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The Law of Unintended Outcomes

by Robert E. Cranston, MD, MA (Ethics)

          Whereas, we all want to help persons in society make truly informed choices about their healthcare decisions, and
          Whereas, the public can only make informed decisions about which healthcare systems and providers they wish to see in regard to health care, and
          Whereas, the federal government has the authority and power to cause physicians and systems to report their clinical outcomes, so that all persons may be better informed so as to make good decisions about their choices in health care, and
          Whereas, informed patients will then choose the caregivers and systems with the best outcomes in order to obtain optimal care,
          Resolve that effective immediately all physicians, surgeons, hospitals, clinics and health systems shall report an established number of health outcomes for continual public dissemination. This list is to include, but not be limited to: 30 day morbidity and mortality after a number of surgical and medical procedures, percentage of patients seen by their primary caregivers within 1 week of hospital discharge, 7 day readmission rates and rate of catheter associated urinary tract infections.

Sounds good, doesn’t it? This hypothetical scenario has a number of built-in assumptions, which make the results of this effort questionable. Are all populations comparable? What about patient selection for procedures? How does follow up of the social system affect outcomes?

The above might be a hypothetical situation, but in the United Kingdom, they are facing real-life problems in regard to the governmentally required reporting of medical outcomes. In an article titled “Patients dying because heart surgeons ‘too chicken’ to operate if it could harm mortality ratings, Telegraph, Science outlines some of the problems associated particularly with surgical outcomes. Transparency isn’t always all it’s cracked up to be. The public access to rates of surgical complications in the United Kingdom has now created a new problem. Good surgeons are avoiding tough cases because they know that if they perform more difficult, riskier procedures, the likelihood that their outcomes will reflect an increase in morbidity and mortality is quite high.

“Some 87 per cent of the 264 heart surgeons who replied to a survey said that publication of surgeon specific mortality data had caused a ‘risk averse’ culture in the NHS,” the article reports. Several reports have come to light of sick young children who could not receive surgery for correctable valve problems because multiple heart surgeons turned them down—fearing a complicated outcome. The study found that one in three surgeons were refusing patients over fears it would affect their scores.

Instead of creating a bridge between the surgeons and their patients through a culture of transparency, this policy has affected clinical decision-making, destroyed physician confidence and fostered a hostile working environment for surgeons in the United Kingdom. It’s quite an unintended outcome from a policy intended to create transparency and accountability in healthcare. 

So where are we seeing the unintended consequences of governmental decision-making and policy setting in healthcare here in the United States? Who knew that opening the floodgate to abortion in 1973 would create a major problem with Social Security in the 21st century? Plus, the ratio of workers to recipients of Social Security will soon drop to 2:1. It’s highly probably that those who could have been funding the system and meeting this need have been aborted. An unintended consequence, for sure.

Many voices today are calling out for wider access to abortion on demand and federal funding for these abortions. Some voices are demanding abortion training be mandatory for most physicians and further stipulate that those capable of performing abortions will be required to do so or risk losing their medical licenses. The intent is less discrimination and greater access to “women’s health” options.

Our counterparts in Britain are starting to see the unintended consequences of their policies, and so are we. Unfortunately, the full outcomes of these measures are yet to be seen, but they will almost certainly be significantly different than expected. The law of unintended consequences—for every action there will be predictable and unpredictable outcomes—may change the face of American healthcare for all time.

Related Resources

Transparent Ethics:
Bearing Fruit to Your Patients

Just Add Water Volume 2.1
with John Patrick, MD

CMDA’s Ethics Statement on Abortion

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