Certainty as the great enemy of tolerance, part 2 of 2

Are we still sure about that?

In last week’s note, I introduced the idea that the certainty we adopt about issues can lead, not infrequently, to us being very wrong, and that this is true for ideas that emerge across the political spectrum. I highlight this perhaps as a caution to all of us, including those who may feel particularly certain of the rightness of their approaches in moments of electoral triumph or defeat. Today I want to build on that and return to Robert Harris’s line that “Certainty is the great enemy of unity. Certainty is the deadly enemy of tolerance.” Why did this grab me, why do I think it matters?

As I see it, certainty as an approach matters because it closes conversation, and indeed inhibits tolerance and contributes to disunity. If I am certain that I am right, I am leaving you no space to tell me you may disagree without being disagreeable. And that ends the discussion right there. This is always the case with any expression of certitude, but it is particularly challenging when we recognize that certainty is often false, misguided, as discussed last week. How many good ideas have been lost to time and history because they were crowded out by false certainty?

By way of example, I often use in my presentations the story of Ignaz Semmelweis. He was a Hungarian obstetrician who, in the 1840s, began to study why so many women were dying from puerperal fever after giving birth. He concluded that doctors were bringing contamination from their work performing autopsies into the delivery rooms where they would deliver babies. This was well before the emergence of germ theory could confirm such an idea; nevertheless, Semmelweis believed that doctors were carrying some form of “morbid poison” on their hands which was infecting new mothers. He began requiring his staff to wash their hands with a chlorine solution. This practice led to a significant drop in maternal mortality.

Semmelweis’s story should have ended with his idea taking hold among doctors, leading to widespread reductions in maternal mortality. But it did not. In fact, Semmelweis faced significant pushback from the medical community. Many doctors were offended by the idea that their uncleanliness could be causing infections and were secure in their certainty that Semmelweis was wrong. This sentiment was captured by the American obstetrician Charles Meigs, who said, “Doctors are gentlemen, and gentlemen’s hands are clean.” Complicating matters was the delay with which Semmelweis published his findings as he considered them to be “self-evident.” His life would end in a mental institution to which he had been consigned, where he apparently died from a kind of sepsis similar to the disease he worked so hard to prevent in new mothers. The resistance he faced led to the coining of a new phrase, “the Semmelweis reflex,” to describe our collective human tendency to sometimes immediately reject innovation and ideas when they seem to contradict established certainties.

In the case of Semmelweis, false certainty by the medical profession not only shut down what was exactly the right approach—that is, handwashing to save lives—but did so in a way that closed the conversation. Had the field simply been a bit less certain, a bit more embracing of humility, it might have allowed this conversation to happen, and many lives might have been saved by an earlier adoption of handwashing.

When we are overly certain, we are disinclined to be tolerant of other perspectives, because how could other perspectives be right if we, after all, know we are right? Similarly, certitude will only countenance unity that falls in line behind it. Because how could we be on the same page as others who do not subscribe to our ideas which we are sure are right?

Not only can this certainty cause us to embrace wrongheaded ideas, and dismiss good ones, it can create real liabilities for movements working in the social and political space. When certainty causes us to shut down conversations and avoid debate, we are liable to fool ourselves into thinking that controversial issues are in fact settled, that only a disgruntled minority, working in bad faith, might take exception to our certainty on a subject. It is true, of course, that such bad faith actors are out there. But it is also true that in recent years movements with which public health has long been broadly aligned have been surprised by the persistence of reasonable people outside of ideological “bubbles” continuing to have conversations we thought we had settled but which we had in fact merely suppressed. This disconnect between our certainties and the debates we have avoided—but which nevertheless continued elsewhere without us—are likely why the result of the recent federal election came as a surprise to many, and indeed likely why, at least in part, it came about at all. By undermining the tolerance that leaves us open to hearing new ideas, certainty causes us to miss out on the conversations and perspectives that contribute to a full understanding of core issues.

Why does this matter to us? It matters because we are in the business of generating ideas. But if we understand both that our ideas may be wrong, and that expounding on ideas in a way that evinces certitude is closing discussion, we may search deeper to find the humility to think harder about our ideas, and, when we do arrive at them, to state them with perhaps more caution, to allow space for conversation and tolerance.

I realize that all this can sound like perhaps a mealymouthed excuse to not speak about what matters with the clarity of expression such issues deserve. I do understand that charge, but I will point out, as I have before, that none of this precludes sharp clarity about core values and a willingness to call out actions and speech that run counter to these values. It is just that our circle of closely held nonnegotiable values should be small indeed. In my circle of such values, I hold dear respect for autonomy of persons, compassion, and the value of hard work. Others may hold other core values dear, but whatever these values, they are generally as intensely held as they are limited in number. It is also true that values are not the same as positions on key issues. Values inform our positions, but we can be firm in our values while being open to the debates that help us to learn about issues, so we can decide where our values urge us to stand on a given subject. We can, and should, remain open to debate while staying secure in our central values. If we are secure in our values, we should not be afraid of opening ourselves to such debate, to interrogating our certainties in the context of robust conversation and disagreement. If we have really thought through why we do what we do, why we hold the positions we hold, the next step is not to embrace certainty but to stress-test our ideas through a process of conversation and reasoned debate.

Consider by way of simple illustration that the generation of ideas should be no different from the manufacture of passenger vehicles. Car designers do not build a vehicle then immediately market it to consumers, certain that the product is safe. They subject their products to rigorous testing, deliberately exposing them to extreme wear and tear.  In fact, we insist on such testing and regulations govern and mandate such testing. Should we be any less rigorous in testing our ideas? We trust cars to carry us forward on the open road—we trust ideas to move us forward as a society. Our ideas, then, should be sturdy indeed and certainty alone will not ensure that they are. Certainty causes us to exclude the ideas, and even the people, that can provide the perspective that lets us truly test our ideas, to ensure that the concepts we embrace at the heart of our efforts are sound. When we exclude in this way, we risk veering into intolerance, into disliking those who challenge our certainties. This undercuts our capacity to build a big-tent movement for health, the kind of movement we will need to truly build a healthier world for all.    

Therein lies the wisdom of Cardinal Lawrence in Conclave. Certainty stops us from achieving our full potential—as individual thinkers and as would-be builders of a movement for health. Rather, we may wish to embrace humility—arguably the opposite of certainty—and the courage that lets us open ourselves to doubt, reflection, and the possibility that we might be wrong.

A final word as I end this note, being posted the weekend before Thanksgiving in the US. I did want to pause for a moment to reflect that, amid tumult, there remains much to be thankful for. I will not use this space to summarize the very good fortune that so many of us have, not least of which is to be alive in a better time than so much of human history. I will simply wish all readers who celebrate Thanksgiving a delightful break with loved ones and wish us all the chance to return rested in December, as we aspire to close out 2024 with hope.

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Also this week

Enjoyed speaking with Dr. Arati Prabhakar, Director of the White House Office of Science and Technology Policy, who joined our students for a conversation about current work and priorities at OSTP. View our conversation here.

I had the privilege of reflecting on the legacy of our much-missed colleague, David Jones, in my review of his book, “Ripples of Hope in the Mississippi Delta: Charting the Health Equity Policy Agenda,” for Health Affairs.

JAMA Health Forum is now offering three editorial fellow positions. Fellows will receive hands-on training in the processes of a health policy journal, working with the journal’s editorial team. Learn more and apply here.

A reminder that hiring is now open at WashU for the new school of public health we are building in St. Louis. Learn more and apply here. 

Thoughts with Dr. Salma Abdalla in SSM – Population Health on reimagining global health scholarship to address health inequities. 

Our new study in Scientific Reports, with Catherine Ettman, Ben Thornburg, Salma Abdalla, and Mark Meiselbach, looks at the intersection of financial assets and mental health over time.

Many thanks to Sharifa Williams for leading our new study in Statistics in Medicine, “Improving Survey Inference Using Administrative Records Without Releasing Individual-Level Continuous Data.”