The unintended consequences of well meaning regulation

Why do we never consider unintended consequences? Whether we are thinking of legislation or physician led guideline panels, or governing bodies (like ACGME), the lack of consideration of unintended consequences remains mind numbing.

Let me provide some examples.

Please read this articles about how the war on drugs has fueled the hepatitis C epidemic. One could also argue that this war damages more young people than the drugs themselves.

Many illicit drugs do damage to users. But the laws impact both the users and innocent bystanders. The laws put too many young adults in prison. The laws force a black market, and for many drugs stimulate crime. Advocating for de-criminalization is not advocating for drug use, but rather focusing on preventing complications (like infections) and on programs to help patients stop drug use.

Next read any number of blog posts on performance measures. Let me give 3 quick examples of poorly considered performance measures.

The most obvious is the 4-hour pneumonia rule that led to increased unnecessary antibiotic usage. Trying to drive HgbA1c below 7% for every patient puts some patients at risk from hypoglycemia and from drug side effects. In Great Britain, paying physicians to decrease appointment waiting time induced less continuity of care (with the primary physician).

Finally, we are learning what many predicted. The work hour restrictions for residents are hampering medical education: For New Doctors, 8 Minutes Per Patient.

In example after example, thoughtful critics receive minimal lip service. Each group of decision makers moved forward, damn the torpedoes, full speed ahead.


I believe that the big problem is the affect heuristic. In short, that decision making heuristic says that if you like an idea, you over value the benefits, and underestimate the harms. We must figure out how to work around this undervalued concept. We desperately need to develop decision making processes that focus on both benefits and harms and develop logical means for balancing the benefits and harms.

Unfortunately, I remain pessimistic. Decision making bodies have biases. Until they understand their biases, we will have the problem of unfortunate, unnecessary and potential dangerous unintended consequences.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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