Jon Snow, a physician journalist, wrote in his chronicles of public policy and diseases, “the disease was a broadcast”, But he wasn’t referring to the opioid epidemic, or even any recent viral outbreak, he was referring to Cholera, and snow lived in 19th century Victorian London, which, like cities in the United States, were ravaged by the bacterial disease. And while most focused on the rise in incidence rates or mortality, he noted a commensurate rise in fear that became – rather quickly – more influential in how people reacted and more predominant in how governments responded to the outbreak. The ensuing public responses and government sanitation programs have since relegated Cholera to the history books, but not before influencing the hearts – Love in the Time of Cholera – and the minds – more frequent use of intravenous fluid therapy – of the world, demonstrating how collective fear of a disease can unite people against a disease.
But in the success lies hidden a curious anomaly, that tends to appear in times of health care crises – the fear appears more severe and grave than the disease itself, and never seems to materialize to the extent we predict. Yet it persists crisis after crisis, giving a fascination to our fears. Replace cholera with corona and you have the making of a modern romance novel. President Roosevelt instructed our war time nation that, “there is nothing to fear but fear itself”, because fear is almost never an accurate gauge of reality, and what we in many healthcare crises, almost never valid or fully realized. After the Allies victory, Japan feared the long term effects of nuclear radiation would increase cancer rates, particularly among the nijyuu hibakusha – the double exposed – the poor souls who endured the effects of both nuclear bombs and of unparalleled levels of radiation. Overall the Japanese were right, cancer rates did rise, and by any metric an absolute tragedy, but the rates did not rise to the levels predicted – they fell well short. Perhaps that is a testament to Japanese resiliency, but nevertheless the fears were overstated and the precautions, with accompanying emotional vitriol, in excess of what materialized. When fear is undefined, and risk unknown, we tend to interpret the problem to be far bigger and more extreme than what it is, and though this may produce an effective response, the response tends to be exaggerated, and the exaggerations themselves can create new problems or exacerbate existing ones. “Men are very apt to run into extremes”, our found president, George Washington said, and the most famous example of an extreme reaction to a perceived healthcare crisis was Prohibition – which did embarrassingly little to stop alcohol use, but did give cultural rise to the glamour and allure of criminal drug trafficking and drug use. Substitute Al Capone for El Chapo and you can see the lingering effects of this culture. And alcoholism has taken as many lives as the entire opioid epidemic, which states like Indiana suffering from an increased incidence of early-onset liver disease due to alcoholism.
I would never understate the impact of the opioid epidemic, which has caused very real damage, devastating innumerable lives, but the exaggerated responses have hurt as much as help our efforts to address this issue, and, actually have reduced the credibility of the government in addressing healthcare issues that transcend into public policy issues. The government needs trust, not tactics, as power needs to be seen as legitimate, a principle advised from business leaders like Dov Seidman, to the heads of the Fraternal Order of Police, who advocate law enforcement work to rebuild trust. William Webster, the only man with the distinction of leading both the FBI and the CIA emphasized federal agents to put, “rule of law over politics”, a statement that has become unrealistic to the point of absurd in our modern politics in which the Department of Justice is as much a political weapon as it is an enforcing legal institution. But politics and law have always been connected, right from the very beginning of this country. And rather than emphasizing separation, we should identify the appropriate balance between law and politics, which may help us find a similar balance between law and medicine.
But government extremism, taken out of balance, does the opposite, it destroys trust, another pattern we see repeated throughout history. In 15th century Spain, a Dominican friar named Tomas de Torquemada became the first grand inquisitor of the Spanish Inquisition, who, in the name of religion, imprisoned and murdered thousands of non-Christians, desecrating religious principles to substantiate a politically motivated genocide. Centuries later, in neighboring France, an extreme idealist turned dictator, named Robespierre, utilized capital punishment by guillotine as his personal political insignia, creating a reign of terror to uphold the ideals of the French Revolution through ignorance and fear, but really, prioritizing the survival of the revolution above all else – which soon cost him his life. Robespierre’s political rival, Danton observed this happening in real time, when he said presciently, “extremism is like a fan destroying everything around it, including the ember that sustains it.” The inevitable self-immolation of extremism appeared again, this time domestically when Wisconsin Senator Joseph McCarthy began accusing political rivals of being covert Communists and conducted sham, predetermined investigations to prove his accusations. He destroyed lives and political careers under the pretense of national security, influencing the public to believe communist conspiracies, formatting fears while garnering a loyal following. Interestingly, even after McCarthy’s tactics were exposed and he fell into disgrace, he still had 34% of the public’s support. But is influencing people by fear the same as representing the public?
The Federalist papers, written predominantly by founding fathers Alexander Hamilton and James Madison, were often signed as Publius, a Roman name that is a very loose Latinization of the word, public, and were used prevailingly to engender support for ratifying the Constitution – and rebelling against the terror of tyranny. The fine line differentiating influencing from representing has blurred into interpretive oblivion, fading further away with each extreme legal ruling in opioid legal cases that become synonymous with Medical McCarthyism. Prosecutors touting public demand for higher sentences or upholding broad, vague interpretations in courts are influencing the public as much as they are representing the public. In upholding their civic duty to the public, attorney generals and public prosecutors pledge to uphold the rule of law, but does that also require the law to be medically appropriate? If so, then the prosecutor’s applying the law are bound by legal interpretations that are medically appropriate. But physicians, health care public policy experts, and now even politicians believe the opioid epidemic was caused by illegally obtained opioids, and interpretations of the law that prevent patients with legitimate medical conditions from receiving medically necessary opioids at a fear of prosecution are not medically appropriate.
What then, constitutes the term medically appropriate? And how do we codify the term to bring much needed structure to the legal interpretations of healthcare laws? Can you define medically appropriate as part of civic duty, and who would bear the burden of acting in a medically appropriate way? In Tennessee schools are teaching students how to administer injections of opioid overdose medications, to prevent overdose fatalities in real time. Is it the school’s responsibility to ensure the students understand how to address an overdose in real time? Dr. Nora Volkow of the National Institute of Drug Abuse acknowledges methamphetamines are more lethal than even fentanyl and believes funds from opioid settlements should include addiction services for patients addicted to methamphetamines, given the rapid rise of the drug’s popularity. And the money, while seemingly large, is still a finite number, which means critical decisions should be as to how it should be spent. If we limit the funds to just opioids, should we focus on fentanyl exclusively, which the Rand Corporation describes as the, “most dangerous opioid”? Should we train law enforcement to focus on specific drugs based on the mortality statistics? But the American Medical Association found regions that expand Medicaid have fewer opioid related deaths, so perhaps the funds would be best used to expand insurance coverage.
The series of questions highlights the complexity in understanding and allocating resources to resolve the opioid epidemic. But one solution that has proven not to work is criminalization overreach. “[We] can’t find one instance where criminalizing a drug has prevented its use”, a Chicago lawmaker is quoted as saying. Such efforts largely fail because they pander to the most extreme aspects of law and medicine and result in a series of reactions and counterreactions that never seem to solve much of anything. The right solutions to the opioid epidemic emerge by balancing medical and legal responsibilities among specific individuals and groups as defined within their civic duty – physicians, lawyers, patients, and teachers are formalizing their responsibilities on issues related to public health, that we as a society, currently address inconsistently and in an impromptu manner. But by organizing everyone’s responsibilities, defining it in explicit, or easily understood ways, we can synchronize their responsibilities to each other – defining the premise of medically appropriate.
The term medically appropriate evaluates how equitably medical responsibilities are distributed throughout society, a goal the legal system has tried to achieve, for select medical conditions and select individuals, but has not comprehensively pursued for healthcare as a whole, failing to recognize the interdependence inherent in many medical conditions and broader human behavior, that grows more and more intertwined in our increasingly interconnected society. And appears most noticeably when law enforcement targets the marketing efforts of health care companies. The Oklahoma attorney general who sued Johnson and Johnson on the basis of public nuisance laws applied the statute to the company’s marketing strategy specifically, claiming Johnson and Johnson marketed too aggressively to patients directly, putting undue influence on patients to take opioids.
The intricacies of the pharmaceutical supply chain involved pharmaceutical manufacturers, distributors, insurance companies, pharmaceutical benefits managers, and of late, the large pharmacy chains themselves – with many acting as competitors in some regions and as partners in others. There are no studies delineating the level of influence of any of these stakeholders in the supply chain on patient decision making or even physician decision making. In many ways, we don’t know if the fines allotted to distributors McKesson, Cardinal, or Amerisource of $18 billion over 18 years is commensurate to their undue influence from inappropriate marketing efforts – the numbers look nice, symmetric, well within their top line revenue, but the assumptions underlying the numbers are as specious as the headlining numbers symmetric.
But is it medically appropriate to fine large sums to large corporations without understanding how the funds will be distributed outside of broad, loosely defined chunks of capital? We should begin instead by defining the responsibilities of large pharmaceutical firms to individual patients and define the financial compensation in terms of that relationship. Which is what prosecutors currently do in targeting the marketing efforts, but relationships in healthcare are deeper than the superficial marketing efforts. A pharmaceutical company manufactures medications to sell, down the supply chain, ultimately to patients, but how they sell and promote their products is critical – but not critical from a marketing standpoint, critical from a patient behavior standpoint. Amgen is not likely to run afoul of the law when it offers rebates to promote the sales of its new cholesterol medication. And companies that target physicians, as long as every encounter is documented appropriately, is widely regarded as permissible if the encounter is educational in nature. Though one could easily say that educating is influencing. But most legal issues seem to arise when patients are involved, and when marketing is perceived to be a priority above and beyond providing good quality of care. But what exactly constitutes medically appropriate marketing? Many would say patient education, though even that is not fully straightforward.
Seema Verma, the head figure at the Centers for Medicare and Medicaid Services, wrote an op-ed touting the virtues of price transparencies in healthcare, comparing the decision-making in healthcare with purchasing a car. Though many car owners do not know every detail about their cars, they know enough to be comfortable making purchasing decisions. And while I agree that patients should be empowered to make clinical decisions, healthcare decision-making is far more complex than car buying and emphasizing price disclosures without any context or education places an intellectual burden on patients to make sense out of a complex array of nuanced numbers. Without the proper understanding or educational training, it becomes difficult for patients to make medically appropriate decisions.
Even among hospitals, the term medically appropriate proves elusive as there tends to be disagreement even among the most basic issues. Hospital serve as community harbors for any and outpatient emergencies, and patients tend to visit hospitals they are most comfortable with. For the medically indigent population of Chicago, that hospital is John Stroger Cook County hospital, caring for an overwhelmingly high percent of that patient population, despite most hospitals in Chicago being non-profits, and mandated to see medically indigent populations – commensurate to the property tax they would have paid if not for their non-profit status. But we do not see a patient distribution that reflects each hospital assuming their respective financial obligations, we see one hospital bearing nearly all the financial burden, with the rest providing minimal levels of required care. John Stroger Hospital CEO, John Jay Shannon, believes other hospitals should be encouraged to accept more indigent patients, stating hospitals bear the responsibility of equitable patient distribution. But can you blame a hospital for a patient decision, or should the patients first educate themselves which hospital makes the best fit?
Patient empowerment creates an ensuing burden that patients make sound medical decisions and protect themselves against harmful medical products and decisions. But patients instinctively trust health care institutions to make medical decisions and protect them, even in nontraditional consumer-oriented forums. Newspapers, the country’s bastion for information, have traditionally informed and educated the public on major safety issues, and an investigation led by USA Today identified hospitals with dangerously low maternal safety standards, but used the standards defined by a healthcare accreditation agency to identify the hospitals, outsourcing the decision-making to a third party. Healthcare is unique from other industries in that manner, as the complexity of decision-making itself creates another burden in educating patients on how to make decisions and process information. But most attempts at educating patients have only increase the complexity, like Russian nesting dolls. If we believe patients should make their own decisions, then we should provide the data to make the decisions, and then we have to explain the data. But explaining the data requires someone to explain the data, creating the need to identify such an individual. And on it goes.
Rather than simply finding the easiest solution for a healthcare problem, creating a medically appropriate balance will define each person’s role and the nature of the relationship. When we imagine how physicians, insurance companies, and hospitals interact in an ideal scenario, we implicitly assume certain characteristics. Identifying the ideal interactions begins by explicitly defining these implicit assumptions and coordinating the basis of the relationship. In explicitly establishing a balance, we don’t presuppose a defined stance – abortion is good or bad – instead we define the framework to look at the issue, and our roles, or specific behaviors, in reference to that issue.
At BYU-Idaho, student insurance does not cover maternal care, and students who become pregnant need to obtain supplemental private insurance, incurring an additional financial burden. The religious views of the private school preclude the school insurance from extending care for abortion related services, and in the process, extended the preclusions to all maternal care. For married students who wish to start families, this has forced them to decide between continuing school or raising a family. A medically appropriate balance would weigh the number of married students who comply with the religious views of the school – as is their right – with the financial costs of additional maternal care needed to start a family, and balance how much of that additional cost should be absorbed by the school’s insurance versus the individual student. The balance first aligns the beliefs of both the school and the students, and then determines how to best balance that alignment. Civic responsibility, which is a more formal way of stating what an individual’s role should be, is not defined in absolute terms, but relative to patient care, and the individual patient needs.
The oaths taken by physicians, the Hippocratic Oath and the Oath of Maimonides, emphasize direct patient care and the fundamental element of medicine, and in modern times, we should extend that patient centric focus to all of healthcare. Something Dr. Stanley Goldfarb opined when he acknowledged that while it is impossible for physicians to avoid social issues, physicians should prioritize the fundamentals of medicine and balance other legal or social issues from the perspective of individual patient care first and foremost. A balance, that when taken out of proportion, creates contradictory laws and social policies bastardizing misinterpretations of physician oaths into nothing more than slogans. ‘Do no harm’, is case in point, and the current, extreme interpretation of the law now prioritizes potential, existential risk to society over direct, real risk to patient care. Instead, law makers and law enforcement agents need to reorient their perspective and center around the medical needs of the patient, and balance the framework of laws around the behaviors of other stakeholders relative to the patient fairly distributing the responsibilities of physicians, pharmacists, and others involved in patient care. Maimonides said, “the greater the contradiction, the deeper the wisdom”, and the wisdom to construct a medically appropriate balance begins by studying the contradictions that arise in extreme interpretations of the law or one sided social policies, creating the framework to balance all perspectives relative to the patient.
“This has turned into a healthcare crisis”, Congressman Kennedy said, but he was not referring to the opioid epidemic or the coronavirus pandemic, he was referring to the vaping crisis, which emerged out of a few company’s attempts to create a new cigarette smoking cessation option that then spawned its own set of addictive behaviors, particularly among the country’s youth. Or so we believed – but seemingly every belief or notion soon came to be refuted by an equally plausible counter-belief or counter-notion. Vaping, or using e-cigarettes, were initially touted as a safe alternative to cigarettes, and spunky startups sprouted about evangelizing public safety in its entrepreneurial zeal to bring these products to market – made up of a vaporizer and liquid cartridges that contain a liquid nicotine solution. But soon the cartridges included various flavors to go along with the nicotine, and some even contained THC, or marijuana, as part of the solution, replicating the high of marijuana smoking.
And it caught on – quickly – and by 2018 there were over 400 flavors, and vaping became so popular that in college, use doubled over from the previous year, and 20% of Americans aged 18 or younger had used e-cigarettes in some capacity. But by 2019, people were developing mysterious lung injuries severe enough to result in hospitalizations and even deaths. The New England Journal of Medicine called teen vaping an epidemic, the CDC studied the cartridge solutions to see what if anything was causing these patient cases – and policy experts and law enforcement went on the offensive, putting restrictions on vaping flavors and where it could be used. Vaping drug busts made headlines with each latest news break an even larger amount of illicit cartridges confiscated.
But high schoolers kept vaping, and increasingly so – and surveys done independently by the New England Journal of Medicine and the National Youth Tobacco Survey both found now 25%, up 5%, of underaged Americans were vaping. Schools across the country went on the frontlines of the vaping crisis and increased drug testing throughout the schools. Some schools went so far as to drug test every student over the course of an academic year.
And despite the increased law enforcement activity, and increased publicity surround the health risks, including the publicized hospitalizations and mortality cases, more and more teens were vaping, and researchers were struggling to make sense of it all. Sixty percent of vaping related deaths involved only nicotine cartridges, but 80% of lung injuries requiring hospitalizations involved cartridges with both nicotine and THC; and the median age of users was 23 but the median age of death was 53 though 78-80% of lung injuries came from users aged 35 or less. And despite the data presenting unfamiliar patterns, lawmakers followed a familiar pattern of reacting to the confusion and uncertainty with criminal investigations – and a high profile probe on the largest vaping company Juul began, targeting the marketing tactics of the firm, now reinterpreted to be aggressive marketing designed to create addictions among its users, but forgetting that the original intention of vaping is to addiction cigarette smoking addictions. A Congressional Oversight Committee evaluated Juul’s marketing strategies, focusing on the use of celebrity endorsers.
But unlike the opioid epidemic, where individuals and companies pleaded and settled, Juul and other vaping companies pushed back, and in the process, created a balance between legal oversight and the benefits of vaping. When the state of Massachusetts instituted a statewide ban on vaping, the Vaping Technology Association promised that, “companies will show the ban is unlawful”, and by resisting, and changing the conversation from one of criminal behavior to one of clinical research, the vaping industry was able to show select benefits among certain users, when used responsibility – the context around the behavior impacts the clinical benefits or harms. The Director of Addiction Psychology at Cornell, New York Presbyterian Hospital, Dr. King, studied the coupling of vaping with traditional cigarette smoking noting an inherent balance between the two – if you limit vaping, you promote cigarette smoking, and vice versa.
Dr. King published her findings in the New England Journal of Medicine stating the vaping epidemic is really a tale of two epidemics, one affecting older users who tend to use traditional nicotine cartridges, affected by lung injuries due to specific lipid-based molecules in the cartridge solutions, and younger users who tend to combine nicotine and THC cartridges, affected by lung injuries that arise in combing THC and nicotine. Though the act of vaping may be the same, different users vaped for different reasons – and by studying the behavior around the use, you can understand the purpose behind why someone is vaping in the first place.
While vaping no doubt is addicting, it is best used in coordination with cigarette smoking in a balance with traditional cigarette smoking. And the medically appropriate legal oversight to influence patient behavior to correspond to the balance between cigarettes and vaping. Explaining why Health and Human Secretary Alex Azar supported a ban on specific flavors of vaping cartridges, and permitted more traditional flavors like menthol, which are more commonly used among those seeking to quit traditional cigarettes. The restrictions acknowledge the risks of both vaping and cigarettes, but realize that if a balance can be found to encourage appropriate patient behavior, vaping can be a net positive to users. A balance surprisingly like the one primary care physicians and addiction specialists increasingly make in juggling opioids and opioid abuse medications like methadone and buprenorphine. But unlike vaping, law enforcement has not taken a medically appropriate, balanced perspective on the opioid epidemic. A balance that considers both the perspectives of individuals and society at large, medical needs with broader legal safety – a balance that understands the complexity in addiction behavior. Most implicitly assume law and behavior are closely benchmarked like crime and punishment, but the wide chasm that exists in healthcare, between its laws and the underlying behavior of people affected by the laws, produce a wide array of unintended behaviors and consequences.
Gun control is a public safety issue that is as old as the country itself, and important enough to be addressed in the second amendment, right after the amendment that secures our natural rights. But it is an issue that has led to bitter discord across our country – in large part because we cannot agree on the interpretation of the law. Originalists, those who interpret the Constitution based on the original writings of the founding fathers, believe the amendment provides the right to bear arms, or possess a gun, in the service of a local militia, balancing individual rights with a civic duty to the local government – balancing an individual right to possess a gun with the obligation to serve in the common defense of a local militia, a social responsibility. More modern interpretations shy away from this balance and simply believe every American has a right to self-protection and should be able to own a gun. But the law itself has been around since even before the Constitution, as part of the common law system our government is based upon. Which leads many to argue that the right to possess a gun is a natural right, or an essential right that the Constitution must protect. But protecting often meanings restricting gun use in certain circumstances or for certain people. And the issue returns to striking the optimal balance between individual rights and broader safety in society.
But laws that balance a civic duty with a legal right are harder to define than laws that simply restrict behavior, and healthcare laws, rather than attempt to define such a balance, focus more on just restricting specific behaviors. But restricting one specific behavior in a spectrum of complex behaviors creates unintended behaviors that vary in large part by the perspective one takes on the law. Abortion is at times a scientific issue, other times a religious issue, but most of the time a poorly constructed balance of both issues – what author Yuval Harari calls a policy derived from combining ethics and facts. And the different combinations produce different perspectives on how abortion is seen – should abortion laws focus on inappropriate sexual behaviors or on sanctity of human life, or on some combination of the two.
While these issues are immensely complex, and cannot be resolved in one book, or one lifetime, we only exacerbate these issues with how we construct the laws around abortion. Most abortion laws target one specific behavior, or aspect related to that behavior and concentrate the full intensity of legal scrutiny on that behavior. Laws that seek to restrict abortions will find one behavior to target, and make that behavior more difficult to complete, believing by restricting one action, the entire set of actions around obtaining an abortion will be more difficult to complete, and assuming by making abortions more difficult to obtain, the underlying behavior that leads to an abortion will be curtailed. But making something more difficult doesn’t deter that behavior, it simply makes the behavior riskier. Something we see over and over in healthcare. And state by state analysis of abortion rates and levels of restrictions show that when one state restricts abortions, the abortion rates increase in neighboring states, prompting females seeking abortions to travel farther for medical care, which has proven to be less safe for patients.
Even recent laws, called TRAP laws, or targeted restriction on abortion providers, that target clinicians or patients in the clinical setting are designed in this way, restricting a specific aspect of the patient encounter, but then giving rise to a series of complex consequences. In Kentucky, abortion providers must now perform a narrated ultrasound for patients considering abortions, in which the provider who would perform the procedure describes the fetal heart rate while showing pictures of the ultrasound, called “display, describe”, as part of obtaining informed consent for the procedure. Opponents of the law describe it as unconstitutional, accusing the law of targeting women in their most vulnerable moments, taking advantage of the moment to deter a potential abortion. But now the discussion changes from the validity of the abortions to the validity of informed consent.
Modern medical ethics define patients as autonomous individuals with control over their body, a sentiment echoed by philosopher Henry David Thoreau who describes, “individuals as independent entities with rights”, implying an individual’s informed consent is viewed in essential terms – either you fully consent or you do not consent, a concept that broadly defines all the complexities around consenting under one legal phrase, ‘informed consent’. But adding a provision to that concept introduces an elemental framework, which now means specific elements, in this case specific behaviors, define informed consent – so now informed consent includes the complex decision of consenting and the specific behavior of participating in a narrated ultrasound. But the added element may or may not be necessary and possibly detrimental to the core decision itself, which if proven detrimental, questions the validity of the law. For example, a patient may be fully comfortable proving informed consent with the current set of information she has or will be given. But if then told to sit and observe an ultrasound, he decision may change, and change in a way that is contrary to her original decision, prompting her to behave opposite to how she would have originally behaved.
Another abortion law, this time in Louisiana, creates similar unintended effects. The law requires abortion providers to have hospital admitting privileges ostensibly to promote continuity of care should a complication arise while performing an abortion, but if applied, reduces the number of abortion providers in the state to just single digits. Continuity of care is important, and a legitimate concern for any outpatient procedure. But does the fear of a potential complication from abortions justify the restrictions on abortions, limiting them in the first place? A medically appropriate balance would weigh the burden of patient load per abortion provider with the risk of complications and find solutions that in effect distribute both burdens as evenly as possible.
The two abortion laws are examples of laws that are fundamentally restrictive in nature, that simply transfer risk or create additional complexities rather than address the underlying issue. The Kentucky law inappropriately attempts to add provisions to a core concept, a core clinical decision, that then affects the decision itself. The Louisiana law creates an undue burden on abortion providers in the state by protecting against a potential risk of complications while exacerbating a more tangible risk of patient overload. Different forms of restrictive laws, both of which appear in one of the most publicized healthcare laws passed in recent decades, the Affordable Care Act (ACA). The law’s keystone element, the health care insurance tax penalty, was intended to incentivize patients to get health insurance or incur a penalty and founded upon the belief that the threat of penalty would motivate patients. Yeah even after the penalty was nullified, patients continue to purchase insurance plans off of the ACA insurance exchange and a major metric that the ACA sought to improve, length of hospital stay, actually improved after the penalty was removed. Lawmakers touting new laws that are more changes in interpretations rather than actual solutions, largely fail to see the aspirational components that influence patient behavior, something long understood implicitly in healthcare, but not often explicitly demonstrated in the way healthcare laws are formed. The adage, carrots are more effective than sticks, very much applies to healthcare, and laws that intend to motivate patient behavior, either by introducing elements or redistributing the burdens in patient care, should focus around the aspirational aspects of patient behavior.
Medicine has always been aspirational in nature, and the optimal overlap between law and healthcare behavior focuses on good behavior. But what is good behavior in healthcare: a simple phrase encompassing a complicated question around a complex set of behaviors – but one that can be answered by studying the balance in the behaviors, both intended and unintended, and determining the type of balance that would optimize medically appropriate behaviors and relationships. A tax penalty for the uninsured assumes a well-intentioned patient would get insurance. But patient behavior has little to no correlation with tax penalties. Just one of many examples in which ill-conceived policies or laws form out of assumptions that are soon proven nonexistent. Optimizing patient behavior, which we in turn simplify by calling good behavior, is a complex concept, and does not correlate one to one, or linearly, with any one factor. Rather, it is an ever changing mix of associations and relationships with a whole host of factors, some of which are far from directly intuitive. Balancing these relationship against each other will help us see relationships that were not apparent before, and help us understand how the layering of laws can mirror the layering of complexities in healthcare behavior.