Complexity theoryBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39602.443785.47 (Published 05 June 2008) Cite this as: BMJ 2008;336:0
All rapid responses
This is another (Copy and Past) piece written by an author who is not
a doctor thus may not be following your journal but I think is most
relevant response to this highly accesswed article because I feel your
readers may wish to know about and are in need of some hope.
My only addition to the article is I belive that (KISS)in the text
should be made (KISSme) about which I wrote to the author and awaits his
reply as he may probably agree.
The Art of Simplicity
a part of (The Power of Stupidity) Book- free access on the net.
by Giancarlo Livraghi
(English translation August 2005)
A “simpleton”, they used to say, or a “simple” person, to mean
someone stupid, or ignorant, or lacking common sense. It’s still a
widespread prejudice that stupidity is simple and intelligence is
complicated. The opposite is often true. When intelligence appears
complicated, or hard to understand, it’s immature. To reach full bloom it
must evolve toward simplicity.
It’s easy to complicate, it’s difficult to simplify. The greatest
advancements in philosophy, science and culture can be explained in clear
and simple concepts. Also in the everyday practice of work, or personal
relations, the most effective solutions are often the simplest.
The exciting experience of a creative synthesis – or of an intuition that
helps to solve a problem – leads us nearly always to discover that the
solution (after we have found it) appears obvious, but we couldn’t see it
because our perceptions and our way of thinking were too complicated.
People have always been made miserable by all sorts of unnecessary
complications. We are now in a state of turbulent transition that makes it
Many things have become easier because of resources that we didn’t
have – or were available only to a few people. But we are producing too
many new complications, caused by the clutter and inefficiency of
communication, our own and other people’s behavior – and a variety of
distressing problems, including poorly conceived or badly used
These stupid complications are very different from the problem of
complexity, as studied by the “Chaos Theory”. On this subject there is a
short note Simple Thoughts on Complexity that (deliberately)
oversimplifies the issue but (I hope) helps to understand some of its
Many years ago, long before we got into today’s mess, I had a sign
hanging in my office that said KISS. It’s common knowledge that it stands
for keep it simple, stupid. But that wise principle is rarely practiced.
Sometimes I would point to it when someone came up with a messy problem
that didn’t seem to have a simple solution. But, above all, I used it to
remind myself to take a dose of my own medicine.
There is a great need for simplicity. While the prevailing trend
continues to add complication, a perception that we should turn the tide
has been spreading in recent years. One of several examples is a bright
article published by Gerry McGovern on December 11, 2000: In praise of
He explains that «we live in a world where change and complexity are
forced on us at every turn. The world is hitting back. People are yearning
Complexity, he says, is a curse. «It is a type of intellectual pollution
that smothers clear thought. Complexity is not a sign of intelligence, but
rather a sign of a hyperactive mind gouging on more. True genius and great
design is about turning something complex into a product that is simple to
use and delivers a real benefit.» That isn’t only true of products or
technologies. It is the same for information, communication, knowledge,
organization and management.
The stupidity of power isn’t caused mainly by complexity. But it often
uses complication to become even more stupid – or exploits it deliberately
to confuse issues, to blur understanding, to hide simple facts behind a
curtain of elaborate appearances.
Not only bureaucracies, but also other oligarchies, power clusters
and cliques often use a complicated jargon that most people can’t
understand, to increase their control and keep the rest of humanity
Academics and “intellectuals” often play the same game. They use obscure
language to hide the fact that they don’t know what they are talking about
– while keeping “ordinary people” in awe and blind obedience, making them
believe that they are stupid because they don’t understand.
Intelligence is clarity and simplicity – not obscurity. When people don’t
understand, the blame of stupidity is on whoever isn’t explaining things
Of course we shouldn’t confuse simplicity with superficiality. An
apparently simple explanation can be just triviality, or silly
commonplace, or a widespread but false notion. Or a deliberate attempt to
hide the real depth of a fact or a debate. In other words, complication is
often stupid, but “simple” answers aren’t always intelligent.
The art of simplicity is as subtle and difficult as the use of
intelligence. Both need dedication, commitment, patience, in-depth
analysis and insatiable curiosity – as well as a constant cultivation of
doubt. When we find a clear and simple answer or solution, we should
always consider that we may be overlooking another approach that can be
even simpler and more effective.
It’s an endless task. But, if we learn to enjoy its taste, it can be
very pleasant – and amusing. Finding truly simple solutions is a happy,
often exhilarating experience.
Simplicity isn’t only an intellectual achievement, it’s also an emotion.
Finding the simple key to an apparently complex problem has intense
aesthetic values. It gives us a clear and unique perception of beauty and
Loving simplicity can be quite delightful. And it breeds intelligence.
Competing interests: No competing interests
I would like to highlight an important aspect of the two papers
referred to in Tony Delamothe's editorial. (1, 2). The most intervened groups are the
asymptomatic hypertensives and
cholesterol elevated groups.
BP; 4S; WOCOPS Relative risk reduction % (-20) (-29) (-21) Absolute risk reduction % (-0.8) (-3.3) (-0.9) Survival with drugs % (96) (88.5) (90.6) Survival without drugs % (96.8) (91.8) (91.4)
HPS was half as good as 4S and EXCEL showed slightly increased total
mortality in the drug treated group!4S; WOCOPS; HPS; and EXCEL were all
cholesterol lowering trials.
In your analysis where do these data fit in? With these results, how
do we convince our informed patients that they need to take drugs life
long that might make them sick: they are apparently very healthy to begin
with. We only have labeled them with the doctor-thinks-you-have –a-disease
syndromes. In the MRC study of mild to moderate hypertension it was shown
that to reduce one stroke death in the community, 850 healthy individuals
will have to take drugs for five years! How many of them would have had
dangerous side effects of the drugs in the meantime is any one’s guess?
1) Should we use large scale healthcare interventions without clear
evidence that benefits outweigh costs and harms? Yes
BMJ 2008 336: 1276.
2) Should we use large scale healthcare interventions without clear
evidence that benefits outweigh costs and harms? No
C Seth Landefeld, Kaveh G Shojania, and Andrew D Auerbach
BMJ 2008 336: 1277.
3) Nuovo J, Melnikow J, Chang D. Reporting Number Needed to Treat and
Absolute Risk Reduction in Randomized Controlled Trials. JAMA
4) Hebert PR, Moser, M, Mayer J, Hennekens CH. Recent evidence on drug
therapy of mild to moderate hypertension and decreased risk of coronary
heart disease. Arch Int Med 1993;153:578-81.
5) Shannon B. Why Too Much Medicine Is Making Us Sicker and Poorer
Bloomsbury USA; 2007; 343 pp
Competing interests: BP; 4S; WOCOPSRelative risk reduction % (-20) (-29) (-21)Absolute risk reduction % (-0.8) (-3.3) (-0.9)Survival with drugs % (96) (88.5) (90.6)Survival without drugs % (96.8) (91.8) (91.4)
Complexity is a commom feature in human lives, and it gains
prominence with every inch of technological advancement in the world
today. Take the example shared by Tony in his article (complexity
theory), of the human body, being a complex system likely to behave in a
non-linear manner. Comparatively, the brain is even a more complex system
within the complex body to be able to develop the technology that controls
human behaviour. Medical technology today has the capacity to intervene
in highly scientific ways, such as use of micro -chips in diagnosing human
internal organs, while viewing it on computer monitor and administering
the intervention [medicine] to treat the diagnosed problem all at the same
It is through appreciating the complexity of the world we live in and
the desire to make it simpler that sent the human mind working overtime to
develop complex multiple interventions, (Edward et al 2004) to deal with
it. Research has played a big role in providing the relevant evidence
necessary for guiding the development of interventions. Drug resistance as
a result of unjudicious use of Antibiotics, is one example of
technological complexities and will take continous research to develop
multiple strategeies to deal with such problems.
Through research we are able to understand the socio-ecological
issues (Kothari et al 2007) inherent in our environment and how they
influence the health outcomes. It is the same complexities that have
influenced research methodologies such that the use of systematic reviews
as the only source of evidence for assessing effective interventions is
increasingly becoming inadequate and may require complimenting with other
mehodologies such as integrative review and realist reviews. This would be
useful in situations where, the patients’ context has a lot to do with how
and when they take medicine, hence influencing the outcome of treatment.
In conclusion, we realize that when we talk of complexity theory and
its role in human life, we cannot fail to think of systems theory, and my
belief is that they co exist in their operations. For example, we know
about health systems, human body systems, social systems and cultural
systems, just to name afew, they are all complex.
Competing interests: No competing interests