-winning economist Milton Friedman admonished the Wall Street Journal for its idée fixe on open-border immigration policy. “It’s just obvious you can’t have free immigration and a welfare state,” he warned. This remark adds insight to the current debate over immigration in the U.S. Senate."

Until the welfare state is eliminated (as in never), it should be obvious that Open Borders is a radical statistic scheme to impose ever high taxes on the American people along with ever greater repression of free speech, political correctness, etc.

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