Innovation is the driver of long-term economic growth and a key ingredient for improvements in healthcare, safety, and security, not to mention those little comforts and conveniences to which we have grown so accustomed. But innovation is not an unqualified good; it taxes society with costs.

The market system internalizes only a portion of the total costs of innovation. Other costs, however, are not included in market prices. Among the most important sources for those unaccounted costs are creative destruction, externalities, and weak safeguards for unwanted consequences.

Creative Destruction and Innovation

Schumpeter described creative destruction as the process by which innovative entrepreneurs outcompete older firms who unable to adapt to a new productive platform go out of business, laying off their employees and writing off their productive assets. Innovation, thus, also produces job loss and wealth destruction. Externalities are side effects with costs not priced in the marketplace such as environmental degradation and pollution. While externalities are largely invisible in the accounting books, they levy very real costs to society in terms of human health and increased vulnerability to environmental shocks. In addition, new technologies are bound to have unwanted deleterious effects, some of which are harmful to workers and consumers, and often, even to third parties not participating in those markets. Yet, there are little financial or cultural incentives for innovators to design new technologies with safeguards against those effects.

Indeed, innovation imposes unaccounted costs and those costs are not allocated in proportion of the benefits. Nothing in the market system obligates the winners of creative destruction to compensate the unemployed of phased-out industries, nor mandates producers to compensate those shouldering the costs of externalities, nor places incentives to invest in preventing unwanted effects in new production processes and new products. It is the role of policy to create the appropriate incentives for a fair distribution of those social costs. As a matter of national policy we must continue every effort to foster innovation, but we must do so recognizing the trade-offs.

Strengthening the Social Safety Net

Society as a whole benefits from creative destruction; society as a whole must then strengthen the safety net for the unemployed and double up efforts to help workers retrain and find employment in emerging industries. Regulators and industry will always disagree on many things but they could agree to collaborate on a system of regulatory incentives to ease transition to productive platforms with low externality costs. Fostering innovation should also mean promoting a culture of anticipation to better manage unwanted consequences.

Let’s invest in innovation with optimism, but let’s be pragmatic about it. To reap the most net social benefit from innovation, we must work on two fronts, to maximize benefits and to minimize the social costs, particularly those costs not traditionally accounted. The challenge for policymakers is to do it fairly and smartly, creating a correspondence of benefits and costs, and not unnecessarily encumbering innovative activity.

Commentary published in The International Economy magazine, Spring 2014 issue, as part of a symposium of experts responding to the question: Does Innovation Lead to prosperity for all?

The challenge of rural poverty and food insecurity in the developing world remains daunting. Recent estimates show that “there are still about 1.2 billion extremely poor people in the world. In addition, about 870 million people are undernourished, and about 2 billion people suffer from micronutrient deficiency. About 70 percent of the world’s poor live in rural areas, and many have some dependency on agriculture,” (Cleaver 2012). Addressing this challenge by assisting rural small-holder farmers in developing countries is the mandate of the International Fund for Agricultural Development (IFAD), an international financial institution based in Rome.

The International Fund for Agricultural Development is a relatively small donor in the global aid architecture, accounting for approximately one-half of 1 percent of all aid paid directly to developing countries in 2010. Although more significant in its core area of agricultural and rural development, IFAD still accounts for less than 5 percent of total official development assistance in that sector.1 Confronted with the gap between its small size and the large scale of the problem it has been mandated to address, IFAD seeks ways to increase its impact for every dollar it invests in agriculture and rural development on behalf of its member states. One indicator of this intention to scale up is that it has set a goal to reach 90 million rural poor between 2012 and 2015 and lift 80 million out of poverty during that time. These numbers are roughly three times the number of poor IFAD has reached previously during a similar time span. More generally, IFAD has declared that scaling up is “mission critical,” and this scaling-up objective is now firmly embedded in its corporate strategy and planning statements. Also, increasingly, IFAD’s operational practices are geared towards helping its clients achieve scaling up on the ground with the support of its loans and grants.

This was not always the case. For many years, IFAD stressed innovation as the key to success, giving little attention to systematically replicating and building on successful innovations. In this regard, IFAD was not alone. In fact, few aid agencies have systematically pursued the scaling up of successful projects. However, in 2009, IFAD management decided to explore how it could increase its focus on scaling up. It gave a grant to the Brookings Institution to review IFAD’s experience with scaling up and to assess its operational strategies, policies and processes with a view to strengthening its approach to scaling up. Based on an extensive review of IFAD documentation, two country case studies and intensive interactions with IFAD staff and managers, the Brookings team prepared a report that it submitted to IFAD management in June 2010 and published as a Brookings Global Working Paper in early 2011 (Linn et al. 2011).

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Far too many people reach their advanced years without planning for how they want their lives to end. The result too often is needless suffering, reduced dignity and autonomy, and agonizing decisions for family members.

Addressing these end-of-life issues is difficult. Most of us don’t want to confront them for ourselves or our family members. And until recently, many people resisted the idea of reimbursing doctors for end-of-life counselling sessions. In 2009, Sarah Palin labelled such sessions as the first step in establishing “death panels.” Although no such thing was contemplated when Representative Earl Blumenauer (D- Oregon) proposed such reimbursement, the majority of the public believed that death panels and euthanasia were just around the corner. Even the Obama Administration subsequently backed away from efforts to allow such reimbursement.

Fortunately, this is now history. In the past year or two the tenor of the debate has shifted toward greater acceptance of the need to deal openly with these issues. At least three developments illustrate the shift.

First, talk of “death panels” has receded, and new regulations, approved in late 2015 to take effect in January of this year, now allow Medicare reimbursement for end of life counselling. The comment period leading up to this decision was, according to most accounts, relatively free of the divisive rhetoric characterizing earlier debates. Both the American Medical Association and the American Hospital Association have signaled their support.

Second, physicians are increasingly recognizing that the objective of extending life must be balanced against the expressed priorities of their patients which often include the quality and not just the length of remaining life. Atal Gwande’s best-selling book, Being Mortal, beautifully illustrates the challenges for both doctors and patients. With well-grounded and persuasive logic, Gwande speaks of the need to de-medicalize death and dying.

The third development is perhaps the most surprising. It is a bold proposal advanced by Governor Jeb Bush before he bowed out of the Presidential race, suggesting that eligibility for Medicare be conditioned on having an advanced directive. His interest in these issues goes back to the time when as governor of Florida he became embroiled in a dispute about the removal of a feeding tube from a comatose Terry Schiavo. Ms. Schiavo’s husband and parents were at odds about what to do, her husband favoring removal and her parents wishing to sustain life. In the end, although the Governor sided with the parents, the courts decided in favor of the husband and allowed her to die. If an advanced directive had existed, the family disagreement along with a long and contentious court battle could have been avoided.

The point of such directives is not to pressure people into choosing one option over another but simply to insure that they consider their own preferences while they are still able. Making this a requirement for receipt of Medicare would almost surely encourage more people to think seriously about the type of care they would like toward the end of life and to talk with both their doctors and their family about these views. However, for many others, it would be a step too far and might reverse the new openness to advanced planning. A softer version nudging Medicare applicants to address these issues might be more acceptable. They would be asked to review several advance directive protocols, to choose one (or substitute their own). If they felt strongly that such planning was inappropriate, they could opt out of the process entirely and still receive their benefits.

Advanced care planning should not be linked only to Medicare. We should encourage people to make these decisions earlier in their lives and provide opportunities for them to revisit their initial decisions. This could be accomplished by implementing a similar nudge-like process for Medicaid recipients and those covered by private insurance.

Right now too few people are well informed about their end-of-life options, have talked to their doctors or their family members, or have created the necessary documents. Only about half of all of those who have reached the age of 60 have an advanced directive such as a living will or a power of attorney specifying their wishes. Individual preferences will naturally vary. Some will want every possible treatment to forestall death even if it comes with some suffering and only a small hope of recovery; others will want to avoid this by being allowed to die sooner or in greater comfort. Research suggests that when given a choice, most people will choose comfort care over extended life.

In the absence of advance planning, the choice of how one dies is often left to doctors, hospitals, and relatives whose wishes may or may not represent the preferences of the individual in their care. For example, most people would prefer to die at home but the majority do not. Physicians are committed to saving lives and relatives often feel guilty about letting a loved one “go.”

The costs of prolonging life when there is little point in doing so can be high. The average Medicare patient in their last year of life costs the government $33,000 with spending in that final year accounting for 25 percent of all Medicare spending. Granted no one knows in advance which year is “their last” so these data exaggerate the savings that better advance planning might yield, but even if it is 10% that represents over $50 billion a year. Dr. Ezekiel Emanuel, an expert in this area, notes that hospice care can reduce costs by 10 to 20 percent for cancer patients but warns that little or no savings have accompanied palliative care for heart failure or emphysema patients, for example. This could reflect the late use of palliative care in such cases or the fact that palliative care is more expensive than assumed.

In the end, Dr. Emanuel concludes, and I heartily agree, that a call for better advance planning should not be based primarily on its potential cost savings but rather on the respect it affords the individual to die in dignity and in accordance with their own preferences.

Editor's note: This piece originally appeared in Inside Sources.