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First Salvendy Symposium on Frontiers on Industrial Engineering.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Held at the Purdue University Campus
April 23, 2010 to April 25, 2010.
Invited session of
Parasuram Balasubramanian
Chief Executive Officer
Theme Work Analytics
Bangalore, India & West Lafayette, IN, USA
& Entrepreneur In Residence at the Discovery Park,
Purdue University, West Lafayette IN 47907
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
 Cell Phone Services : Both Caller and Receiver share the
charges equally vs. Caller pays all charges. SMS popularity
 Accounts Payable System: At Arms Length ( 30 days,2 % ) Vs
Tightly Coupled( settle ahead of time)
 Exit Strategy in VC funded projects
Three Examples
Is there a Cultural Gap ?
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Decision
Content
Decision Context
Context impacts heavily
on decision content
Decision
Content
Decision Context
Culture is not an overlapping
layer on Context
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Decision
Content
Decision Context
Instead it permeates into both the Context and the Content.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
 Sufficient literature exists to show how culture manifests itself
in the form of arts, literature, history, architecture, food ,
socializing or purchasing habits etc
 to show differences in thinking, acting and communicating or
negotiating postures
 to define culture and relate it to values and beliefs
Yet it is a grey area when it comes to relating
cultural factors to decision processes and choices.
A Framework that would link the two is missing.
This is the focus of our research
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Image Credit:
Kaplan, Robert B. 1966. Cultural Thought Patterns in Inter-cultural
Education. Language Learning 16: 1-20.."
Communication patterns
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Image Credit:
Images of the book "Ost trifft West" (East meets West),Hermann Schmidt
Verlag Mainz-Differences between Germans and Chinese - A diary of
Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439
Tackling an obstacle
West
East
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Image Credit:
Images of the book "Ost trifft West" (East meets West),Hermann Schmidt
Verlag Mainz-Differences between Germans and Chinese - A diary of
Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439
Communication
West
East
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Image Credit:
Images of the book "Ost trifft West" (East meets West),Hermann Schmidt
Verlag Mainz-Differences between Germans and Chinese - A diary of
Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439
Interaction in a Group
West
East
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Image Credit:
Images of the book "Ost trifft West" (East meets West),Hermann Schmidt
Verlag Mainz-Differences between Germans and Chinese - A diary of
Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439
Ego / Self Esteem
West
East
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Image Credit:
Images of the book "Ost trifft West" (East meets West),Hermann Schmidt
Verlag Mainz-Differences between Germans and Chinese - A diary of
Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439
Team Lead
West
East
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Culture
ThoughtsAction Words
culture manifests itself in the form of arts, literature, history,
architecture, food , socializing or purchasing habits etc
(Visible) (Visible)(Invisible)
Any Decision can be understood only through the actions and written or spoken
words of the decision maker. DM’s thoughts can only be inferred.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Culture
ThoughtsAction Words
culture manifests itself in the form of arts, literature, history,
architecture, food , socializing or purchasing habits etc
(Visible) (Visible)(Invisible)
Values & Beliefs
(define)
Is culture a function of what we eat ? How we dress? What language we speak ? Which religion we
are affiliated to ? It may relate to these factors but at depth it is all about our values and beliefs
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Values & Beliefs
On Material possession, Happiness, Austerity, Self Worth, Humility,
Ego, Ecological Balance ,wisdom, gender and role etc
Age Vs
Wisdom
End vs.
Means
Community
vs. Individual
ownership of
assets
Gender
& role
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Age Vs
Wisdom
End vs.
Means
Community
vs. Individual
ownership of
assets
Gender &
role
Age is a proxy variable for accumulated wisdom in the Oriental culture even today
When scientific evidence is not available, guidance is sought and obtained from the elders.
Even when there is a conflict between the observed and belief, the latter is given supremacy.
Respect for senior roles and positions emanates from this. Humility is a virtue as it facilitates
learning.
Contexts are given equal importance to content.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Age Vs
Wisdom
End vs.
Means
Community
vs. Individual
ownership of
assets
Gender &
role
Industrialization, migration to the new world and the two world wars have played a significant role in
empowering women in the West.
Women were denied opportunities for education, better health care and in some cases voting rights till
hundred years ago in India. In most of Asia, a woman’s role has been confined to the home as the
homemaker
Oriental women are still shown in the setting of a home, caring for their family members but making
decisions based on facts and figures. They are treated as value conscious buyers in context settings that
are heavily culture biased.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Age Vs
Wisdom
End vs.
Means
Community
vs. Individual
ownership of
assets
Gender &
role
Physical and intellectual assets are treated as properties of the community in East.
Individual ownership of assets is not a right but a privilege.
Spartan living is stressed.
Human beings are treated as an equal species amongst all creations in every culture
Coexistence with nature is sought as well.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Age Vs
Wisdom
End vs.
Means
Community
vs. Individual
ownership of
assets
Gender &
role
In East, Distinction between the means and the end is not as sharp as it is in occidental culture
from the values perspective.
Goal driven behavior is applauded and encouraged in the West
The means ( often specified as the journey of life) is expected to be just and equitable in the
East
End is often uncontrollable is their common belief in Oriental communities.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Help Desk Process
Telephone call received from a
customer
Interact with the customer to
authenticate customer bonafide
Interact with the customer to
authenticate the person
Interact with the computer to
validate service eligibility
Interact with the customer to
learn about the issue
Determine prima facie if the
issue is within the service
agreement (use system)
Regret
Service
Refer to system to
seek resolution if
issue is of known
causes
Seek customer
feedback ;complete
system log
Communicate to
the customer
Transfer the
conversation
to an expert
for resolution
Negative
response
Negative
response
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Help Desk Process : Notable Features
Telephone call received from a
customer
Interact with the customer to
authenticate customer bonafide
Interact with the customer to
authenticate the person
Interact with the computer to
validate service eligibility
Interact with the customer to
learn about the issue
Determine prima facie if the
issue is within the service
agreement (use system)
Regret
Service
Refer to system to
seek resolution if
issue is of known
causes
Seek customer
feedback ;complete
system log
Communicate to
the customer
Transfer the
conversation
to an expert
for resolution
Negative
response
Negative
response
 It recognizes the need to be time efficient
from both the customer and service provider
perspectives.
 It is a fair system of service for agreed value.
 It recognizes the need for division of labor.
 It creates separate queues based on severity
of the problem.
 And it treats the customer as a valuable
resource for system improvement
 Selling function is separated from the
Servicing function
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Help Desk Process : Issues from the East
Telephone call received from a
customer
Interact with the customer to
authenticate customer bonafide
Interact with the customer to
authenticate the person
Interact with the computer to
validate service eligibility
Interact with the customer to
learn about the issue
Determine prima facie if the
issue is within the service
agreement (use system)
Regret
Service
Refer to system to
seek resolution if
issue is of known
causes
Seek customer
feedback ;complete
system log
Communicate to
the customer
Transfer the
conversation
to an expert
for resolution
Negative
response
Negative
response
 Customer Preference is to talk to a person
 To set the Context
 To describe the issue in detail to start
with
 Authentication must wait
 Family needs to be signed up for service
 To combine sales and service functions
 To train the agent on multi tasking
These design issues are discernable from the
four Values & Beliefs Dimensions
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Health Care Delivery
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Country Name Feature
Germany Bismarck Hospitals and Insurers are Private
entities. Payment through payroll
deductions
Britain Beveridge Model Government provides Health Care
for all funded by taxes
Canada Canadian Plan Private doctors and hospitals are
paid by government; tax funded
Cambodia Out of Pocket Pay from own means
Source:
Health Care Delivery Systems
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
Health Care Delivery
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
 Scheduling: extended day to attend to an urgent patient versus
concern for physician’s time
 Diagnosis: tests performed sequentially versus in parallel
 Interaction:
 Treatment : less explanation to do to the patient; Physician can
experiment and innovate
 Payment : multi tiered systems
 Costs: significantly lower
Health Care Delivery
The impact of four identified Values & Beliefs Dimensions
is apparent in Scheduling, Diagnosis and Treatment functions.
Also in clinical trials.
Cross Cultural Decision Making-
Impact of values and beliefs on decision choices
 This approach needs to be validated for effectiveness
 The four dimensions need to be assessed for Completeness and
non overlap
 Development of filters for use in system design and pre
implementation stages
Way Forward
Thanks and Best Wishes
Dr.P.Balasubramanian
Founder and C.E.O.,
Theme Work Analytics,
Bangalore, India, 560 041 &
3000 Kent Avenue, West Lafayette, IN 47906
balasubp@gmail.com
Phone : India 91 80 4121 4297
USA 765 337 3098

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Cross Cultural Decision Making

  • 1. balasubp@gmail.com First Salvendy Symposium on Frontiers on Industrial Engineering. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Held at the Purdue University Campus April 23, 2010 to April 25, 2010. Invited session of Parasuram Balasubramanian Chief Executive Officer Theme Work Analytics Bangalore, India & West Lafayette, IN, USA & Entrepreneur In Residence at the Discovery Park, Purdue University, West Lafayette IN 47907
  • 2. Cross Cultural Decision Making- Impact of values and beliefs on decision choices  Cell Phone Services : Both Caller and Receiver share the charges equally vs. Caller pays all charges. SMS popularity  Accounts Payable System: At Arms Length ( 30 days,2 % ) Vs Tightly Coupled( settle ahead of time)  Exit Strategy in VC funded projects Three Examples Is there a Cultural Gap ?
  • 3. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Decision Content Decision Context Context impacts heavily on decision content Decision Content Decision Context Culture is not an overlapping layer on Context
  • 4. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Decision Content Decision Context Instead it permeates into both the Context and the Content.
  • 5. Cross Cultural Decision Making- Impact of values and beliefs on decision choices  Sufficient literature exists to show how culture manifests itself in the form of arts, literature, history, architecture, food , socializing or purchasing habits etc  to show differences in thinking, acting and communicating or negotiating postures  to define culture and relate it to values and beliefs Yet it is a grey area when it comes to relating cultural factors to decision processes and choices. A Framework that would link the two is missing. This is the focus of our research
  • 6. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Image Credit: Kaplan, Robert B. 1966. Cultural Thought Patterns in Inter-cultural Education. Language Learning 16: 1-20.." Communication patterns
  • 7. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Image Credit: Images of the book "Ost trifft West" (East meets West),Hermann Schmidt Verlag Mainz-Differences between Germans and Chinese - A diary of Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439 Tackling an obstacle West East
  • 8. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Image Credit: Images of the book "Ost trifft West" (East meets West),Hermann Schmidt Verlag Mainz-Differences between Germans and Chinese - A diary of Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439 Communication West East
  • 9. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Image Credit: Images of the book "Ost trifft West" (East meets West),Hermann Schmidt Verlag Mainz-Differences between Germans and Chinese - A diary of Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439 Interaction in a Group West East
  • 10. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Image Credit: Images of the book "Ost trifft West" (East meets West),Hermann Schmidt Verlag Mainz-Differences between Germans and Chinese - A diary of Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439 Ego / Self Esteem West East
  • 11. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Image Credit: Images of the book "Ost trifft West" (East meets West),Hermann Schmidt Verlag Mainz-Differences between Germans and Chinese - A diary of Yang Liu @Yang Liu Design, 31 July 2007 ; ISBN-10: 387439 Team Lead West East
  • 12. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Culture ThoughtsAction Words culture manifests itself in the form of arts, literature, history, architecture, food , socializing or purchasing habits etc (Visible) (Visible)(Invisible) Any Decision can be understood only through the actions and written or spoken words of the decision maker. DM’s thoughts can only be inferred.
  • 13. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Culture ThoughtsAction Words culture manifests itself in the form of arts, literature, history, architecture, food , socializing or purchasing habits etc (Visible) (Visible)(Invisible) Values & Beliefs (define) Is culture a function of what we eat ? How we dress? What language we speak ? Which religion we are affiliated to ? It may relate to these factors but at depth it is all about our values and beliefs
  • 14. Cross Cultural Decision Making- Impact of values and beliefs on decision choices
  • 15. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Values & Beliefs On Material possession, Happiness, Austerity, Self Worth, Humility, Ego, Ecological Balance ,wisdom, gender and role etc Age Vs Wisdom End vs. Means Community vs. Individual ownership of assets Gender & role
  • 16. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Age Vs Wisdom End vs. Means Community vs. Individual ownership of assets Gender & role Age is a proxy variable for accumulated wisdom in the Oriental culture even today When scientific evidence is not available, guidance is sought and obtained from the elders. Even when there is a conflict between the observed and belief, the latter is given supremacy. Respect for senior roles and positions emanates from this. Humility is a virtue as it facilitates learning. Contexts are given equal importance to content.
  • 17. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Age Vs Wisdom End vs. Means Community vs. Individual ownership of assets Gender & role Industrialization, migration to the new world and the two world wars have played a significant role in empowering women in the West. Women were denied opportunities for education, better health care and in some cases voting rights till hundred years ago in India. In most of Asia, a woman’s role has been confined to the home as the homemaker Oriental women are still shown in the setting of a home, caring for their family members but making decisions based on facts and figures. They are treated as value conscious buyers in context settings that are heavily culture biased.
  • 18. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Age Vs Wisdom End vs. Means Community vs. Individual ownership of assets Gender & role Physical and intellectual assets are treated as properties of the community in East. Individual ownership of assets is not a right but a privilege. Spartan living is stressed. Human beings are treated as an equal species amongst all creations in every culture Coexistence with nature is sought as well.
  • 19. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Age Vs Wisdom End vs. Means Community vs. Individual ownership of assets Gender & role In East, Distinction between the means and the end is not as sharp as it is in occidental culture from the values perspective. Goal driven behavior is applauded and encouraged in the West The means ( often specified as the journey of life) is expected to be just and equitable in the East End is often uncontrollable is their common belief in Oriental communities.
  • 20. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Help Desk Process Telephone call received from a customer Interact with the customer to authenticate customer bonafide Interact with the customer to authenticate the person Interact with the computer to validate service eligibility Interact with the customer to learn about the issue Determine prima facie if the issue is within the service agreement (use system) Regret Service Refer to system to seek resolution if issue is of known causes Seek customer feedback ;complete system log Communicate to the customer Transfer the conversation to an expert for resolution Negative response Negative response
  • 21. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Help Desk Process : Notable Features Telephone call received from a customer Interact with the customer to authenticate customer bonafide Interact with the customer to authenticate the person Interact with the computer to validate service eligibility Interact with the customer to learn about the issue Determine prima facie if the issue is within the service agreement (use system) Regret Service Refer to system to seek resolution if issue is of known causes Seek customer feedback ;complete system log Communicate to the customer Transfer the conversation to an expert for resolution Negative response Negative response  It recognizes the need to be time efficient from both the customer and service provider perspectives.  It is a fair system of service for agreed value.  It recognizes the need for division of labor.  It creates separate queues based on severity of the problem.  And it treats the customer as a valuable resource for system improvement  Selling function is separated from the Servicing function
  • 22. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Help Desk Process : Issues from the East Telephone call received from a customer Interact with the customer to authenticate customer bonafide Interact with the customer to authenticate the person Interact with the computer to validate service eligibility Interact with the customer to learn about the issue Determine prima facie if the issue is within the service agreement (use system) Regret Service Refer to system to seek resolution if issue is of known causes Seek customer feedback ;complete system log Communicate to the customer Transfer the conversation to an expert for resolution Negative response Negative response  Customer Preference is to talk to a person  To set the Context  To describe the issue in detail to start with  Authentication must wait  Family needs to be signed up for service  To combine sales and service functions  To train the agent on multi tasking These design issues are discernable from the four Values & Beliefs Dimensions
  • 23. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Health Care Delivery
  • 24. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Country Name Feature Germany Bismarck Hospitals and Insurers are Private entities. Payment through payroll deductions Britain Beveridge Model Government provides Health Care for all funded by taxes Canada Canadian Plan Private doctors and hospitals are paid by government; tax funded Cambodia Out of Pocket Pay from own means Source: Health Care Delivery Systems
  • 25. Cross Cultural Decision Making- Impact of values and beliefs on decision choices Health Care Delivery
  • 26. Cross Cultural Decision Making- Impact of values and beliefs on decision choices  Scheduling: extended day to attend to an urgent patient versus concern for physician’s time  Diagnosis: tests performed sequentially versus in parallel  Interaction:  Treatment : less explanation to do to the patient; Physician can experiment and innovate  Payment : multi tiered systems  Costs: significantly lower Health Care Delivery The impact of four identified Values & Beliefs Dimensions is apparent in Scheduling, Diagnosis and Treatment functions. Also in clinical trials.
  • 27. Cross Cultural Decision Making- Impact of values and beliefs on decision choices  This approach needs to be validated for effectiveness  The four dimensions need to be assessed for Completeness and non overlap  Development of filters for use in system design and pre implementation stages Way Forward
  • 28. Thanks and Best Wishes Dr.P.Balasubramanian Founder and C.E.O., Theme Work Analytics, Bangalore, India, 560 041 & 3000 Kent Avenue, West Lafayette, IN 47906 balasubp@gmail.com Phone : India 91 80 4121 4297 USA 765 337 3098

Editor's Notes

  1. Good afternoon. I thank the organizers for this invitation. My talk is focused on the underlying values and beliefs that shape a culture and their impact on decision choices, particularly in cross cultural settings. I have studied and worked in 3 different cultures, namely, Indian, North American and Caribbean. I have served customers in three continents the Asian, American and the European. Hence what I share with you today is based on my work and experience of three decades. Yet can we state upfront that this is still Work In Progress?
  2. Why do mobile phone service providers have chosen to adopt two entirely different charging mechanisms in the East and the West ? Why is their system geared to encourage SMS in the Asian countries ? Is this merely due to the Context variation or has culture got to do anything with it ? Why do companies in the West try to optimize the payment of dues by leveraging the credit norms while some of the companies in India, like Infosys where I worked for 9 years, choose to settle the bills quickly and plan to build a lasting relationship with vendors ? What motivates these behaviors? Why does a VC firm from the West is shocked to find that an entrepreneur from East has no exit strategy when he can be meticulous in all other aspects? We as business executives, encounter thousands of such instances in our business environment. And we as researchers have studied them in depth over the past decades.
  3. Five decades of research work has helped us to understand the cultural differences as they exist in all walks of life, including in the decisions we make. We know that the differences exist both at the choice level as well as the process level. We have learnt to distinguish between the Decision Content and the Decision Context. We are aware of the impact of culture on decision choices. We learnt our lessons and came with the mantra “ global design and Local implementation” It has not worked ! Our first proposition is that Culture is not an overlapping layer on Context and hence it can’t be post fitted over an existing design to be marketed in a new Culture.
  4. Instead Culture has to be seen as a matter that is fully diffused and has permeated through both the Context and Content layers. Hence Changes at design level are needed for cultural fit of every system. Similarly the implementation strategy has to be culture specific too. Hence the approach “global thinking and local design”. It has had partial success. Essentially due to the patching approach with respect to culture.
  5. Culture has been defined as the shared values and beliefs and common attitude and behavior of a community.
  6. Observing communication patterns have enabled researchers to discern cultural differences.
  7. Observing and studying action (or behavior) has helped us to know how people respond to specific situations in each culture.
  8. Yet we can’t fathom their thought processes.
  9. Our second proposition is that DM’s thoughts are invisible and we infer it from the words and actions of the DM. Third proposition is that the forms of manifestation of Culture are the stock variables and the ATW are the flow variables. One should not be inferred from the other.
  10. Instead, we need to be focused on the Values and Beliefs that shape a culture and hence impact on both the stock and flow variables. That would be the fourth and key proposition.
  11. Even when different cultures profess faith is similar tenets or principles, differences can occur in their Values and Beliefs.
  12. We have identified four major factors of Values and Beliefs that have a critical impact on decisions. They have been extracted by analyzing recorded cases of success and failures. We have kept two criteria in deriving them, viz, that they be mutually exclusive and collectively comprehensive. They should be actionable too.
  13. Invention of the Printing machine and break up of the joint family system caused the linkage between age and wisdom to be broken first in the West.
  14. Gender biased roles are still the norm in the East. Women’s intellect is respected but role is demarcated. Business communication that conveys the value proposition has to have an excellent grasp of gender and role clarity in each culture.
  15. Capitalism vs Communism issue has erupted two decades ago in the West and has settled in in favor of individual ownership and initiative. Collective welfare of the society is enhanced through individual enterprise is the strong belief. Eastern philosophies differ significantly from the West. Community interest prevails over individual rights at all times. IP,WIPO,WTO NDA ,Indemnity clauses
  16. Communication pattern and negotiation strategy differences can be understood through this factor. Content vs Context focus in one culture vs another is also understood through this lens.
  17. As designed in the West
  18. The End vs Means dimension, Gender and role expectation, Collective vs individual ownership dimensions,
  19. Insurer plays a pivotal role in this system. Has strong linkages to both the patient/Payer and the service provider.
  20. Contextual differences. ( The role of the insurer, supply, demand gap, limited role of the regulator) Cultural differences ( in long hours of working of the service providers, flexible charging mechanisms, seamless intertwining of charity and commercial, no malpractice suits,sequencing of diagnostic tests, knowledge sharing, clinical trials) (Age vs Wisdom, End vs Means, Individual vs Collective ownership dimensions)