David Leonhardt’s excellent piece on health care reminded me of the debates within philanthropy.

For most of human history … [doctors’] treatments consisted of inducing vomiting or diarrhea and, most common of all, bleeding their patients … Yet patients continued to go to doctors, and many continued to put great in faith in medicine … There was a strong intuitive logic behind those old treatments; they seemed to be ridding the body of its ills. They made a lot more sense on their face than the abstract theories about germs and viruses that began to appear in the late 19th century … So the victory of those theories would require a struggle. The doctors and scientists who tried to overturn centuries of intuitive wisdom were often met with scorn. Hippocrates himself wrote that a physician’s judgment mattered more than any external measurement, and the practice of medicine was long organized accordingly.

The single most common retort to the GiveWell approach is that the staffers, volunteers, and even donors “know” the programs they fund are working, based on their intuitions.

Then again, many highly intuitive programs have been shown not to work, and there’s good reason to distrust intuition in this area:

Behavioral researchers have come to believe that there is a clear pattern to when intuition works and when it doesn’t. “Intuitive diagnosis is reliable when people have a lot of relevant feedback,” says Daniel Kahneman, a Nobel laureate in economics who recently collaborated on a project about intuition with Klein. People need a great deal of experience, and the feedback from these experiences — whether a treatment is working, say — needs to come quickly and to be clear. “But,” Kahneman adds, “people are very often willing to make intuitive diagnoses even when they’re very likely to be wrong.” When doctors have been asked to estimate the likelihood of a treatment succeeding based on experience, for example, they give wildly divergent answers. Medicine is full of such examples.”

Feedback is near-nonexistent in the field of philanthropy.

As Toyota built better cars than its competition for less money, it won new customers. Some rivals matched its successes (as Honda did); some lost market share (as Detroit did). No such dynamic exists in health care. William Lewis, a former director of the McKinsey Global Institute who studies productivity, says that the economic benefits from the various quality movements have been quite large but that they are also largely in the past. Most industries have incorporated Deming’s big ideas and are now making only incremental progress. “However, there is one big exception,” Lewis adds. “You guessed it: health care.”

I can think of another exception.