Why do we love to hate ourselves?

Dhaliwal’s comment on Zwaan et al nicely refutes what has been called ‘the hypothesis of special cause’—the notion that when things turn out wrong, the cognitive processes leading to that outcome must have been fundamentally different (ie, error-prone) from when they turn out right. Dhaliwal’s argument recapitulates thinking that is over 100 years old; one of the early contributors to psychology, Ernst Mach, wrote (in 1905): ‘Knowledge and error flow from the same mental source; only success can tell one from the other’. What is interesting here is not that the hypothesis of special cause is wrong, but rather the question of why has it been so popular and persistent. What is it about the notion of humans as fundamentally irrational, poor decision-makers that gives this idea such wide appeal? After all, broad acceptance of this sort is not the norm for most psychological or medical research; controversy, argument, or outright disbelief are much more common. Christensen-Szalanski and Beach surveyed decisionmaking studies in psychology and reported that, although the studies’ conclusions were roughly evenly divided between finding good or poor decision-making performance (56% vs 44%), studies reporting human performance as flawed were cited almost six times more frequently than those reporting it as good. Citations outside of psychology journals were overwhelmingly used to advance the claim that people are poor decision-makers. One reason for this strange popularity is that the people-are-irrational claim provides benefits for those who have rationality to sell: guideline authors, healthcare managers, and other proponents of scientific– bureaucratic medicine. 7 Another is that it paradoxically provides individual benefits: once we understand the clever puzzles of heuristics and biases problems, even in retrospect, we tend to feel that we must be pretty clever also. And a final, and likely strongest, influence is that it protects organisations and elites: attributing adverse events to flawed mental processes at the front lines serves as a kind of lightning rod, conducting the harmful consequences of bad outcomes down an organisationally safe pathway. Unfortunately, the history of patient safety to date does not suggest that cautions such as Dhaliwal’s will have much effect; such cautions have been raised and ignored before. Patient safety’s fixation on ‘medical error’ as the fundament of medical harm serves many (perhaps extraneous) purposes, but is based on an ontological will-of-the-wisp. 13 14 Given general agreement on the meagre progress of the patient safety movement to date, a fundamental re-thinking of our basic premises and hidden assumptions is desperately needed if we are to move forward. And as with many fixations, a sea change of this sort is not likely to come from within the present patient safety movement, but must come from the outside. 20 We can only hope ‘these barbarians’ challenge us sooner rather than later.