Unintended Consequences

IN 1936, AMERICAN SOCIOLOGIST Robert K. Merton wrote "The Unanticipated Consequences of Purposive Social Action," describing five different variations. This general pattern of events is often referred to as the Law of Unintended Consequences. An example in medicine could be the "side effects" of medical or pharmaceutical interventions.

Yet, in social action or legislation that affect medical care, commerce or correct behavior, the unforeseen effects are more pervasive, and usually more perverse. It is conceivable that creating a part-time state Legislature could keep these well-meaning bunglers under control, yet that seems rather doubtful.

Merton called the third variation of such consequences the "imperious immediacy of interest," referring to cases where our devotion to the intended favorable consequence of an action makes us ignore any unintended effect. For example, banning abortion on moral grounds — even though unwanted children are born as a result and may lead to more children dependent on the state.

"Basic values" was Merton's fourth example. The ethic of hard work and asceticism, he said, "paradoxically leads to its own decline through the accumulation of wealth and possessions."

His fifth category was the "self-defeating prediction," when the prediction of a social development alters the course of events. Predictions that population growth would cause Malthusian mass starvation promoted increased agricultural production. Today, people starve for social and political reasons rather than the inability of the world to grow enough food.

Not all unintended consequences are unwelcome, of course. Sunken ships and oceanic oil rigs in shallow water create new ecosystems for sealife. The set-aside of hunting preserves for the nobility of England conserved green areas for the present age.

Well-known cases of the unexpected consequences of social action include:

Steel import quotas were imposed to protect steel companies and workers from lower-priced foreign competition. U.S. Automakers paid more for steel, making it harder to compete with foreign auto imports, and causing a severe loss of jobs and production.

The Exxon Valdez oil spill led to legislation allowing limitless liability for spills by major tanker operators; these in turn sharply curtailed shipping oil, so the demand was filled by operators with leaky ships and inadequate insurance.

Prohibition was intended to suppress the harmful effects of alcohol. While it did reduce the incidence of cancer of the liver, it nourished organized and unorganized crime. Now, the "war on drugs" has had a nearly identical effect.

"Blowback" is a term used when we support the enemy of our enemy and thereby create another enemy. We supported the Mujaheddin/ Taliban in Afghanistan against the USSR, and Saddam Hussein in his war with Iran.

Rent control in Mexico, intended to protect the poor, created nearly endless slums when owners refused to maintain or repair their property. This is a common tale.

But we are physicians with a time-honored obligation to our patients and to one another. Is it likely that such things affect our practice?

You bet.

The list of unintended consequences of social action medical legislation since the 1960s is so long and the story so well documented in these pages and elsewhere, that there is neither room nor need to detail them again now.

To refer to only a few:

CPS legislation: Cases of thoughtless accusations to Children's Protective Services, leading to irreparable damage to the accused, have been documented both in the press and in the experience of local physicians.

Lapse of consciousness mandatory reporting to DMV: While changes are being made, it remains to be seen whether these will prevent hardship on patients who have clearly innocuous events but are reported "just in case."

Federal and state regulations on the prescription of narcotics and marijuana: It is maddening to be threatened by one branch of government for prescribing narcotics liberally for pain, and by another for not doing so.

Compensation injury regulations: How is it that the truly seriously injured worker is the only powerless person in the chain of people involved in such cases? How is it that insurer and employer liability is strictly limited by law in such cases, unlike other injury? Surely there are fine reasons; but the result is injustice.

Outrageous charges: Despite a litany of justification for them, charges by hospitals and emergency departments are simply outrageous. They are far higher for the uninsured than for insurance carriers who negotiate down, or the government that imposes regulations. Here again, the only powerless people are the uninsured patient and the physician. The rest of us are willing to be still so long as we are personally "ok." The excuse that these cruel charges are necessary because of unfunded mandates may be accurate; but it is also tragic and unjust.

Physicians often appear divided, self serving, hesitant, and ineffective when we call attention to the unwanted side effects of legislation impacting medicine.

The important issue for us is this: Are we willing to remain isolated in self-interested, medical cliques, or are we able to step out of our comfort zones in the interest of our profession and our patients?

john@loofbourow.com