Comment by topkai22 | Hacker News Reader

Comment by topkai22 | Hacker News Reader

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Dentists and doctors are not all of one mind about treatment effectiveness or necessity, so the tails of the bell curve matter. There may very well be some small percentage of dentists who believe that procedure X is beneficial in almost all cases. They might be quacks, but most quacks I've met believe what they are selling (even if they are wrong.)

If there also is a government program that reimburses for X in almost all cases, then you could see the emergence of clinics that "exploit" the rule even if everyone involved believes they are behaving ethically.

There are feedback loops that then exacerbate the problem- for example a successful clinic might bring on additional dentists, who despite misgivings will be influenced by existing practice at the clinic and begin self justifying the procedures to conform to the senior partner. After all, they clearly know what they are doing, right?

While I have no idea if that's what happened here, it is well with in the realm of possibility. The government does bear some responsibility to ensure that thier programs and rules provide sufficient oversight and feedback to keep fringey participants within the bounds of what the government considers acceptable.

I understand your arguments, which in my view, "shift the blame", and in your view, "charge with at least some responsibility" to the government. The problem I see is that this sort of arguments, if accepted as OK/inevitable and universalized lead to a dilution of responsibility that would make no one fully accountable for any intentional wrongdoing: for example, if you pay for your car to be repaired at your regular car repair shop, but the mechanic knowingly used parts that were not certified or due to time pressure skipped standard checks, and you let someone drive your car a year later, and there is an accident that was caused as a consequence of that sloppy repair-work, do you share responsibility for your oversight? - You might argue you do; well, I would argue you don't.

The moral blame rests fully on the clinic, but the responsibility to fix the system rests fully on the government (in this case). It's really no different than a production line with a quality problem. You can yell and scream about the morality of the workers all you want, but you can't expect them to improve if you don't fix the system and incentives that cause the problems.

the reason the analogy doesn’t hold up is there isn’t a system there — that’s a set of actually individual choices. When you see systematic behavior, you need to look for the system to fix it. The problem with blame is it doesn’t get you far enough, even if it feels good or right. Finding and fixing incentives is the only way to systematically enact change. Whether it feels good or not.

is the threat of punishment for wrongdoing not enough?

Clearly not--when there is systemic rulebreaking, the point is that it's impossible to enforce the rules in a way that is "enough".

btw, I think it is important to place the blame correctly and take whatever action is possible on the perpetrators to deter such behavior and at the same time patch systemic loopholes that are identified. They are not incompatible actions. If anything, they are complementary.

The government is not an individual- appropriate morality and responsibility at scale are different then as an individual. Additionally, if insurance / the government agrees to pay for a procedure that serves as a form of confirmation for the end user - after all, the department of health and human services approved the procedure!

A better example would be if a Sr Director of a rental car company shifted sourcing of thier repair contractor. If the new repair contractor consistently did way more repairs then the rental company needed, should the director of fleet maintenance be held responsible? Absolutely.

The same dynamic exists for private insurance companies. The existence of incentives for illegal activity doesn't shift the blame off the criminal.

We don't say that an ATM mugging victim bears some responsibility just because a criminal knows that such people will almost always pay out.

blame/responsibility is a red herring here. mugging is already illegal and, if caught, the perpetrator faces imprisonment. the salient question to ask here is what changes we can make to reduce the unwanted behavior.

possible actions:

politely ask the general public not to mug one another

increase penalties or rate of apprehension for perpetrators

encourage people to minimize their ATM visits, not walk around with debit cards, etc.

give people money so they don't feel the need to mug other people

You're right, "blame" is too loaded of a word, and also inadequate. However, in order to identify the actions to take, you still need something like a full systems analysis of weak points. Your list is a pretty good start on representing those.

That requires setting up objective bureaucratic rules, which are the same problem as "Management by metrics leads us astray."

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