Wicked Problems, Black Swans, and Healthcare

Abstract

There is an interesting cluster of literature around the concept of complex, persistent, and contradictory relevant to broad groups of stakeholders, each having a different, potentially diametrically opposed perspective on an issue. I first encountered the concept of problems in the Harvard Business Review (Camillus, 2008). John C. Camillus was writing about Strategy as a Wicked Problem. He directed me back to the work of Horst Rittel and Melvin Webber, published in Policy Sciences in 1973. They named 10 properties of wicked among social issues that set them apart from ordinary problems, and that make their solution virtually impossible. Camillus lists them (with his comments) as follows:1. There is no definitive formulation of a wicked problem. It's not possible to write a welldefined statement of the problem, as can be done with an ordinary problem.2. Wicked have no stopping rule. You can tell when you've reached a solution with an ordinary problem. With a wicked problem, the search for solutions never stops.3. Solutions to wicked are not true or false, but good or bad. Ordinary have solutions that can be objectively evaluated as right or wrong. Choosing a solution to a wicked problem is largely a matter of judgment.4. There is no immediate and no ultimate test of a solution to a wicked problem. It's possible to determine right away if a solution to an ordinary problem is working. But solutions to wicked generate unexpected consequences over time, making it difficult to measure their effectiveness.5. Every solution to a wicked problem is a oneshot operation; because there is no opportunity to learn by trial and error, every attempt counts significantly. Solutions to ordinary can be easily tried and abandoned. With wicked problems, every implemented solution has consequences that cannot be undone.6. Wicked do not have an exhaustively describable set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan. By contrast, ordinary come with a limited set of potential solutions.7. Every wicked problem is essentially unique. An ordinary problem belongs to a class of similar that are all solved in the same way. A wicked problem is substantially without precedent; experience does not help you address it.8. Every wicked problem can be considered to be a symptom of another problem. While an ordinary problem is self-contained, a wicked problem is entwined with other problems. However, those don't have one root cause.9. The existence of a discrepancy representing a wicked problem can be explained in numerous ways. A wicked problem involves many stakeholders, who all will have different ideas about what the problem really is and what its causes are.10. The planner has no right to be wrong. Problem solvers dealing with a wicked issue are held liable for the consequences of any actions they take, because those actions will have such a large impact and are hard to justify. (Camillus, 2008, p. 101)I was stunned by the unintended, yet eloquent, description of the wicked problem of healthcare today. With competing stakeholders energetically vying for mutually exclusive solutions to portions of the larger problem, the chance of success seems thin. At best, there is a prospect of solutions that will raise new issues demanding ever more new solutions. A series of such partial solutions might bring the wicked problem under greater control, but it may never reach anything resembling a complete solution.Is it possible to somehow leap past the current understanding of a wicked problem? I was reminded of two other perspectives that seem relevant. In 1996, Ian Morrison published The Second Curve, in which he contended that innovation can allow the natural adoption curve or business growth curve to jump to a second curve, thus avoiding the downside of a standard curve as it deteriorates beyond its peak. …