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Iatrogenics: Why Intervention Often Leads to Worse Outcomes
- sebcat 4y agoDoes intervention lead to worse outcomes more often than not?
- M95D 4y agoIt takes homeostasis, a biological mechanism, and tries to suggest that it applies to politics and economy, too. What a strange ideea... Yes, the decisions to intervene should be taken more carefully, but I don't think that interventions "often leads to worse outcomes". In fact, where I live, indecision and lack of interventions are a very big problem.
- readthenotes1 4y agoThere is a fairly famous story in management of a guy in the 1960s who fought against building housing projects for the poor by tearing down neighborhoods and building big high rises. 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.
- zamfi 4y agoThis is a very interesting story, but I feel like I'm missing something -- any chance you could dig up a reference to this for us? 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!
- AlbertCory 4y ago> any chance you could dig up a reference to this for us? 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.
- zamfi 4y agoAh, thanks, yes I'm familiar with the legacies of torn-down public housing projects. 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...
- readthenotes1 4y agoIt was, if I recall correctly, discussed in the book called _The Fifth Discipline_ by Senge. 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.
- HPsquared 4y agoSee also, Le Chatelier's principle. 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.
- kryogen1c 4y ago> if a complex system has found some kind of steady state there must be some "restoring forces" 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.
- empthought 4y agoI think you and the parent commenter are talking about the anthropic principle. It might be "derivable" but only in the particular situation in which we have found ourselves—and then it becomes less remarkable.
- kryogen1c 4y ago> the anthropic principle 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!
- empthought 4y agoGlad to have spurred some thought... thanks for telling me!
- voldacar 4y agoIt is strictly true, in the sense that a stable equilibrium state is a potential well in a system's phase space.
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- manmal 4y agoIsn’t that what Adam Smith was all about? It’s not a new idea at least.
- empthought 4y agoThe word “Intervention” is just fraught with unconscious bias and makes it seem like the intention that motivates an action is relevant when it is not. The characteristics noted in the essay apply to all actions. 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.
- DoreenMichele 4y agoI learned this big time as a parent: If the only solution you have is guaranteed to make it worse, it's better to stand there and watch it burn than to put out the fire with gasoline. The piece I wrote about it (titled The Hand Licking Incident) did well on HN if you want to read a variation on this theme.
- loa_in_ 4y agoI actually remember reading your story! 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! https://news.ycombinator.com/item?id=18842009 https://news.ycombinator.com/item?id=18842009
- redeyedtreefrog 4y agoWas hoping to find an intelligent and well researched article on medical interventions. Instead it's just some extremely hand wavy libertarian college essay.
- empeyot 4y agoIatrogenesis (adj.: iatrogenic) is, I suspect, what the fist word should be.
- projektfu 4y agoAgree, this is the first time I've seen this term, although the author attributes it to Taleb.
- 4RealFreedom 4y agoAmerican politics are riddled with examples - look at the Patriot Act and the Affordable Care Act. It seems to happen most with sweeping legislation. Of course, large legislation will have additional consequences because the point is it intervenes more. The flipside is that administrations that don't pass laws are referred to in derogatory ways - they are a lame duck. We've basically forced action, any action, no matter the consequences.
- m0llusk 4y agoThat misses a lot of context. The Affordable Care Act is considered by many to be an attempt to meet medical care needs with a market solution while most competing ideas go a completely different route such as Single Payer. It isn't just a patch to a system, but an attempt to fit some difficult constraints. Portraying extremely complex systems as simple may be the most common form of the first failing listed here.
- 4RealFreedom 4y agoWhat context was missing? You can argue that the ACA has benefits or the US system is complicated but I did not simplify anything. From the article "Intervention—by people or governments—should only be used when the benefits visibly outweigh the negatives." My argument was 'damned if you do, damned if you don't' and politicians do not worry about the consequences of their actions.
- m0llusk 4y agoYou are asking a question yet seem committed to ideas and political views already. here is an attempt to answer: 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.
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- QuadmasterXLII 4y agoSomebody’s mad that his taxes are paying for 5th grade teachers even though his kid’s in 7th grade
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- MadSudaca 4y agoIntervention wouldn't be so bad if it wasn't so hard to roll back on interventions set in motion that turned out to be a failure. When dealing with complex systems specially, our attempts to make things "better" often don't go so well.
- pixl97 4y agoThe path to hell is lined with good intentions, but we must never forget it is paved with bad intentions.
- anonymouskimmer 4y agoThe sunk cost fallacy applies to both interventionism and noninterventionism. "An ounce of prevention is worth a pound of cure" is an idiom for a reason. 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.
- MadSudaca 4y agoHow do you know that was an unanticipated effect? Also, what about all other cases where interventionism didn't work, that is, made things worse? How can you tell a priori wether intervening will have good results? 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?
- anonymouskimmer 4y agoI'm just stating that lack of action is an action. I'm not arguing the points you're asking me questions about. > 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.
- m0llusk 4y agoThis misses the problem of scale. Often the only way to patch an existing system is to try small and localized changes and then propagate them slowly. Even correct changes may require unexpected related details to be in order for a successful result. Going slowly allows for analysis of related factors and anticipating range of variation.
- Kamq 4y agoThis reminds me of Eisenhower's old quote to his advisors: “Let's make our mistakes slowly" 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.
- cracrecry 4y agoHe talks about bloodletting but ignores the elephant in the room: circumcision. 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.
- hcayless 4y agoI had an interesting experience as a child. I grew up in Barbados, where circumcision is not a common practice. In Biology class on day, the teacher talked about the practice, and basically everyone in the class went “Eww”. I moved to the US the next year, and when the same topic came up in Biology, the teacher mentioned that in other countries, most men are uncircumcised. And the class went “Eww”.
- jwie 4y agoYou can’t sell non-action. 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.
- akiselev 4y agoImagine a future where espionage between nation-states becomes impossible not because of omnipresent surveillance but because the multinational advertisers realize that spies have nearly unlimited disposable incomes backed by other nation states so they have the best click through ROI and thus get targeted by the most bizarre ads that civilians aren’t.
- mbustamanter 4y agoRelated to N. N. Taleb, his colleague and CIO of Black Swan fund Universa Investments Mark Spitznagel [1] discusses iatrogenics in the context of hedge funds in a recent interview [0], at 18:20. [0] https://www.youtube.com/watch?v=s5yVDVIvQL4 https://www.youtube.com/watch?v=s5yVDVIvQL4 [1] https://en.wikipedia.org/wiki/Mark_Spitznagel https://en.wikipedia.org/wiki/Mark_Spitznagel
- littlestymaar 4y agoWhile conservatives love the stories of interventions failing with second order effects being worse than the initial situation, in practice these are only rare instances among plenty of successful intervention we don't even think about. 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.
- throw_pm23 4y agoIn the medical field, cases of interventions being harmful are not rare, and entire classes of interventions have been reconsidered in light of evidence.
- littlestymaar 4y agoThere's several billion medical intervention of all kinds every year, harmful interventions do exist but they are only a very tiny fraction of the total.
- throw_pm23 4y agoYes, but there are _kinds of_ interventions which turned out to be systematically harmful. For instance, in most developed countries it was a policy to thoroughly wash newborns, until they realized it was harmful.
- littlestymaar 4y agoTrue, but if you look at the entire collection of kinds of intervention you'll find that the harmful kinds are also a small fraction of them.
- DoreenMichele 4y agoIn my experience, bad mental models in medicine lead to all kinds of horrors for entire classes of patients. If they decide to call it a genetic disorder, they throw their hands in the air and give up on actually making you better and trot out phrases designed to politely break you of demanding such, like "the normal progression...", a phrase intended to make you accept that you will get steadily worse, you hurtling towards your death is nothing to be concerned about and please stop annoying your doctor by expecting real help.
- CipherThrowaway 4y agoAlthough it is certainly written by a human being, this article gives me a similar feeling to ChatGPT essays. The tone is compelling and plausible. But when I thought about it, I realized it didn't make much sense. > 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.
- kaczordon 4y agoAnd yet governments worldwide ignored the cost-benefit of lockdowns and removing kids from schools. Perhaps it’s not such an obvious thing…
- vosper 4y agoOr their cost-benefit analysis said that the cost of removing kids from schools was worth it. 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)?
- ouid 4y agoI read something recently here, comparing this phenomenon to the phenomenon of overfitting. 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.
- anonymouskimmer 4y ago> The key lesson here is that if we are to intervene, we need a solid idea of not only the benefits of our interventions but also the harm we may cause—the second and subsequent order consequences. Otherwise, how will we know when, despite our best intentions, we cause more harm than we do good? 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".
- potatohead00 4y agothis reminds me of the 'leading change' performance metric some mil leaders were (are?) evaluated on. the incentive is to be seen making changes, but there isn't anything about following up to ensure the change accomplished anything.
- barathr 4y agoSomeone needs to write an update to the classic book Medical Nemesis by Ivan Illich. A short review gives the flavor: https://jech.bmj.com/content/57/12/928 https://jech.bmj.com/content/57/12/928 https://en.wikipedia.org/wiki/Ivan_Illich#Medical_Nemesis https://en.wikipedia.org/wiki/Ivan_Illich#Medical_Nemesis
- photochemsyn 4y agoHomeopathy has been widely ridiculed as having no scientific basis, but in terms of outcomes, it might have been better than the heroic interventions of times past, such as bloodletting, mercuric chloride enemas, and whatnot. 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.
- tonto 4y agosee also: the noise/experimental music label (iatrogenesis tapes), created by brother of "casiotone for the painfully alone"
- projektfu 4y agoDoctors are always thinking about the potential for harm in their therapies but you don't always have a lot of options. For example, amoxicillin is the standard of care for strep but some people are allergic. Azithromycin is also standard but overuse of macrolides is driving resistance in organisms that are already resistant to other antibiotics. 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?