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Unintended Consequences
A resource for understanding unintended consequences throughout the world. Curated by Lorien Pratt |
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"The failure to predict the unintended consequences of technology is deeply problematic and raises thorny questions. Should entrepreneurs be held responsible for the harmful consequences of their innovations? And is there a way to prevent these unintended consequences?"
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"In this time of coronavirus diease-2019 (COVID-19), shelter-in-place mandates that have clearly limited the spread of the pandemic also may have unintended consequences of delayed presentation of pediatric disease, precluding timely diagnosis and treatment. This can result in increased morbidity and mortality.
We describe cases of delayed diagnosis of new-onset type 1 diabetes (T1D) leading to presentation in severe diabetic ketoacidosis (DKA) with the aim of highlighting the need to remember basic pediatric principles to provide optimal care. Fear of contracting COVID-19 in a hospital setting, the inability to contact a medical provider for timely evaluation, and lack of consideration of DKA in the differential diagnosis at presentation are described. In addition to new-onset T1D, other pediatric diagnoses may be delayed owing to the focus on COVID-19 and DKA serves as a paradigm for these concerns."
Main Insight: The 2020 lockdown helped prevent COVID-19 cases and deaths. However, unintended consequences included the delayed diagnosis of new-onset type 1 diabetes (T1D), undiagnosed severe pediatric diabetic ketoacidosis (DKA), and limited healthcare access for patients with chronic diseases.
ACTIONS
• Issue strict lockdown orders
• Reduce access to emergency hospitals
INTENDED OUTCOMES
• Cases of COVID-19 measured as cases per million by the end of 2020
• COVID-19 related deaths measured as deaths per million by the end of 2020
UNINTENDED CONSEQUENCES
• Cases of delayed diagnosis of new-onset type 1 diabetes (T1D) measured as cases per million by the end of 2020
• Cases of undiagnosed pediatric diabetic ketoacidosis (DKA) measured as cases per million by the end of 2020
Analysis by: Frida Rodríguez Escobar
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"Every new invention changes the world -- in ways both intentional and unexpected. Historian Edward Tenner tells stories that illustrate the under-appreciated gap between our ability to innovate and our ability to foresee the consequences."
Outcomes and actions
Background: The Seamen’s Act, which was passed after the RMS Titanic disaster, required retrofitting of lifeboats to passenger ships. Management also replaced hardwood floors with concrete in upper decks, adding more weight to an already top-heavy ship.
Unintended consequence
• SS Eastland capsizes, killing 844 passengers. “Ship Safety” might be a starting outcome wording, but to make it measurable, you’d probably need to develop or use some safety audit methodology.
Intended consequence
• Improve the safety of passengers. “Ship safety measured by safety audit score”
• Ease of cleaning and maintenance. “Maintenance burden measured by monthly maintenance cost”, or perhaps another “Ease of cleaning measured by average turnaround time”
Actions taken
• Add lifeboats (Lever: “Number of lifeboats”)
• Replace wooden floors with concrete
Alternative action
• Detailed safety audit, including lifeboat complement
• Proper investigation of previous issues with top-heaviness
• Both of these demand another action “Implement actions suggested by reports”
Analysis by: Carl Sandrock
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"A tender ban imposed on all government departments and entities by the treasury in February caused by a court battle over bungled preferential procurement regulations has been lifted.
But what has been put in place could result in increased irregular expenditure — rather than curbing it — because accounting officers have been given powers to grant variations or extensions, with decisions open to review by the auditor general at the end of the financial year."
This article has two examples of unintended consequences. The article hypothesises an unintended consequence of a decision made as a response to an initial unintended consequence. The Treasury attempted to curb the irregular spending of state funds by instituting a ban on tenders and procurement. In practice, this ban required that all procurement made by government departments, municipalities and state-owned entities.
Action: Any procurement above R30k had to be signed off by the Treasury.
Intended consequence: Limit the opportunity for irregular spending.
Unintended consequence: Single point of failure bottleneck created a severe backlog in requisitions meaning that govt. departments, municipalities and state-owned entities could not issue tenders. The effect of this is poor service delivery.
Analysis: There is a political incentive to push for broad and "effective-looking" changes to expenditure policy. A showing of "zero-tolerance" gives the impression of well-regulated expenditure, but this poorly chosen intermediary has the effect of actually locking down local level service delivery.
As a response to the unintended consequence above, the issued new procurement regulations: Accounting officers now have the ability to issue deviances from the tender and must report them to the treasury in 14 days.
Action: Issue regulation that accounting officers can now vary tenders.
Intended consequence: Give the departments the power to vary tenders and alleviate the bottleneck of Treasury sign-off.
Unintended consequence: (Potential) The safeguards for irregular expenditure are now in the hands of the individuals who might spend irregularly.
Analysis: This is essentially a rollback of the action previously taken instead of re-analysing it as its own decision. This is still not a systemic solution to the problem of irregular expenditure and tender awarding.
Analysis by: Jaco Stroebel
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"Vaccination policies have shifted dramatically during COVID-19 with the rapid emergence of population-wide vaccine mandates, domestic vaccine passports and differential restrictions based on vaccination status. While these policies have prompted ethical, scientific, practical, legal and political debate, there has been limited evaluation of their potential unintended consequences. Here, we outline a comprehensive set of hypotheses for why these policies may ultimately be counterproductive and harmful."
Actions:
• Workplace mandates.
• Limit access to social activities and travel.
• School-based mandates.
• Differential lockdowns for the unvaccinated.
• Differential access to medical insurance and healthcare.
• Mandatory population-wide vaccination with taxes, fines, and imprisonment for the unvaccinated.
• Governments announcements that promise vaccination would ensure a ‘return to normal’ if many people (especially younger people) had vaccinated.
Intended consequences:
• Increase vaccination rates.
• Reach herd immunity.
• Reduce hospital/ICU burden.
Alternative actions:
• Transparency in government metrics for policy making.
• Scientific and objective government announces.
• Social and psychological focused analysis for policy making.
• Invest more in Hospital/ICU infrastructure and personnel.
• Social cohesive instead of punitive and discriminatory politic discourse.
(Aggregated) Alternative consequences:
• Social trustiness for preventing confirmation bias.
Analysis by: Raul Navarro
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"The most obvious problem is the behavior this change would incentivize. Consider a first lieutenant with no dependents who currently rents an apartment in the DC area with two other people. She currently receives a housing allowance of $2241 per month, but because she’s living with roommates, her share of the rent might only be $1200. With this change, she would no longer get to keep the $1041 difference. So what incentive would she have to economize and live with roommates? Why not get her own place—or move with her roommates to a larger, more luxurious apartment with better amenities—and use the full amount of the benefit? Under the change proposed by the Senate, the housing allowance would become a use it or lose it benefit."
Action: Increase the Basic Housing Allowance (BAH) to military personnel Intended consequence: an appropriate compensation
Unintended consequences:
1) No incentive to save costs, so personnel will move from many-roommate homes to more expensive single-dwelling housing
2) Landlords in military areas raise rents to satisfy increasingly wealthy personnel
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According to Ben Ramalingam’s Aid on the Edge of Chaos, international development is just such an invasive species. Why Dertu doesn’t have a vaccination clinic, why Kenyan schoolkids can’t read, it’s a combination of culture, politics, history, laws, infrastructure, individuals—all of a society’s component parts, their harmony and their discord, working as one organism. Introducing something foreign into that system—millions in donor cash, dozens of trained personnel and equipment, U.N. Land Rovers—causes it to adapt in ways you can’t predict.
A must-read. One unintended consequence after another, from well-meaning, but ultimately misguided initiatives. But my conclusion is a bit less bleak than the author's. I think that with better understanding of complex adaptive systems (including adjacent areas like knowledge transfer between domains, real-time systems modeling with adaptive learning, integrated human, evidence-based analysis, and automated decision making), we can still do good. We must.
A must-read. One unintended consequence after another, from well-meaning, but ultimately misguided initiatives. But my conclusion is a bit less bleak than the author's. I think that with better understanding of complex adaptive systems (including adjacent areas like knowledge transfer between domains, real-time systems modeling with adaptive learning, integrated human-in-the-loop, evidence-based analysis, and automated decision making), we can still do good. We must.
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His course ... will he held in the game space. In it, students will experience ethical dilemmas that emerge as unintended consequences of the decisions they make in playing the game. Each decision either opens up or closes off later choices in the game. Students can better understand the complexities of ethical judgment and better evaluate the choices they make if they see the effects of those choices.
Unintended consequences are mentioned explicitly in this report; nice to see some semi-formal attention to this topic.
This article by John Seely Brown is the most important thing written so far this year. More than just about education, it addresses the profound difference in the emerging 21st-century workforce, what we've learned about education from World of Warcraft, the importance of experiential learning and simulation, and much more.
Watch this space: five years from now we'll look back on this moment as the time when complexity theory, visual/spatial learning, simulation, computer gaming, the formal analysis of unintended consequences, and emerging educational best practices collided for everyone's good, and we won't know how to do it any differently.
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Members of the church of cannabis may be able to smoke weed legally under Indiana's new religious freedom law, one of a slew of unintended consequences of the law's passage.
Action: Indiana's new religious freedom law
Intended consequence: to protect religious expression
Unintended consequence: Massive "blowback": boycotts, legalized pot, and more.
Analysis: This debate has raged throughout the history of the United States. It stems from what this author calls "an inability to distinguish between: 1) the universal spiritual values that underlie the American experiment in democracy, and 2) the role assigned to government to advance those same values by protecting freedom of conscience and belief." Experiences like Indiana bring this distinction into sharp relief.
It stems from
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Is it just me, or is the Rube Goldberg meme taking off a bit lately? Now if we could just model complex interactions between the economy, climate, and more with this much sophistication, we'd be getting somewhere!
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This year the powers that be at some of the country’s top universities have decreed that one A* is no longer enough to merit a place at their institutions. In a predictable attempt to solve the problem of over-subscription at our leading universities, the hopeful few sending off their UCAS applications for Oxford or Cambridge, as well as those sending off applications for select courses at Imperial College London or Warwick University later on in this academic year, will be expected to obtain at
Action: Require two A* exam scores instead of one for Oxford / Cambridge entrance.
Intended consequence: solve the problem of over-subscription at universities.
Unintended consequence: Students who receive special coaching in test-taking are the only ones who can receive two A*s, which decreases the prevalence of "out-of-the-box" creative thinkers, creating a situation where the university is populated by good test takers.
Analysis: Test scores by definition are proxies for a student's true ability to benefit, and to benefit from, a university education. So if test score criteria are changed, it's important to reexamine the link between those who achieve those scores, and the true outcomes for which the score is a proxy. Is Oxbridge looking for creative thinking? Are they looking for the diversity of thought that leads to great decision making? If they are trying to balance these kinds of goals with the simple goal of ensuring the right admissions numbers, then they need to take a more nuanced approach to admissions criteria than simply changing one A* to two. If you believe this article, there is a qualitative difference between the student populations that are generated by this policy, which goes well beyond what the school might be intending.
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There may be unintended consequences of the air campaign -- in a way that will give the West a headache.
Action: US airstrikes in Syria
Intended consequence: impair ISIS
Unintended consequence: ISIS and Al-Ansari, who had previously experienced a "bitter split", could call a truce and/or unite under one banner, according to CNN, producing a level of power that could overwhelm more moderate rebel groups.
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This is not the first intervention in the history of U.S. involvement in the Middle East that has resulted in unintended consequences.
Lorien Pratt's insight:
Action: US begins bombing ISIS in Iraq and Syria
Intended consequence: Reducing ISIS' influence
Unintended consequences:
- this author says that blowback from civilian collateral damage will incentivize ISIS to attack the U.S.
- Aleppo-based al-Monitor correspondent, Edward Dark says that US attacks would stoke anti-Western resentment, and that ISIS is "secretly overjoyed" at the attacks for this reason.
- "Syria and Iraq as we know them...will disappear"
Analysis:
This is an incredibly complex situation, with wheels within wheels. Every consequence, intended and otherwise, should be considered, including these.
Action: US begins bombing ISIS in Iraq and Syria
Intended consequence: Reducing ISIS' influence
Unintended consequences:
- this author says that blowback from civilian collateral damage will incentivize ISIS to attack the U.S.
- Aleppo-based al-Monitor correspondent, Edward Dark says that US attacks would stoke anti-Western resentment, and that ISIS is "secretly overjoyed" at the attacks for this reason.
- "Syria and Iraq as we know them...will disappear"
Analysis:
This is an incredibly complex situation, with wheels within wheels. Every consequence, intended and otherwise, should be considered, including these.
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In the rush to video record everything so we always know for sure "what happened," it is important not to lose sight of the risk of unintended consequences. Two studies, not directly involving police and body cams, illustrate the point.
Transparency seems like a good thing, but it can lead to unintended behaviors based on the fact that observed persons know they're being watched. It can reduce (good) risk-taking, and the use of judgment and intuition.
Another cause here: rules in any situation cannot capture every nuance of a situation, and so the use of context-based judgment is goes beyond optional and occasional to absolutely essential. Create too tight control - as can happen with the use of cameras - and you throw the appropriate use of instinct out with the inappropriate bad judgment bathwater.
Perhaps an adjunct or even substitute for cameras would be to train good judgment more effectively through role-playing and a deeper systems understanding and then, still, to trust your officers.
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It was a sound idea with noble intentions: Craft legislation to identify official government records and documents available on demand to the public.
Decision: Legislation makes government records available to the public
Intended consequence: Transparency / informed citizenry / better government participation.
Unintended consequence: Opposition research firms hired by political candidates submit lots of requests, end up forcing office workers to spend hours photocopying, at considerable taxpayer cost.
Analysis: This is the Exploit pattern: a new system is created, and certain persons discover that it can be used to achieve an outcome that was not intended by its designers. Now that the exploit has been discovered, it's time to do a system redesign / tweak to patch the hole. Perhaps improvements to automation would help, funded by an access charge?
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QUEENSLAND’S Education Minister wants a wide-ranging review of NAPLAN amid controversy over the writing task this year.
Action: Creation of the NAPLAN: The National Assessment Program – Literacy and Numeracy
Intended consequence: Improvements to education through objective measurement
Unintended consequence: stress symptoms amongst students
Analysis: This is a classic example of the "side effects" unintended consequence pattern: where an intervention with largely positive results creates some negative effects in certain students. As with side effects from medicine, a side effect can be considered acceptable if it is rare enough and if the impact is small enough compared to the benefit.
Also as with medicine, a better understanding of who is susceptible to the side effect, along with design of mitigation strategies for affected populations, can increase the net positive impact of the intervention.
As always, a good visual model showing the cause-and-effect pathway to desired as well as undesired outcomes can be helpful.
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"..MonsterMind software would add a unique new capability: Instead of simply detecting and killing the malware at the point of entry, MonsterMind would automatically fire back, with no human involvement. That’s a problem, Snowden says, because the initial attacks are often routed through computers in innocent third countries. “These attacks can be spoofed,” he says. “You could have someone sitting in China, for example, making it appear that one of these attacks is originating in Russia. And then we end up shooting back at a Russian hospital. What happens next?”
Action: Create a powerful new system-called MonsterMind-which can respond rapidly to cyberattacks to trigger a real-world strike.
Intended consequence: powerful deterrant to cyberattacks
Unintended consequence: If true, this massive concentration of power could create an opportunity for hackers to spoof identities in order to trigger an attack.
Analysis: This seems unlikely, but if true it illustrates an unintended consequence pattern, which is overlooking a specific kind of external factor: specifically the susceptibility of a powerful new system to intrusion/spoofing/illegal activity, and the resulting opportunity for that intrusion to have an equally strong negative consequence. Any time that information is concentrated in a single place - whether a credit card database, a facebook server, or a google server, or any it lowers the effort and raises the benefit of a criminal attack.
Attention to antifragility principles and good system modeling would probably go a long way here.
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The top defense lawmaker in the Senate is calling for a rethinking of the policy giving billions of dollars worth of military gear to local police departments.
Action: The National Defense Authorization Act (NDAA) was established out of concern that local law enforcement agencies were literally being outgunned by drug criminals.
Intended consequence: Drug enforcement
Unintended consequence: Unnecessary escalation in Ferguson.
Analysis: This situation illustrates four unintended consequence patterns:
1) focus on just one outcome (law enforcement) instead of multiple outcomes from the decision (potential for unnecessary escalation of a conflict).
2) Underemphasis on the impact of one lever (training in the proper use of this equipment)
3) Underemphasis on two intangibles:
a) value of training
b) causal flows involving psychological / social factors
4) ignoring a feedback loop / vicious cycle: (armed cops->angry citizens->more use of force->etc.)
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Trade sanctions limit work options available to poor children, often forcing them into more dangerous work...
Action: A bill in the senate would ban the import of goods from countries the employ children.
Intended consequence: Reduce child labor
Unintended consequence: Children don't go back to school or remain out of the labor force. Instead, many took jobs with unregistered workshops that have even worse conditions.
Analysis: Benjamin Powell, director of the Free Market Institute, says that economic growth, not labor laws, is the answer to this problem. As countries become wealthy, their child labor rates fall.
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I hadn't realized this! Bad decisions often come from unintended consequences, and most of those can be seen as arising from a lack of ability to see the entire system. Ergo: solve them through better systems thinking.
We seem to be suffering from an epidemic of hindsight, judging the situation by the data, not the system. It's like trying to predict where the elephant will walk based on her footprints (or maybe something else she leaves behind) rather than actually understanding elephants themselves.
Many of the bad decisions in this articlecan be seen a consequence of this lack of deep systems knowledge / systems navigational ability: the firing of Steve Jobs, Bank of America's purchase of Countrywide Financial, Fed moves that led to the Great Depression, and many more.
Wow. Hadn't realized. Let's fix this together, OK, friends???!!
I hadn't realized this! Bad decisions often come from unintended consequences, and most of those can be seen as arising from a lack of ability to see the entire system. Ergo: solve them through better systems thinking.
We seem to be suffering from an epidemic of hindsight, judging the situation by the data, not the system. It's like trying to predict where the elephant will walk based on her footprints (or maybe something else she leaves behind) rather than actually understanding elephants themselves.
Many of the bad decisions in this article can be seen a consequence of this lack of deep systems knowledge / systems navigational ability: the firing of Steve Jobs, Bank of America's purchase of Countrywide Financial, Fed moves that led to the Great Depression, and many more.
Wow. Hadn't realized. Let's fix this together, OK, friends???!!
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The Colorado Right to Know initiative, which would mandate GMO labeling, would cause hardships for smaller food sellers.
Action: New GMO labeling law is set to come into effect: one of 35 bills in 20 states that have been introduced this year.
Intended consequence: Consumers know what GMOs are in their food
Unintended consequence: smaller grocers must incur unreasonable expense to comply, or go to jail!
Analysis: Legislators appear to have not thought through the negative impact on small grocers that the law will create.
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As human beings, we cannot change the past. We have control only of our individual destiny and the decisions that we make today. The tagline for the movie The Butterfly Effect is, “Change one thing, Change everything.”
An analysis of the situation with the U.S. border children through the lens of unintended consequences.
An analysis through the lens of unintended consequences of the situation with the U.S. border children.
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Join TDI3 for an informative discussion about how the work done behind the conference room door is evolving, how it needs to evolve, and how “unintended consequences’ can be contained.
Better executive decisions => reduced unintended consequences.
We've substantially improved many aspects of corporate life, except decision making at the executive level, which is done the same as it was 100 years ago. Seems there might be room for improvement. Especially as we seem to see an increasing disease of unintended consequences.
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Raising state-mandated math and science course graduation requirements (CGRs) may increase high school dropout rates without a meaningful effect on college enrollment or degree attainment, according to new research published in Educational Researcher (ER), a peer-reviewed journal of the American Educational Research Association.
Action: Raise state-mandated math and science course graduation requirements.
Intended consequence: Improve college enrollment, college degree attainment.
Unintended consequence: Increasing dropout rates
Analysis: misunderstanding of the fact that raising standards, without a commensurate improvement in education to allow students to meet those standards, can increase dropout rates.
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FDA warnings about the potential danger for young people from taking antidepressants have resulted in a dramatic increase in suicide attempts.
Decision: To add safety warnings on antidepressants based on recent studies that 1% of teens and young adults have adverse reactions, actually leading to a greater level of depression.
Intended consequence: To decrease the incidence of this negative effect among teens and young adults, and thereby decrease the depression and suicide rate in this population.
Unintended consequence: In the year following the warnings, antidepressant prescriptions fell by more than a fifth. There has also been a 21.7 percent increase in suicide attempts by overdose with psychotropic drugs, and this number goes up to 33.7 percent in the young adult population.
Analysis: This study is "one of the first to directly measure a health outcome driven by the interaction of public policy and mass media." The news about the 1% of patients with adverse consequences ended up drowning out the fact that under-treatment of depression can have a big effect, too.
This is an illustration of a cognitive bias called the "availability bias". Our brains tend to take a short-cut: instead of analyzing the facts, we use the frequency of an incident in the media as a proxy for its true frequency. In this case, even doctors were fooled.
Actions
Intended Consequences/Outcomes:
Unintended Consequence:
Analysis by: Cynthia Cui