—Analyzing Cause and Effect
When bad things happen, we are quick to ask who is to blame?
You are sad, hurt, and probably angry because you suffered a loss, insult, or injury. You are certain that someone must be held responsible, and you are quick to find someone to blame. We seek to blame others to assign responsibility for some loss we have suffered, or to mitigate some insult or injury we have endured. Sometimes we are quick to blame others in an attempt to feel better about ourselves, to explain our hurt, or to uphold moral virtue.
Unfortunately we are often overcome by the single cause fallacy, the false belief that each action is attributable to a single cause. We are also inclined to attribute agency and motives to anyone or anything we decide to blame. Some people are slow to take personal responsibility and blame themselves for bad outcomes; others are too quick to blame themselves.
Because we live in a vast and complex world full of interactions, careful investigation often determines that each event is the result of many contributing causes. It is helpful to determine a full range of contributing causes before beginning to assign blame.
The objectives of this course are to help you to:
- Better understand our motivation for assigning blame,
- Overcome the single cause fallacy,
- Identify the various causes of adverse effects that occur,
- Accurately analyze causes and effects,
- Accurately assign responsibility for a loss,
- Better understand your motivations for assigning blame.
This course is primarily about identifying various causes that contribute to a wide variety of adverse events that result in some loss. The severity of these adverse events can include catastrophes, disasters, tragedies, accidents, mishaps, injuries, errors, defects, embarrassments, slip ups, nuisances, inconveniences, and missed opportunities. Although the term used to describe any particular adverse event varies throughout the course, the course materials are useful throughout a wide range of problems.
We are often quick to accuse, find someone to answer for, charge, hold responsible, incriminate, indict, fault, take the fall, or find someone guilty when we suffer some loss.
We often blame others to dispose of problems and protect our sense of self-worth when things go bad. We are tempted to take credit ourselves to enhance our sense of self-worth when things go well.
Assigning blame for your loss is an effort to sustain your stature as you resolve your grief. The questions: “Whose fault is it?”, “Who do you blame”, “Who do you hold responsible”, and “Are you willing to take the blame for this?” are so common we rarely give them a second thought. But they each help to perpetuate the single cause fallacy—the mistaken belief that a single person, group, organization, decision, or event caused the loss. In almost every situation many factors contribute to each outcome. Relying quickly on blame to dispose of our loss also relies on the fallacy of intentional stance—the mistaken belief that results only follow from an agent acting with deliberate intent. When things go well, many people are quick to take credit. When things go bad, surely the same number of people also contributed. Self-justification—describing events in a way that preserves our pride and reduces cognitive dissonance—causes us to distort the evidence and shift blame to others.
Optimists and pessimists tend to assign blame differently. The optimist takes broad credit for good outcomes and narrow responsibility for bad outcomes. The pessimist blames himself broadly for bad outcomes and attributes good outcomes to external factors.
A careful and thoughtful analysis will consider all the involved parties along with each of their actions and inactions before attributing causes. You can begin this analysis by answering these questions whenever a loss occurs:
- What are all the things that could have been done to prevent the loss?
- What people, groups, and organizations were involved in planning and carrying out the events leading to the loss?
- If things went well, who are all the people who would take credit?
- What decisions, events, failures, or inactions contributed to the loss?
- What actions did each take that contributed to the loss?
- What actions did they fail to take to prevent the loss?
- What did you do to contribute to the loss?
- In what ways was this loss foreseeable? Who had the earliest opportunity to avoid the loss? Who had the last chance? Why were these opportunities missed?
- How could you have prevented the loss?
- How do you divide up responsibility for the loss among all the contributing factors you have identified? (Assign “percent responsibility” to each contributing factor and adjust this assignment to arrive at a total of 100%) How much responsibility falls on you?
The 9/11 commission report is an excellent example of careful analysis that results in allocating blame across many contributing causes. To understand the causes of the tragic September 11, 2001 terrorist attack on the United States, the members of the 9/11 commission interviewed over 1,200 people in 10 countries and reviewed over two and a half million pages of documents, including some closely-guarded classified national security documents. The report begins by assigning blame broadly to “A failure of imagination” and ends with 97 specific recommendations for preventive action.
Instead of asking “Who is to blame for …?” ask “What are the causes that contributed to …?”
- Identify some harm or loss you have incurred.
- Identify the several causes that contribute to this loss by answering the questions listed above. Be sure to include actions you did or did not take that contributed to the loss.
Recast each of the following questions in the form of “What are the causes of …”: (If none of these issues are relevant or interesting to you, choose other relevant issues selected from popular news stories, talk shows, blogs, or gossip.)
- Who is to blame for the rise of ISIS?
- Who is to blame for the government shutdown?
- Who is to blame for terrorism?
- Who is to blame for the increased cost of [fill in anything you want]?
- Who is to blame for the subprime mortgage crisis?
- Who is to blame for inflation?
- Who is to blame for a recent crime wave?
- Who is to blame for obesity in America?
- Who is to blame for drunken driving accidents?
- Who was to blame for the First World War?
- Who is to blame for poverty?
- Who is to blame for child abuse?
- Who is to blame for unemployment?
- Who is to blame for crimes?
- Who is to blame for immigration issues?
- Who is responsible for spreading false rumors?
Choose one of these topics to study in depth. Answer the question “What are the causes of (the issue you have chosen)”.
Several difficult philosophical issues surround the problem of assigning causes to effects, accounting for luck, and assigning responsibility for causes. Briefly, the principle of sufficient reason claims that each effect is the result of some reason or cause. However, the principle of sufficient reason is disputed and some facts, known as brute facts, are considered to have no further explanation. Outcomes often depend on luck, however the role of luck in justly assigning moral responsibility is complex and controversial. Additionally, the commonsense concept of responsibility, desert, and free will are also unresolved philosophical issues.
In short, A causes B if B occurs whenever A occurs, and B does not occur, when A does not occur. Although this is a necessary condition for causality, it is not a sufficient condition. Keep in mind that correlation does not imply causation, and there are other complexities in rigorously determining causality. Furthermore, because many causes typically contribute to any particular result, removing or assigning a single cause is often inconclusive.
For the purposes of this course, we will analyze causes to a depth that best suits your purpose. If you are a professional physicist, philosopher, or ethicist, then it may be helpful to explore theories of causality in great depth. For most students, however, less precise common-sense notions of A causes B will be sufficient. Continue going deeper as long as the analysis is providing useful insights. In any case, ensure the depth of analysis fully supports the importance of the decisions being made.
Several systematic approaches are used to carefully analyze and identify the many contributing causes of system failures. Each of these tools avoids the single cause fallacy, by helping to identify the many factors contributing to each outcome. One of the simplest and most powerful is the Cause-and-Effect diagram, also known as a fishbone diagram or an Ishikawa diagram, which is the focus of this course. The failure mode and effects analysis is a related tool that is more rigorous and will not be covered further in this course.
To illustrate use of the fishbone diagram, consider this example that identifies the factors contributing to a particular tragic automobile accident. Begin by identifying the loss being studied, in this case it is a particular auto accident. Then list high level categories of contributing factors, in this case “driver”, “car”, “road”, and “traffic” are each listed. Then enumerate the contributing causes under each of those categories. Continue expanding the outline until all the contributing factors are identified. Often simply asking “why did this happen” in a curious and nonthreatening way for each listed cause can help to expand the outline. Consider all the evidence and many diverse points of view. The information can be recorded in an outline as shown below, or more traditionally as an actual fishbone diagram.
Causes contributing to an Auto Accident:
- Driver completed only minimal driver training
- New driver
- Only practiced on local roads
- Got very little sleep last night
- Had already been driving 15 hours today before the accident
- Did not take rest stops, share driving, or drink coffee
- Distracted by a cell phone call
- Friends in the back seat were horsing around
- Driving decisions
- Not wearing seat belts
- Vehicle design is prone to skids and rolls.
- Brakes were badly worn.
- Tire pressure was low
- Poor visibility out the windows
- No side-view mirrors
- Road Conditions
- Dangerous curve not well marked
- Unlit roadway
- Dangerous intersection
- Slick surface
- Non-reflective paint
- Poor weather, night, fog, and rain.
- Traffic Conditions
- Other driver was not alert and experienced
- Traffic was very variable; often no cars then suddenly lots of cars
This outline now provides a structure for allocating responsibility (assigning blame) to each contributing cause. Divide 100% responsibility across the major contributing factors. The resulting assignment might look like this:
- 40% Driver related causes
- 20% Car design and maintenance related causes
- 30% Road design and road conditions
- 10% Traffic, including the other driver.
Based on this analysis, who is to blame? It looks like the blame is shared across many causes with the driver (could that be you?) bearing the greatest blame at 40% and the other driver (traffic) bearing the least blame at 10%. This detailed analysis is probably substantially different from your immediate impulse to blame the other guy.
- Identify some loss you incurred. This may be the same incident you analyzed in the previous assignment, or some other incident.
- Use the above analysis of the auto accident as a model to follow as you create a cause-effect analysis to identify the causes contributing to the loss you have chosen to study for this assignment.
- Refer to the resulting diagram to answer: Who is to blame? What is to blame?
- What, if any, insights can the diagram provide for solving similar problems?
- How could the loss have been prevented?
Internal and External Factors
The auto accident example above includes factors attributed to the driver—these are internal factors—and other factors attributed to the car, road design, and traffic conditions. These are external factors. In any analysis it is important to include both internal and external factors.
Although people enjoy taking credit when things go well, they generally dislike accepting blame and often avoid being blamed for problems, or any adverse outcome. Notice the locus of control: internal, external, or chance, that each person adopts when suggesting contributing causes. Some people may adopt only an external locus of control and identify only external causes. Others may be too quick to blame themselves and adopt primarily an internal locus of control. Work to include consideration of each stance.
Find Solutions Beyond Blame
When problems are encountered, it is easy to quickly find someone to blame and move on. Unfortunately, this prematurely ends inquiry, investigation, understanding, and learning. Scapegoating may seem expedient, but it is no substitute for thorough and careful analysis. A better approach is to:
- Identify the many likely contributing causes using a cause-effect analysis,
- Consider system elements including individuals, tools, and methods,
- Consider relationships among elements,
- Consider system effects,
- Discuss the role of chance. Sometimes “It just happened to happen” and sometimes there is some identifiable nonrandom cause.
- Ensure each identified cause precedes the effect.
- Identify characteristics within the tools, procedures, climate, training, management systems, and individual accountability that contributed to this problem,
- Provide the personal safety and trust that allows the team to use active voice to explicitly name the causal agents. Rather than saying “it fell” or “it dropped” say “Sam dropped it.”
- As each contributing cause is identified continue to ask, “why did that happen”, and “why else did that happen” to include each of the identifiable causes,
- Identify improvements that can be made throughout the system to avoid similar problems.
Avoid crediting causes to events simply because the cause proceeded the event
Avoid the Post hoc ergo propter hoc fallacy which is the error of concluding that what occurs after some action is caused by that action. Although the sun rose after the roster crowed, it is a fallacy to conclude that the sun rose because the rooster crowed. Superstitions, quackery, pseudoscientific claims, mysticism, conspiracy theories, and supernatural beliefs are sustained by this fallacy.
Ensure the depth of analysis fully supports the importance of the decisions being made. Seek out the most important (highest impact, broadest scope…) cause that is actionable. For example, guard rails save lives from car accidents, although they do not address a root cause.
The cause-effect analysis described here works to broaden the scope of causes to consider and investigate further. It is a tool to use early in the process of analyzing mishaps and solving problems. It can help to identify areas of inquiry that need further investigation. Other more powerful tools can be used whenever further investigation is warranted.
More through investigations are warranted for:
- Product reliability studies,
- Product safety studies,
- Accident investigations,
- Criminal investigations,
- Evaluation of new drugs, medical equipment, medical procedures,
- Medical diagnosis,
- Evaluating, proposing, or developing public policy,
- Whenever the consequences of misattribution are high.
Stories capture our attention and often shift blame. Alluring stories often displace ambiguity and sometimes obscure facts. The best story often wins. Red herrings—stories designed to distract attention from inconvenient facts—are often used to avoid blame and shift blame. Stories can create scapegoats by shifting blame for the group's misfortune to one particular person. Because stories often create a complete and consistent explanation of events, they tempt us to close off investigations, even before all the facts are uncovered. The story may distract us from what is relevant by making us so comfortable with what is irrelevant. Even if a story is true, it may present only one point of view and may not accurately represent all that happened.
Here are some common examples:
- If you do not eat fat you cannot become fat, so please do not blame sugar for your weight gain.
- Saddam Hussein is building weapons of mass destruction. We can blame him for the terrorism emerging from the Middle East.
- Illegal aliens are taking our jobs, look no further for the cause of our economic and social problems.
- Children's vaccinations cause autism, so now we have an object for our anger.
- George Washington chopped down a cherry tree and cannot tell a lie.
- Christopher Columbus discovered the new world.
Enjoy stories, then keep probing, check the facts and continue the investigation. Beware of scapegoats identified in stories. It may be helpful to complicate the narrative to get the conversation unstuck and consider other points of view.
- Recall some story you have heard or told recently that assigns blame for some loss.
- Repeat the previous assignments focusing on that loss.
- Recast that story to more accurately attribute blame to the variety of causes you identified.
- Rewrite the story you plan to tell in the future about the causes of that loss.
The term “corrective action” refers to steps taken to repair or recover from the loss. In our example this may include getting the car fixed and attending to any injured people or other property. It may also include paying restitution.
The term “preventive action” refers to steps taken to learn from the original loss and to prevent additional similar losses. The phrase “you can be sure I'll never do that again” begins to capture the idea. Continuing with “and this is how I'll make sure it never happens again” completes the thought. In our example, taking steps to improve driving skill, stay alert, minimize distractions, use seat belts, improve automobile maintenance, and share the driving on long trips are all helpful preventive actions.
Correctly identifying the causes contributing to a problem can lead to a much better outcome than identifying the wrong causes. Consider the importance of correctly identifying causes in the 1983 Soviet nuclear false alarm incident. During this incident, nuclear missile attack warnings were correctly identified as a false alarm by Stanislav Yevgrafovich Petrov, an officer of the Soviet Air Defense Forces. This decision is seen as having prevented a retaliatory nuclear attack based on erroneous data on the United States and its NATO allies, which would have probably resulted in immediate escalation of the cold-war stalemate to a full-scale nuclear war. Investigation of the satellite warning system later confirmed that the system had malfunctioned.
Unfortunately, causes are often incorrectly identified, leading to tragic outcomes.
- From the 1600s through the mid-to-late 1800s many newborn babies were dying mysteriously of what was then called childbed fever. Unfortunately, most cases were caused by the doctors themselves. This doctor’s plague ended when the germ theory of disease became accepted, and doctors were finally convinced that hand washing was needed to prevent the spread of germs.
- Decades of medical doctrine held that peptic ulcers were caused primarily by stress, spicy foods, and too much acid. Based on this understanding of the cause, antacids and stress reduction were widely prescribed, but were not very effective. Research by Barry Marshall in the 1980’s began to show the bacteria Helicobacter pylori plays a major role in causing many peptic ulcers. The medical community was slow to accept this finding, however in 2005 Marshall and Robin Warren, his long-time collaborator were awarded the Nobel Prize in Physiology or Medicine for "for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease". Treatment of ulcers was transformed by correctly identifying their cause.
- On June 1, 2009, Air France flight 447 crashed killing all 228 passengers and crew on board. While several factors contributed to this crash, it was found that the crew failed to recognize the aircraft had stalled and consequently did not make inputs that would have made it possible to recover from the stall. The pilot believed loss of altitude was caused by lack of thrust, when it was actually caused by excessive pitch.
- Border patrol agent Rogelio Martinez was found clinging to life and his partner severely injured at the bottom of a culvert in a remote part of Texas 110 miles southeast of El Paso on Nov. 18, 2017. He died in a hospital the following day. Although his death was likely an accident, his death was incorrectly attributed to criminal activity by illegal immigrants. Politicians and unions seized upon this incorrect cause to call for beefed-up national security.
- The miasma theory is an obsolete medical theory that held that diseases—such as cholera, chlamydia, or the Black Death—were caused by a miasma, a noxious form of "bad air", also known as night air. This was found to be incorrect and was superseded by the germ theory of disease which more accurately identifies the causes of disease. Correctly identifying the causes of disease improves healthcare. Based on the pattern of illness among residents during the 1854 Broad Street cholera outbreak, John Snow correctly hypothesized that cholera was spread by an agent in contaminated water.
- In ancient times many natural phenomena, including daily sunrise and sunset, the phases of the moon, seasonal changes, thunder and lightning, floods, volcanoes, and others were attributed to various deities. Today we understand how the laws of physics cause these phenomena.
- Incorrectly attributing misfortune to angry deities, human sacrifices have long been made as offerings to appease deities. It is more effective to correctly identify the causes of disease, famine, crop failure, and other tragedies before taking corrective and preventive action.
- The Gulf of Tonkin resolution, attributing the Gulf of Tonkin incident to Vietnamize military aggression, was used as a primary justification for military action in the Vietnam war. Careful investigation determined the incident was not caused by Vietnam aggression and the resolution was eventually repealed.
- When an innocent person is found guilty of a crime they did not commit, the causes of the crime are incorrectly identified. Two tragedies result from this error; an innocent person is punished, and a dangerous person is often free to cause additional harm. The innocence project continues to identify many such errors.
- Justification for the 2003 Iraq war was based on many incorrectly identified causes, often resulting from motivated reasoning. These include Secretary of Defense Donald Rumsfeld asking his aides for: “best info fast. Judge whether good enough hit Saddam Hussein at same time”, false claims that Iraq was building and stockpiling weapons of mass destruction, and reliance on unreliable sources and forgeries.
- These lists of disasters and conspiracy theories provide many more examples that can be examined to identify other examples of correctly and incorrectly attributing blame.
- Choose some failure to study for this assignment. This may be one of the case studies listed above, some other failure, mishap or disaster, or some problem you are facing.
- Use the techniques described in this course to identify the various causes contributing to the mishap you are studying.
- Scan the identified causes to suggest possible solutions.
Truth and Reconciliation
The Truth and Reconciliation Commission was a court-like restorative justice body assembled in South Africa after the end of apartheid. Witnesses who were identified as victims of gross human rights violations were invited to give statements about their experiences, and some were selected for public hearings.
Reliable accounts that accurately identified the people who caused unspeakable horrors allowed victims to tell their story, publicly assigned blame, allowed responsible people to accept blame, and encouraged sincere apology, and forgiveness. This is leading to reconciliation.
The Paths of Blame
Events that can trigger blaming are common and frequent occurrences. How we respond to those provocations and the choices we make critically affect our peace of mind, well-being, and our lives. The figure on the right illustrates choices we have and paths we can take to either get stuck blaming and seeking revenge, or to constructively resolve the problem. Use this like you would any other map: 1) decide where you are now, 2) decide where you want to go, 3) choose the best path to get there, and 4) go down the chosen path. Keep in mind: as you walk you make your path.
This diagram is an example of a type of chart known by systems analysts as a state transition diagram. Each colored elliptical bubble represents a state of being that represents the way you are now. The labels on the arrows represent actions or events and the arrows show paths into or out of each state. You are at one place on this chart for one particular relationship or interaction at any particular time. Other people are likely to be in other places on the chart. This is similar to an ordinary road map where you plot where you are now, while other people are at other places on the same map. Begin the analysis at the green “OK” bubble, or wherever else you believe you are now.
OK: This is the beginning or neutral state. It corresponds to someone who is not now suffering a loss. The green color represents safety, tranquility, equanimity, and growth potential.
Loss: We were OK until we suffered a loss or injury. We are sad, hurt, and probably angry. The urge to blame someone for the loss is nearly overwhelming.
Injured: After the loss we are injured. We now face an important choice in how to proceed and cope with our loss. The injury contributes to our stress. The yellow color represents our loss.
Snap Judgment: We may yield to our primal thinking, make a snap judgment, and fall into the fallacy of single cause by finding someone to blame for our troubles. The orange color reflects the increasing danger this path encounters.
Blaming: Here we are finding someone, perhaps anyone, to pin the blame on.
Seeking Revenge: Having decided who is to blame, we can now seek revenge on them.
Vengeful: We are indulging our vengeful passions.
Careful Analysis: Rather than rushing to judgment and finding someone to blame, we decide to conduct a careful analysis, as described in detail above. We carefully create a cause-and-effect diagram to list all the contributing causes to the problem.
Causes Known: The analysis helps us to know all the causes that contributed to our loss. This information allows us to take effective corrective and preventive actions.
Corrective Action: We take steps to remedy the loss. We understand what we can change and what we cannot change and take constructive action.
Loss Mitigated: Although we cannot change the past, we have done what we can to repair the damage and reduce the loss.
Preventive Action: We learn from the mistakes that were made and take steps to prevent further similar problems from occurring.
Students wishing to learn more about attributing blame, analyzing cause and effect, and assigning responsibility for a loss may be interested in reading the following books:
- Tavris, Carol; Aronson, Elliot (October 20, 2015). Mistakes Were Made (but Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts. Mariner Books. p. 400. ISBN 978-0544574786.
- National Commission on Terrorist Attacks (September 1, 2004). 9/11 and Terrorist Travel: A Staff Report of the National Commission on Terrorist Attacks Upon the United States. Turner. p. 310. ISBN 978-1577363415.
- Wilson, Paul F.; Dell, Larry D.; Anderson, Gaylord F. (September 1, 1993). Root Cause Analysis : A Tool for Total Quality Management. American Society for Quality. p. 216. ISBN 978-0873891639.
- Pearl, Judea; Mackenzie, Dana (May 15, 2018). The Book of Why: The New Science of Cause and Effect. Basic Books. p. 432. ISBN 978-0465097609.
- Defeo, Joseph A. (November 3, 2016). Juran's Quality Handbook: The Complete Guide to Performance Excellence. McGraw-Hill Education. p. 992. ISBN 978-1259643613.
I have not yet read the following books, but they seem interesting and relevant. They are listed here to invite further research.
- Blame: Its Nature and Norms, by D. Justin Coates, Neal A. Tognazzini
- In Praise of Blame, by George Sher
- Thinking in Bets, by Annie Duke
- Mastermind: How to Think Like Sherlock Holmes, by Maria Konnikova
- This material is adapted from the EmotionalCompetency.com website with permission from the author.
- Carroll, Sean (May 16, 2017). The Big Picture: On the Origins of Life, Meaning, and the Universe Itself. Dutton. p. 480. ISBN 978-1101984253. @142 of 1573.
- Eshleman, Andrew, "Moral Responsibility", The Stanford Encyclopedia of Philosophy (Winter 2016 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/win2016/entries/moral-responsibility/>.
- Lippert-Rasmussen, Kasper, "Justice and Bad Luck", The Stanford Encyclopedia of Philosophy (Summer 2018 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/sum2018/entries/justice-bad-luck/>.
- Moving from Blame To Accountability, Marilyn Paul, The System Thinker,
- Beyond Blaming, March 5, 2006, Jerry Weinberg, Exploring Human Systems in Action.
- Complicating the Narratives, June 27, 2018, Solutions Journalism, Amanda Ripley.
- Border patrol agent’s death likely an accident, by Max Jaeger, February 8, 2018, NY Post