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Consider, for example, the conundrum that occurs every time a client fails to become pregnant. The client—let’s call her Sally—is determined to conceive a child. The doctor—we’ll call him Dr. Welby—wants to help Sally and earn revenue at the same time. He also has some knowledge about Sally’s statistical chances of achieving pregnancy, knowledge that presumably is accurate in the aggregate although not necessarily relevant to her situation. In many cases, these three dimensions work perfectly well together. Dr. Welby uses his medical expertise to diagnose Sally’s problem and prescribe an appropriate course of treatment; Sally undergoes the treatment and pays Dr. Welby; and some months later, the proud mother carries her infant home.

When the treatment doesn’t work, however, this happy equilibrium can fall seriously out of balance. Imagine that Sally is forty-two years old and her eggs are only marginally viable. Dr. Welby prescribes an initial course of treatment with Gonal-F (a leading brand of FSH) at about $3,000 a cycle. Sally undergoes three cycles without becoming pregnant. Commercially, this state of affairs is rather beneficial to both Dr. Welby and Ares-Serono, the producer of Gonal-F. They earn revenues from each cycle, and Sally is unlikely to complain about what, to be blunt, is a repeated purchase of a service that doesn’t work. In fact, even if Dr. Welby were to advise Sally to stop the treatment, using his professional judgment to conclude that Gonal-F isn’t going to help in her case, she might very well insist on trying again. And again, and again, and again. Indeed, fertility specialists regularly describe women who continue with treatment well after the chances of success have declined. To quote one industry insider, “Talk about a big business . . . it’s carrots hanging out there, because it’s so hard to say when enough is enough.” [52]

Note the dilemma that is thus inherent in the product. If Dr. Welby were selling, say, potato chips, his commercial incentives would be straightforward: he would want to continue selling his product to Sally, convincing her each time of the desirability of her purchase. If she didn’t like the plain chips, he’d try to sell the barbecue flavor, or the salt and vinegar—anything to keep her coming back. By contrast, if Dr. Welby were only practicing medicine, both Sally and the state would eventually put limits on what he could sell. If the cancer treatment didn’t work, she would abandon it (or die). If the ulcer medication was too expensive, she (or her insurance company) would look for less-expensive alternatives.