What is iatrogenics, why its important and how to avoid it for social change

Ethics and integrity should be measured primarily by the oath of the Greek physician Hippocrates. Primum Non Noncera — First, do no harm ~ Drucker

Image Courtest, edenpictures (8928257201) on Flickr

Image Courtesy, edenpictures (8928257201) on Flickr

In the field of social change this is the most important thing to remember – Good intentions does not always convert into good outcomes. The Drucker quote above is a great reminder for all of us.

So, what is Iatrogenics?

I always knew the concept but never had a word for it and then I found it in Anti-Fragile by Nassim Taleb through the fantastic blog Farnam Street.

Taleb says:

In the case of tonsillectomies, the harm to the children undergoing unnecessary treatment is coupled with the trumpeted gain for some others. The name for such net loss, the (usually bitten or delayed) damage from treatment in excess of the benefits, is iatrogenics, literally, “caused by the healer,” iatros being a healer in Greek.


Medicine has known about iatrogenics since at least the fourth century before our era-primum non nocere (“first do no harm”) is a first principle attributed to Hippocrates and integrated in the so called Hippocratic Oath taken by every medical doctor on his commencement day.

The very notion of iatrogenics is quite absent from the discourse outside medicine (which, to repeat, has been a rather slow learner.)

This is a powerful concept. Caused by the healer in our case is possible in many different ways.

  • Caused by the policy maker
  • Caused by the social worker
  • Caused by the manager
  • Caused by the minister
  • Caused by the psychologist
  • Caused by the funder
  • Caused by the ……..(your favourite example here)

This is a key concept that needs to be implemented by all the programs, services and enterprises that work in the space. It is not enough to focus on the right outcomes, it is important to decrease the possibility of the wrong outcomes from happening.

What does a bad outcome look like?

  • A couples therapy increasing domestic violence
  • State care of children creating drug addicts
  • Welfare payments creating intergenerational unemployment
  • Subsidised housing getting trashed

Some of them may be due to unintended consequences and some are genuinely due to the program design.

How do we solve it?

One of the best way to solve it is by using a technique called “theory of change” or sometimes called “program logic”. There are a variety of ways to implement this but the one I use works this way.

Every program is a theory incarnate. All the activities that are conducted in the program are towards a particular outcome. Each step in the program activity are based on a number of assumptions. These assumptions will determine whether the activity is the right one to do. And, most importantly, these assumptions can be tested and verified. If they fail, we need to change the activity and if they are validated, then we can go ahead. In time, the entire chain of activities are validated and the outcomes are reached.

In theory it is quite simple but in practice, like everything, its not.

However, there is great value in implementing this process.

Technically, this is how you can describe it.

A theory of change takes a wide view of a desired change, carefully probing the assumptions behind each step in what may be a long and complex process. Articulating a theory of change often entails thinking through all the steps along a path toward a desired change, identifying the preconditions that will enable (and possibly inhibit) each step, listing the activities that will produce those conditions, and explaining why those activities are likely to work. It is often, but not always, presented as a flowchart.

A logic model takes a more narrowly practical look at the relationship between inputs and results. It is often presented as a table listing the steps from inputs or resources through the achievement of a desired program goal. Some grant makers use separate logic models to chart the implementation components of theory of change.

Implementing like a designer

In our work at TACSI, we believe in making things easy to use and to create processes that enable individuals to use complex but important ideas to create better outcomes.

We have taken a visual process to theory of change by making it interactive, collaborative and explicit. Let’s look at it through the example of the famous health program An apple a day keeps the doctor away.

Apple a day program logic

What you need:

  • A large piece of butchers paper
  • Post its
  • A few hours
  • A team and a program
  • A facilitator would be good

We start with the problem at the left (the purple postit) and the goal is to create outcomes (orange on the right, both short term and long term). In between, the actions (blue) help determine the steps to be taken to achieve the outcomes. The assumptions (green) for each step are made explicit.

This process enables a team to clearly understand how their program runs and why it creates change? Both are important. In most of the teams this is possibly the first time they have detailed a process in this fashion. Even if the process is clear, the assumptions are never discussed. And this is the most useful part of the process.

By identifying the most critical assumptions, they can be tested and validated and in the process the entire process is improved. Most importantly, we can find out where it does not work and in the process creates more harm than good and thus avoiding iatrogenics.

This is the most powerful and useful way of testing and prototyping out your program.

Why are assumptions important?

Assumptions are important for a variety of a reasons. One major reason is that some of the fundamental assumptions will drive the whole program. For example, lets look at this idea to increase fitness.

Increase fitness program logic

If the problem as shown above is that there is too little physical activity and it could be totally true. The outcomes expected are increased fitness  and in the long term reduced health service usage. Both are good goals to have.

However, based on the assumptions behind the problem, whether the reduced physical activity is due to cost, being busy or spending time with loved ones the programs you would create will be entirely different. The initial assumptions you will make are fundamental to the engagement of people and the success of the program. Depending on the context, any one of the three assumptions behind the problem identified can be true and in some cases all three. However, unless the context is identified the solutions will be wrong.

The key is to remember the idea of first, do no harm and consciously use tools like theory of change to avoid creating more harm than good.

So, why would individuals do this?

Psychological Biases

Shane Parish lays out three possible biases that will make people do things even when the evidence says otherwise.

The first thing that goes through my mind is incentive caused bias. What is the incentive for action? Is there an agency gap where the outcome from person doing the intervention is disconnected from the outcome for the person experiencing it?

In my experience this is powerful stuff. If your job depends on it, if your beliefs depend it, if you are clouded because of the need to finish your work and reach targets and a myraid other reasons we will avoid it.

Another big reason I think this happens is a lack of clear feedback loops between action and outcome. It’s hard to know you’re causing harm if you can’t trace action to outcome.

This is more common in the case of social programs. Most are not funded to do evaluation, tools like theory of change are not common. Definitely they are not implemented like a designer to make the process easier.

Shorter and longer feedback loops are critical for success in these cases.

And the third major contributor, I’d say is our bias for action (especially what we consider positive action). This is also known as, to paraphrase Charlie Munger, do something syndrome. If you’re a policy advisor or politician, or heck, even a modern office worker, social norms make it hard for you to say “I don’t know.” You’re expected to have an answer for everything.

This is a biggy. We all have a bias for action. We are doing our work because we believe in the cause. That cause drives us and in the process we forget whether our actions create more harm than good because of the wrong belief that any action is better than no action.

What’s your theory of change?

System vs the Lifeworld

What happens when we forget the language of the people whose life we want to change?

LanguagePic by Ron Mader on Flickr

In the book Moment of Clarity, the authors discuss the work of the German philosopher, Jürgen Habermas, who developed extensive analysis to understand what happens when technical language outstrips the language of everyday life.

When technical language conquers simple language of the everyday, it is a sign that the system is gaining ground and everyday human reality, what he calls the lifeworld, is losing ground.


Such a shift leads to a far more systematic, rule-based, and technical idea of the world. It widens the gap between who we really are and the systems that we have become.

This is a very powerful and deep idea. In the social sector, I see this on a daily basis. The not-for-profits and the government  are rooted in their own jargon.

In a recent project, I asked the client and their stakeholders to discuss the “wants, needs & aspirations” of their primary customer – the individual or group whose life you want to improve. The client and the entire group were experienced individuals who have worked in this space for a long time. After a lot of discussion, I saw that they were using language which the primary customer would not identify with.

Then, I asked a simple question,

How would you describe this in the language of the primary customer?

That one question was enough to stop the discussion around the room. There was a lot of struggle to explain in the everyday language of the primary customer. For me, this is a clear sign that people do know enough about their primary customer. The technical language or the system language is very different from everyday reality and we can easily forget what it means to be an individual, a human being. This means it is tough to understand how a single individual experiences life?

Part of my work is to help innovators understand this challenge, to help them move away from the technical language and think about the individual: the things they see, do, hear and feel. One way of doing this is through the use ethnography techniques and problem interviews to get a sense of the individual, the language they use, the way they think about their “wants, needs & aspirations”. This is the starting phase of gaining deep insight.

A second but different challenge is for policymakers. Due to the nature of the system these individuals and teams are away from the on-the-ground experience where services and programs interact with the primary customer. The lack of interaction coupled with policy tools that are focussed on data, analysis, trends, large scale statistics miss the key insight needed to understand what is that an individual aspires for?

As Roger Martin suggests:

The greatest weakness of the quantitative approach is that it decontextualizes human behavior, removing an event from its real-world setting and ignoring the effects of variables not included in the model.

Understanding the real world setting, the context, is the key to the insight. I knew that language use is a good way to gauge the way an individual or team in terms of how they see the world. But now I know why this is important. The insight from the philosopher Jürgen Habermas, provides the context for why this powerful and the barriers it creates for innovation.



The virtue of doing nothing

Interesting exchange from Andrew Bolt and Josh Frydenberg on cutting red tape:

ANDREW BOLT: Alright. Well, look, all this goes to a philosophy, right? Now, the former productivity commissioner – commission chairman, Gary Banks, said, you know, politicians who pass silly laws are just really doing something – they’re showing the public they’re doing something, getting a reward for it. I would hope that this government is looking at saying, “Well sometimes, doing nothing is the best thing, and the public just have to get used to it.” What are you doing to show that you are a doing-nothing Government, so to speak, rather than always doing-something useless Government?

JOSH FRYDENBERG: Look, you’re absolutely right, Andrew. The last government gave us 21,000 additional regulations. And would you believe that the carbon tax, the mining tax, the NBN, were never subject to a regulatory impact statement. We’ve said, “Enough is enough with that.” So what we’ve done is put out a new handbook for the public servants, for the bureaucrats, which have said, “Look at the options available to you. One of those options is no regulation.”

ANDREW BOLT: Doing nothing.

JOSH FRYDENBERG: Doing nothing.

ANDREW BOLT: The virtue of doing nothing.

JOSH FRYDENBERG: Exactly right.

ANDREW BOLT: I’m very keen on the virtue of doing nothing.

JOSH FRYDENBERG: And the other thing that we’ve done, is we’ve said we’re going to incentivise the public servants to cut red and green tape. So we’ve said to them, “If you want a promotion, if you want a higher remuneration, you will be judged by your proven ability to cut red and green tape, not how much regulation you’ve introduced.”

This is interesting. There are few governments who value the virtue of doing nothing. They are talking about changing the incentives for public servants to do nothing which is important if this needs to be achieved. A lot of times, more laws, more regulations are not the solution.

Reminds me of this Drucker quote:

“There is nothing quite so useless, as doing with great efficiency, something that should not be done at all.”

Basic Income

The Hawkins brothers on what is Basic Income and its benefits.

What is Basic Income?

Basic income is providing every citizen regular, flat cash payments unconditionally.  In other words, if you can prove you are a citizen, you get a regular paycheck.

What are the definite benefits of Basic Income?

  • It is the most efficient possible form of wealth redistribution because there is no bureaucratic overhead needed.  More money reaches the poor directly.
  • It is more equitable than retirement plans, which transfer wealth from young to old.
  • It enables people to work on only what they want to.
  • It improves opportunities for individuals to use their Basic Income to get an education, start businesses, or make investments.
  • The amount of Basic Income could rise over time with productivity & automation growth.NewImage
  • It would enable resources spent on the current bureaucracy to work on other tasks beneficial to society.
  • It reduces the marginal tax rate for the poor, creating better incentives.  Currently, the poorest receive a combination of unemployment, food stamps, and other government subsidies, which often go away if they take a job.  Each of these issues create in effect high marginal tax rates.  In extreme situations, it means people can go back to work and make less money than before.  With basic income, there is more incentive to work, as everything you make is additive.
  • It should replace unemployment, which is pay to not work, which creates a perverse incentive.
  • It should replace minimum wages, which incentive employers to reduce jobs.
  • It reduces political corruption.  There are fewer government bureaucrats and fewer spending levers to grant political favored groups favorable treatment.

What are probable benefits of Basic Income?

  • It would provide a more stable consumer purchasing base, stabilizing the economy.
  • It would reduce crime as a result of lower levels of desperation, particularly among the youth.

In the HackerNews discussion, I found this article by Rutger Berman, who goes into experiments of basic income across the world. Lots more to learn and understand. But this is fascinating.

London, May 2009. Read the Dutch version here / Lees de Nederlandse versie van dit artikel hier. A small experiment involving thirteen homeless men takes off. They are street veterans. Some of them have been sleeping on the cold tiles of The Square Mile, the financial center of the world, for more than forty years. Their presence is far from cheap. Police, legal services, healthcare: the thirteen cost taxpayers hundreds of thousands of pounds. Every year.

That spring, a local charity takes a radical decision. The street veterans are to become the beneficiaries of an innovative social experiment. No more food stamps, food kitchen dinners or sporadic shelter stays for them. The men will get a drastic bailout, financed by taxpayers. They’ll each receive 3,000 pounds, cash, with no strings attached. The men are free to decide what to spend it on; counseling services are completely optional. No requirements, no hard questions. The only question they have to answer is:
What do you think is good for you?


A year after the experiment had started, eleven out of thirteen had a roof above their heads. They accepted accommodation, enrolled in education, learnt how to cook, got treatment for drug use, visited their families and made plans for the future. ‘I loved the cold weather,’ one of them remembers. ‘Now I hate it.’ After decades of authorities’ fruitless pushing, pulling, fines and persecution, eleven notorious vagrants finally moved off the streets.  The Joseph Rowntree Foundation did a study of this experiment.

Costs? 50,000 pounds a year, including the wages of the aid workers. In addition to giving eleven individuals another shot at life, the project had saved money by a factor of at least 7. Even The Economist concluded:

‘The most efficient way to spend money on the homeless might be to give it to them.’

‘Poverty is fundamentally about a lack of cash. It's not about stupidity,’ author Joseph Hanlon remarks. ‘You can't pull yourself up by your bootstraps if you have no boots.’

An idea whose time has come.

The idea has been propagated by some of history’s greatest minds. Thomas More dreamt of it in his famous Utopia (1516). Countless economists and philosophers, many of them Nobel laureates, would follow suit. Proponents cannot be pinned down on the political spectrum: it appeals to both left- and right-wing thinkers. Even the founders of neoliberalism, Friedrich Hayek and Milton Friedman supported the idea. Article 25 of the Universal Declaration of Human Rights (1948) directly refers to it.

The basic income.

And not just for a few years, in developing countries only, or merely for the poor – but free money as a basic human right for everyone. The philosopher Philippe van Parijs has called it ‘the capitalist road to communism.’ A monthly allowance, enough to live off, without any outside control on whether you spend it well or whether you even deserve it. No jungle of extra charges, benefits, rebates – all of which cost tons to implement. At most with some extras for the elderly, unemployed and disabled.

The basic income – it is an idea whose time has come.

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