Iatrogenics: Why Intervention Often Leads to Worse Outcomes
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> Rarely do we even consider that the cost of doing something might outweigh the benefits.
Cost vs benefit is the main thing that people consider when making decisions. It's a core decision making framework taught as early as elementary school social studies. Institutional decision making is rife with processes for assessing risks and performing cost-benefit analysis.
> Intervention—by people or governments—should only be used when the benefits visibly outweigh the negatives.
This advice is the decision making equivalent of "just don't write code with bugs." Easily achievable but pretty useless and completely impractical. Real world decision making involves operating under uncertainty at almost all times. If it didn't, the topic wouldn't be worth writing articles about.
Do you have any evidence of ignored cost-benefit studies that were available at lockdown decision time (there wasn’t much time for studies when these decisions needed to be made)?
Getting that estimate wrong is not the same as failing to consider it.
Cost is incurred by the children who have no voice, so zero cost to decision makers. Benefit is to one of the largest donor groups to politicians, so also large benefit to decision makers. Cost/benefit to society, population at large, the country? Seems to be willfully ignored.
Many of the studies referenced in that article are from 2020, yet schools had not re-opened.
In addition to that the teachers union in the US influenced guidance by the CDC on school openings: https://nypost.com/2021/05/01/teachers-union-collaborated-wi...
I don't know what people you are talking about, but my experience is so different from this that I suspect your conclusion is purely platonic. You expect people to decide based on a cost/benefit analysis, or you hear people telling you they do.
People almost never do a cost/benefit analysis. On the best cases, they analyze one of that pair.
This is the explanation many of the unvaxed smart people I know used to justify relying on their immune systems which were developed and tested for a million+ years over recently developed covid vaccines.
Also as always you must remember that not every single person will be harmed equally. And in many cases solutions are chosen not because they are best(cheaper/least harmful), but because they harm specific portion of population. Think why swimming pools were filled with concrete and many more.
> Cost vs benefit is the main thing that people consider when making decisions.
This article also makes the mistake of equation "we", the average reader of the blog, with the doctors who are making prescribing decisions.
Understanding the risks and side effects of prescribing a medication or procedure is core to the practice of medicine. It's integral to everything doctors do.
The field of medicine is often criticized for not being aggressive enough with treatments, though these criticisms often come from people who only see the potential upside but not the risks. We saw this most recently with complaints about how long the FDA took to get vaccines out (which was actually lightning fast) or in how the field of medicine didn't rush to recommend theoretical COVID treatments based on small-scale studies and petri dish studies (which turned out to be the right choice, given that none of them replicated at scale in controlled studies).
It's also the reason why the most effective medication may not be the first-line treatment, because the first-line treatment is chosen as a tradeoff of risks versus benefits.
Doctors know all of this. Unfortunately, doctors who decline to give patients the medications they think they need or recommend against surgical procedures patients think they want are subject to a lot of negative pressure in today's medical system. If someone goes into a doctor and demands antibiotics for their cold, the doctor must find a way to talk them down without risking another negative review which can impact their career and compensation in many systems. Some doctors just don't care enough, and will hand out prescriptions as asked. It's becoming a real problem now that medical systems have so many layers of middle management trying to put NPS scores and other feedback loops into the medical system, combined with social media pushing so many people to think they know they need antibiotics or thyroid medicine or other treatments that come with more downsides than benefits.
The idea was to give more people a better place to live.
What the opponent said was you're going to concentrate a bunch of poor people in a building that neither we nor they will maintain, it will be far away from any jobs, and it will lead to more crime and more poverty.
I don't think it takes much to say that people are short-sighted and some are only interested in their own personal short-term gain, certainly no metaphor or analogy is needed to state the obvious.
Housing projects and private high rises seem like they would have similar problems...I'm not finding this easily, but confess I have no academic background in management!
you could search for Robert Taylor Homes in Chicago (torn down) or Pruitt-Igoe towers in St. Louis (torn down), for starters. Or the Cabrini–Green Homes in Chicago.
It was the private ones and the implied comparison that I was after -- but now that I'm re-reading the parent post maybe there was no comparison, just a long sentence describing public housing projects as torn-down neighborhoods with high-rises...
The entire book is about systems and how we typically ignore them to our disadvantage.
There is some overlap between this and Weinberg's Quality books.
And, of course, _Systematics_ explains it all clearly.
It kind of makes sense, if a complex system has found some kind of steady state there must be some "restoring forces" at work to hold it there.
I think this is one of those things that is True with a capital T.
If you start with the premise that life is valuable, it is eventually derivable. Life tries to exist, and since existence is path-dependent making a change is likelier to be wrong than right.
How interesting. Can't exactly run a placebo controlled double blind experiment against the full state of the universe, hm?
I've never thought about the universal preconditions that must be true for me to be thinking about them. This is shifting my whole worldview, thanks!
This agrees with the slightly-neutral theory of evolution. A given mutation is more likely to break something a little bit than improve that something a little bit.
It’s a broken window problem. It’s difficult to measure the value of leaving stuff alone. The line on the chart doesn’t go up.
We intervene because it allows us to sell product. There’s no commission on discretion.
No one would characterize the Industrial Revolution or adding lead to gasoline as “intervention” yet clearly the second-order thinking this article prescribes for “interventions” needed to be applied in those cases.
“The key lesson here is that if we are to act, we need a solid idea of not only the benefits of our actions but also the harm we may cause—the second and subsequent order consequences.” is more correct but doesn’t serve this author’s agenda.
What made interventions such as the Berlin Air Lift work is that they were stuck with until they were no longer needed. An unanticipatable effect of the Berlin Air Lift was the "Tear down this wall" speech and the end of the USSR.
> How do you know that was an unanticipated effect?
Wanting to support Berlin so that the communist regime would eventually collapse might be a desired outcome, but the way it happened couldn't have been anticipated, it could at most be wished for. Wishfulness is the very thing the parent article is arguing against.
> How can you tell a priori wether intervening will have good results?
You try to learn history and figure out parameters for successful predictions?
> Moreover, if you're a decision-maker, will you bear any cost if your decision turns out wrong? If not, how is that supposed to be ethical?
I don't disagree? Ethics effects exist to encourage people to take precautions when it comes to the effects of their actions or inactions. There are obviously entrenched interests that push back against ethical consequences.
The gist is that we want to leverage our ability to measure things that are easy to measure, which are correlated with things that are hard to measure, and then optimize for those things. The downside being that you will always implicitly be sacrificing the things you don't/can't measure, and these sacrifices tend to occur in greater marginal amounts as the low hanging fruit gets eaten.
There are obviously interventions which are so ill convceived that they have no place being implemented in the first place, but this mechanism applies to every intervention eventually.
It's a good read, because these things happen every day around the world but the world usually finds people too dumbfounded in this to learn from it, much less write a cautionary tale!
I understand the article is really trying to reach into medicine to find the reason to push back on other actions. If doctors recognize they can cause harm when they try to heal, so must other practitioners, presumably politicians, bureaucrats, engineers, marketers, activists, parents, etc.
It's not enough to identify the problem. We can bias for or against intervention. But neither bias is scientific or necessarily likely to produce a good outcome without externalities or adverse effects. Ideally we would try more things with small samples and also try to understand externalities, comparing that to other possible interventions or nonintervention. However, the status quo bias also has an implicit blind spot, which is assuming that things will remain the same. Unfortunately, conditions do change.
We also have a problem with the moral aspect of the question. Who has the right to intervene? Who has an obligation? Is it moral to decline to intervene? If you intervene for good reasons, but cause bad outcomes, is that a moral failing? Is one person's assessment of the outcome more morally correct than another's?
I've watched enough time travel shows to know that we don't fully know the "benefits" of our intervention, in addition to the "harm".
Through the Industrial Revolution medicine increased in scope and complexity and cost. By the 1970s people expected access to hospital care which was increasingly expensive to provide. Around the world most developed nations came up with some kind of universal insurance or single payer system to handle this. The US went with employer based care which limits who is covered and puts a burden on business.
Ongoing calls for universal basic care threatened market based care in the US, so Mitt Romney came up with a plan to provide universal care through government regulated insurance markets. Obama tried to bring this plan to a Federal level but was stopped by a complex array of social and political forces. As a notable example of what happened, Frank Luntz who often has interesting ideas to contribute to this day insists that the ACA was not an insurance program even though providing health care through private insurance was the central concept.
So now there are people who see the ACA as a compromised attempt to save market based insurance provided medical care and others who see it as some kind of strange intervention amounting to socialized medicine which oddly enough is exactly what it was designed to avoid. Where ACA was adopted it seems to be working reasonably well, and in Massachusetts where the original Romney plan was adopted everyone is insured and gets care through private insurance markets coordinated by the government.
The really big irony here is that by compromising ACA and then not even adopting it in some states it is increasingly likely that some kind of Single Payer system will end up being adopted at a Federal level. In this sense those who attempted political intervention have generated the most harmful possible result. That is the increasingly likely possibility that the existing system of providing health care in the US through insurance markets will be completely swept away instead of being reformed as Mitt Romney and Barack Obama advocated.
Both of the laws referenced were very strategic laws that largely accomplished their purpose. The ACA in particular was designed to appeal to republicans first - it was in alignment with old guard GOP values. It patched some of the holes in healthcare (pre existing conditions, etc) and drove the economic activity that will drive future universal healthcare (the consolidation of providers into health networks) when political conditions allow.
Overall US governance is deliberately designed to make doing something impossible. Think of any issue of the day that would benefit from Federal action. In general, nothing at all happens unless it’s some spin on an existing law.
Edit I didn't address one of your points. You said the laws largely accomplished their purpose. What did you see as their purpose?
Patriot act was ultimately designed to avoid the types of failures to coordinate that stopped the authorities from preventing 9/11 attacks. It was very successful at that aim, but created a bunch of other problems in the process. My statement isn’t an endorsement of it.
ACA reduced the number of uninsured individuals by 50%, eliminated a few key policy holes (ie pre-existing conditions) and slowed cost growth.
Edit - source - https://www.kff.org/report-section/the-uninsured-and-the-aca...
You go to the US and you have to be careful if you have a boy because they will circumcise your child without asking for permission.
If you ask Americans they will tell you that it is an hygienic, prophylactic measure, but the real reason is that it became fashion to copy the British royal family that did it, and after that they just continued the tradition.
People support it not because they "don't have skin in the game" but because they have. Because the majority of them were already circumcised and there is no way back,or experience the alternative, so they want to believe there is a real reason for that, instead of the bogus Royal thing.
I asked a lot of people there and they painted a terrible world if you dare not to do that. I come from a country in which 90% are not circumcised and the image they had about the alternate reality was surreal and made no sense.
Another thing that Americans do is boiling eggs requirement, for "hygienic" reasons, destroying natural antioxidants, or natural antibiotics and antifungi so eggs could be way more dangerous than natural ones after time.
In France we had irradiated food for a long time. Crazy if they don't let you choose.
Today there are lots of things that could lead to secondary effects:
You have forced Water fluoridation. You have forced GMO food you could no opt out. Forced electromagnetic signals everywhere you can not opt out. Forced flame retardant in foams, sofas and bed mattresses. Forced COVID vaccination.
But the most absurd of all is the Daylight Saving Time.
I believe the real culprit of that behavior is human hubris. People simplify the world, and under the simplification a new idea is fantastic.
So for example you take the statistics and see smokers usually burn their houses while they smoke in bed and something happen, and forcing everybody to use flame retardants will save the risk of those people, but you can not see the new dead people that you create after they get cancer that will never smoke in bed.
Modern circumcision is evil. The foreskin is analogous to the clitorus. It is filled with nerve endings and keeps the head skin from keratinizing (hardening and losing sensitivity).
Biblical circumcision was a notch in the foreskin. It was not the radical removal of it entirely.
No, they won't, unless they really want to lose a slam-dunk lawsuit and possibly face criminal charges. Outside of a very limited set of circumstances, you can't just perform surgery on a person without their consent (or in this case, the proxy consent of the parents).
Which, ironically enough, if you make changes slowly, and have a good way to back them out when they go wrong, you can change much faster. Mostly because you don't have people screaming about a change being the end of the world so hard that you need to go to war in order to change the smallest thing.
The main factor leading to a disaster is usually the desire to make grandiose interventions (instead of steadily increasing ones that have proven successful at small scale) and refusal to listen to early signs of something going wrong. That is, if you're Mao Zedong or any kind of dictators with a “brilliant plan”®, then your intervention have a high risk of such failures, but otherwise the odds are low.
Doctors operate under the Standard of Care rules. If the doctor does not follow SoC they open themselves to medical malpractice liability. Problem is that the SoC is imperfect, especially for less common afflictions. Doctors often know their prescriptions will not help their patients or even worsen conditions, but recommending non SoC treatments will potentially cost them the medical license that came to them at high cost and represents their livelihood.
It can be argued that the SoC maximizes EV and minimizes cost across the population, however, even if that were true on day 1 of the implementation it would quickly degrade as bureaucratic lockin blunted the learning and innovation that doctors have historically used to advance knowledge.
Now it may well be that many interventions are successful. But your assumption of your conclusion is actually the bias the article describes.
Nobody ever ran a controlled trial on parachutes, how can we do know that they work?
Controlled trial aren't the alpha and omega of knowledge. They are powerful tools, but they also have a fairly narrow scope of applicability (and they are also a quite recent addition to the collection of scientific tools).
Of course, there are no 'crystal signatures' in water and homeopathy has no more scientific basis than astrology does as an actual cure for anything - just a less bad approach compared to the above.