Virtue Ethics in a Value-driven World: The Just-world Fallacy

It’s awful what happened to her, but she really shouldn’t have dressed like that.

He deserves all of his riches after working so hard all those years.

It’s sad he was shot, but he wasn’t a saint. He had already spent time in prison.

These statements share a similar view: People—whether they are victims or benefactors—generally get what they deserve. This perspective is widespread. It is also a cognitive fallacy, which social psychologist Dr. Melvin Lerner [5] termed the just-world belief (also known as the just-world hypothesis or the just-world fallacy).

The just-world belief overvalues the role of individuals in controlling their fate and undervalues the importance of societal structures. The belief in a just world can drive positive behavior—we choose to act in a positive manner to be equivalently rewarded. But it can also lead to justification of another person’s suffering. No matter how great the person’s misery, it must in some way be deserved. Believing in a just world is comforting—it creates order and predictability, rather than acknowledging the capricious nature of things.

As physicians, we are constantly faced with examples of how the world is unfair, unjust, and fickle: the young child with leukemia, the teenager with Ewing sarcoma, or the older woman with multiple fractures after being struck in a hit and run. Do our experiences make us more empathic and understanding, or is it possible that we are more susceptible to this cognitive fallacy compared to those not in healthcare?

In my view, physicians go to extremes with their most unfortunate patients, separating them into what I call “the innocents”—those unjustly treated by the world—and those who are wholly responsible for their fate. We acknowledge that the world can be unjust to many, and thus reserve harsh judgment for those not wholly “innocent” of their disease.

Who hasn’t been to a Morbidity and Mortality conference at which a complication is presented, which was framed as the patient’s fault:

• “The morbidly obese patient presented to the emergency department with a total knee infection.”

• “The patient presented for second opinion after a nonunion. She endorsed smoking a pack per day during her recuperation.”

While these patient-related factors certainly can increase the risk of a complication, patients without those kinds of comorbidities still experience those complications, and many with those comorbidities don’t. But when a patient has a comorbidity that could increase the risk of a particular complication, it is almost inevitable that we latch onto the concept of a patient-caused, preventable comorbidity. In a world of innocent victims, it is psychologically appealing to blame the not-so-innocent victim, the patient whose health or health choices increases their likelihood of medically poor outcome.

By blaming the victim, we shield ourselves from the vulnerable possibility that we too could have a medically poor outcome even if we do everything right. As surgeons, we are also shielding ourselves from the possibility that it is our error—rather than the patient’s error or simply bad luck—that caused the negative outcome. Orthopaedic surgeons have high rates of burnout and suicide, in part due to overly high standards and perfectionist tendencies [1, 3]. And so, victim blaming makes sense psychologically, as we are able to avoid acknowledging the unpredictable nature of the world while concurrently avoiding responsibility for the problem.

But an overfocus on preventable or modifiable factors harms the patient-physician relationship. When we focus on the patient factors as the cause of an issue, rather than one potential factor of many, patients are likely to feel badgered and frustrated, doomed to negative health outcomes that they believe are a direct function of their own bad choices. We can also create unrealistic expectations about their role in improving their situation—while weight loss can improve the load on arthritic joints, patients with a normal BMI and arthritis still experience pain. Additionally, these particular conditions are not as modifiable as many surgeons would think [6]. Yet, even if these conditions were clearly modifiable, it is morally wrong to use them to apportion blame.

We have an ethical duty to both understand and to combat the just-world fallacy in our practices. Cognitive fallacies (such as the belief in a just world) are heuristics. Heuristics, or mental shortcuts, help us make sense of the world. These heuristics were termed System-1 thinking or quickly made emotional reactions by behavioral scientists Daniel Kahneman and Amos Tversky [4]. Physicians make hundreds of decisions a day [2], and we must use System-1 thinking to function. Indeed, emergency physicians are fairly accurate in rapidly assessing a patient’s acuity [7]. However, in nonemergent situations, System-1 thinking limits our formation of differential diagnoses. When I automatically blame a patient and his or her smoking as the cause of the nonunion, I fail to consider other factors, such as infection, poor nutrition, or metabolic bone disease, any of which may be the underlying issue. Most of our biases exist in System-1 thinking. More rational, calculated processing is termed System-2 or slow thinking. The challenge is to switch from System-1 to System-2 thinking when circumstances or an activity are improved by us doing so.

It is likely not possible to rid ourselves of our cognitive biases, given their unconscious nature. However, being aware of the existence of biases is an important first step in limiting their impact. This type of metacognition—having an awareness of our own thought processes and patterns—is necessary to limit the impact of these biases. We can identify some of these tendencies by running cases and complications by mentors, partners, or trainees, seeing what possibilities we didn’t consider. We should also be aware of our implicit biases, and we should consider whether we have a tendency to resort to blaming the victim more often when the patient is impoverished, a woman, or a member of an underrepresented minority.

Systematic approaches, such as a checklist (whether mental or written) can also help to avoid cognitive bias when evaluating a patient who has had a complication. For example, my work-up of a nonunion always includes infection and metabolic bone abnormality, and I have built a work-up checklist into my electronic medical record. This approach helps me to avoid falling into cognitive fallacies, such as the belief in the just world.

The belief in a just world is an extremely common cognitive fallacy because it is intuitively appealing—the world is rational and ordered. Yet, to best care for our patients, we must embrace the vulnerability of uncertainty and chaos, shepherding our patients from their own self-blame and finding a way forward together.