Gratitude, Trust, and Moral Sentiments in Global Health: A Personal Exchange with Vernon L. Smith Volume 61- Issue 3

Matteo Maria Cati*

• University of Bologna, Italy

Received: April 08, 2025; Published: April 14, 2025

*Corresponding author: Matteo Maria Cati, University of Bologna, 2 Scaravilli Square 40126 Bologna, Italy

DOI: 10.26717/BJSTR.2025.61.009592

Abstract PDF

Gratitude and other moral sentiments play a powerful role in shaping trust and cooperation in global health systems. Sparked by a personal correspondence with Nobel Laureate Vernon L. Smith, it builds on Adam Smith’s Theory of Moral Sentiments and recent behavioral economics research to question the limitations of incentive- based models in health policy. Drawing on experimental trust games and a simulated physician–patient interaction model, the piece proposes a shift toward frameworks grounded in moral emotion, not just rational utility. In contexts of moral fatigue and structural fragility, such as long-term care and underserved communities, gratitude and social norms may offer a more accurate and ethically robust account of health behavior. As Vernon L. Smith noted in his response, good-hearted actions invoke a moral obligation to reciprocate, which standard models fail to capture. This piece calls for a renewed behavioral health economics that integrates emotional and ethical motivations—offering a richer, more human-centered approach to health systems and public health ethics.

This Editorial reflects on the ethical and emotional foundations of trust in global health. Prompted by a personal exchange with Nobel Laureate Vernon L. Smith following the publication of my previously published article on trust and moral sentiments in health economics. In it, he reflected on the nature of reciprocity, the meaning of gratitude, and the emotional foundations of human cooperation. His words challenged many of the assumptions I had worked with and sparked a deeper rethinking of how we model behavior in healthcare, not as the outcome of rational calculation, but as something more fundamentally moral. His message challenged the utilitarian foundations that still dominate our understanding of health-related behavior. That exchange reshaped my view of the emotional drivers of cooperation in healthcare and inspired a new framework for behavioral health economics—one rooted in moral sentiment rather than utility [1]. In his email, Professor Smith recalled how Adam Smith, in The Theory of Moral Sentiments (TMS), made a crucial distinction between being self-interested and acting self-interestedly. “We are all self- interested, and it is right and proper that this be so,” he wrote, paraphrasing TMS, “but we cannot look humankind in the face and avow that all our actions are in our strict self-interest.” He explained that humans seek to “get along with their neighbors” and that “actions of a beneficent tendency, which are properly motivated, alone require reward because of the gratitude felt by the observer... There is a social consensus that good-hearted actions must be rewarded out of gratitude.”

This idea struck a deep chord. For years, behavioral scientists have documented unexpected cooperation in one-shot trust games, interactions with no reputational or material incentive to reciprocate. And yet, people do reciprocate. First movers take risks. Second movers, with nothing to gain by returning value, often do. Why? Standard models try to salvage rational choice by adding other-regarding preferences or “prosocial” utility. But as Vernon Smith points out, these modifications beg the real question: why do people care about others’ outcomes to begin with? Adam Smith—and Vernon L. Smith following him—offer a better explanation. We reciprocate not because it is useful, but because it is right. Gratitude is not a function of expected payoff. It is a moral- emotional response to perceived benevolence. And this has immediate implications for how we understand health behavior. Consider a physician who acts with exceptional attentiveness or compassion, going beyond what protocols require [2]. This is a prosocial gesture not driven by incentives. The patient, recognizing this effort, may be more likely to follow a complex treatment plan— not through cost-benefit reasoning, but from a felt need to reciprocate goodwill. Gratitude becomes the bridge between risked generosity and behavioral adherence. Inspired by this exchange with Vernon Smith, I built a simulation model of the physician–patient trust dynamic. The model includes a probabilistic measure of gratitude and a behavioral rule for norm compliance.

Cooperation emerged organically in over 76% of simulated interactions. But more importantly, the model captured the deeper moral architecture that Adam Smith described: reciprocity not as a strategy, but as a sentiment. This reframing is urgently needed. Health systems today face financial strain as well as moral exhaustion. Policies focused solely on cost-effectiveness may not be as successful as they should be and they often miss the emotional foundations that sustain trust, compassion, and adherence. Especially in fragile settings—underserved communities, crisis zones, and long-term care— transactional models fall short. A behavioral health economics grounded in moral sentiments—gratitude, fairness, resentment, propriety—offers not only better predictive power, but also a more ethically resilient foundation for policy. Behavioral health economics grounded in moral sentiments—gratitude, fairness, resentment, propriety—offers better predictive power and a more ethically grounded foundation for policy. As Vernon Smith reminded me, Adam Smith was not rejecting self-interest, but refining it: showing how our motivations are shaped by our desire to be worthy of others’ moral approval. This, I believe, is a lesson global health must urgently relearn.

1. Matteo Maria Cati (2025) Moral Sentiments and Trust in Health Economics: Insights from Vernon L. Smith’s Experimental Research. BJSTR 60(5).
2. Smith VL (2024) Adam Smith, Human Betterment, and His Erroneous Identification with Self-Interested Human Action. Journal of Behavioral and Experimental Economics 113: 102292.