Treatment Worse than the Illness: How the Study of Iatrogenics can have a Profound Impact on Our Decisions and Actions
“All of men’s miseries derive from not being able to sit in a quiet room alone.”
- Blaise Pascal, Pensées
“The surgery was successful. The Maharaja is dead.”, ended The Tiger King by Kalki, a compulsory reading for high school students in the CBSE system. Befuddled by the notion of a surgery being successful but the patient not making it, I queried my then English teacher. The Tiger King is a story about a fictional Maharaja of Pratibandapuram who is foretold by the kingdom’s chief astrologer about his eventual death by the hands of a tiger. The Maharaja, in response, goes on a mindless tiger hunt within his state. In a cruel twist of fate, he gets infected by a splinter from a wooden toy tiger he gives his son as a birthday present. A few days later, following a surgery, he dies. While there are many interpretations to the ending, my English teacher chose a rather austere one — “Often, the objective of a surgery is just to treat a certain condition. And as long as the surgery treats this condition, it is successful whether the patient survives or not.”
A decade later, on a short trip to Delhi, I found myself reading Nassim Taleb’s iconic book, The Black Swan. While not the easiest of readings, it delves in some detail into interesting and often unexplored ideas such as flimsiness of the bell curve, the role of fractals, extreme uncertainty, etc. Another concept explored in The Black Swan with great sincerity is the science of Iatrogenics — the study of damage caused by the healer in the process of healing. While the study of Iatrogenics has been garnering increasing attention in the field of medicine in recent decades, it remains poorly understood in many other areas including politics, economics, finance, etc., where it is equally important, if not more.
The idea of Iatrogenics rests on three main pillars — a Bias for Action, an Illusion of Control, and a poor understanding of the Limits of our Knowledge.
It is in the nature of human beings to seek solutions to problems — real or made up. From personal health to relationships to politics, we often request or order interventions at the slightest sign of unrest. Without properly appreciating the complexities which underlie these systems — the human body and global politics, alike — we place these intricate organisms at the mercy of what Taleb calls Interventionistas. Armed with a go-getter attitude, an incomplete understanding of the system, and first-order solutions, these interventionistas often end up causing further damage; and, they’re everywhere. Doctors prescribing strong medications at mildest of symptoms, politicians sending armed forces in to sensitive areas, CEOs responding to every little move by competitors, traders buying and selling stocks at the smallest blip only to end up shutting shop, etc. are some of the examples where unnecessary interventions with first-order solutions often result in worse subsequent problems. Bias for action, amongst its other dangers, has a particularly injurious consequence — it forces people to confuse calmness for hollowness, i.e., if they’re doing nothing, they probably amount to nothing. This internal tension often forces people, much like those edgy CEOs and politicians, to sacrifice their peace of mind and do something even at their own detriment.
With great advancements in science and technology of the last century, our confidence has grown ever-stronger in the power of the knowledge we possess, frequently disregarding the unknown as irrelevant. An immediate corollary of this development is us having fallen victim to the illusion of having control over the outcomes of our actions. This deadly belief further reinforces our bias for action, sometimes in the wrong direction. With the modern emphasis on specialisation, this has only worsened. Narrow specialists — what they add in depth, they lose in width. Today, for every problem which arises, we assemble a collection of “experts” each specialising in one critical area. The presence of these supposed experts further strengthens our illusion of control. Quite often, rather ironically, the resulting solutions from these experts are in complete disharmony because of an absence of holistic approaches and the discounting of the interplay of components in complex systems. Because of a lack of systems thinking, we frequently end up missing the forest for the trees and introducing even greater vulnerabilities and uncertainties in complex, and often fragile, systems with our “solutions”.
In our bias for action, illusion of control, and an unshaken belief in the power of our knowledge, we oftentimes ignore a powerful property of many complex systems — Homeostasis. It is the tendency of intricate systems to achieve a relatively stable equilibrium over time and self-correct in case of deviance. From Mother Nature to the human body, all systems have means to self-heal and achieve balance in due course, following damage. Taleb goes so far as to contend that, in the past, religion played an active role in saving lives by taking patients away from quacks and letting the human body do its job. Without getting into the validity of this postulate, I would still maintain that there is merit in the strategy of watchful waiting and letting nature do its job instead of jumping into action at the first sign of potential trouble. The best course of action, after all, may lie in inaction.
The ancients understood it well. Ensconced in the Hippocratic Oath from ancient Greece, the foundational document for modern ethics in medicine, is the phrase — “first, do no harm”. It demands of the practitioner a complete understanding of the consequences of their treatment and only proceed if it is wholly beneficial to the patient. Yet, in the unfolding of history over the next two millennia, and amidst the recent scientific revolution and the age of innovation, we lost sight of this simple yet powerful edict. As the world gets increasingly more complex and interconnected, the science of Iatrogenesis will play an important role as a guiding tool in preventing these complex systems from collapsing under the weight of their own elaborateness and the overconfidence of their masters.
Alas, the poor Maharaja of Pratibandapuram died not by the hands of a tiger, as prophesied, but by the hands of his well-intentioned but ignorant doctors. Tigers know better.
