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June 29, 2020

Cognitive Bias and Public Health Policy During the COVID-19 Pandemic

Author Affiliations
  • 1Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia
  • 2Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
  • 3Center for Bioethics, Harvard Medical School, Boston, Massachusetts
  • 4Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 5Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, New York, New York
JAMA. Published online June 29, 2020. doi:10.1001/jama.2020.11623

As the coronavirus disease 2019 (COVID-19) pandemic abates in many countries worldwide, and a new normal phase arrives, critically assessing policy responses to this public health crisis may promote better preparedness for the next wave or the next pandemic. A key lesson is revealed by one of the earliest and most sizeable US federal responses to the pandemic: the investment of $3 billion to build more ventilators. These extra ventilators, even had they been needed, would likely have done little to improve population survival because of the high mortality among patients with COVID-19 who require mechanical ventilation and diversion of clinicians away from more health-promoting endeavors.1 Yet most US residents supported this response because the belief that enough ventilators would be available averted their having to contemplate potentially preventable deaths due to insufficient supply of these devices.

Why are so many people distressed at the possibility that a patient in plain view—such as a person presenting to an emergency department with severe respiratory distress—would be denied an attempt at rescue because of a ventilator shortfall, but do not mount similarly impassioned concerns regarding failures to implement earlier, more aggressive physical distancing, testing, and contact tracing policies that would have saved far more lives?2 These inconsistent responses may be related to errors in human cognition that prioritize the readily imaginable over the statistical, the present over the future, and the direct over the indirect. Together, these biases may have promoted medicalized responses to and messaging about the pandemic, rather than those rooted in the traditions and practices of public health.

These cognitive errors, which distract leaders from optimal policy making and citizens from taking steps to promote their own and others’ interests, cannot merely be ascribed to repudiations of science. Rather, these biases are pervasive and may have been evolutionarily selected. Even at academic medical centers, where a premium is placed on having science guide policy, COVID-19 action plans prioritized expanding critical care capacity at the outset, and many clinicians treated seriously ill patients with drugs with little evidence of effectiveness, often before these institutions and clinicians enacted strategies to prevent spread of disease.

Identifiable Lives and Optimism Bias

The first error that thwarts effective policy making during crises stems from what economists have called the “identifiable victim effect.” Humans respond more aggressively to threats to identifiable lives, ie, those that an individual can easily imagine being their own or belonging to people they care about (such as family members) or care for (such as a clinician’s patients) than to the hidden, “statistical” deaths reported in accounts of the population-level tolls of the crisis. Similarly, psychologists have described efforts to rescue endangered lives as an inviolable goal, such that immediate efforts to save visible lives cannot be abandoned even if more lives would be saved through alternative responses.3

Some may view the focus on saving immediately threatened lives as rational because doing so entails less uncertainty than policies designed to save invisible lives that are not yet imminently threatened. Individuals who harbor such instincts may feel vindicated knowing that during the present pandemic, few if any patients in the US who could have benefited from a ventilator were denied one.

Yet such views represent a second reason for the broad endorsement of policies that prioritize saving visible, immediately jeopardized lives: that humans are imbued with a strong and neurally mediated3 tendency to predict outcomes that are systematically more optimistic than observed outcomes. Early pandemic prediction models provided best-case, worst-case, and most-likely estimates, fully depicting the intrinsic uncertainty.4 Sound policy would have attempted to minimize mortality by doing everything possible to prevent the worst case, but human optimism bias led many to act as if the best case was in fact the most likely.

Present Bias

A third driver of misguided policy responses is that humans are present biased, ie, people tend to prefer immediate benefits to even larger benefits in the future.5 Even if the tendency to prioritize visibly affected individuals could be resisted, many people would still place greater value on saving a life today than a life tomorrow. Thus, if escalating critical care capacity enables the prevention of certain deaths in the short term, it is a more attractive policy option than taking steps that would prevent more deaths over the long term. Similar psychology helps explain the reluctance of many nations to limit refrigeration and air conditioning, forgo fuel-inefficient transportation, and take other near-term steps to reduce the future effects of climate change. More fundamentally, present bias has in part motivated US governments controlled by both parties to allocate only 2.5% of health funding to public health initiatives6 despite the opportunities for better promoting population health through a more balanced policy portfolio.

Omission Bias

The fourth contributing factor is that virtually everyone is subject to omission bias, which involves the tendency to prefer that a harm occur by failure to take action rather than as direct consequence of the actions that are taken.7 This bias helps explain why some parents refuse to vaccinate their children, even when they understand that harms are more likely without vaccination. Similarly, controversy about how to allocate ventilators if they became scarce arose in part because planning and implementing such policies seemed to hold potential to actively contribute to causing deaths.

Although those who set policies for rationing ventilators and other scarce therapies do not intend the deaths of those who receive insufficient priority for these treatments, such policies nevertheless prevent clinicians from taking all possible steps to save certain lives. Accordingly, policy makers who do not advocate for increasing the ventilator supply, and clinicians who follow triage guidelines, may perceive that they are responsible for the deaths. In contrast, responsibility is more effortlessly evaded for causing greater numbers of deaths through failures to enact policies that effectively suppress viral spread, or those that prevent speeding on highways or easy access to firearms.

Toward Behaviorally Informed Policy Making and Communication

An important goal of governance is to mitigate the effects of these and other biases on public policy and to effectively communicate the reasons for difficult decisions to the public. However, health systems’ routine use of wartime terminology of “standing up” and “standing down” intensive care units illustrate problematic messaging aimed at the need to address immediate danger. Instead of emphasizing aggressive medical interventions to counteract cases of current disease, more effective messaging would have focused on counteracting disease spread. If war references were to be used at all, instead of saying “Ventilators are to this war what bombs were to World War Two,”8 leaders might have more consistently emphasized disease control by saying “You can protect yourself and your family by sheltering in place and practicing physical distancing and handwashing when outside the home. We all have to sacrifice in the short term to win the war against COVID-19.”

Second, had governments, health systems, and clinicians better understood the “identifiable victim effect,” they may have realized that promoting flattening the curve as a way to reduce pressure on hospitals and health care workers would be less effective than promoting early restaurant and retail store closures by saying “The lives you save when you close your doors include your own.”

Third, these leaders’ routine use of terms such as “nonpharmaceutical interventions”9 portrays public health responses negatively by labeling them according to what they are not. Instead, support for heavily funding contact tracing could have been generated by communicating such efforts as “lifesaving.” If committing more resources to testing and contact tracing meant fewer dollars for additional ventilators, leaders could have countered the optimism bias that might favor investing in ventilators using language that clinicians often use with their optimistic but seriously ill patients, such as “While we hope for the best, we must prepare for the worst by curbing further spread.”

Fourth, although errors of human cognition are challenging to surmount, policy making, even in a crisis, occurs over a sufficient period to be meaningfully improved by deliberate efforts to counter untoward biases. Government leaders could constrain their own present bias by passing laws that require estimating the effects on lives saved or life-years gained over several years to justify policy responses. Leaders also could improve adherence to measures such as mandatory quarantining by promoting future thinking among their electorates, such as by saying “Following these rules today is the best way to ensure that you and your family will see tomorrow.”

By starkly revealing the biases that cloud effective policy making and communication, a legacy of COVID-19 could be that future governments implement policies that reduce morbidity and mortality under worst-case rather than best-case scenarios, consider future harms as readily as present ones, and attend as strongly to hidden deaths as to visible lives. COVID-19 could provide the impetus for greater ascendancy of public health ethics over clinical ethics. If so, as difficult as it may be to imagine now, the pandemic might have served, paradoxically, as a stimulus to improve population health.

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Article Information

Corresponding Author: Scott D. Halpern, MD, PhD, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, 301 Blockley Hall, Philadelphia, PA 19104 (shalpern@upenn.edu).

Published Online: June 29, 2020. doi:10.1001/jama.2020.11623

Conflict of Interest Disclosures: Dr Truog reported serving as a paid member of data and safety monitoring boards for Sanofi, Gilead, and Covance. No other disclosures were reported.

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    5 Comments for this article
    Values and Health
    Vincent Degenhart, M.D. | Retired
    Americans and much of Western world look to the quick and easy fix. The media, health care industry, pharmaceutical companies, and academia all contribute. We seek a drug or an operation to fix preventable illness and disease.

    Look at obesity in America. This is an epidemic that has insidiously occurred over the past 50 years. The causes are many: sedentary life styles, poor nutrition, soft/sweet drinks, less agrarian society, etc. We have the highest rates of childhood obesity in the world. Yet the media, health care industry, academia give little
    more than lip service to this pandemic. They might offend certain groups:  advertisers, pharmaceutical companies, even physicians who treat this killer.

    We do not talk about BMIs, exercise tolerance, or ideal body weight. We should. We teach little about nutrition, exercise, or metabolic equivalents. We should. We do not reach out to our at risk children showing signs of overweight or obesity. We should. We teach little of the risks of hypertension, heart disease, and stroke, related to obesity. We should. We do not talk about premature death, loss of productivity, depression, even suicide related to obesity. We should.

    Yes the Coronavirus pandemic will reveal many misspent efforts. This pandemic is barely 5 months old. It came upon us quickly. We will survive it, find therapies, and vaccines. Yet like obesity, it would have been better had it been contained at its beginning.

    Vincent Degenhart, M.D.
    South Carolina
    Remedial Bias in Public Health Policy for COVID-19
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    The informative and welcome Viewpoint by experts in public health policy throw light on cognitive bias during COVID-19 that can affect optimal decision making and effective communication.

    There is a balance that must be struck between human cognition and statistical science to mitigate the inherent and pervasive bias in treating patients suffering from COVID-19, among other diseases.

    The eight types of errors that counteract a scientific approach to effective public health policy, together with appropriate remedies, may be classified as:

     (1) Observable immediacy versus statistical expectations: the “identifiable victim effect” emphasizes the perceived certainty of responding to
    immediately observable threats to life, as compared with nebulous, uncertain and invisible statistical expectations, a strategy that can only be overcome through community education and informed consent regarding immediate versus future outcomes.

    (2) Optimism versus reality: unrealistic and systematically more optimistic outcomes, as compared with worst case scenarios based on intrinsic uncertainty, lead to imbalances in treatment strategies, though it is recognized that improved education and greater information might be insufficient to deal with systematically hard-wired sub-consciousness in the community..

    (3) Present versus future: introducing intertemporal dynamics to illuminate contemporaneous judgments highlight the fact that the present is not necessarily more advantageous than the future, which has the potential to save more lives by taking a longer term perspective.

    (4) Passive versus active: omission bias suggests that ignoring the health problem is often seen as preferable to taking direct action, with immediately observable and possibly unexpected outcomes, which can only be alleviated through more well-informed strategies.

    (5) Effective communication versus problematic messaging: optimal policy making requires that the public be informed of dealing with immediate danger by balancing aggressive medical interventions with more effective messaging with regard to disease control and curtailing disease spread.

    (6) Positive versus negative policy responses: emphasizing informative and positive outcomes rather than their negative counterparts though more effective distribution of information requires greater community education and more widespread forms of communication, such as through social media.

    (7) Legislation versus prejudice: introducing legal requirements and regulations based on statistics and science over an extended period would enable counteraction against biased political considerations and prejudices.

    (8) Emphasizing good behaviour versus bad: informed communication requires public goodwill, so emphasizing the benefits of sensible community behaviour to protect those who need it the most is more effective than threats of punishment.

    Failure to anticipate future consequences in favour of concentrating on immediate benefits leads to the aphorism that failure to plan for the future means there will be no future, or at least not one that future generations will acknowledge with gratitude.
    Wow! I'll try to be nice...
    Michael Rethman, DDS, MS | Univ. of Maryland, Ohio State University
    These authors seem unfairly judgemental calling things done outright "errors," as if such "errors" could have been seen or known back in March.

    Ironically, the authors seem blissfully unaware of their own "hindsight bias" -- as they trash or support patient management concepts that seem obvious now -- but weren't at all obvious around the last equinox.

    One example was how these authors decry efforts in late March to obviate what then seemed to be a looming need for ventilators. And yes, that need turned out to be overstated, seen now with 20-20 hindsight.
    But back then the actual need was uncertain because there was little info on how ineffective they would be, what the needs would be. Plus, Italian and Chinese victims were dying in streets and waiting rooms -- a problem that doesn't impress these authors all that much.

    More: On the one hand they argue against the pervasive "bias to the null" that pervades clinical decision making yet they take time to trash (not by name) the widespread use of low toxicity hydroxycholorquine/azithro. Which is it?

    More: They take precious column inches to discuss their concepts of societal trade-offs that they think relevant to (purported) anthropogenic climate change but provide no specifics (other than 20-20 hindsight I suppose) why we should believe their argument that 2.5% of governmental health expenditures on public health is too low. (One might want to take a close look at the research portfolio of the CDC before concluding it doesn't have enough money to better prepare for and/or address pandemics.)

    More: They argue that "worst case" scenarios ought to drive decisions. Really? Perhaps they ought to consistent how this might be accomplished in any sort of consistent way in the context of a biased media, like those who rhetorically hanged President Ford for (what turned out to be needless) concerns about a strain of flu back in the mid-1970's.

    Finally, the authors also assume that earlier and more pervasive cloistering would have better limited deaths. And they may be right. But they may also be wrong, esp. if the only way herd immunity is attained is via natural means, IOW, not vaccine-aided -- in which case the sooner we get there the better, maybe. In this context, somehow I missed the discussion of why these authors seem to assume that it's simply not a good idea to allow lots of low-risk people get this disease -- as a means to get herd immunity sooner rather than later.

    I don't routinely read JAMA, but this is the second time in the past several months that someone drew my attention to a JAMA op-ed. The other op-ed was a series of arguments that hydroxychloroquine and azithromycin ought not be used against COVID-19. Once those comments were distilled, the only potentially sound reason remaining was that the widespread use of those drugs would make it harder to recruit patients for clinical trials -- on those very drugs. (Of course, this is not a pretty argument to make in the raw, thus a picture frame of sophistry was necessary.)

    JAMA can and should do better.

    Be well all.
    One more bias
    Olga Vasylyeva, MD | Rochester, NY
    Another cognitive bias commonly observed when the budget is in the discussion (and probably rises from the very nature of budget: it is not bottomless) is the bias of thinking "either/or" instead of "both."

    Here the need for ventilators is opposed to the need for public health measurements, literally "instead of ventilators - public health measurements." But both are important, and both can be life-saving.

    In fact, having a sufficient number of ventilators is nothing but a preparation for the worst-case scenario the authors advocate to be ready for.

    We should expect and
    demand more than the "either...or" trap.
    The Elephant in the Room
    John Glantz, MD, MPH | University of Rochester
    I appreciate the authors' insightsb ut suggest an additional and perhaps even more pervasive bias: political. For many in high political office, how the data were viewed, how subsequent decisions were made, and what was modeled was based on what was deemed most politically expedient instead of on science and what was most likely to save lives. A number of political leaders, generally with little understanding of virology and epidemiology, made definitive statements shaped by what they perceived would appeal to their constituents rather than on what was in their constituents' best health interests. As such, recommendations about social distancing and masks were re-cast as political statements about individual freedom instead of about public health. Once characterized as such, science and thoughtful discussion took a back seat. It was easier for the public to view public health recommendations as consistent or inconsistent with their political beliefs rather than based on mathematical modeling of disease probabilities.