In lean, standard work is “the agreed-upon, best-known, least wasteful way of doing the work today until a better way is found.” Standard work provides a structure to communicate, train, practice, and deliver an expected sequence of activities that generate value. Starting with continuous self-improvement, leader standard work is developing people to solve problems and improve outcomes (individual, team, organization, community). PDSA stands for Plan-Do-Study-Act. PDSA is the iterative cycle of scientific thinking and continuous improvement. PDSA is part of human nature: it’s how we predict and try things, learn, adapt, and improve.

Value-Focused Decisive Leadership (VFDL) is leading with values, ensuring decision quality, and getting results in a way that inspires trust.

A decision is an irrevocable allocation of resources — time, energy, money, people, physical assets, and opportunity costs. Nothing is more important.

Strategy execution frameworks are maps to achieve our goals. Decisions are the process of navigating a changing environment with our maps in hand.

These tables are your VFDL maps for knowing, being, doing. Use them, and insist your staff use them to brief you on their problem-solving and decision-making.1 Used daily, and in different settings, these tables become a foundation of leader standard work. Prioritize Tables 1 to 3.

1. Decision Quality (DQ) Checklist

2. PDSA problem solving (lean A3 thinking)

3. Modified Shingo Principles

4. SBAR+ for Situation Updates (on-the-spot verbal or 1-2 page written)

5. PDSA Problem Solving (A3 thinking) compared to design thinking and lean startup

6. Results-Based Accountability (RBA) for collective impact initiatives

The tables below, and more, are available as Google Docs.

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Value-Focused Decisive Leadership (VFDL) is leading with values, ensuring decision quality, and getting results in a way that inspires trust.

A decision is an irrevocable allocation of resources — time, energy, money, people, physical assets, and opportunity costs. Nothing is more important.

Strategy execution frameworks are maps to achieve our goals. Decisions are the process of navigating a changing environment with our maps in hand.

The remaining tables are available as Google Docs. Please review, share, and provide critical feedback.

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Tomás

Footnotes

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Here is my request:

1. Subscribe to TEAM Public Health and share posts.

2. Check out my webinar Google slides.

3. Visit Dialogue4Health and subscribe to receive their announcements.

4. Re-visit this page where I will be writing content to explain the slides.

Background and introduction

coming soon

“Effort is the algorithm”

coming soon

Wrangling with LLMs

coming soon

Examples and Tools

coming soon

Summary

coming soon.

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Tomás

Appendix

coming soon

Footnotes

Also read Value-Focused Decisive Leadership — Part 1.

I was honored to present on Value-Focused Decisive Leadership at a UCSF Health Managing to Lead Program workshop for program alumni in Los Angeles on May 14, 2026. Here are the workshop materials.

Value-Focused Decisive Leadership (VFDL) is

• leading with values,1

• ensuring decision quality, and

• getting results in a way that inspires trust.

We all aspire to be value-focused decisive leaders! VFDL is a key component of the Decision Intelligence 4 Health framework (Figure 1).

Decision Intelligence 4 Health

Embedded in all our journeys — individually and collectively — are the choices we make. A decision is “an irrevocable allocation of resources”2 — time, energy, money, people, physical assets, and opportunity costs — nothing is more important! Decision making is our most important daily activity.

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Decision Intelligence 4 Health (DI4H) (Figure 1) was developed for health organizations, but is widely applicable to other fields. DI4H starts with decision quality (DQ). In spite of its importance, DQ is rarely taught. This is unfortunate! Barriers to training include committing time for learning and practice, and the organizational and analytical complexity of decision making. Figure 1 depicts how decision professionals tackle and manage these two dimensions of complexity (Figure 2).3

Fortunately, because of advances in decision science, cognitive neuroscience, and behavioral economics, we know much more about how we actually make decisions (descriptive) and how we can improve our decision processes (prescriptive). We will focus on The DQ Checklist.

The Decision Quality (DQ) Checklist

Below is the The DQ Checklist (Figure 3) with key questions to consider. Steps 1 to 3 are the most important and promote value-focused thinking (VFT).456 Most decisions are based on “alternatives-focused thinking” — we react to circumstances or others’ decisions that impact us, and we start by choosing from our default alternatives. This approach is reactive. In contrast, VFT is proactive; we clarify our values and brainstorm to uncover more values. Then we use our values to generate meaningful objectives and creative alternatives to achieve our objectives and desired future.

The DQ checklist is evidence-based and includes judgement (steps 4 and 5), preference (steps 1 and 2), and choice (steps 3 and 6). Judgment includes probabilistic and causal reasoning. Preference reflects values. Choice involves using judgment and preference to assess trade-offs and make a selection.7

1 Helpful Frame

Framing is planning and problem/opportunity definition. Framing is like creating context for a generative AI large language model (LLM).

• What decision problem or opportunity are you addressing? (statement)

• What is your purpose in making the decision? (clarify values)

• What is the scope of the decision? (decision hierarchy*)

• What are the perspectives? (decision makers, stakeholders, subject matter experts)

Here is the template for a decision statement:

“I (or we) will decide … + {which, what, when, whether, how, if, who} + {value or objective you want to achieve} or {category of alternatives you want to consider}.”

Here are some decision statements:

• We will decide WHICH strategy to promote higher measles vaccinations.

• We will decide HOW TO adapt to the loss of grant funding.

• We will decide HOW TO manage workforce reductions, reduce staff burnout, reduce physician turnover, and meet service demands.

• We will decide HOW TO design a GenAI strategy that advances our health equity mission.

• We will decide HOW TO align Cal AIM priorities with federal orders without compromising our values and mission.

• We will decide WHETHER TO accept new patients given our service constraints.

To create a decision hierarchy we brainstorm on the multitude of issues involving the decision problem, and categorize them as either

• decisions: issues suggesting choices that can be made as part of the decision

• values: including objectives and value measures,

• uncertainties: issues suggesting uncertainties

• others: other issues not categorized above

The decision hierarchy (Figure 4) displays the three decision types:

• High level decisions that are take as given

• Decision that are the focus of this process

• Decision that can be deferred until latter or delegated to others

2 Clear Values and Objectives

Here are the key questions to ask:

• What’s important to you? (values: core, context) — review (HELP)² checklist

• What do you want to achieve? (objectives) — convert from objectives

• What consequences do you care about? (value measures; aka, key results)

• What are the worst outcomes (premortem) and best outcomes (backcasting)? Any more values or objectives?

The premortem, backcast, and (HELP)^2 checklist (Figure 5) help to create a comprehensive set of values, objectives, and alternatives. Other tools, like a SWOT analysis, etc. are also helpful.

Objectives should categorized as means objectives and fundamental objectives. Means objectives contribute to fundamental objective. The fundamental objectives are used as criteria to select the alternatives.

3 Creative Alternatives

• What alternatives will lead to outcomes that contribute to your objectives?

• How will you avoid your worst outcomes (premortem) and how will you achieve your best outcomes (backcasting)?

• What new behaviors and activities do you need to start and to stop?

• How will you design alternatives that satisfy the values of others (eg, supervisor, community)?

Decisions often occur within a strategy or continuous improvement framework. I recommend starting with PDSA problem solving. You will need to decide on a problem to solve, what consequences matter, what causes matter, and what countermeasures will be effective.

Once you have decided a problem to solve, then the following causal graph applies.

4 Useful Information

Information is a big category!

• What are the sources of relevant and reliable information?

• How will you close your information gaps (known knowns, known unknowns, unknown knowns, and unknown unknowns)?

• How will you mitigate biased information and biased information processing (cognitive biases)?

• How will you leverage expertise and technology (eg, generative artificial intelligence) to sample and summarize information?

Known-Unknowns (“Rumsfeld“) Matrix

Understanding the Known-Unknowns Matrix is critical for closing relevant information gaps (Figure 8). From your perspective, read across the first row. The first row is what you are aware of.

Generative AI can help in sampling these spaces.

5 Sound Reasoning

• Who will be involved in evaluating and selecting the alternatives?

• How will you evaluate and select the alternatives? (causal-diagnostic reasoning vs causal-predictive reasoning)

• How will you organize the objectives, alternatives, and consequences to facilitate reasoning (consequence table, strategy table, decision tree, etc.)?

• Will you need decision modeling support?

Causal-diagnostic reasoning vs. Causal-predictive reasoning

Choices are be based on either causal-diagnostic reasoning (eg, What is causing this outcome?) or on causal-predictive reasoning (eg, Which alternative will achieve our objective?). (Figure 9)

Think like a clinician!

1. What is the problem? (chief complaint, symptom, sign, consequence, etc.)

2. What the diagnosis? (causal-diagnostic reasoning)

3. What is the treatment? (causal-predictive reasoning)

Do not skip the diagnosis phase of problem solving!!!

Value-Focused Thinking + Prospect (uncertainty) analysis

Figure 10 depicts an expanded DQ Checklist. All six steps apply always, but value-focused thinking occurs with steps 1 to 3 and is the foundation of multiple-objective decision analysis (MODA).

Most decision problems involve multiple-objective decision analysis. With MODA, a prospect (uncertainty) analysis is often not feasible. Instead, alternatives are chosen using value measures designed from objectives that align with values. (Figure 11)

With MODA, the primary focus is on value-focused thinking that produces values, objectives, and alternatives. Then tools, such as Consequence Tables and Strategy Tables, are used to evaluate trade-offs and select which alternatives are more likely achieve the objectives. These qualitative and quantitative assessments should involve decision makers, stakeholders, and subject matter experts. (see Figures 12—14)

Consequence Table

Strategy Table

Consequence Table with Strategy options

PICK chart and table

In quality improvement, a PICK chart is a visual tool used to rank projects by considering their level of difficulty (cost/effort) and level of payoff (the improvement gain).

6 Commitment to Action

How will you manage the team meeting dynamics (psychological safety and cognitive diversity, core beliefs, cognitive biases, emotions, groupthink, cascading, etc.) so that the team makes good decisions that stick? Consider the following team decision-making components from Professor Michael Roberto:8

• Composition: Who should be involved in the decision-making process?

• Context: In what type of environment does the decision take place?

• Communication: What are the means of dialogue among the participants?

• Control: How will the leader control the process and the content of the decision?

Path to Decision Success

The Path to Decision Success (Figure 15) is from Professor Michael Roberto. Most of this planning occurs in the Framing stage (Step 1).

Summary

For Value-Focused Decisive Leadership we covered the Decision Quality Checklist with selected examples. VFDL is leading with values, ensuring good decision quality, and getting results in a way that inspires trust.

VFDL is a mindset for everyday — at home, at work, in the community.

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Tomás

Appendix

Consequence table examples

Selecting a job with value measures (consequences)

Here is consequence table to selecting a job.9

Selecting a job with value measures ranked

Ranking alternative is a great way to start. It allows you to quickly identify which alternatives dominate other alternatives (ie, they rand higher on all, or almost all, objective value measures).

Consequence table for managing Caribou population

In this table, the alternatives are scored by how well they meet the objectives. Notice that the objectives are separately weighted with respect to importance. When objectives are weighted and then alternative are rated, this is called the weight and rate method.

Footnote

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Slide presentation

Here are my entire Google slides (title slide and link below)

Video presentation

Here is the video presentation (on Google Drive).

Selected original slides

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TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Review Value-Focused Decisive Leadership handout (Google Docs)

1 Values-based leadership

When I became the health officer of San Francisco in 2011 I realized I needed more leadership training. I enrolled in several leadership fellowships (UCSF/CHCF, NACCHO, Kresge, and others). They were all amazing! But one training that deeply impacted me was the Leadership for Equity and Opportunity (LEO) with Dr. Monica Sharma. Dr. Sharma trained as a physician and epidemiologist, worked for the United Nations in leadership development for more than twenty years. She worked on public health projects around the globe.

Her model centered on becoming a leader that embodied and promoted universal values. Universal values are values that apply to everyone, everywhere, leaving no one behind, including our adversaries. She discovered that promoting the universal values of dignity, equity/fairness, and compassion enabled field teams to tackle public health challenges in all corners of the world.

Our goal is to embody and promote universal values in every conversation and in every interaction. With universal values,

• we can connect with others through our shared humanity,

• we can transcend differences to find common ground, and

• we can co-create to solve problems together.

Her approach might be called values-based leadership. To learn more read her leadership book.1

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Universal values are values that apply to everyone, everywhere, leaving no one behind, including our adversaries.

2 Values-based behavior change

Over the years I have come to appreciate the effectiveness of values-based frameworks. For example, clinical psychologist, Dr. Judy Ho uses her Blueprint for Change (Figure 1) to help readers to start new behaviors — and to stop old behaviors — when behavior change is very hard.

Antecedents — also called thinking “triggers” — have an oversized influence on our decisions and subsequent behaviors. Centering your values gives you a fighting chance to change your ingrained negative behaviors and to adopt positive behaviors.

From Dr. Ho (p. 213):2

We all have values, and each of us has a unique set of values that determine what’s really important and meaningful to us. They are the True North of your internal compass. … Taking time to understand what your personal core values are will help to guide your behaviors more consciously, provide you with a code of conduct, and influence the choices you make throughout the day.

Don’t underestimate the power of centering your values to influence — and even better — to drive your decisions.

Centering your values gives you a fighting chance to change your ingrained negative behaviors and to adopt positive behaviors.

3 Design thinking (human-centered design)

Design thinking is human-centered, values-based innovation. Figure 2 depicts the decision quality (divergent-convergent) process in design thinking which is explicit. (See recent blog on this topic.)

Human-centered design is a creative, need and problem-finding process for designing products, services, or environments that delight humans and fulfill their needs or wants (ie, their values). They ask “What results (value) do our customers care about that we could deliver?” Humans value experiences that are emotionally fulfilling and solve their problems. Design thinking is value-focused thinking: you discover, prototype, and test new solutions that are process, functional, and emotional innovations.

Design thinking is value-focused thinking: you discover, prototype, and test new solutions that are process, functional, and emotional innovations.

4 Value-focused decision-making

With decision analysis we often think about the quantitative, analytic methods to model uncertainty and optimize expected values given the alternatives under consideration. Professor Ralph Keeney calls this the “back end” of decision analysis.3 This back end analysis is used to select an alternative (or set of alternatives) that optimizes the expected value of the primary outcome (eg, reducing disease rates). Starting with alternatives, and moving to selection is called “alternative-focused thinking.” This sounds reasonable; however, there’s a big potential problem! The available alternatives may be lousy: “garbage in, garbage out.”

Professor Keeney urges us to start on the “front end” of generating and designing the best alternatives — and it starts with your values!

Front end: define and structure the decision that you face

1. State the decision problem or decision opportunity that

   you face

2. Identify your values, and state them as objectives, to

   clarify what you want to achieve

3. Create alternatives that contribute to achieving your

   objectives

This is followed by the back end: (4) Describe the possible consequences of each alternative to indicate how well it achieves your objectives. (5) Identify the pros and cons of each alternative and weigh their importance. And, (6) Select an alternative using information and insight from your evaluation. This is called value-focused decision-making.

Why do we want to create better alternatives? Professor Keeney writes (p. 81):

You want to have a set of good alternatives for any decision that you face. The reason is based on two simple facts about alternatives. First, if you have not thought of a particular alternative, you cannot choose it. Second, your chosen alternative can be no better than the best of the alternatives under consideration.

It follows from these facts that your ability to achieve what you want from any decision will sometimes depend more on the quality of the alternatives that you have identified than on the quality of your choice between those alternatives.

The self-reflection process for identifying your values enables you

• to design better objectives for what you want to achieve,

• to generate better alternatives to achieve your objectives,

• to describe the consequences of the alternatives (aka, value measures), and

• to use the value measures as criteria to evaluate and select the best alternatives.

Value-focused thinking — the front end — is the superpower of value-focused decision-making.

3.1 The Decision Quality (DQ) Checklist

Value-focused thinking — the front end — are the first three steps of The DQ Checklist (aka, “decision quality chain”). See Figure 3.

The six elements of Decision Quality — The DQ Checklist

1. What are we really deciding? (frame)

2. What do we want? (values & objectives)

3. What can we do? (alternatives)

4. What do we need to know? (information)

5. Are we thinking straight? (reasoning)

6. Will we do it? (commitment to action)

Value-focused thinking is deployed in the first three steps of the The DQ Checklist (Figure 3).

“A decision, like a chain, is only as strong as its weakest link.”

Value-focused thinking — the front end — is the superpower of value-focused decision-making.

Summary

In this blog I covered the superpower of value-focused and values-based thinking. I gave three examples:

• values-based leadership,

• values-based behavior change,

• design thinking (human-centered design), and

• value-based decision-making

Value-focused thinking is the foundation of decision analysis and The DQ Checklist (ie, decision quality chain).4 Leading with values will transform your leadership practice.

Review Value-Focused Decisive Leadership handout (Google Docs)

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Appendix

A Value-focused vs values-based — what’s the difference?

The distinction between “value-focused” and “values-based” often comes down to the difference between utility (what is beneficial or effective) and ethics (what is right or principled).5

While they sound similar, they operate in different domains of decision-making and organizational behavior.

A.1 Value-Focused Thinking (VFT)

This is an analytical approach to decision-making developed by Ralph Keeney.

• The focus: Singular “value.” It is about identifying what you want to achieve (objectives) before looking at the options available.

• The logic: Most people use “alternative-focused thinking,” where they look at the available choices and pick the best one. Value-focused thinking reverses this: you define your fundamental objectives first, then use those to create better alternatives.

• The goal: Maximizing utility, efficiency, and desired outcomes. It asks, “What is the most valuable way to spend our resources to reach this goal?”

• Example: In public health, a value-focused approach might define “minimizing HIV community viral load” as a fundamental objective, which then leads to creating innovative programs like mobile testing units rather than just choosing between existing clinic-based programs.

A.2 Values-Based Leadership (VBL)

This is an ethical and philosophical framework for behavior and organizational culture.

• The focus: Plural “values.” It is centered on core beliefs, moral principles, and the “why” behind actions (eg, integrity, empathy, social justice, transparency).

• The logic: It posits that leaders should be guided by a clear set of deeply held principles. Decisions are not made based on what is most efficient or profitable in the moment, but on what aligns with the identity and morality of the leader and the organization.

• The goal: Authenticity, trust, and long-term sustainability. It asks, “Does this action align with our core principles?”

• Example: A values-based leader might refuse a lucrative partnership because the partner’s labor practices conflict with the organization’s value of “human dignity,” even if the partnership would have provided significant financial “value.”

A.3 Key Differences at a glance

A.4 How they work together

The most effective strategies often combine both. Values-based leadership provides the ethical boundaries and the “compass,” ensuring the mission remains honorable. Value-focused thinking then provides the analytical “engine,” ensuring that once the ethical path is chosen, the decisions made are as impactful and efficient as possible.

B Book recommendations

I highly recommend these two books by Ralph Keeney. I primarily used the “Nudge” book as the source for this blog article.

1. Hammond, John S. Smart Choices: A Practical Guide to Making Better Decisions. 1st ed. With Ralph L. Keeney and Howard Raiffa. Harvard Business Review Press, 2015.

2. Keeney, Ralph L. Give Yourself a Nudge: Helping Smart People Make Smarter Personal and Business Decisions. Cambridge University Press, 2020.

Listen to Professor Ralph Keeney on YouTube: Value-Focused Thinking and Decisions

Footnotes

However, I was able to read parts of their book. One particular series of diagrams, the “Dynamics of Group Decision Making” (DGDM), made a strong impression on me. Figure 1 depicts my adaptation of one of the DGDM figures from the book. That divergence-convergence diamond was encoded into my long-term memory — especially the “groan zone.” The DGDM diamond influenced my leadership facilitation style. It was my foundational mindset on how to run meetings to get to consensus and to “get things done.” But I still had (and have) a lot more to learn.

Fortunately, I finally had the opportunity to complete their 3-day training earlier this month! They are based in San Francisco’s Dog Patch neighborhood, so it was a pleasant daily commute.

I learned a tremendous amount! I highly recommend their workshop!

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In most organizations meetings are of the “business as usual” (BAU) type (left side of Figure 1). Most meetings are heavily influenced by organizational culture and norms. Workplace trainings on facilitating participatory decision making may not be available.

In general, meetings that end with an concrete action plan are considered a success. Having this “bias to action” is considered a positive leadership trait. This approach is fine in a stable environment (Figure 2) where the link between action and desired outcome are tightly coupled.

However, in public health, the only thing that is constant is change — sometimes with big changes like pandemics, extreme weather events, and funding disruptions. Public health operates in a VUCA environment (volatility, uncertainty, complexity, and ambiguity). Unfortunately, how we make high stake decisions are often an extension of BAU processes.1

Figure 3 depicts the SIREN Checklist to detect opportunities to improve DQ. Unfortunately, we miss this opportunity more than we realize. In the face of a sudden — or even not-so-sudden — change to the environment (high stakes, high impact, high resources (cost, time, people), high emotions, high novelty), managers are likely to lean on familiar BAU processes.

Figure 4 depicts how the SIREN Checklist supports detecting an opportunity to improve DQ.

Some frameworks have DQ built explicitly into their BAU. For example, DQ is part of design thinking (Figure 5).

The Community At Work training focused on learning and practicing the skills of neutral facilitation with a special emphasis on three stages:

• divergence

• groan zone

• convergence

We learned and practiced listening, mirroring, paraphrasing, capturing ideas on poster paper using legible writing, facilitating brainstorming and building consensus, managing disruptions, setting meeting agendas, co-creating sustainable agreements, facilitating closure, and much more.

The workshop content comes from their book (Figure 6) which is a comprehensive “how to” manual with many techniques and graphics (like the “Dynamics of Group Decision Making”).

I am excited because the 4th edition of their book comes out this year!

My instructor was Diamond Lee, MSW, owner of Liberation by Design (Figure 7). She’s has extensive frontline experience in Los Angeles County, including working with public health and health care stakeholders. She modeled the best practices of neutral facilitation of participatory decision making.

Comments on “bias to action”

In general, having a “bias to action” is considered a good leadership trait. An action is the product of a decision — good and bad decisions. We want leaders to aim for good decisions and to have a “bias to action.” They are not mutually exclusive. “Bias to action” is a cardinal feature of design thinking (ie, prototyping, testing, and learning) and “"Commitment to Action” is a DQ requirement.

Actions are experiments, or the “D” in PDSA, and can lead to learnings (aka, “action learning”) that contribute to DQ (Figure 8).

But leaders also need to be mindful of when to slow down to explore, deliberate, and innovate. The DGDM divergence-convergence model is a great reminder!

Closing

I am thrilled that I finally completed the Community At Work training on facilitating participatory decision-making. I have just scratched the surface and have much more to learn. I look forward to testing these techniques when I facilitate meetings.

Please share your recommendations on learning opportunities to develop our team facilitation skills.2

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Appendix

Here are other depictions of the Sam Kaner’s DGDM.

Footnotes

No!!!

Choosing wisely means choices that align with my values and goals. I value and want to become stronger and healthier. Therefore, I chose to get a regular bike because I want to expend more physical effort and become stronger and healthier.

RULE: “Effort is the algorithm.” Improvements in cognitive, emotional, behavioral, and social (CEBS) capabilities must go through expenditures in effort. This is called productive struggle.

Changes in CEBS capabilities are mediated by the effort-activated rewiring of our brains. Unfortunately, through cognitive offloading,1 generative artificial intelligence (GenAI) can lead to decreases in cognitive capabilities including reasoning, critical thinking, and problem solving. Naturally, we should be very concerned about the adoption of GenAI tools and their potential negative impacts on our human capabilities, especially for our youth.

Figure 1 summarizes how I think about GenAI impacts along three key dimensions:

1. Value (addressing an important need for self, client, patient, community, etc.)

2. Cognitive effort (required for learning, improving, and brain rewiring)

3. Human capability (without GenAI assistance)

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Combined capability, human + GenAI, leads to increases in productivity, but not necessarily increases in human capabilities when the GenAI is removed. Agency Gap is the decrement in human capability when GenAI is removed. This can be avoided if we use GenAI wisely.

When we use GenAI, our goal should always be to deliver positive value. In Figure 1, delivering positive values occurs in the top four quadrants. For example, at work, GenAI can increase your productivity and contribute to the organization’s mission. However, because of cognitive offloading, GenAI use can also lead to metacognitive laziness and dependence on GenAI.

Figure 2 lists examples of AI use that delivers positive value and impacts effort and capability. On the road, Google Maps enables convenient GPS navigation to geographic locations, decreases cognitive effort, but also decreases the capability of deploying and reading paper street maps.

At work, a GenAI deep research report saves time, decreases cognitive load, and contributes to the organization knowledge base. Unfortunately, what is good for the organization is not necessarily good for the employee’s intellectual development.

At home, a high quality AI foreign language app uses learning science to customize its interaction with the individual learner. The app increases the user’s cognitive load in a way that optimizes learning (eg, space repetition, comprehensible input, speaking, writing, dialog).

The impact of coding assistants (for Julia, Python, R, etc.) vary depending on how the user interacts with GenAI. Figure 3 depicts this interaction. GenAI can automatically provide coding suggestions (“proactive”) or wait for the user to seek assistance (“reactive”). In general, avoid proactive interaction.2

Ideally, user interaction with GenAI should be reactive: seeking evaluation, scaffolding, or information. Within reactive, we should prioritize

• Evaluative-seeking, and

• Scaffolding-seeking.

Both of these strategically INCREASE our cognitive effort directed toward learning and increasing our human capability independent of GenAI; in other words, there is no agency gap. This is what we want.

Evaluative-seeking is a best practice. We elicit critical feedback and then we work on fixing it — not the GenAI — us! Have the GenAI adopt different personas or perspectives (eg, play Devil’s Advocate). Even better: we should also elicit critical feedback from human partners. It’s good for us and our human partners!

Answer-seeking should be used sparingly or strategically. Gathering information or conducting AI deep research can be integrated into a high quality, decision making process (see Decision Intelligence 4 Health).

Figure 4 is the bottom 4 quadrants of negative value (Figure 1). Keep these empty. Displayed is an example of academic cheating by having GenAI write a school paper. Not only is this unethical (ie, negative value), but it also decreases human capability (agency gap) by cognitive offloading and avoiding productive struggle.

Figure 5 graphically depicts the ideal relationship between GenAI assistance, human capability (learning and improvement), and human cognitive effort. We want

• AI to increase our cognitive effort (it rewires our brain), and

• AI to optimize the human effort-capability curve to learn more faster in a way that is customized to our individual needs.

Done correctly, AI-human interaction will shift the effort-capability curve upwards. We learn and improve more per unit of cognitive effort. We want the right type of cognitive loading.

So far I have been covering aspects of pedagogical literacy. Generative AI literacy identifies four intersecting domains of understanding (Figure 6):

• Functional literacy: How does AI work?

• Ethical literacy: How do we navigate the ethical issues of AI?

• Rhetorical literacy: How do we use natural and AI-generated language to achieve our goals?

• Pedagogical literacy: How do we use AI to enhance teaching and learning?

To learn more visit Understanding AI Literacy from Stanford University.

Summary

GenAI has the potential to make us smarter and dumber.3

Generative AI literacy can provide us the tools to use GenAI to increase our human capabilities by optimizing the effort-capability curve to meet our individual learning goals.

Be careful! Many of our organizations only care about productivity (positive value to them) which make us feel good and appear smart. But GenAI may actually be making us dumber. This is exposed when we do not have GenAI as a crutch. Again, this is the agency gap.

Finally, remember to stay intellectually humble and hungry.

Use the your smarter future self to do good.

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Tomás

Appendix

Glossary

• Agency gap

• AI literacy

• Cognitive offloading

• Evaluative seeking behavior

• Metacognitive laziness

• Pedagogical scaffolding

• Productive struggle

• Self-regulated learning

Videos

Priya Lakhani. This Is How Kids Should Be Learning with AI. TED. 2026. Video, 10:58.

Derek Muller. Veritasium: What Everyone Gets Wrong About AI and Learning – Derek Muller Explains. Perimeter Institute for Theoretical Physics. 2025. Video, 1:15:05.

Footnotes

Special acknowledgment and thanks to Youngjae Kim, Chief Lean Transformation Officer, Assistant Deputy Director, Policy and Planning (Lean Transformation Branch) at the California Department of Public Health.

What do PDSA, decision quality, and design thinking have in common? (Figure 1)

They can all be conceptualized and deployed using PDSA. PDSA is universally applicable.

I love PDSA!

PDSA stands for Plan-Do-Study-Act. PDSA is the cycle of scientific thinking, action, and continuous improvement. Unconsciously, PDSA thinking and problem solving is part of human nature: it is how we predict and try things, learn, adapt, and improve. Being intentional about embracing PDSA supercharges your reasoning, deciding, learning, and improving.

In my recent blog on PDSA, “PDSA thinking for daily problem-solving,” I covered how to use PDSA for

• scientific thinking,

• single-loop and double-loop learning, and

• deductive, inductive, and abductive reasoning

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PDSA is also a powerful way to organize your strategic, problem solving, and innovation frameworks. Today I demonstrate this with four tables covering

1. PDSA core and comparison to design thinking and lean startup.

2. PDSA decision making using decision quality (DQ) requirements

3. PDSA lean A3 thinking/reporting

4. PDSA Results-Based Accountability (RBA)

In lean, standard work is “the agreed-upon, best-known, least wasteful way of doing the work today until a better way is found.” Standard work provides a structure to communicate, train, practice, and deliver an expected sequence of activities. Starting with continuous self-improvement, leader standard work is developing people to solve problems and improve performance (individual, team, organization).

PDSA supercharges your leader standard work!

The tables below are available as markdown and LaTeX tables on Github.

PDSA problem solving core

Table 1 uses PDSA to organize PDSA problem solving. The steps are self-explanatory. Tables 1 also compares the PDSA core components to design thinking1 (aka, human-centered design) and lean startup.2 PDSA aligns with and can accommodate the best practices from these innovation frameworks.

IDEO describes design thinking as having a beginner’s mindset with three core activities: inspiration (empathize, define), ideation, and implementation (prototype, test). Eric Ries, author of The Lean Startup, summarizes lean startup with three words: build, measure, learn. Both use the Power of 3 to make their innovation frameworks memorable. The key takeaway is that learning other innovations frameworks does not detract from PDSA; they all use — more or less — the same iterative process of diagnosis, discovery, implementation, evaluation, learning, and improvement. Design thinking emphasizes human-centered empathy. Lean startup emphasizes building a minimum viable product (MVP) for testing and learning. These powerful concepts can be integrated into your PDSA thinking and problem solving.

IDEO also calls out the importance of good decision making as the process of divergent and convergent thinking (Figure 2).

Figure 3 depicts PDSA problem solving as a series of key decisions. The quality of problem solving depends on the quality of decision making.

Not only is PDSA problem solving a series of key decisions, decision quality requirements can be organized as PDSA.

PDSA for the quality of decision making

Table 2 uses PDSA to organize decision quality (DQ) requirements for decision making and continuous improvement. The DQ requirements are like links in a chain: the quality of a decision is only as good as its weakest link.

Figure 4 depicts the DQ Checklist. PDSA operationalizes DQ into a continuous improvement process.

To learn more about decision making, visit TEAM Public Health here:

PDSA lean A3 thinking/reporting

Lean practice is “systematically developing people to solve problems and consuming the fewest possible resources while continuously improving processes to provide value to community members and prosperity to society.”

Table 3 uses PDSA to display the components of A3 thinking which is used for teams solving complex problems. A3 reports are usually summarized into one page (A3 paper), or the way I prefer, two pages (8.5in x 11in).

To learn more about lean visit: https://teampublichealth.substack.com/t/lean.

PDSA Results-Based Accountability

Results-Based Accountability (RBA) is a results-based framework for improving communities for families and children. RBA is also an epidemiologic framework for guiding a collective impact initiative. RBA complements lean and emphasizes:

• Aspirational, outcomes focus (“Is anyone better off?”)

• Framework for designing and selecting indicators

• Root cause analysis (“What’s the story behind the curve?”)

• Decision criteria for selecting promising, effective strategies

Table 4 list the 6 RBA questions. To learn more download the RBA Accountability Guide.

Whereas lean A3 thinking tend to focus on organization operational processes, RBA was designed to engage and mobilized communities towards a common goal.

Summary

PDSA is for scientific thinking, problem solving, decision making, and much more (deductive reasoning, inductive reasoning, abductive reasoning).

PDSA is the foundation of lean practice, including A3 thinking, and RBA.

PDSA also enables you to learn, evaluate, and integrate more effectively other innovation frameworks such as design thinking and lean startup.

PDSA is a standard for evaluating new and emerging innovation frameworks.

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NOTE: The tables below are available as markdown and LaTeX tables on Github.

TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix — Lean 8Ds

Lean has similar frameworks that get confused with A3 thinking. To learn more, read this article. Here is quick summary:

“The 8Ds or the eight disciplines were developed by Ford in the 1980s as a team problem-solving approach. The A3 process is a Toyota-pioneered practice of getting the problem, analysis, corrective actions, and action plan on a single sheet of large (A3) paper, often with the use of graphics. The main difference is that the 8Ds, summarized below, are oriented toward organizing and leading a team through a structured problem-solving process.”

The 8Ds

1. Form a team with product or process knowledge

2. Describe the problem in quantifiable terms such as what, where, how many, etc.

3. Implement containment actions to isolate the problem from customers.

4. Determine and verify all applicable causes

5. Select and verify permanent corrections

6. Implement the best corrective actions

7. Take actions to prevent the problem from recurring

8. Recognize and congratulate the team

As an exercise, convert the 8Ds into a PDSA table.

Footnotes

“… there are only two things that determine how your life turns out: luck and the quality of your decisions. You have control over only one of those two things.”

“… your decision-making is the single most important thing you have control over that will help you achieve your goals.”

Annie Duke, How to Decide: Simple Tools for Making Better Choices. Penguin Publishing Group, 2020.

Often times, we do not have the time, capabilities, or funding to conduct computational decision modeling. With advances in computation and artificial intelligence, we have the opportunity to improve on individual, team, and organizational decision modeling. To support this journey for practitioners we are building a decision modeling code repository for learning: https://di4health.github.io/.1

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Figure 1 and Figure 2 depict two different ways of solving a practical policy decision program: influence diagram and decision tree. The analyses for these Figures are available here.

The purpose of di4health.github.io is to develop a Jupyter notebook repository of health economic decision modeling (aka, decision analysis) coding examples to support health analysts who are learning how to code to solve practical decision problems. A secondary purpose is to have a repository for training artificial intelligence to assist us in tackling more complex decision problems.

For decision modeling we are focusing on the following approaches:

• decision trees

• influence diagrams (Bayesian decision networks)

• agent-based modeling

The following open source software packages are used for decision modeling and leverage different approaches: decision trees, Bayesian networks (eg, influence diagrams), mixed-integer linear programming (MILP) (ie, optimization), and agent-based modeling.

1. R: rdecision: for decision trees

2. Python: pyAgrum: for influence diagrams with Bayesian networks

3. Julia: DecisionProgramming.jl: for influence diagrams with MILP

4. Julia: Agents.jl: for agent-based modeling

We are early in our journey and invite critical feedback, input, and suggestions.

Do you want to contribute a Jupyter notebook? Contact Tomás Aragón.

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TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix

From Mirko von Hein, learn how to build a healthcare decision tree model in R from scratch to calculate ICERs, run one-way sensitivity analyses, and create tornado diagrams for cost-effectiveness analysis.

Here is the R code for this YouTube tutorial (Feb 15, 2026).

Here is original tutorial on Rpubs (2020).

Footnotes

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The CT is a simple and intuitive way to organize your objectives, alternatives (choices), and consequences (measures) (Figure 1). This is brilliant!

Objectives, alternatives, and consequences are key components of their 8-element framework with the acronym PROACT—URL. This is easy to remember: think “PROACTive URL”

1. PRoblem

2. Objectives*

3. Alternatives*

4. Consequences*

5. Trade-offs

6. Uncertainty

7. Risk tolerance

8. Linked decisions

This blog posting focuses on objectives, alternatives, and consequences organized as a CT.

CT can be deployed by anyone! My wife is a public school first-grade teacher and she uses a consequence table frequently for organizing decision options. Using a whiteboard and marker you can answer the following questions:

• What do we want to accomplish (objectives)?

• What choices do we have (alternatives)?

• What outcome measures (consequences) will guide our selection?

That’s it! It is very easy to apply.

With some reflection you will recognize that a CT is just a 2-way table with Objectives and Key Results (OKRs) and Alternatives (Table 1).

With more reflection you can also see a decision tree version of the 2-way table (Figure 2). The probability of an outcome can be multiplied by its utility (eg, quality of life).2

To learn more about decision trees in decision analysis, see recent post.

A CT is very powerful because of its immediate practical use, but it also connects you to higher level concepts of 2-way tables and decision trees for decision analysis. For concreteness, we briefly review a simple example.

Example — MMR vaccine to prevent measles infection (scenario)

The measles virus is transmitted through airborne transmission. An unvaccinated child exposed to measles has a 90% change of becoming infected. Unvaccinated, young children with measles have a significant risk of severe complications, including pneumonia, brain swelling, and death, particularly. MMR vaccine uptake has been low in recent years. There is now an ongoing outbreak of measles in the community. Our objective is to minimize measles cases.

Here are three important questions:

1. I am a parent. Should I vaccinate by baby against measles with the MMR vaccine?

2. I am a pediatrician. Should I recommend that my 12-month old patient be vaccinated against measles with the MMR vaccine?

3. I am the directer of US Department of Health and Human Services. Should I recommend that young children be vaccinated against measles with the MMR vaccine?

Here is fictitious data of recent measles cases from a community outbreak.

The risk of measles among the vaccinated children was 0.027 (2.7%), and risk of measles among the unvaccinated children was 0.9 (90%). The vaccine effectiveness (VE) is 97%.

Based on these results, the decision is clear: the parent, the pediatrician, and the directer of US Department of Health and Human Services should recommend MMR vaccination for unvaccinated children, especially during a community measles outbreak.

Example — MMR vaccine to prevent hospitalizations and death

In Table 2 above we had one objective: minimize measles cases. We can extend our objectives:

• Minimize measles cases (9 in 10 in unvaccinated exposed)

• Minimize measles hospitalization (1 in 5 in vaccinated cases)

• Minimize measles death (1 in 500 in unvaccinated cases)

A template for an updated consequence table is displayed in Table 3 below.

Table 3 demonstrates how we can add objectives to the CT, and how the Key Results can be designed to inform our decision. In this measles scenario, because MMR is so effective in preventing infection (97%), the vaccine effectiveness against preventing hospitalization and deaths is even higher. Because the measures are so close to 100%, the increases in VE are “marginal.” In any case, getting MMR is very, very effective, and very, very safe.

I could have included minimizing MMR vaccine severe adverse effects (such as hospitalization and death) as an objective. However, because these outcomes are essentially zero (0), their impact on the analysis is negligible.

Challenges and limitations

CTs are great for getting focused on discussing and deciding which alternatives are most likely to contribute to achieving the objectives. These objectives become your decision criteria. The obvious challenge is that the measures of these objectives may not be directly comparable. Here are some possible approaches:

• For each objective, rank the alternatives: for example, if you have five alternatives, rank them from 1 to 5, with 1 being the most favorable. Add up the scores for each column, and the alternative with the lowest score is leading contender for selection.

• For each objective, rate the alternatives using an appropriate Likert scale, and add up the scores.

Another challenge is that the objectives may not be equally important. You can weight the objectives based on importance. I posted a blog this topic: Simple method for calculating decision criteria weights.

Whatever you do — keep it simple!!!

You want to maximize discussion. Too much cognitive load leads to disengagement. You want teams focused, energized, and engaged.

In March, 2020, public health officials faced this COVID-19 pandemic challenge of competing objectives when implementing public health interventions under uncertainty, time constraints, and trade-offs. Table 5 below is a CT that qualitatively summarizes the objectives and the alternatives regarding a shelter-in-place order early in the pandemic.

Summary

Consequence Tables are very powerful for their simplicity and effectiveness in getting teams focused and discussing objectives, alternatives, and measures for a single decision. Key features include:

• Connection to OKRs (Objectives & Key Results)

• Connection to 2-way epidemiological analysis

• Connection to decision trees (decision analysis)

When there are multiple decisions that can be selected in different combinations, then we can use a Strategy Table (also called a Policy Table). See Appendix for an example.

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TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix — Strategy Table

Source: 3

Footnotes

This posting is part of a series on Bayesian Algorithmic Thinking (BAT). We will unpack Bayes’ theorem and then demonstrate how to use its components for basic decision analysis and more. Bayes’ theorem is depicted in Figure 1. H stands for causal hypothesis, and E stands for evidence.

The 2-node Bayesian network for Figure 1 is

Bayes’s theorem components can be used for the following:

1. Using evidence to update the prior probability to the posterior probability.

2. Calculating marginal probabilities of evidence for decision analysis (aka, “folding back”).

3. Calculating expected values of decision options for decision analysis (aka, “folding back and averaging”).

4. Comparing risks from decision options for causal inference.

We are focusing on 1 to 3.

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2-node Bayesian network as a tree

Figure 2 depicts the tree version of Figure 1 with a value node at the end. A value node can collect attributes such as utility (eg, quality of life), costs, and benefits.

Now, we can combine Figure 1 and Figure 2 into one Figure 3 (below).

First, from Figure 3, we see that Bayes’s theorem can used to update the prior probability to the posterior probability when new evidence is available.

Second, from Figure 3, we see that the Bayes’ theorem denominator can be used to calculate the marginal probability of evidence, P(E), for decision trees. We’ll see this later.

The outcome E can be weighted by a number between 0 and 1, where 0 is the worst possible health state (usually death) and 1 is the best possible health state. This is called a utility. The expected utility is

If E is the best possible outcome, say survival, then U(E) = 1. Then, the expected utility is

The expected utility of survival is the sum of the product of the probabilities along each path to survival. Those paths are highlighted with light blue in Figure 3.

2-node decision network as a decision tree

Now, let’s change the first node from a chance node to a decision node.

This can now be depicted as a decision tree (Figure 4) with a value node at the end. A value node can collect attributes such as utility (eg, quality of life), costs, and benefits. Notice that Figure 4 is almost identical to Figure 3 except that the first chance node was converted to a decision node.

Now, we can combine Figure 1 and Figure 4 into one Figure 5 (below).

Third, we can use the expected value (EV) formula to calculate the expected value of each decision branch.

2-node* decision network as a 2x3 table

Fourth, we can compare P( E | H ) to P( E | H^c ) components from Figure 5 for the purposes of causal inference. This is easiest to see as a 2x2 table (Table 1 below).

When the decision option is randomly allocated this is called a randomized controlled trial (RCT).

*Notice that I am not counting the value node; if I did it would be a 3-node decision tree. The reason is that all the action is in the decision and chance nodes: the value node is just a deterministic calculation of all this action (final outcomes, expected values, utility, costs, and benefits).

3-node decision tree

Using above concepts we can enlarge the decision tree to 3 nodes plus a terminal value node (Figure 6). By understanding the basic concepts we can tackle larger, more complex problems.

Decision analysis using the rdecision R package

We are now ready to conduct a basic decision analysis (Figure 7).

Case study from Diana Petitti, 2000 book:1 “In the context of an epidemic of measles in an inner-city population, experts estimate that 20 out of every 100 children age 8 through 15 will come in contact with an infectious case of measles each year. Literature review reveals that the probability of getting measles if exposed to an infectious case is 0.33 in a child who has had only one measles vaccination and 0.05 in a child who is revaccinated (Mast et al. 1990). The probability of getting measles in children who are not exposed to measles is, of course, zero. During the current epidemic, the probability of dying from measles if a child gets measles is 23 per 10,000 cases, or 0.0023 (Centers for Disease Control 1990). It is assumed that the probability of dying from measles in children who don’t get measles is zero. Figure 6 below shows the decision tree on which these probability estimates are shown.”

It is beyond the scope of this blog to show and discuss this entire analysis. Here is the R code (Figure 8) using the rdecision R package.2

Figure 9 (below) is the decision tree from rdecision R analysis in Figure 7.

The U(dead) = 0, and U(well) = 1. There are 8 paths to U(well).

To learn how to conduct this basic decision analysis using the rdecision R package visit https://github.com/tomasaragon/di4h and select “Decision analysis using a decision tree: R Jupyter Notebook” link under “Coding Examples.” Conducting a basic decision analysis is feasible for most public health practitioners.

Summary

Bayes’ theorem is like a Swiss Army knife. It connects you to the powerful world of Bayesian Algorithm Thinking. Today we covered how components from a single equation gives us insights into four powerful applications:

1. Using evidence to update the prior probability to the posterior probability.

2. Calculating marginal probabilities of evidence for decision analysis (aka, “folding back”).

3. Calculating expected values of decision options for decision analysis (aka, “folding back and averaging”).

4. Comparing risks from decision options for causal inference.

We were focused on 1 to 3.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix — Influence diagram for decision tree in Figure 6

Figure 9 depicts an influence diagram345 (aka, decision network) for Figure 6. This was based on the measles case study in Petitti Chapter 2. Notice there is no arrow from the measles node to the value node. The value node only contains input information on revaccination status and mortality. If measles morbidity was included then we would add an arrow from the measles node to value node.

I find influence diagrams much more concise and interpretable. Because influence diagrams are directed acyclic graphs (DAGs), they promote causal reasoning.

Footnotes

“… character formation means building up three types of strengths: strengths of the heart (being kind, considerate, generous), strengths of the mind (being curious, open-minded, having good judgment) and strengths of the will (self-control, determination, courage).”

… David Brooks quoting Angela Duckworth1

Background — Crisis of poor character

In the United States, we are suffering from a crisis of poor character in our institutions, our electorate, and our elected officials.2 High profile public and private sector leaders with wealth, power, and policy influence seem to be driven by cruelty, corruption, coercion, and cult-like ideology — in short, lack of character. This has spread at the leadership level of our federal health institutions3 4 and even to some states.5 This is adversely impacting our mental, emotional, behavioral, physical, and social health.

In short — character matters!

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Stoic philosophy centers on character development, improvement, and more.

Good character is the foundation of being trustworthy and building trust.

Moral character is the foundation of ethical reasoning and decision making.

Good character, trustworthiness, and credibility lead to stronger partnerships and better policies that protect and promote health and human rights for all.

Why should health leaders care about character? First, character is the foundation of being trustworthy and building trust. Second, in public health and medicine, morality, moral character, and ethics are relevant because interventions can lead to unintentional harms and moral outrage. (See What does Florida’s Surgeon General teaches us about public health ethics and decision making?) And third, as health leaders, we have the responsibility to model good character and to promote good character development and ethical reasoning without promoting religion, dogma, ideology, or partisanship.

In a recent interview with the New York Times’ Erza Klein (Figure 1), I was thrilled to see California Governor Gavin Newsom promoting character development by recommending Meditations by Marcus Aurelius.6 Meditations is a foundational book for practitioners of Stoic philosophy.7 So, what is Stoicism?

What is Stoicism? (a brief introduction)

Stoic philosophy (Stoicism) is a non-religious, engaging way to promote character development. The premise of Stoicism is to live in accordance with nature. Humans are social beings capable of reason. We use our power of human reasoning to choose (wisdom) what is right (justice) even when it’s hard (courage, temperance). These cardinal virtues (wisdom, justice, courage, temperance) are good character in action. Stoics believe that being a good person (being virtuous) is necessary and sufficient to living a good life (human flourishing or eudaimonia). We are more effective by focusing on what we can control (dichotomy of control) and it always starts with self (humility, critical self-reflection, learning, and continuous improvement).

We can achieve living a life well lived (human flourishing or eudaimonia) by relying on the two pillars of Stoicism:

1. the four cardinal virtues and

2. the dichotomy of control.

First, the four cardinal virtues as the basis of good character:

1. wisdom (making better decisions by daily reflection and improvement)

2. courage (risking personal vulnerability to do what is right and just)

3. justice (promoting dignity, equity, inclusion, due process)

4. temperance (moderation, self-control, discipline)

Second, focus our cognitive, emotional, and behavioral efforts on what we can control — and it always starts with self.

From Tim LeBon, et al.,8 “Stoicism is a life philosophy developed initially by Zeno of Citium around the third century BCE. It reached its zenith in ancient Rome, where its most famous proponents included Seneca, Epictetus, and the Emperor Marcus Aurelius. In contemporary times, Stoic philosophy re-emerged as a major influence on Cognitive Behavioral Therapy (CBT).9 10 In the twenty-first century, Stoicism has enjoyed a further resurgence as a practical philosophy of life, as evidenced by many best-selling books, online communities,11 and renewed interest in its application in healthcare and other professional settings.”12 13 14

The Stoic mindset and behaviors

Building upon the pillars above, a team of academics and psychotherapists developed, tested, and validated the Stoic Attitudes and Behaviors Scale (SABS) questionnaire to measure genuine Stoic practice. The SABS identifies seven dimensions of Stoicism (mindset and behaviors):15

1. Beliefs about control — recognizing that while we cannot control events, other people or the past, our attitudes, considered thoughts, and voluntary behaviors are up to us.

2. Beliefs about happiness — Understanding that true well-being (human flourishing or eudaimonia) depends on the things up to us — including character and virtue — not on wealth or success.

3. Stoic mindfulness — paying close attention to our judgments and habits of thought, and using practices like daily reflection to catch unhelpful patterns.

4. Virtue — putting wisdom, courage, justice, and temperance* into practice. (* moderation, self-control, and discipline) )

5. Benevolence and compassion — recognizing our shared humanity and extending kindness and care.

6. Ethical development — seeing life as a lifelong journey of continuous self-improvement and growth in moral character and ethical reasoning.

7. Stoic worldview — placing our lives in a bigger picture, which can bring perspective, acceptance, and gratitude.

The SABS was tested with thousands of people worldwide. Participants who scored high on Stoicism reported greater life satisfaction, stronger resilience, and lower levels of anger and anxiety.

Stoicism in public health and medicine

The SABS was developed based on six principles of Stoic philosophy.

1. The Dichotomy of Control (→ Beliefs about control)

2. Theory of the Good Life (→ Beliefs about happiness)

3. Stoic Mindfulness and Cognitive Therapy (→ Stoic mindfulness)

4. Developing a Good Character (→ Virtue)

5. Oikeiosis (→ Benevolence, compassion, and ethical development)

6. Stoic Physics and Worldview (→ Stoic worldview)

The Stoic principles, mindset, and behaviors (Figure 2) are interdependent, mutually reinforcing, and generative. Stoic principles are already deeply rooted in public health values, ethics, and practice.

1. The Dichotomy of Control (→ Beliefs about control)

“The chief task in life is simply this: to identify and separate matters so that I can say clearly to myself which are externals not under my control, and which have to do with the choices I actually control.” — Epictetus

The Dichotomy of Control is central to public health leadership, practice, effectiveness, and resiliency, and helps us to

• improve leadership effectiveness by focusing on the “controllables.”

• reduce anxiety by not worrying about what is out of your control

• reduce helplessness by recognizing where you have agency (control)

• improve decision making by focusing on choices, causality, and prediction

• reduce moral injury and increase resiliency by deploying principles

• promote effectiveness and implementation science

The Dichotomy of Control principle is at work in the “Serenity Prayer” used in addiction recovery: “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

2. Theory of the Good Life (→ Beliefs about happiness)

“Wealth consists not in having great possessions, but in having few wants.” — Epictetus

“Very little is needed to make a happy life; it is all within yourself, in your way of thinking.” — Marcus Aurelius, Meditations

Stoics believe that pursuing of life of virtue (good character) is necessary and sufficient for eudaimonia — a Greek term that translates to “flourishing” or “well-being” and represents living a life of purpose, virtue, and fulfillment. Other things that people usually consider important such as status, money, and good reputation, may be of value but are not essential for crafting a well-lived life.16

In public health good character shows up as personal values-based, servant leadership — an intrinsic motivation to serve others.

Stoics believe that pursuing of life of virtue (good character) is necessary and sufficient for eudaimonia — a Greek term that translates to “flourishing” or “well-being” and represents living a life of purpose, virtue, and fulfillment.

3. Stoic Mindfulness and Cognitive Therapy

“It’s not events that upset us but our opinions about them.” — Epictetus

“If you are distressed by anything external,* the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.” — Marcus Aurelius, Meditations (* outside of your control)

“Be curious, not judgmental.” — Walt Whitman; popularized by Ted Lasso17

Events, on their own, do not have the inherent power to distress us. It’s our interpretation; that is, the meaning we give to events that may distress us. Stoic mindfulness is noticing and changing our interpretations and judgments. The first element — noticing — is used in mindfulness practices, and the second — changing — is cognitive restructuring used in CBT.

4. Developing a Good Character (→ Virtue)

“Nothing is more hostile to a firm grasp on knowledge than self-deception.” — Zeno of Citium

“If anyone can refute me — show me I’m making a mistake or looking at things from the wrong perspective — I’ll gladly change. It’s the truth I’m after, and the truth never harmed anyone.” — Marcus Aurelius, Meditations

“It is not because things are difficult that we do not dare; it is because we do not dare that they are difficult.” — Seneca

“The duty of a man is to be useful to his fellow-men; if possible, to be useful to many of them; failing this, to be useful to a few; failing this, to be useful to his neighbours, and, failing them, to himself.” — Seneca

Building trust starts with being trustworthy: having character, and being caring, competent, and consistent (and reliable). But what is good character? Virtues are agreed upon character traits, values, and behaviors that are considered to be good. Virtues are good character in action.

The Stoics prioritized four cardinal virtues as the basis of good character:

1. wisdom (making better decisions by daily reflection and improvement)

2. courage (risking personal vulnerability to do what is right and just)

3. justice (promoting dignity, equity, inclusion, due process, etc.)

4. temperance (moderation, self-control, and discipline)

“Stoics recommend that people cultivate these virtues and prioritize keeping a good character above everything else. People should always do the right thing rather than take what might be the easier — but less good — option.”

Justice is a core value in public health, and its pursuit often requires courage, wisdom, and temperance. For examples of intellectual, moral, civic, and performance virtues see “Character Matters: The Moral Determinants of Health - and What to Do about It.”18

5. Oikeiosis (→ Benevolence, compassion, and ethics)

“Wherever there is a human being, there is an opportunity for kindness. — Seneca

“What brings no benefit to the hive brings none to the bee.” — Marcus Aurelius, Meditations

“We were born to work together like feet, hands, and eyes, like the two rows of teeth, upper and lower. To obstruct each other is unnatural.” — Marcus Aurelius, Meditations

The Greek word oikeiosis is best understood as our potential for rational and moral progress. “As humans age and become more rational, they understand that others are like us and worthy of care. With this growth, which Stoics assert is a natural process, people expand their care from themselves to others.” (See Hierocles’ Circles)

Circles of Concern/Caring (Hierocles’ Circles)

From the Daily Stoic: “Hierocles’ Circles was the picture … used to teach oikeiosis. We should always seek to draw the further circles toward ourselves, treating family as we would ourselves, friends as family, neighbors as friends, citizens as neighbors, and ultimately foreigners as fellow citizens.” (Figure 3)

In public health, we promote belonging without othering” and “bridging without breaking” (see Figure 4 for belonging).19

We also see this in lean Shingo Principles (respect every individual, lead with humility, etc.).

Public health and biomedical ethics

Expanding our circles of caring means protecting others from harm, preventing harms, and promoting healing. Harms are defined as infringement on moral values. Ethical reasoning is required to minimize harms and maximize benefits, and to resolve conflicting trade-offs when values collide.

To learn more see: “What Does Florida’s Surgeon General Teach Us about Public Health Ethics and Decision Making?”20

6. Stoic Physics and Worldview (→ Stoic worldview)

“Meditate often on the interconnectedness and mutual interdependence of all things in the universe. For in a sense, all things are mutually woven together and therefore have an affinity for each other.” Marcus Aurelius, Meditations

Whereas oikeiosis starts with self and moves outward (inside-out), the Stoic worldview starts with the universe and the laws of nature (outside-in). In other words, to see the big picture and to appreciate that we are connected and interdependent.21 In public health we see this systems perspective in two important models:

• Socio-ecological health model (Figure 5)

• One health model (Figure 6)

Socio-ecological health model (Figure 4)

One health model (Figure 5)

Summary

As health leaders, we have the responsibility to model good character and to promote good character development and ethical reasoning without promoting religion, dogma, ideology, or partisanship.

One approach — the one I recommend — is to leverage the wisdom of ancient philosophers that is accessible to all, promotes daily reflection and continuous improvement, and has scientific thinking, humility, and truth-seeking built in.

A good place to start is Stoic philosophy (Stoicism) which inspired the creation of CBT in clinical psychology. Many of the Stoic principles are already in public health science and practice. Stoicism provides an ethical, evidence-based framework to strengthen public health trust, partnerships, and practice.

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TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix

A. The Stoic Playbook by Professor Massimo Pigliucci

This is an outstanding introduction to Stoicism from Professor Massimo Pigliucci and is worth watching (published January 6, 2026; 110 min).

Selected Stoic techniques covered in YouTube video

1. Managing your emotions

2. Preparing for difficult situations

3. Finding peace in a chaotic world

4. Making difficult decisions

5. Becoming a better person

B. Stoic mindset and behaviors (graphic)

The 7 Stoic practices from Figure 2.

C. Relation to Jubilee Center Framework (JCF)

I recently posted the blog article “Character Matters: The Moral Determinants of Health - and What to Do about It.” TEAM Public Health, November 9, 2025. https://teampublichealth.substack.com/p/character-matters. I introduced the The Jubilee Centre Framework (JCF) for Character Education.

The JCF is based on neo-Aristotelian virtue ethics (NAVE). Stoicism and NAVE overlap significantly. The major difference is that Stoics believe that being a good person (being virtuous) is necessary and sufficient to living a good life (human flourishing or eudaimonia). NAVE adherents believe that being a good person (being virtuous) is necessary but not sufficient to living a good life (human flourishing or eudaimonia). NAVE adherents believe we must accrue a minimum amount of “goods” (wealth, health, etc.) to truly flourish. Stoics categorize these “goods” as “indifferents”; that is, they would be nice to have but are not necessary.

As a practical philosophy, Stoicism’s definition of being a good person is more accessible to all. When my mom wished for me to focus on being a good person, even as a kid, I felt this was within reach. This is more consistent with Stoicism. If she had included accruing wealth, etc., then I might have had different expectations and goals for myself.

As you can see, definitions matter. Character matters.

Footnotes

In Part 1, I introduced “Bayesian networks for algorithmic thinking.” We learned that a Bayesian network (BN) is a graphical model for representing probabilistic, but not necessarily causal, relationships between variables called nodes.1 2 Nodes are just variables; eg, like field names in a data table. The nodes are connected by one-way arrows called edges. BNs have a superpower — they provide a unifying framework for understanding …

1. probabilistic reasoning (with Bayesian networks),

2. causal inference (with directed acyclic graphs), and

3. decision analysis (with influence diagrams).

We learned that with 2-variable causal graphs we can understand

• causal/predictive reasoning, and

• evidential/diagnostic reasoning.

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This posting (Part 2) will cover causal/predictive reasoning.

… Bayes’ theorem

Evidential/diagnostic reasoning requires Bayes’ theorem (Figure 1). As new data/evidence becomes available, Bayes’ theorem enables us to update

• probabilities (eg, risks of adverse events, diagnostic testing),

• credibility of a hypothesis (eg, new evidence regarding causal claims), and

• beliefs (subjective, personal beliefs).

Table 1 summarizes the components of Bayes’ theorem from Figure 1.

… Aside: cause→effect vs. hypothesis→evidence nodes

I use Cause → Effect nodes when a causal relationship is established or assumed. Otherwise, I use Hypothesis → Evidence nodes. Here is another way of thinking about it: both depictions below are acceptable, but using hypothesis-evidence nodes is preferred because you do not need to keep adding ? marks.

Cause → Effect nodes (without the ? mark) are used for predictive modeling.

Hypothesis → Evidence nodes are used for diagnostic modeling.

Bayes’ theorem applies equally to both; just pay attention to conditional probabilities; eg, P(Evidence|Hypothesis) vs. P(Hypothesis|Evidence) — rows 2 and 4 in Table 1.

… Bayesian algorithmic thinking

Finally, Bayesian algorithmic thinking (BAT) enables us to generalize more broadly to the everyday processing of data (evidence), evaluating causality (hypothesis), and drawing conclusions (inference).

“BNs have a superpower — they provide a unifying framework for understanding … probabilistic reasoning, causal inference, and decision analysis.”

BAT supercharges your critical thinking, keeps you intellectually humble, and accelerates your learning and improvement. All public health professionals should understand basic BAT.

Figure 2 and Figure 3 depicts BAT as

1. inputs (data),

2. processes (algorithms),

3. outputs (inferences), and

4. outcomes (emotions, thoughts, decisions, and behaviors).

Figure 2 depicts causal/predictive reasoning with cause-effect nodes

and the conditional probability P(Effect | Cause) which is used for prediction.

In contrast, Figure 3 depicts evidential/diagnostic reasoning and Bayes’ Theorem with the hypothesis-evidence nodes

and the inverse conditional probability P(Hypothesis | Evidence) which is used for diagnosis.

For this posting (Part 2), we focus on Figure 2 — causal/predictive reasoning.

Causal/predictive reasoning — Cognitive biases

From Table 1 we see that the causal/predictive reasoning rows have two probabilities

• P(H) or prior probability of H

• P(E|H) or likelihood (how probable the evidence is if the hypothesis is true)

For concreteness, let’s consider the false claim that vaccines (hypothesis) are causally linked to autism (evidence).34 The prior probability is the P(vaccine exposure in early childhood) or P(V) — the P(hypothesis). The likelihood is P(autism given exposure to vaccines in early childhood) or P(A|V). — the P(evidence|hypothesis).

• P(V) = P(vaccine exposure in early childhood)

• P(A|V) = P(autism | vaccine exposure in early childhood)

Ideally, these probabilities, P(V)and P(A|V), should only come from objective, high quality, scientific studies. However, even when great evidence exists, this is insufficient. Remember, with BAT we consider three entities:

• probabilities (eg, risks of adverse events, diagnostic testing),

• credibility of a hypothesis (eg, new evidence regarding causal claims), and

• beliefs (subjective, personal beliefs).

So, even when strong evidence (probabilities) exists, others may not find it credible because of their beliefs. BAT handles not only probabilities, but also psychological information processing. As humans, we have

• core beliefs (eg, medical freedom movement) — data (inputs)

• cognitive biases (eg, confirmation bias) — algorithms (processes)

• updated beliefs about vaccines and autism — inferences (outputs)

Rather than Bayesian Algorithmic Thinking — the ideal — we instead have “Biased” Algorithmic Thinking. From Oeberst and Imhoff:5

“One of the essential insights from psychological research is that people’s information processing is often biased. … [cognitive] biases (e.g., bias blind spot, hostile media bias, egocentric/ethnocentric bias, outcome bias) can be traced back to the combination of a fundamental prior belief and humans’ tendency toward belief-consistent information processing.” (emphasis added)

These bias-generation algorithms applies to all of us and not just to “anti-vaxxers” or anti-science conspiracy theorists. All of us generate and reinforce cognitive biases:

1. fundamental prior beliefs — data (inputs)

2. belief-consistent information processing — algorithms (processes)

3. generation/reinforcing of cognitive biases — inferences (outputs)

These biases drive reinforcing causal feedback loops making non-science-based beliefs strong and stronger. Understanding this is critically important so that we …

• empathize with and have compassion for others whose conspiratorial beliefs clash with scientific, evidence-based norms,6

• do not judge others whose conspiratorial beliefs clash with scientific, evidence-based norms, and

• check and mitigate our cognitive biases.

Oeberst and Imhoff argue that humans have six fundamental prior beliefs (data) that shape belief-consistent information processing (algorithms) resulting in biases (inferences). Here are the six fundamental prior beliefs:

1. “My experience is a reasonable reference.”

2. “I make correct assessments of the world.”

3. “I am good.” (eg, character, competence, caring)

4. “My group is a reasonable reference.”

5. “My group (members) is (are) good.” (eg, character, competence, caring)

6. “People’s attributes (not context) shape outcomes.”

To begin to mitigate your biases, assume these six fundamental beliefs are false with respect to you and your group: “WHAT IF …

1. …, my experience is NOT a reasonable reference.”

2. …, I make INCORRECT assessments of the world.”

3. …, I am NOT good.” (eg, character, competence, caring)

4. …, my group is NOT a reasonable reference.”

5. …, my group (members) is (are) NOT good.” (eg, character, competence, caring)

6. …, people’s attributes (not context) DO NOT shape outcomes.”

Then, with intent and vigor, always

• challenge your assumptions

• seek objective, verifiable data and evidence

• prove yourself wrong — cultivate “disconfirmation bias”

Stay intellectually humble; make hypothesis-evidence your default; then, predict, experiment (or measure), identify and close prediction-error gaps, learn, and improve.

Part 3 preview

For Part 3 we will continue with causal/predictive reasoning with a focus on

• Correlation is not causation

• Alternative explanations

  • Confounding (common effect)

  • Abduction (common causes)

In future posts, I will cover decision analysis, computation, and more than two nodes.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Footnotes

4

Céline Gounder. “What the CDC’s Vaccine Language Shift Reveals About Pseudoscience.” Substack. Ask Dr. Gounder, December 20, 2025.

Ask Dr. Gounder

What the CDC’s Vaccine Language Shift Reveals About Pseudoscience

When the Centers for Disease Control and Prevention rewrote its vaccine safety webpage last month, it landed like a bombshell…

Read more

6 months ago · 5 likes · Dr. Céline Gounder

This post was inspired by this presentation on data science.

During graduate school at UC Berkeley one of my favorite professors was Steve Selvin. I took most of his courses and bought most of his books. Steve introduced me to S-PLUS — the proprietary precursor of the open source R.1 I came to love S-PLUS, and then R — a programming language and environment for statistical computing and graphics.2 I used R for all my number-crunching — except for decision analysis! I was disappointed that R was not designed to construct decision trees like other software.3 I was determined to figure this out.

In 2015, I enrolled in Stanford’s certificate program in “Strategic Decision and Risk Management in Healthcare.” I learned a ton! I learned that decision trees (Figure 1, right) can be represented as influence diagrams (Figure 1, left).4 And that an influence diagram is also called a “decision network” — a type of “Bayesian network.” No, not “Bayesian statistics” but a Bayesian network! This really piqued my interest! It turns out that Bayesian networks — a type of probabilistic graphical model — could be implemented in R. I was thrilled!

Bayesian networks could be used not only for probabilistic reasoning, but also for causal inference and decision analysis! At the time, I was teaching R programming at UC Berkeley and I immediately integrated this into my course. A Bayesian network is the Swiss Army knife of population health thinking (which I now call Bayesian algorithmic thinking). Bayesian network concepts are easy to learn, promotes critical thinking, and are broadly applicable.

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What is a Bayesian network?

A Bayesian network (BN) is a graphical model for representing probabilistic, but not necessarily causal, relationships between variables called nodes.56 The nodes are connected by one-way arrows called edges. BNs have a superpower — they provide a unifying framework for understanding the following types of reasoning:

1. probabilistic reasoning (with Bayesian networks)

2. causal inference (with directed acyclic graphs)

3. decision analysis (with influence diagrams)

Nodes are just variables; eg, field names in a data table.

All public health professionals should understand basic Bayesian networks — starting with mastering two nodes (variables).

Consider this noncausal BN:

Smelling smoke indicates an increased probability of a fire burning nearby, but obviously smoke alone does not cause a fire. In other words, knowing X (smelling smoke) changes the credibility of Y (fire nearby). This can be formulated as a probability:

In contrast, now consider this causal BN:

This causal BN depicts fire causing smoke. The causal arrow (edge) represents a unidirectional causal effect that can only point in direction. This specific causal network can also be expressed as a probability:

Notice that both noncausal and causal BNs have probabilistic dependencies, and that conditional probabilities arrows can always be formulated in both directions: eg, Pr(Y|X) or Pr(X|Y). In contrast, a causality arrow is always unidirectional.

To review: we have a Bayesian network with two variables (nodes) with a probabilistic relationship. And, we have a causal network (ie, a directed acyclic graph) which is a type of Bayesian network with a unidirectional, causal arrow.

Causal/predictive reasoning vs. evidential/diagnostic reasoning

Causal networks (DAGs) can be used for causal reasoning such as prediction:

Inferring causality comes natural to humans. In fact, we are quick to infer causality because we mistaken correlation for causation. For now, we will assume real causal effects. Causality enables prediction, but requires some effort. Fortunately, prediction can improve with practice, and in fact, is highly encourage.7 When a prediction disagrees with an outcome, we have prediction error. Closing the prediction error gap is called learning!

When a cause-effect relationship is not firmly established, the BN can represent the hypothesis-evidence concept:

We substituted “hypothesis” for “cause,” and “evidence” for “effect.” Notice that the probability of hypothesis given evidence, P(hypothesis|evidence), is the inverse probability of an effect given a cause: P(effect|cause).

In contrast to calculating P(effect|cause), that is used for causal/predictive reasoning, calculating P(hypothesis|evidence) requires Bayes’ theorem that is used for evidential/diagnostic reasoning. Whereas humans can become proficient at prediction calculations for causal/predictive reasoning, humans are terrible at calculating inverse probabilities using Bayes’ theorem for evidential/diagnostic reasoning.

Causal/predictive reasoning and evidential/diagnostic reasoning are used frequently in public health and medicine (Figure 2) — and sometimes not used!

Here are more public health examples:

DAGs can be used to estimate average causal effects which are not covered here. To learn about formal methods for causal influence, see Appendix for recommendations.

Bayes’ theorem for evidential/diagnostic reasoning

When we have a causal hypothesis (Does acetaminophen cause autism?) we use Bayes’ theorem to calculate the probability the hypothesis is credible given the evidence; ie, P(H | E), also called the posterior probability.

Bayes’ theorem is also used to quantify our subjective probabilities or beliefs. In Figure 3, P(H) is the prior (old) belief, P(H|E) is the posterior (new) belief, and P(E|H) is called the likelihood. The likelihood is critical because it is usually measurable, allowing us to update our belief. See Table 1.

The marginal probabilty P(E) can be “marginalized over H” which is a sum of conditional probabilities.

Bayes’ theorem is used to update

• probabilities (eg, risks of adverse events, diagnostic testing),

• credibility of a hypothesis (eg, evidence regarding causal claims), and

• beliefs (subjective beliefs).

Bayes’ theorem provides us with a systematic algorithm for processing evidence about a hypothesis.

• P(H|E) is the posterior probability: the probability the hypothesis is credible given the evidence.

• P(H) is the prior probability: the probability the hypothesis is credible before considering any evidence.

• P(E|H) is the likelihood: the accuracy of the evidence as a measure of the hypothesis (sensitivity, specificity, false positive, false negative, etc.)

  • sensitivity: the probability the evidence is present (eg, positive test) given the hypothesis is true (eg, disease present)

  • specificity: the probability the evidence is absent (eg, negative test) given the hypothesis is false (eg, disease absent)

A common application is using the results of a diagnostic test (evidence) to diagnose a disease state (hypothesis). For a worked out example see Richard Neapolitan, et al. “A Primer on Bayesian Decision Analysis With an Application to a Kidney Transplant Decision.” Transplantation 100, no. 3 (2016): 489–96. https://doi.org/10.1097/TP.0000000000001145. (also see8 )

Bayesian algorithmic thinking (BAT)

An alternative approach is to use Bayesian algorithmic thinking (BAT). From an individual agent’s perspective we have the following

• data (inputs: facts and signals from the internal and external environment)

• algorithms for processing data (cognitive, but can be computational)

  • causal reasoning (comes natural to humans)

  • evidential reasoning (requires Bayes’s theorem)

• inferences from algorithms

  • prediction (based on strength of causal reasoning)

  • diagnosis (based on strength of evidential reasoning)

Figure 4 is BAT for causal reasoning and prediction. An agent receives and processes data, applies an algorithm (causal reasoning), and generates an inference (prediction). This can happen automatically without our awareness. This is analogous to Daniel Kahneman’s System 1.9 Or, this can happen within our awareness with conscious intent, effort, and deliberation. This is analogous to Daniel Kahneman’s System 2. Causal reasoning and prediction comes natural to humans and improves with practice.

Figure 5 is BAT for evidential reasoning and diagnosis. An agent receives and processes data, applies an algorithm (evidential reasoning), and generates an inference (diagnosis). This can happen automatically without our awareness. This is analogous to Daniel Kahneman’s System 1. Or, this can happen with intent, effort, and deliberation within our awareness. This is analogous to Daniel Kahneman’s System 2. Evidential reasoning and diagnosis, done correctly, requires Bayes’s theorem. This process is much more challenging for humans.

For BAT, we want to be aware of how our core beliefs, cognitive biases and heuristics, and psychological triggers impact

• posterior probabilities (think “hypothesis” and “evidence”),

• prior probabilities (baseline beliefs and credibilities), and

• likelihoods (ie, accuracy: true positives [sensitivity], false positives [1 - specificity]).

Be aware of the impacts on the thoughts, emotions, and behaviors of ourselves and others. We all learn as if we are applying Bayes’ theorem — but we are not. By embracing and deploying BAT, we will improve our reasoning skills.

CAUTION! Our System 1 brain actually predicts first using pre-existing causal models in our memory (ie, “priors”). If the prediction is not strongly refuted by the data; ie, the prediction error gap is small, the brain accepts the pre-existing causal model. This is energy efficient and preferred by our brains. If the prediction is strongly refuted by the data; ie, the prediction error gap is large, the brain has a “choice”: reject the pre-existing causal model, which is learning but requires energy, or stay with the pre-existing causal model, which is energy efficient but results in no learning. The brain learns by closing the prediction error gap.

Summary

In this blog we introduced Bayesian networks as a unifying framework for

• probabilistic reasoning,

• cause inference, and

• decision analysis.

We learned that with 2-variable causal graphs we can understand

• causal/predictive reasoning, and

• evidential/diagnostic reasoning.

Evidential/diagnostic reasoning requires Bayes’ theorem. As new data/evidence becomes available, Bayes’ theorem enables us to update

• probabilities (eg, risks of adverse events, diagnostic testing),

• credibility of a hypothesis (eg, new evidence regarding causal claims), and

• beliefs (subjective, personal beliefs).

Finally, Bayesian algorithmic thinking (BAT) allows us to generalize more broadly to the everyday processing of data (evidence), evaluating causality (hypothesis), and drawing conclusions (inference).

BAT will supercharge your critical thinking, keep you intellectually humble, and accelerate your learning and improvement.

In future posts, I will cover decision analysis, computation, and more than two nodes.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix — Recommended

Read The Book of Why by Judea Pearl

Take Professor Miguel Hernán’s course

https://pll.harvard.edu/course/causal-diagrams-draw-your-assumptions-your-conclusions

Read the causal roadmap article by LE Dang, et al.

Footnotes

“… character formation means building up three types of strengths: strengths of the heart (being kind, considerate, generous), strengths of the mind (being curious, open-minded, having good judgment) and strengths of the will (self-control, determination, courage).”

… David Brooks quoting Angela Duckworth1

In the United States, we are suffering from a crisis of character in our institutions, our electorate, and our elected officials.2 High profile public and private sector leaders with wealth, power, and policy influence seem to be driven by cruelty, coercion, and corruption — in short, lack of character. This is adversely impacting our mental, emotional, behavioral, and social health.

Character matters!

Good character is the foundation of being trustworthy and building trust.

Moral character is the foundation of ethical reasoning and decision making.

Good character and trust leads to better partnerships and policies that protect and promote health and human rights for all.

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Growing up

My family immigrated from Nicaragua in the 1950s and settled in San Francisco’s Mission District, a vibrant Latino community with a high concentration of Central American immigrants. My mother had completed a sixth-grade education, worked as a seamstress, and raised four children as a single parent.

When I would ask my mom what she wanted for Mother’s Day or her birthday, she always replied, “The only thing I want is for you to be a good person.”

“Okay!,” I thought, “I can do that!” Even though we were materially poor, I always felt loved, supported, and accepted.

With the raising of my own three kids (now in their mid to late 20s), I adopted the same strategy. I reminded them that what mattered most was being a good person. When they were young, I would say and write often:

“Be good. Be safe. Be healthy. Be humble.”

Then, my wife and I would model and discuss with our kids what it meant to be good, safe, healthy, and humble.

We recognized that they would face new social challenges in middle school, so we added two adjectives:

“Be good. Be safe. Be healthy. Be humble. Be smart. Be strong.”

Again, we would also model and discuss with them what it meant to be smart and strong.

What mattered to us was promoting character development in our children in a way that they could embody, implement, reflect, and improve.

Working at health departments

When I became the health officer of San Francisco and director of the Population Health Division at the San Francisco Department of Public Health I promoted building organizational trust from Stephen M. R. Covey’s book: The Speed of Trust: The One Thing That Changes Everything.3 Covey’s 4 core capabilities were clustered under character (integrity and intent) and competence (capability and results). Why should we care about character?

First, character is the foundation of being trustworthy and building trust. Second, in public health, morality, moral character, and ethics are relevant because public health interventions can lead to unintentional harms and moral outrage. (See What does Florida’s Surgeon General teach us about public health ethics and decision making?) Because of this, as public health leaders, we have the responsibility to model good character and to promote appropriate character development and ethical reasoning without promoting religion, dogma, ideology, or partisanship.

Holistic framework for character development

For character development content and definitions I lean on The Jubilee Centre Framework (JCF) for Character Education in Schools (Figure 1).45 Although this content was develop for youth education, the concepts apply just as much to adults — especially to adults!

Good character is “having steady and permanent dispositions to do what is right and to refrain from doing what is wrong; having morally desirable wishes, desires, purposes, and goals; and having the tendency to respond emotionally toward things in the morally appropriate way.”6 7

Virtue is the act of good character. The JCF organizes virtues into four mutually supportive categories that are necessary for a well-rounded life:

• Intellectual virtues: Traits necessary for discernment and the pursuit of truth and knowledge, such as curiosity, critical thinking, and reasoning.

• Moral virtues: Traits that enable individuals to act well in situations requiring an ethical response, including honesty, courage, justice, compassion, and respect. (In short, have a moral compass.)

• Civic virtues: Traits necessary for engaged, responsible citizenship and contributing to the common good, such as service, civility, and community awareness. (In short, be a good team member. Contribute.)

• Performance (enabling) virtues: Traits that enable and support the other three categories. These include resilience, determination, motivation, and self-regulation.

The categories are integrated with the overarching virtue of Practical Wisdom (phronesis). Practical wisdom is the capacity, developed through experience and critical reflection, to choose intelligently between alternatives and discern the right course of action, especially when two or more virtues collide. The ultimate goal of character development is to equip us with this capability to make wise choices.

Intellectual virtues are character traits necessary for discernment, right action and the pursuit of knowledge, truth and understanding. Examples include:

• Intellectual humility — the ability to recognize and own your intellectual limitations in service of pursuing deeper knowledge, truth, and understanding through curiosity and inquiry.

• Autonomy — the ability to be independent in one’s thinking and action.

• Critical thinking — the ability to think reflectively and come to independent conclusions.

• Curiosity — genuine eagerness to know or learn something new.

• Judgment and reasoning — the ability to make decisions after careful consideration.

• Reflection — the ability to ponder alternative possibilities and not jump to conclusions; to practice critical self-reflection, humility, and self improvement.

• Resourcefulness — The ability to find quick and clever ways to overcome difficulties.

Moral virtues are character traits that enable us to act well in situations that require an ethical reasoning and response. They are fundamental to interacting with others, and responding appropriately. The examples that follow are found in most philosophical and religious systems of morality:

• Compassion — exhibiting care and concern for others.

• Courage — risking vulnerability to do what is right.

• Gratitude — feeling and expressing thanks for benefits.

• Honesty — being truthful and sincere.

• Humility — assessing accurately of one’s importance without pride or arrogance (see our other definitions of humility).

• Integrity — aligning of moral values, ethical reasoning, and behaviors.

• Justice — acting with fairness towards others by honoring rights and responsibilities.

• Respect — due regard for someone’s feelings and rights.

Civic virtues are character traits that are necessary for engaged, responsible citizenship, contributing to the common good (team, organization, community).

• Citizenship — active engagement in projects that benefit the community or contribute to the common good.

• Civility — being polite and courteous in our thoughts, behaviors, and speech.

• Community awareness — to actively learn from and share information with communities.

• Neighborliness — a disposition to be friendly and helpful to others.

• Service — working hard to serve and help other people.

• Volunteering — giving your time to help someone else.

Performance (enabling) virtues — are character traits that enable and support the intellectual, moral, and civic virtues.

• Confidence — being certain in your own abilities, and the abilities of others.

• Determination — the ability to keep going even when things are really tough.

• Motivation — having a strong reason and drive to act or accomplish a goal.

• Perseverance — the steady persistence in a course of action especially in spite of difficulties.

• Resilience — bouncing back from adversity despite obstacles in your path.

• Leadership — “… is getting results in a way that inspires trust.”

• Teamwork — the ability to work with others ethically and effectively.

In public health, our goal is to promote flourishing teams, institutions, and communities. The JCF describes the development of virtue through three integrated methods:

• Character Caught: Leaders must model good character by their behaviors.

• Character Taught: Organization should promote explicit instruction. In public health, this would be trainings on public health ethics and decision making.

• Character Sought: Leaders providing practical opportunities for staff to express, experience, and practice behaviors that reflect good character; for example, volunteering to serve and help others.

Promoting character development aligns with becoming a decisive, learning, healing, and impactful leader, team, and organization (Figure 2). Frameworks are necessary road maps for strategic decision making.

Summary

For public health leaders, character matters immensely. Good character is the foundation of being trustworthy and building trust. Moral character is the foundation of ethical reasoning and decision making. Good character and trust leads to better partnerships and policies that protect and promote health and human rights for all.

Public health leaders should not only model good character, they should model ethical reasoning and deliberation about the trade offs in public health policies. I believe this contributes to building trust with communities by taking their concerns seriously and into account.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Appendix

The Building Blocks of Character (infographic)

The 4 Cs of Building Trust (infographic)

Relation to Stoic philosophy (Stoicism)

The JCF is based on neo-Aristotelian virtue ethics (NAVE). Here is my summary of Stoicism. They overlap significantly. The major difference is that Stoics believe that being a good person (being virtuous) is necessary and sufficient to living a good life (human flourishing or eudaimonia). NAVE adherents believe that being a good person (being virtuous) is necessary but not sufficient to living a good life (human flourishing or eudaimonia). NAVE adherents believe we must accrue a minimum amount of “goods” (wealth, health, etc.) to truly flourish. Stoics categorize these “goods” as “indifferents”; that is, they would be nice to have but are not necessary.

As a practical philosophy, Stoicism’s definition of being a good person is more accessible to all. When my mom wished for me to focus on being a good person, even as a kid, I felt this was within reach. This is more consistent with Stoicism. If she had included accruing wealth, etc., then I might have had different expectations and goals for myself.

As you can see, definitions matter. Character matters.

Footnotes

Also read Decision Intelligence 4 Health.

When I was a medical resident I took pride in directing cardiopulmonary arrest resuscitations (aka, “running a code”). To become more proficient I rotated on elective services in the CCU, ICU, and ED. I became decisive and confident in running codes. I had a formula for success: study, practice, execute. I applied this formula to my medical and public health roles. My formula for success contributed, in part, to my promotions into leadership opportunities.

When I was introduced to lean quality improvement I learned that no matter how good I thought I was, I could always be better. This required embracing intellectual humility and being open to learning and improving. Although I embraced lean, I noticed from others a resistance to learning new things. Of course, this is old news: resistance to change is commonplace — that’s why we hire “change management” consultants! Another area I have encountered resistance to learning is in how to improve decision making.

I am on a mission to change this for health and human service organizations.

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Embedded in all journeys (life, learning, strategy, innovation, etc.) are the choices we make. Since medical school in the 1980s, when I was introduced to the nascent field “decision analysis,”1 I have appreciated that decision making is our most important daily activity. Annie Duke says it best:2

“… there are only two things that determine how your life turns out: luck and the quality of your decisions. You have control over only one of those two things.”

“… your decision-making is the single most important thing you have control over that will help you achieve your goals.”

In spite of its importance, why do leaders (in all fields) avoid learning how to improve their decision making? I assert there are three key reasons:

1. illusion of decisive leadership,

2. competing demands on leaders, and

3. complexity of decision competencies.

The illusion of decisive leadership

First, why mess with success? Leaders are in leadership positions because they know how to lead others, how to get things done, and how to make decisions! They are perceived to be decisive leaders — including sometimes by the leaders themselves. How do we define decisive leadership?

From Professor Michael Roberto: “Effective leaders do take charge when confronted with difficult organizational decisions. However, there are two different approaches to taking charge.”3

1. The leader dives right into the problem, trying to find the right solution. This type of leader focuses on what to do to improve the organization’s performance.

2. The leader takes a step back and focuses first on how the organization should tackle the problem. This leader asks, “What kind of decision process should we deploy? He or she focuses on trying to find the right process.

Roberto emphasizes that a much more powerful and effective definition of a decisive leader: A decisive leader ensures good decision processes. Good decision processes produce good solutions.

CAUTION: Roberto is not suggesting that we ignore solutions. It’s a polarity, both are true and important. He wants us to think critically about the definition of decisive leadership and to not settle for the stereotype. His thinking is similar to lean practice: focus on process *and* deliver value to the customer.

A decisive leader ensures good decision processes.

Good decision processes produce good solutions.

Second, all of us, including leaders, have cognitive biases that influence us to stick with the status quo.

• Overconfidence bias occurs when an individual’s subjective confidence in their judgments, decisions, or abilities exceeds their objective accuracy.

• Resulting (outcome bias) is the flawed tendency to judge the quality of a decision based on its outcome. When a leader’s decision leads to a good outcome, this confirms their intuition, falsely validating their decision-making process and reinforcing their overconfidence.

• Self-serving bias occurs when leaders attribute successful outcomes to their own skill while externalizing failures to uncontrollable factors. This attribution error prevents a leader from engaging in genuine learning and improvement opportunities.

• Status quo / Inertia bias occurs because we have a natural preference for familiarity. This preference for existing processes makes leaders reluctant to embrace change, even when a new process would yield superior results. This inertia can be exacerbated by decision fatigue from the sheer volume of high-stake decisions. When fatigued, leaders default to intuitive, familiar shortcuts rather than engaging in the structured deliberations required for higher quality decisions.

Third, leaders confuse participatory decision processes with decision quality. A good participatory decision process is necessary, but not sufficient, for a high decision quality. Participatory decision processes, without achieving objective decision quality criteria, creates an illusion of decision quality.

All of us have participated in meetings where high-stake decisions were made where we felt good about the meeting and the decisions. There was diverse representation, psychological safety, and everyone had a chance to speak up. “Feeling good” about a decision meeting is not the same as achieving high decision quality.

Participatory decision processes, without achieving objective decision quality criteria, creates an illusion of decision quality.

“Feeling good” about a decision meeting is not the same as achieving high decision quality.

Finally, Professors Don Moore and Max Bazerman, authors of Decision Leadership: Empowering Others to Make Better Choices,4 “define leadership in a new way, one grounded in the belief that leaders’ success depends not only on their ability to make good decisions but also on their ability to help others make wise decisions.”

“… leaders’ success depends not only on their ability to make good decisions but also on their ability to help others make wise decisions.”

Competing demands on leaders

In spite of its importance, many leaders believe they do not have the time or cognitive bandwidth to receive training in decision quality. Some believe that structured decision making is inefficient and will slow them down. Believing one is too busy to learn how to make better decisions is an indication that one absolutely needs the training. If they are too busy, then better decision making can improve their priority-setting and saying “no” to activities that do not add value to strategic priorities.

In general, to introduce a new productivity skill, such as decision quality, you will be more successful if the skill

• fits into existing staff and leader workflows,

• adds immediate value for staff, leaders, and/or customers, and

• and can be applied immediately at work, at home, and in the community.

Productivity skills that really matter improve quality of work and quality of life.

Any person who believes they are too busy to learn how to make better decisions is an indication that they absolutely need the training.

Complexity of decision competencies

Why is learning how to improve decision making so difficult? It’s complicated!

For starters, every decision involves

1. choices, causality, and prediction

2. outcomes, trade-offs, and opportunity costs

3. memory and sensory inputs

4. core beliefs and cognitive biases

5. emotions, reasoning, and actions

6. uncertainty and constraints

7. intuitive (“System 1”) vs deliberative (“System 2”) decisions5

8. first order vs second order6 decisions

9. individual vs. group (non-competing) decisions

10. single party vs multi-party (competing, interdependent)7 decisions

Every decision is influenced by one or more of the following:

1. values and/or goals

2. drives and/or impulses

3. stresses and/or pressures

4. faulty reasoning (eg, from VUCA)

5. learning and/or improvement opportunities

Finally, every decision has consequences (including unseen, unintentional, etc.).

Yikes!!! Where do I start?

The answer → Decision Intelligence 4 Health (DI4H) — The “Duolingo” of decision quality frameworks! See Figure 1.

Introducing Decision Intelligence 4 Health

Decision Intelligence 4 Health has

• 4 dimensions (Figure 1),

• 4 constraint types (values, information, time, and resources),

• 4 competency domains, and

• 4 DEEP decision challenges.

For more details see this slide presentation.

The DI4H 4 dimensions (Figure 1) with examples are

1. Decision Quality requirements:

   1. Decision Quality Chain (see below)

   2. Annie Duke’s “Six Steps”

   3. MG Myriam Hunink’s “PROACTIVE”

   4. Judy Ho’s “Blueprint for Change”

2. Strategy Execution frameworks:

   1. Lean / Shingo / Hoshin Kanri

   2. Objectives & Key Results (OKRs)

   3. Incident Command System (ICS)

3. Continuous Improvement frameworks:

   1. Lean / PDSA / A3 Thinking

   2. Results-Based Accountability (RBA)

   3. Needs-Driven Innovation (NDI)

4. Ethics, Science, and Technology

   1. Public health ethics

   2. Scientific Thinking

   3. Computational support (modeling, artificial intelligence, etc.).

The DI4H 4 competency domains are

1. Recognizing and resisting cognitive biases

2. Valuing and applying rationality8

3. Thinking probabilistically

4. Structuring decisions (ie, DQ tool)

The 4 competency domains are from the Alliance for Decision Education.

And, the DI4H 4 DEEP decision challenges faced by health and human services organizations are

1. Decision making under uncertainty (including deep uncertainty)

2. Ethical decision making (moral trade-offs, including personal decisions)

3. Emergency and crisis decision making (high stakes with time constraints)

4. Priority setting and resource allocation (budgetary/investment trade-offs)

Leaders and teams for health and human services organizations are confronted with these four DEEP decision challenges. These highlight important constraints: values, information, time, and resources. These categories are not mutually exclusive — they overlap!

Health and human services organizations must master these DI4H DEEP decision challenges.

Yikes again! Where do I really start?

First and foremost, read Annie Duke. How to Decide: Simple Tools for Making Better Choices. Penguin Publishing Group, 2020. https://www.annieduke.com/books/.

Use her Six Steps from the book as your default DQ framework.

Alternatively, if you do not have time to read a book, use the Decision Quality Chain (Figure 2) as a DQ checklist.

These are the elements of Decision Quality Chain:

1. What do I care about/need/want? (values)

2. What am I really deciding? (frame)

3. What can I do? (alternatives)

4. What do I need to know? (information)

5. Am I thinking straight? (reasoning)

6. Will I do it? (commitment to action)

For more ideas on how to use the Decision Quality Chain, download this 24-page booklet from the Decision Education Foundation.

The elements of decision quality are always applied within a strategic execution or continuous improvement framework. I recommend starting with PDSA.

Figure 3 is a different view of the Decision Quality Chain.

Figure 4 and 5 depicts how it is actually used in practice. Figure 4 is PDSA problem solving as a causal graph.

Figure 5 is a graphical depiction of the DQ Chain deployed within PDSA problem solving.

For more details, see this slide presentation or read this article:

• Aragón, Tomás J., Sara H. Cody, Christopher Farnitano, et al. “Crisis Decision-Making at the Speed of COVID-19: Field Report on Issuing the First Regional Shelter-in-Place Orders in the United States.” Journal of Public Health Management and Practice 27, no. Supplement 1 (2021): S19–28. https://doi.org/10.1097/PHH.0000000000001292.

The elements of decision quality are always applied within a strategic execution or continuous improvement framework. I recommend starting with PDSA.

Summary

To summarize, leaders (in all fields) avoid learning how to improve their decision making for three reasons:

1. illusion of decisive leadership,

2. competing demands on leaders, and

3. complexity of decision competencies.

Decision making is complicated! To introduce a new productivity skill, such as decision quality, you will be more successful if the skill

• fits into existing staff and leader workflows,

• adds immediate value for staff, leaders, and/or customers, and

• and can be applied immediately at home and in the community.

Decision Intelligence 4 Health can scale to the competency needs of any organization. It has

• 4 dimensions (Figure 1),

• 4 constraint types (values, information, time, and resources),

• 4 competency domains, and

• 4 DEEP decision challenges.

Remember, decision making is your most important daily activity; it’s a skill that is rarely formally taught. It will improve all aspects of your personal and professional life.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not-for-profit and reader-supported — blog. All content is freely available to all and is designed to be evergreen.

Serving with you,

Tomás

Footnotes

Amanda Ripley, journalist and author of “High Conflict—Why we get trapped and how we get out,” reminds us that any one of us can be swept up into conflicts that can spiral into self-perpetuating, all-consuming states of distrust, polarization, dehumanization, and harm.1

To avoid conflict or dig ourselves out of a heated conversations we need to practice “Looping for Understanding” — a mediation and conflict resolution technique.2 When speaking with someone where there is the potential for conflict, seek dialogue not debate. Until someone feels seen, heard, and understood, there will be a barrier to dialogue.

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When you are in conversation with someone and there’s potential for conflict, be humble and with genuine curiosity ask about their concerns. Your goal is to prove to them that you are genuinely trying to understand them. Focus on mindful, deep, and reflective listening (see Appendix). “Looping” has four steps (ie, PDSA — Plan-Do-Study-Act).

1. Understand: (Plan [based on a theory of change]: humble inquiry with listening for understanding can improve dialogue, connection, belonging, trust, and reveal the “understory”3)

2. Communicate: ask, listen, and reflect (Do)

3. Check: check with them for accuracy (Study)

4. Correct and update your understanding (Act on what you learn)

In the YouTube video below, Amanda Ripley summarizes the challenge of high conflict and discusses looping at 11:15 min.

NOTE! In the video Amanda Ripley presents “Looping” as these four steps: Listen, Repeat back, Check, and Correct. Listen to what is most important to the speaker. Repeat back (reflect) to them your understanding of their concerns. Use your own words. Check with them. Correct yourself. Charles Duhigg, author of Supercommunicators, lists three steps: 4

1. Ask a question;

2. Repeat back what you heard in your own words; and then

3. Ask if you got it right.

I use the four-step model from the Center for Understanding in Conflict which aligns with PDSA. The PDSA planning step is critical because it contains the theory of change. Read on to understand why this is so important!

The PDSA planning step is critical because it contains the theory of change.

Why is Looping for Understanding so effective?

The power of “Looping for Understanding” is the iterative Plan-Do-Study-Act (PDSA) cycle. The PDSA cycle is for learning and improving in pursuit of a goal. Looping is just PDSA to learn (ie, understanding) to improve dialogue and connection, and to avoid high conflict.

Let’s review the PDSA cycle. From The Deming Institute:

“The PDSA Cycle (Plan-Do-Study-Act) is a systematic process for gaining valuable learning and knowledge for the continual improvement of a product, process, or service. …” (Figure 1)

“The cycle begins with the Plan step. This involves

• identifying a goal or purpose,

• formulating a theory,

• defining success metrics … .

These activities are followed by the Do step, in which the components of the plan are implemented … . Next comes the Study step, where outcomes are monitored to test the validity of the plan for signs of progress and success, or problems and areas for improvement. The Act step closes the cycle, integrating the learning generated by the entire process, which can be used to adjust the goal, change methods, reformulate a theory altogether, or broaden the learning – improvement cycle from a small-scale experiment to a larger implementation Plan. These four steps can be repeated over and over as part of a never-ending cycle of continual learning and improvement.”

Incremental performance improvements occur by improving processes. Processes have underlying cause-effect assumptions called theories. The typical approach is to use PDSA cycles to test and adjust process improvements. We plan to test a process innovation, we make a prediction and test (do) the process innovation, we study the results, and we act on what we learned. This leads to incremental process improvements. Figure 2 depicts the relationship between a theory (model), a cause (process, action, condition, exposure), and an effect (result; ie, output or outcome).

Chris Argyris called this single-loop learning.5 6 He recognized that PDSA can also be used for double-loop learning which can lead to new theories and breakthrough performance improvements. Figure 3 depicts PDSA with single-loop and double-loop learning. For example, when efforts to improve a process are failing (unsatisfactory results), we have two choices:

• continue attempts to improve the process (single-loop learning; possible incremental improvements), or

• consider improving the theory (double-loop learning; possible breakthrough improvements)

Now, we can reformulate “Looping for Understanding” with the PDSA cycle framework (Figure 4).

Figure 5 (below) is the rearrangement of Figure 4 (above) into a table.

The superpower of PDSA cycles is the opportunity to implement single and double learning! Hence, the term “Looping for Understanding” is apropos!7

Finally, Looping for Understanding was popularized in Charles Duhigg’s best selling book8 Supercommunicators: How to Unlock the Secret Language of Connection. 2025 Random House trade paperback edition. With Charles Duhigg. Random House, 2025. Here is his 2024 TED talk.

He categorized conversations into three types:

1. Practical

2. Emotional

3. Social

Although he does not focus on exclusively on conflict, this is an amazing talk and worth watching. Duhigg’s TED talk complements Amanda Ripley’s talk.

The superpower of PDSA cycles is the opportunity to implement single and double learning! Hence, the term “Looping for Understanding” is apropos!

He promotes asking “deep” questions that move conversations into emotionally-laden territory that invite vulnerability. In the setting of psychological safety this can lead to stronger connection and trust.

In today’s increasingly divided world we need to dialogue across differences in order to build trust and positive social connections. Then we are equipped to co-create a better future for all.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not for profit — blog. All of the content will be freely available to all subscribers. The content is designed to be evergreen.

Serving with you,

Tomás

Appendix

Mindful, Deep, and Reflective (MDR) Listening

Mindful, deep, and reflective listening is always usefu1. Click here to learn more applications.

Appreciative Inquiry (the other “AI”)

“Looping for Understanding” aligns with the practice of Appreciative Inquiry.

Footnotes

“Driven largely by concerns about potential side effects, there has been a shift in some parents’ attitudes toward the child immunization schedule. The Childhood Immunization Schedule and Safety identifies research approaches, methodologies, and study designs that could address questions about the safety of the current schedule.”

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The Committee was multidisciplinary with a diversity of experts that included parents representing the numerous concerns about the magnitude and complexity of the childhood immunization schedule. In order to wrap my mind around all the issues and perspectives, I applied systems thinking using causal loops. After several iterations I settled on the version in Figure 1 below.2

The complexity of the childhood immunization has only increased over time. In 2013, “children younger than six may receive as many as 24 immunizations by their second birthday.”3 In 2025, children may receive as many as 25 to 31 immunizations by their second birthday.

From Figure 1, as complexity of the childhood immunization has only increased over time, we can draw the following absolute conclusions:

• Number of vaccine adverse effects will increase (not the per-vaccination risk — vaccines are extremely safe and effective)

• Parental concerns about vaccine adverse effects will increase

• Demand for reduced, alternative schedules will increase

Social media, conspiracy theories, and conflict entrepreneurs have amplified parents’ perceptions and concerns. This feeds the following:

• anti-science movement,4

• medical freedom movement,5 and

• lost of trust in public health and medicine.

Based on the current outbreaks of measles in the United States,6 we can also conclude:

• Numbers of vaccinations have decreased

• Community (herd) immunity has decreased

• Incidence of vaccine preventable diseases have increased

To make matters worse, the process for evaluating and approving vaccines have been taken over by Secretary Robert F. Kennedy, Jr. who is an anti-science conspiracy theorist.7

The Figure 1 systems map helped me tremendously understand the challenges we were facing then, and the challenges we are facing now. Unfortunately, Figure 1 was never published in the final IOM report; however, I assert that it continues to summarize accurately the system components and their relationships.

Systems thinking using causal loop diagrams is a powerful method to clarify your thinking and improve your reasoning. Identifying absolute directionality in a component of the systems supports prediction. In complex systems it’s rare to be able to predict with confidence.

Review of causal loop diagrams

A causal loop diagram is a complex network of causal influences where each node is a quantity of something (eg, number of infectious cases). When the quantity of one node changes (up or down) it causally influences the quantity of a connected node (up or down). A causal loop has two nodes with two connections. If the change in quantity of both nodes move in the same direction (up or down) the causal influence is “positive.” If the change in quantity of both nodes move in the opposite direction the causal influence is “negative.”

A causal loop between two nodes can result in either a balancing loop or a reinforcing loop. A balancing loop has one positive arrow and one negative arrow (Figure 2). Like a thermostat, balancing loops drive towards stability. A reinforcing loop has either two positive arrows or two negative arrows. In contrast to balancing loops, reinforcing loops drive towards higher and higher quantities (negative or positive). A reinforcing loop accelerates or amplifies a process, and can spiral out of control into instability and danger. To learn more study Peter Senge.8

Like a thermostat, balancing loops drive towards stability.

Using both feedback loops we can draw complex system maps (Figure 1) to gain a deep conceptual understanding of the forces driving a system problem, and to use it for problem solving. The United States vaccination-population health system is a complex adaptive system with diverse entities that are connected, interdependent and adapting through feedback loops. Emergent properties of a system can only be observed empirically from the interaction of components, and are not properties of individual components. For example, the transmission dynamics of a microbial agent in human populations is an emergent property: it is dependent on the prevalence of infectious persons, duration of infectiousness, the prevalence of susceptible persons, contact with susceptible persons, microbe transmissibility, host susceptibility, and microbial virulence.

A reinforcing loop accelerates or amplifies a process, and can spiral out of control into instability and danger.

Community immunity, the collective immunity of a population, is an emergent property that includes the indirect protection from immunized persons, whether by vaccination or natural infection, that benefits both unvaccinated and vaccinated persons.

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not for profit — blog. All of the content will be freely available to all subscribers. The content is designed to be evergreen.

Serving with you,

Tomás

Footnotes

Unfortunately, Dr. Susan Monarez did not survive politically, but she modeled strong ethical leadership, preparation, and moral courage for this moment. While she lost her CDC job she gained much more in the eyes of the public health community. She served and survived government service for several years. Being an appointed agency director brought additional risks. As public health officials, how can we improve our chances of political survival while adhering to our personal, professional, and organizational values?

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Political survival of local health officials

For several years I have been asked by the Health Officer Association of California (HOAC) to give a talk to new local health officers on “Political Survival for Appointed Public Health Officials.” Political survival of public health officials has always been an occupational risk that increased during the COVID-19 pandemic when officials lost or left their jobs because of burnout, dismissal, political pressure, or threats to their safety.1 2

In fact, political survival of public health officials has been an occupational risk for many decades as summarized in Dr. Joshua Sharfstein’s 2018 book “The Public Health Crisis Survival Guide: Leadership and Management in Trying Times” which was updated in 2023.3 I highly recommend this book which is given to every new State Health Official by the Association of State and Territorial Health Officials (ASTHO). (see Appendix)

I gave my latest HOAC presentation on September 24, 2025. My presentation is organized loosely using Stephen MR Covey’s quote that “Leadership is getting results in a way that inspires trust.”

“Leadership is getting results in a way that inspires trust.”

I used the The 4 C’s of Building Trust (Figure 1) as the framework to organize my presentation. For a full discussion of this model see this blog posting. Building trust is the foundation of political survival and it starts with being trustworthy. For health officials our only currency is credibility and public trust.

The 4 C’s of Building Trust

Building trust is the foundation of political survival and it starts with being trustworthy.

For health officials our only currency is credibility and public trust.

Appointed public health officials serve “at will” and can be dismissed without cause. To improve your survival chances you need to earn people’s trust. Start with your boss and other superiors: In one of your 1-on-1 check-in meetings say

“Earning your trust and confidence is important to me.” “I’d like to hear from you what I can do to increase your confidence in me.”4

Listen deeply, takes notes, reflect back your list, confirm accuracy, and make corrections. Use this validated list for follow-up check-ins. Continue to iterate. See below for “Looping to Understand” for improving dialogue during conflicts.

With everyone else, use the “4 C’s of Building Trust.” I will summarize selected concepts from each category.

1. Have Character (“Can I believe you?”)

Good character is the foundation of building trust. But what is good character? Good character is “having steady and permanent dispositions to do what is right and to refrain from doing what is wrong; having morally desirable wishes, desires, purposes, and goals; and having the tendency to respond emotionally toward things in the morally appropriate way.”5 Virtue is the act of good character. Below are generally accepted moral virtues found in most philosophical and religious systems of morality:6

• Courage — risking vulnerability to do what this right

• Justice — acting with fairness towards others by honoring rights and responsibilities

• Humility — accurate assessment of one’s importance without pride or arrogance (see our other definitions of humility)

• Honesty — being truthful and sincere

• Compassion — exhibiting care and concern for others

• Gratitude — reeling and expressing thanks for benefits

• Integrity — alignment of moral values, ethical reasoning, and behaviors align

• Respect — due regard for someone’s feelings and rights

Other important character virtues include loyalty and accountability:

• Loyalty

  • Do not bad-mouth anyone — ever — even to a trusted person. This requires self-control and discipline. A corollary: do not bad-mouth previous administrations. Model good character and leadership for your staff.

  • Do not criticize anyone on social media.

  • Do not be, or appear to be, partisan; you represent everyone in your jurisdiction. In this case you are loyal to all the residents.

• Accountability — Own your responsibilities and be willing to face the consequences that come with success or failure. Furthermore, accountable people “look out the window to apportion credit . . . when things go well, [and] they look in the mirror to apportion responsibility . . . when things go poorly.”7 In other words, when failures occur, actively seek full responsibility for anything we could have influenced — we do not seek blame or look to “hold someone accountable” — we problem-solve and ask “how can I (or we) make things better?”

Good character is the most important ingredient of being trustworthy. But how do we promote character development without promoting a religious framework? Philosophy! The ancients struggled with questions like “what is good moral character and good ethical reasoning?” I gravitated towards the philosophical tradition of Stoicism that inspired clinical psychologists to develop the evidence-based practice of cognitive behavioral therapy or CBT.8 9 10

Stoic philosophy (see Appendix)

The premise of Stoic philosophy (Stoicism) is to live according to nature. Humans are social beings capable of reason. Stoicism promotes the four cardinal virtues wisdom, courage, justice, and temperance (moderation, self-control, and discipline). Stoics use the power of human reasoning to choose (wisdom) what is right (justice) even when it’s hard (courage, temperance). Focus on what you can control (dichotomy of control) and it always starts with self — this requires humility, critical self-reflection, and continuous self-improvement.

Focus on what you can control and it always starts with self — this requires humility, critical self-reflection, and continuous self-improvement.

2. Be Caring (“Do you care about me?“)

The quickest way to build trust is to show you genuinely care.

1. Embody and promote Universal Values

2. Promote belonging without othering

Universal values are values that apply to everyone, everywhere, leaving no one behind, including your adversaries. Dr. Monica Sharma, former Director of Leadership Development at the United Nations, discovered that promoting the universal values of dignity, equity, and compassion enabled field teams to tackle difficult public health problems in all corners of the world.11

Embody and promote the universal values in every conversation and interaction. With universal values,

• we can connect with others through our shared humanity,

• we can transcend differences to find common ground, and

• we can co-create to solve problems together.

Othering is the process of defining individuals or groups as “other” — different, inferior, less deserving, or a threat — thereby denying their and our full humanity and dignity.

Belonging occurs:

• When we are included.

• When we have agency and are empowered to co-create our journey.

• When we are recognized by being seen and heard.

• When we feel connected to each other.

We endeavor to promote belonging without othering.12 This inclusive approach leads to targeted universalism:

“Targeted universalism is a policy and communication framework that sets a shared, universal goal for everyone while using targeted strategies to help different groups achieve it, acknowledging that groups are situated differently and face unique barriers. … this approach seeks to eliminate marginalization by not only supporting the needs of vulnerable groups but also addressing the needs of dominant groups, ensuring all can thrive and belong to the same social and civic fabric.”13

3. Be competent (“Can you deliver?“)

As a public health official you are expected to make good decisions, lead across boundaries (meta-leadership), manage crises and high conflict, and achieve results. This is a tall order! You need to become what Professor Edward Hess calls a hyperlearner.

Decision making

In public health we face four types of DEEP decision challenges:

1. Decision making under uncertainty (including deep uncertainty)

2. Ethical decision making (moral trade-offs, including personal decisions)

3. Emergency and crisis decision making (high stakes with time constraints)

4. Priority setting and resource allocation (budgetary/investment trade-offs)

For decision-making under uncertainty, read and re-read

• Annie Duke’s How to Decide: Simple Tools for Making Better Choices. Penguin Publishing Group, 2020. https://www.annieduke.com/books/.

Alternatively, I cover decision concepts from her book on the TPH blog.

For public health ethical decision making read this blog posting:

• Tomás Aragón. “What Does Florida’s Surgeon General Teach Us about Public Health Ethics and Decision Making?” TEAM Public Health, September 13, 2025. https://teampublichealth.substack.com/p/what-does-floridas-surgeon-general.

Crisis management and meta-leadership

Leading and managing a crisis has five phases:

1. Identifying the crisis

2. Leading the crisis response — you’re the default “incident commander”

3. Communications — see Table 1 and see Appendix

4. Managing multiple dimensions — see Table 1

5. Pivoting to achieve long-term gains (ie, “Never let a crisis go to waste.”)

For a health official, a crisis can be very personal or involve many others. A crisis is any event or circumstance that is

• a health threat, or a perceived health threat,

• an important issue that requires a fast decision from you, or

• a surprise no body was expecting (especially your superiors).14

Some of these are crises with a small “c”. You need to deal with these, even if it means delegating some of them to a trusted “fixer” with follow-up by you.

The (HELP)^2 Checklist (Table 1) is an acronym to remind you of eight key dimensions that require your attention during all phases of a crisis. This becomes more important below.

Crises with a big “C” are threats to the public’s health, including disasters that might require ICS15 activation. Leading during a large, complex disaster requires regional meta-leadership networks that respond, adapt, and scale to public health threats. The meta-leadership framework16 was developed from the empirical study of leadership during large-scale disasters (eg, World Trade Center terrorist attack, Hurricane Katrina, Boston Marathon bombing). Meta-leadership has 3 dimensions (Figure 2): the person (eg, health official), the situation (eg, COVID-19 pandemic), and connectivity (stakeholder relationships). Connectivity has 4 facets: leading down (your staff), leading up (your bosses), leading across (your institutional silos), and leading beyond (cross-sector relationships in the community and beyond). To be effective public health leaders, health officials must be effective meta-leaders.

Be crystal clear on your leading up relationships. When I was the health officer of San Francisco and director of the Population Health Division, I would remind myself that I could be dismissed without cause by upsetting just one of four entities: the mayor, the health commission, the agency director, or the Board of Supervisors. By extension, when you develop trust-based relationships in all directions you are more likely to survive when “someone” targets you for dismissal.

In the COVID-19 pandemic, the San Francisco Bay Area local health officers’ strong, preexisting relationships and collaborations enabled the spontaneous activation of what Dr. Leonard Marcus calls “swarm leadership”:

1. Unity of mission (focused on saving lives);

2. Generosity of spirit and action;

3. Staying in their own lanes;

4. No ego, no blame; and

5. Trust-based relationships.

Again, using the loyalty virtue, do not bad-mouth other organizations; focus on building trust-based relationships.

The bottom line: you need to always respond and adapt with speed and agility!

To learn more about meta-leadership and crisis management, read my article:

• Aragón, Tomás J., Sara H. Cody, Christopher Farnitano, et al. “Crisis Decision-Making at the Speed of COVID-19: Field Report on Issuing the First Regional Shelter-in-Place Orders in the United States.” Journal of Public Health Management and Practice 27, no. Supplement 1 (2021): S19–28. https://doi.org/10.1097/PHH.0000000000001292. (Also read the supplementary materials)

The bottom line: you need to always respond and adapt with speed and agility!

Managing conflict and avoiding high conflict

Protecting the public’s health sometimes requires interventions that impinge on individual rights. Sometimes these moral trade-offs result in moral outrage. You may need to interact with people who are angry and upset, including those who do not share your public health values or goals.

For these situations, Amanda Ripley, journalist and author of High Conflict: Why We Get Trapped and How We Get Out,17 recommends a mediation/conflict resolution technique called “Looping for Understanding.”18 19

When speaking with someone where there is the potential for high conflict, seek dialogue not debate. Ask about their concerns and focus on deep listening and dialogue with four steps (similar to PDSA — Plan-Do-Study-Act).

1. Understand: (Plan [based on a theory of change]: humble inquiry with listening for understanding can improve dialogue, connection, belonging, trust, and reveal the “understory”³)

2. Communicate: ask, listen, and reflect (Do)

3. Check: check with them for accuracy (Study)

4. Correct and update your understanding (Act on what you learn)

Until someone feels heard, seen, and understood, there will be a barrier to dialogue. In the YouTube video below, Amanda Ripley summarizes the challenge of high conflict and discusses looping at 11:15 min.

Looping is just PDSA for understanding to strengthen dialogue and connection, and to avoid high conflict.

For details, see: Tomás Aragón. “Manage Conflict with PDSA Looping: A Practical Tool for Humble Inquiry, Listening, Learning, and Understanding.” TEAM Public Health, October 11, 2025. https://teampublichealth.substack.com/p/manage-conflict-with-pdsa-looping.

Achieving results

Finally, health officials need to be results focused (remember, you are the default “incident commander”). Being a “decisive” leadership is not about having the right answer or making the right decision, it’s about being competent in ensuring a good process for making decisions and solving problems. To learn more read the following blog posting:

• Tomás Aragón. “Why Leaders Embrace OKRs -- and You Should Too.” TEAM Public Health, August 4, 2024. https://teampublichealth.substack.com/p/why-leaders-embrace-okrs-and-you.

4. Be consistent and reliable (“Can I count on you“)

Consistency and reliability is a blindspot for busy leaders! You might be too busy to return phone calls or follow through on commitments. You might be a benevolent, competent health official with impeccable character, but no one trusts you because you are inconsistent and/or unreliable.

In short, they cannot count on you!

Consistency and reliability is a blindspot for busy leaders!

Summary

I survived in public health official roles for 29 years — and I made my share of stupid mistakes. As you can see, a lot goes into building trust, and I have only scratched the surface. Reading books and news stories helped. I would ask myself, what would I do if I was in their shoes? Early and late in my career, I received great advice from senior health officials.20

Finally, do not hesitate to ask for help and advice. In California, HOAC provides a network of experienced health officials packed with wisdom and practical advice. At the national level, ASTHO plays a similar role. For example, see Appendix.

Let me know what I missed about this topic of political survival.

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TEAM Public Health is a FREE — not for profit — blog. All of the content will be freely available to all subscribers. The content is designed to be evergreen.

Serving with you,

Tomás

Appendix

ASTHO Survival Tips

Dr. David Lakey was Former Commissioner of the Texas Department of State Health Services. He served as president of the Association of State and Territorial Health Officials (ASTHO) from 2011 to 2012 and as the ASTHO Alumni President from 2019 to 2021. Here are his 12 tips for surviving as a state health official.

Six principles of effective emergency and risk communications

Source: https://www.cdc.gov/cerc/php/about/index.html

• Be first: Crises are time-sensitive. Communicating information quickly is crucial. For members of the public, the first source of information often becomes the preferred source.

• Be right: Accuracy establishes credibility. Information can include what is known, what is not known, and what is being done to fill in the gaps.

• Be credible: Honesty and truthfulness should not be compromised during crises.

• Express empathy: Crises create harm, and the suffering should be acknowledged in words. Addressing what people are feeling, and the challenges they face, builds trust and rapport.

• Promote action: Giving people meaningful things to do calms anxiety, helps restore order, and promotes some sense of control.

• Show respect: Respectful communication is particularly important when people feel vulnerable. Respectful communication promotes cooperation and rapport.

Stoic philosophy (Stoicism)

Stoic philosophy (Stoicism) is a non-religious, engaging way to promote character development.21 The premise of Stoicism is to live according to nature. Humans are social beings capable of reason. Stoicism promotes the four cardinal virtues wisdom, courage, justice, and temperance (moderation, self-control, and discipline). Stoics use the power of human reasoning to choose (wisdom) what is right (justice) even when it’s hard (courage, temperance). Focus on what you can control (dichotomy of control) and it always starts with self — this requires humility, critical self-reflection, and continuous self-improvement.

From Massimo Pigliucci, biologist and Professor of Philosophy

The premise of Stoicism (Stoic philosophy) is to live according to nature. Humans are social beings capable of reason.

We can achieve a life well lived (eudaimonia) by relying on the two pillars of Stoicism:

1. the four cardinal virtues, and

2. the dichotomy of control.

First, the four cardinal virtues are the basis of good character:

1. wisdom

2. courage

3. justice

4. temperance (moderation, self-control, and discipline)

Second, focus your cognitive, emotional, and behavioral efforts on what you can control, and it always starts with self.

From Tim LeBon, clinical psychologist

Stoic philosophy inspired the modern clinical psychology field of Cognitive Behavioral Therapy (CBT). “New research shows authentic Stoicism, unlike ‘stiff upper lip’ suppression, predicts better well-being. The Stoic Attitudes and Behaviors Scale (SABS) identifies seven key dimensions of Stoic practice. High SABS scores are linked with greater resilience, lower anger, and higher life satisfaction.”22

1. Beliefs about control – recognizing that while we cannot control events, other people or the past, our attitudes, considered thoughts, and voluntary behaviors are up to us.

2. Beliefs about happiness – understanding that true well-being depends on the things up to us — including character and virtue — not on wealth or success.

3. Stoic mindfulness — paying close attention to our judgments and habits of thought, and using practices like daily reflection to catch unhelpful patterns.

4. Virtue — putting wisdom, courage, justice, and temperance* into practice.

5. Benevolence and compassion — recognizing our shared humanity and extending kindness and care.

6. Ethical development — seeing life as a lifelong journey of growth and self-improvement.

7. Stoic worldview — placing our lives in a bigger picture, which can bring perspective, acceptance, and gratitude.

*moderation, self-control, and discipline

Recommended readings

1. Duke, Annie. How to Decide: Simple Tools for Making Better Choices. Penguin Publishing Group, 2020. https://www.annieduke.com/books/.

2. Robertson, Donald. How to Think like a Roman Emperor: The Stoic Philosophy of Marcus Aurelius. First St. Martin’s Griffin edition. St. Martin’s Griffin, 2020. https://us.macmillan.com/books/9781250196620/howtothinklikearomanemperor.

3. Amanda Ripley. High Conflict: Why We Get Trapped and How We Get Out. Simon & Schuster, 2022. https://www.simonandschuster.com/books/High-Conflict/Amanda-Ripley/9781982128579.

4. Gray, Kurt James. Outraged: Why We Fight about Morality and Politics and How to Find Common Ground. First edition. Pantheon Books, 2025. https://www.penguinrandomhouse.com/books/714327/outraged-by-kurt-gray/.

5. powell, john a., and Rachelle Galloway-Popotas. The Power of Bridging: How to Build a World Where We All Belong. Sounds True, 2025. https://www.soundstrue.com/products/the-power-of-bridging.

6. Sharfstein, Joshua M. The Public Health Crisis Survival Guide: Leadership and Management in Trying Times. Updated edition. Oxford Scholarship Online. Oxford University Press, 2023.https://doi.org/10.1093/oso/9780197660294.001.0001.

Footnotes

Florida plans to become the first state to end all vaccine mandates, including for schoolchildren, rejecting a practice that public health experts have credited for decades with limiting the spread of infectious diseases.

Dr. Joseph A. Ladapo, the Florida surgeon general, made the announcement on Wednesday alongside Gov. Ron DeSantis, a Republican. Mr. DeSantis rose to national prominence during the coronavirus pandemic, and over time he has espoused increasingly anti-vaccine views.

“Who am I to tell you what your child should put in their body?” Dr. Ladapo, a vocal denigrator of vaccines, said to applause during an event on Wednesday in Valrico, Fla., near Tampa. “Your body is a gift from God.”

He added that the administration would be “working to end” all vaccine mandates. “Every last one of them is wrong and drips with disdain and slavery,” Dr. Ladapo said, without elaborating.

This announcement sent shock waves through the mainstream public health community in the United States.1 2 3 4 5 6 7 8

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Dr. Ladapo is claiming that this is a straightforward decision between “right and wrong” — “Who am I to tell you what your child should put in their body?” … “Your body is a gift from God.” In other words, he felt he had no other choice — it was his moral duty.

This proposal, made in collaboration with Governor Ron DeSantis, positions the state as a leading proponent of "medical freedom," a philosophy that prioritizes individual and parental autonomy over communal health protection.9 10 This move challenges decades of established public health consensus and practice in the United States which has long relied on state vaccine mandates as a cornerstone for preventing the spread of infectious diseases.11

Below is the full announcement by Dr. Joseph Ladapo, Florida’s Surgeon General.

Full Announcement: Florida surgeon general says state is working to end all vaccine mandates, September 3, 2025

This announcement did not include any document or analysis. He explicitly disparaged mRNA Covid vaccines.

Subsequently, he was interviewed by Jake Tapper on CNN:

Florida surgeon general questioned on data before ending vaccine mandates

In this interview, Jake Tapper was very surprised that Dr. Ladapo did not conduct any public health analyses of the implications of this policy change, including epidemiological projections of potential increases in infectious diseases. Dr. Ladapo argued that no analyses were warranted because it was an easy moral decision between “right and wrong.”

Public health ethics and decision making

The Florida Department of Health (DOH) is accredited by the Public Health Accreditation Board (PHAB). Dr. Joseph Ladapo, a physician, directs the Florida DOH. As a physician, public health official, and director of a PHAB-accredited agency, he is obligated to justify his consequential public health decisions using public health ethical principles. That’s his job. That’s his duty as a physician, health official, and agency director.

In fact, it’s our duty too. So we need to review our public health ethical obligations. What can we learn from this story to improve ourselves?

“While morals are personal or internal principles of right and wrong, ethics are external, formal codes of conduct or societal standards applied to a community or profession, though the terms are often used interchangeably. Morals stem from an individual's beliefs and background, while ethics are more objective, systematic, and reasoned frameworks for conduct within a group.”12

In public health ethics there are four categories to review (the 4 As): Agenda, Agent, Agency, and Action.13

1. Agenda — What are the values and responsibility of public health, as a field? What can society reasonable expect from public health? What is the public health “agenda”? — See Section 4 (Ethical Action Guidance for Policy and Practice in Functional Domains of Public Health) in the APHA Public Health Code of Ethics, 2019.

2. Agent — What are the values and responsibilities of the public health official.

   1. Virtue ethics

      1. Character: honesty, loyalty, sincerity, courage, reliability, trustworthiness, and benevolence

      2. Leadership: excellence (expertise), integrity (the integration of one’s roles, responsibilities, and values), and judgement (practical wisdom)

   2. Professional ethics — eg, for physicians, see the AMA Principles of Medical Ethics.14

3. Agency — What are the values and responsibilities of the public health agency?

   1. Organizational ethics — Florida DPH Health Mission, Vision and Values

4. Action — What are the health and ethical consequences of a public health action?

   1. Public policy ethics — see below: Section 3: Guidance for Ethical Analysis

For PHAB-accredited health departments in the United States, the APHA Public Health Code of Ethics, 2019 is the key source of public health ethics guidance.

APHA Public Health Code of Ethics, 2019

Below are excerpts with minor edits for clarity, and my comments in italics.

Introduction

This 2019 version of the Public Health Code of Ethics contains ethical standards and obligations for both public health practitioners and institutions, and it is intended to guide individual and collective decision making, especially in ethically challenging situations. Section 2 outlines the “what” of public health ethics; it lists and defines the shared foundational values of public health. These values form the high-level moral justification for public health work. Section 3 provides guidance for the “how” of public health ethics; it provides a set of considerations for use in a deliberative decision-making process that allows public health practitioners to ensure that authority and power in public health are exercised in fair and productive ways.

Addressing complex ethics questions requires public health personnel to have a set of skills that include the ability to:

• Identify the ethical dimensions of public health work,

• Articulate conflicting values and ethical dilemmas when they arise,

• Deliberate on options and courses of action using inclusive methods that engage individuals and groups affected by public health work, and

• Implement and evaluate solutions to keep the process open for revision, especially in situations where information is limited or developing quickly.

Section 2: Public Health Core Values and Related Obligations

See Appendix.

Section 3: Guidance for Ethical Analysis — our focus for this blog posting

Ethical analysis of proposed or contemplated public health actions involves four important components:

1. Determination of the public health goals of the proposed action: Dr. Ladapo did not state any public health goals, only religious morality goals.

2. Identification of the ethically relevant facts and uncertainties: Except for “medical freedom” from vaccination, no other facts or uncertainties were addressed.

3. Analysis of the meaning and implications of the action for the health and rights of affected individuals and communities: Parents would not have to vaccinate their children and they would not need to file a religious exemption.

4. Analysis of how the proposed action fits with core public health values. Dr. Ladapo did not state how removing vaccine mandates aligned with public health values, only how the policy aligned with religious values.

Below are eight considerations that should arise in virtually any setting where public health interventions and policies are planned and significant decisions concerning such interventions and policies are made. If these issues are not considered, whatever the ultimate decision, it would be difficult to say that the decision had been given sufficient ethical scrutiny.

1. Permissibility: “Would the action being considered be ethically wrong even if it were to have a good outcome?” Florida’s removal of vaccine mandates could be considered ethically wrong because there was no process to assess the moral claims of affected stakeholders and communities.

2. Respect: “Would the proposed action be demeaning or disrespectful to individuals and communities even if it benefited their health?” Some stakeholders could feel “disrespected” because their concerns and moral claims were not considered.

3. Reciprocity: “Have we done what is reasonable to offset the potential harms and losses that the proposed action imposes on individuals and communities?” Dr. Ladapo did not consider countermeasures to prevent and mitigate the consequences of more infectious diseases in the community.

4. Effectiveness: “Is it reasonable to expect, based on best available evidence and past experience, that the proposed action would achieve its stated health goals?” No goals were stated.

5. Responsible Use of Scarce Resources: “Would the proposed action demonstrate good stewardship and deserve the trust that the public has invested in public health practitioners?” Dr. Ladapo is using public health government resources and authority to promote a religious agenda.

6. Proportionality: Will the probable benefits of the action outweigh the infringed moral considerations?15 There was no process to assess the moral claims of affected stakeholders and communities.

7. Accountability and Transparency: “Would the proposed action withstand close ethical scrutiny and be justified by valid reasons that the general public will understand?” There was no documentation of how this decision was made, or to justify its public health value.

8. Public Participation: “In deciding on a proposed action, have all potentially affected stakeholders had a meaningful opportunity to participate. If some are to be deliberately excluded from decision making, is there an ethical justification for doing so?” There was no public or community participation in decision making.

See appendix for detailed Table.

My summary analysis

This decision was not based on public health values, principles, and goals. Dr. Ladapo does not justify why this policy change is necessary. Florida already has a religious and medical exemption for vaccinations, so this policy change is unnecessary. He did not articulate any public health goal.

As a PHAB-accredited health department, they are required to have a process for deliberating the public health ethical implications of consequential policy decisions. He and the Florida DOH clearly abdicated their responsibility.

If there was political pressure from the Governor’s office — his boss — to end vaccine mandates, then he could have crafted a public health policy using the clear guidance from the APHA Public Health Code of Ethics, 2019. After all, there are countries without vaccine mandates, such as Sweden and Norway. In those countries vaccine mandates are not needed because vaccine acceptance is very high (>95%), so the “least infringement” option — vaccine recommendations — is sufficient. That has not been the case in the United States.

I always ask myself, what would I do if I were in his shoes and was told by the Governor to design and implement a state policy of no vaccine mandates.

• Situation: political decision to remove all vaccine mandates

• Public health goals:

  • Build trust and confidence in vaccines

  • Increase vaccine acceptance

  • Increase vaccine access

  • Improve vaccine administration

  • Reduce transmission of infectious disease in the communities

• Examples of activities:

  • Media campaign promoting vaccines and non-pharmaceutical interventions

  • Mobile vaccine clinics at schools

  • etc.

Finally, Florida’s removal of vaccine mandates is primary driven by religious — not public health — values. To understand these religious moral claims please review my one-page document on Moral Foundations Theory (Google docs).16

Thanks for supporting TEAM Public Health by reading this blog! Please share.

TEAM Public Health is a FREE — not for profit — blog. All of the content will be freely available to all subscribers. The content is designed to be evergreen.

Serving with you,

Tomás

Appendix:

Section 2: Public Health Core Values and Related Obligations (APHA Public Health Code of Ethics, 2019)

The following core ethical values are equally important and are not presented in rank order. These values are multifaceted conceptually and can be realized in practice in different ways. They do not have simple definitions. They require ongoing and explicit reflection and reaffirmation.

1. Professionalism and Trust. The effectiveness of public health policies, practices, and actions depends upon public trust gained through decisions based on the highest ethical, scientific, and professional standards.

2. Health and Safety. Health and safety are essential conditions for human flourishing.

3. Health Justice and Equity. Human flourishing requires the resources and social conditions necessary to secure equal opportunities for the realization of health and other capabilities by individuals and communities.

4. Interdependence and Solidarity. The health of every individual is linked to the health of every other individual within the human community, to other living creatures, and to the integrity and functioning of environmental ecosystems.

5. Human Rights and Civil Liberties. While coercive legal measures limiting behavior can be ethically justified in certain circumstances, overall the effective and ethical practice of public health depends upon social and cultural conditions of respect for personal autonomy, self-determination, privacy, and the absence of domination in its many interpersonal and institutional forms.

6. Inclusivity and Engagement. Preventing adverse health outcomes and protecting and promoting the flourishing of individuals, societies, and ecosystems require informed public decision-making processes that engage affected individuals and communities.

From Section 3: Eight key considerations for public health ethical analysis

Source: Lisa Lee, et al.17

Alternative Framework for Ethical Analysis and Deliberation

Available here (from UC Berkeley DrPH Seminar): https://docs.google.com/document/d/1zpXOHTRC9xLsUt4gwPYQK5OEUjHS8HeR1IiYP-8xRqw/edit?usp=sharing

Footnotes