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Professor Barry Schwartz, the engaging American academic who closed last week's NHS Confederation conference, is interested in the law of unintended consequences. His thesis is that increasing reliance on rules and incentives robs us of the ability to do the right thing.

"There is a notion that self-interest, well harnessed can do the job - it can't," said the professor. And if you need convincing, the recent history of investment banking is littered with examples.

A better example comes from a Swiss town where the population was canvassed about its views of a nuclear waste dump due to be built in the locality. In a remarkable display of public-spiritedness, 50% accepted that the facility had to go somewhere and declared that they wouldn't object to the plan. When a second survey was conducted, this time with the added incentive of the equivalent of six weeks' pay, the yes vote fell to 25%. Why?

According to the professor, this is an example of what happens to moral will when you attach money to it. The incentive, which is designed to make the decision easier, actually confuses it.

There was also the example of a junior doctor who took a decision to make a medical intervention against the wishes of a patient and the patient's distraught wife. The outcome in this case was good - the man lived and there were no recriminations or lawsuits. But it might have been very different. Did the intern do the right thing? Was the man, in the grip of a life-threatening infection, able to take an informed decision? What about his hysterical wife?

As the professor put it: "There's a right answer to the question of who should decide, but the right answer is different in every case."

Barry Schwartz advocates what Aristotle called practical wisdom, a combination of moral will and moral skill. These qualities, he argues, are not born but made by experience and by following the example of ordinary heroes, people who "know when and how to make an exception to every rule".

One consequence of practical wisdom is increased risk, but the consequence of suppressing it is worse.

"Too many rules prevent accomplished jazz musicians from improvising. As a result, they lose their gift or worse, they give up playing," the professor said.

Although Professor Schwartz's words were warmly received, there was a sense that some in the audience were struggling to understand what it had to do with the NHS. If so, then we have a lot more to worry about than the economic downturn.

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