In re Zimmerman

Stages of a Project

In project management, we frequently say that the stages of a project go like this:

1. Enthusiasm
2. Disillusionment
3. Despair
4. Panic
5. Search for the Guilty
6. Punishment of the Innocent
7. Praise for Non-Participants

The key problem comes in Step 5, “Search for the Guilty,” as opposed to the alternative, “Fix the Problem.” The overwhelming need to punish the offender outweighs the need to fix the problem.

In re Zimmerman

These days, I’ve mostly sworn off political topics. I hate that I’ve lost friends that way. But the shooting of Trayvon Martin by George Zimmerman also raises issues relevant to project management, cognitive bias, and fallacies of logic, all of which are legitimate subjects of this blog.

As is too often the case in any sensational media matter, the professional outrage machinery is in full swing. The most extreme and definite opinions on both sides receive the majority of coverage, even though they are a minority of the population, and in response, both defenders and accusers try to delegitimize the comments and opinions of those who disagree.

My goal in writing this is not to start an argument about the relative culpability of either Zimmerman or Martin — and in fact, I’d vastly prefer not to have one. There are many other places you can go to have that argument. Right now, let's look at the nature of those opinions.

In the case of Zimmerman — or, for that matter, any criminal suspect — there are four separate questions:

1. Should Zimmerman be suspected?
2. Should Zimmerman have been arrested?
3. Should Zimmerman be put on trial?
4. Should Zimmerman be convicted?

The Decision Hierarchy

Decision-making processes are normally hierarchical. There are earlier, tentative decisions we make before we reach our final conclusion. Should we, for example, do a particular project? The initial decision may be to do a feasibility study, or a pilot test. Only when those results are in will we make our final choice and commit resources to the solution.

The legal concept of level of proof is particularly meaningful. Depending on the stage of the process, different levels of proof are required to support a given decision.

Should Zimmerman be suspected? The legal standard for suspecting someone of a crime is a low bar: reasonable suspicion. This standard is based on "specific and articulable facts", "taken together with rational inferences from those facts," to distinguish it from an "unparticularized suspicion" or a hunch. In Zimmerman's case, there's no real doubt that Zimmerman shot Martin. Even Zimmerman admits as much.

In project management, a related question is whether the environment contains opportunities or problems worthy of addressing. Coming up with a target list doesn't mean you've made a final decision, so the burden of proof is low.

Should Zimmerman have been arrested? The standard for an arrest is probable cause. That standard is higher than "reasonable suspicion," but much lower than the standard required for a criminal conviction. The best-known definition of probable cause is "a reasonable belief that a person has committed a crime." Another common definition is "a reasonable amount of suspicion, supported by circumstances sufficiently strong to justify a prudent and cautious person's belief that certain facts are probably true." 

This question, not the question of whether Zimmerman is ultimately found guilty, is the core of the current controversy. Frankly, had Zimmerman been charged and tried at the time — even if he were subsequently acquitted — it’s hard to believe that this case would have ever achieved national prominence. It’s not exactly as if shootings are an uncommon occurrence in the United States.

"Probable cause" also has a role in project management. Feasibility studies aren't free, so you have to pick your shots. Establishing a proof level equivalent to "probable cause" helps you focus on the issues that matter most.

Should Zimmerman be put on trial? Prosecutors can bring charges based on no more than probable cause, but a grand jury, which reviews the case prior to trial, is supposed to make its judgment based on the preponderance of the evidence, that is, whether is charge is more likely to be true than not true. Prosecutors also have the benefit of a more comprehensive investigation than is normally performed at the time an arrest is made. The additional information may well alter an initial determination.

A full-fledged project is the equivalent of a trial, because you have to do all the work, and in the process, you may discover surprises and risks not part of the initial process. The initial project plan rests not on final determinations, but rather on the preponderance of the evidence available in the initiating and planning stages.

Should Zimmerman be convicted? Depending on the charge, two standards may apply: clear and convincing evidence, or proof beyond reasonable doubt. The first standard applies in some civil cases; the second in criminal cases. Zimmerman clearly falls into the second category. Our adversarial legal system is designed to put the strongest burden on the shoulders of those who would convict someone of a crime.

There is a final standard of proof, proof beyond a shadow of a doubt, but that is often an impossible burden to meet, so that standard doesn't apply in a criminal case. Indeed, given that there are only two people with full knowledge, and one of them is dead, the "shadow of doubt" may never be completely eliminated.

At the end of the project, the results must necessarily speak for themselves. Did you solve the issue that led to the project? Perhaps clear and convincing evidence is all you need, but sometimes a higher burden of proof rests on the project manager.

Justified and Unjustified Opinions

If there's one fundamental American right, it's the right to an opinion, but not all opinions are equal. To have a legitimate, justified opinion, you need to have some actual facts and apply an appropriate standard of proof. As long as you're clear about what stage of the decision is currently on the table, saying "yes" to one level doesn't necessarily equate to a final determination.

In an imperfect world, armed with imperfect knowledge, we cannot escape the reality that we must necessarily make some decisions and hold some opinions in advance of all the facts. And that raises the question about what makes an opinion justified and legitimate.

It's often argued that [insert side of the argument] has already convicted [Zimmerman] [Martin], rather than wait for the judicial machinery to work its course. And, of course, some extremists have already rushed to final judgment on the matter. But the vast majority of us have not.

That doesn't mean judgments, even in preliminary stages, are inappropriate. As noted, there's no reasonable doubt of the basic fact that Zimmerman shot Martin. It's hard for anyone to argue that the police should not have looked into the matter.

Can a "prudent and cautious person" reasonably conclude, at this stage of the investigation, that Zimmerman should be arrested? Clearly, the answer is yes. Even without the discredited claim of a racial slur, the 911 call, in which Zimmerman disregarded the recommendation of the dispatcher not to get out of his car, casts a "reasonable amount of suspicion" on Zimmerman's actions.

Does the preponderance of the evidence lean in favor of putting Zimmerman on trial? The Florida prosecutor assigned to the case has determined the answer to be yes, so it's not unreasonable or unjustified for an outsider to agree with it.

It's possible, and even legitimate, to have a definite opinion on the questions of arrest and trial. It's much less justified to have a definite and final opinion about Zimmerman's ultimate guilt. The standard of "reasonable doubt" has not yet been overcome, and will not be until all the evidence — including evidence presented by the defense — is out in the open.

The claim is often made that Trayvon Martin's supporters have already convicted Zimmerman, but that's an exaggeration. It's true that Martin's supporters have generally concluded that Zimmerman should be arrested and tried, but those opinions are valid at a much lower standard of proof. It's not "convicting" Zimmerman to argue that the evidence supports arrest and trial.

Bias and Judgment

When it comes to the final decision, a prudent person should be cautious. You not only need evidence, but the evidence itself often needs to be challenged and validated. But that doesn't mean you can't hold a preliminary opinion, as long as you're willing to modify it in the face of persuasive information to the contrary.

If you rate opinions about Zimmerman on a scale of 10 (certain he's guilty) to 0 (certain he's innocent), people with scores of 10 or 0 are clearly making decisions ahead of the facts. For such people, the outcome of a trial will mean nothing: if the verdict goes their way, they knew it all along, but if the verdict goes against their opinions, it will mean that the trial was rigged and thus invalid. People who are unwilling to revise their opinions in the face of new facts aren't reasonable. Fortunately, their number isn't large.

More common is people whose opinions are 8-2, strongly convinced of Zimmerman's guilt or innocence, but not so locked into their positions that persuasive contrary evidence is incapable of changing their minds. People in this category need to be extremely careful of the actions of cognitive bias in their information processing and decision process. Even if you are trying to be open-minded, once a mind's made up, inertia takes hold. Change is difficult.

People with opinions in the 4-6 range are in less danger from cognitive bias, because their opinions are inherently more tentative. In my case, I am not paying detailed attention to the story, because of the general unreliability of most of what's published at this point. That's not the same as saying I have no opinion, or that I don't lean toward one side, but I'm fully aware that the eventual factual record may not support my tentative ideas. Even so, cognitive bias can have its effects even on people of more moderate opinion, so it's important to stay on one's guard.

But that's opinions about Zimmerman's guilt. Opinions about arrest or trial fall into different standards of proof.

The Process of Proof

After watching innumerable crime shows, we all should have a pretty good idea how the police and trial process is supposed to work. When it goes according to plan, it does a reasonably good job of establishing a factual record in support of a decision. Of course, your mileage may vary.

Even if the story seems straightforward at first glance, investigators still go through the process of reconstructing the story, gathering physical evidence, and taking initial testimony. Raw evidence, of course, is of little use until it’s processed — the body examined, witnesses interviewed in detail, a timeline reconstructed, DNA tests performed, etc. In processing evidence, investigators create a story, a timeline of events and people that ideally reveals the truth of a situation.

Stories, of course, always begin as outlines, and as they take shape and form, you can fill in greater detail. Sometimes, stories surprise you, and you find yourself in an unexpected place. Minor characters (“persons of interest”) become suspects — people with motive, means, and opportunity. Some suspects are ruled out as the process moves forward; other suspects are eventually charged with a crime.

But all that assumes police and prosecutors are doing their jobs properly. To me, the most important question is not whether George Zimmerman committed second degree murder in the shooting of Trayvon Martin, but whether he should have been arrested in the first place.

What's the Real Problem?

Questions about the process will probably not be part of the trial, because it’s Zimmerman, not the police department, who is its subject. One hopes that the Justice Department investigation will address these matters. Again, I don’t claim to know the right answers. But as a management consultant, my job is to ask the right questions. Here are some things I'd like to know.

First, was the behavior of the Sanford Police Department appropriate? To measure "appropriate," consider the following: Did the department follow established protocols? Were those protocols adequate to the situation? Did any special circumstances make it more difficult to follow the protocols? What can we do about that in the future?

If protocols were not followed, why not? Are there management or organizational issues, problems with internal culture, changes in the environment, or other factors? And if so, what can we do to address those issues? Even if the more serious allegations of political interference by Zimmerman’s father (a retired Virginia magistrate) or charges of institutional racism turn out to be true, the reflexive “search for the guilty” is a much less effective response than fix the problem.

Wasting a Crisis

I have a stronger opinion about process in this case than I have about guilt. One of the facts of management consulting is that if you have a really bad outcome, you need to adjust your process as necessary to keep it from happening again.

The Sanford police were, no doubt, shocked at the public response and degree of national interest. Regardless of the assignment of fault or blame, they have to adapt to the new reality that their work will receive increasing scrutiny in the future. The 1982 Chicago Tylenol murders were clearly not the fault of the manufacturer, but the ubiquitous tamper-evident seals on all that we eat or drink date from that crime. And if they truly are at fault, then there’s all the more reason to work harder and better in the future.

Too much emphasis on determining guilt can, unfortunately, detract from the more important matter of change. In the cognitive biases series, I covered my version of the “Semmelweis Effect," the reality that peoples’ views harden when you accuse them of terrible crimes. Moral indignation can backfire, and that does no one any good.

Because it’s so easy to identify the most inflammatory and outrageous pieces on either side, it’s equally easy to miss the large amount of reasonable, proportionate commentary—also on both sides. A crisis, as has been noted, is a terrible thing to waste. That doesn’t mean we want a crisis or welcome it when it comes, but if we waste the crisis, we’re often doomed to experience it again. That’s the worst possible outcome.

It’s clear that something went terribly wrong in the Trayvon Martin case. Less clear is what went wrong, and the purpose of trial and investigation is to establish the narrative in an authoritative manner. Whether the trial and investigation accomplish that goal remains to be seen.

But it’s truly the most important part of the matter. Because once we answer that question, we can move forward to the two questions that matter in the long run:

• Why did it happen?

• And how can we keep it from happening again?

Project: Impossible — The Savior of Mothers

Dr. Ignaz Semmelweis

My 26th book will be Project: Impossible, an exploration of how people achieved goals any reasonable person would have thought impossible. This week, the story of the Doctor's Plague.

Childbed Fever

The advent of hospitals and the establishment of obstetrics as a medical discipline had an unanticipated side effect: a dramatic increase in cases of puerperal fever, commonly known as childbed fever.

It was a horrific disease. Death rates for all women giving birth in hospitals ranged from 20-25%. From time to time, there were epidemics of the disease, with death rates approaching 100%. Famous victims included the mother and two wives of Henry VIII and famous feminist and mother of the author of Frankenstein, Mary Wollstonecraft. (Today, puerperal fever is known to be a collection of several different diseases, including endometriosis, routinely treated with antibiotics, though it still occasionally results in death.)

The advent of pathological anatomy as a medical practice correlated strongly with the increase in cases of puerperal fever, though this link did not become clear until much later.

Childbed fever deaths spiked at the Vienna hospital, where pathological anatomy was performed, but not at the Dublin hospital, which did not practice it.

Paging Dr. Semmelweis

As the 19th century opened, the crown jewel, the largest hospital in the world, the center of medical practice in 18th Century Europe was the Allgemeines Krankenhaus der Stadt Wien, the Vienna General Hospital. Ignaz Semmelweis, newly admitted to the practice of obstetrics, spurred by the recent death of his mother, became obsessed with childbed fever.

The obstetrics department had two clinics: the First Clinic, staffed by doctors, and the Second Clinic, staffed by midwives.  Women often pleaded to be admitted to the Second Clinic rather than submit themselves to the care of doctors. Their fear was well founded, as there was a dramatic difference in mortality rates between the two clinics.

The First Clinic, staffed by doctors, had a death rate from childbed fever as high as 16%, but the Second Clinic, staffed by midwives, had a corresponding rate as low as 2%.

The most common theory was that the disease was simply a general miasma, just one of those things. It was nobody’s fault. Especially not the doctors.

An unhappy accident pointed Semmelweis to the answer, when his friend and mentor Professor Jakob Kolletschka died suddenly. The symptoms and progress of his disease were identical to childbed fever. It turned out that Kolletschka’s finger had been nicked by a student with the same knife that was being used in the autopsy. Somehow, contact with the corpse during the autopsy had led to the disease.

And it was in the performance of autopsies that the doctors of the First Clinic differed from the midwives of the Second Clinic.

Cadaver Particles

Ignorant of microscopes, microbes, and the germ theory of disease, Semmelweis could only observe one fact: that there was a connection of some sort between the cadaver and the death of Kolletschka, and by extension, between the cadavers used in pathology to the deaths of the childbed fever victims. What the agency of infection was, Semmelweis did not know and had at the time no way of finding out. He referred to them as “cadaver particles,” although he could not see them, measure them, or learn much about them directly.

But that didn’t mean he couldn’t come up with a treatment. What distinguished cadavers was the putrid smell, and what got rid of the putrid smell was a solution of chloride. In May 1847, Semmelweis embarked on a clinical experiment by placing a dilute concentration of chlorine at the entrance to the obstetrics ward and insisting that everyone who would touch a patient washed in it.

Today, of course, cleanliness for physicians is a matter of routine, but at the time, this was a radical break with traditional practice. Most Europeans at the time felt that a few baths a year were sufficient, and doctors were no exception. In fact, the blood-stained frock was a sign that a physician was hard working and professional. If doctors scrubbed themselves, who would know how hard they worked?

Against the criticism, however, the statistics spoke loudly and clearly. Semmelweis began his handwashing process in May, and by June the drop in puerperal fever was dramatic. First Clinic death rates fell to Second Clinic levels.

Change in death rates from childbed fever following the introduction of handwashing.

You’d expect that to be conclusive, but that turned out not to be the case.

The Semmelweis Reflex

Elsewhere in this blog, I’ve written about the Semmelweis Reflex, originally defined as “the automatic rejection of the obvious, without thought, inspection, or experiment.” As I've argued, what triggers the Semmelweis Reflex, however, isn't new knowledge per se,  but the implied criticism of previous behavior that results.

To accept the Semmelweis approach, doctors had to also accept the idea that they themselves had been responsible for the deaths of thousands of women. Who wants to think of himself or herself as a killer, however inadvertent? It’s not surprising that there is a human tendency to reject or challenge scientific or other factual information that portrays us in a negative light.

You don’t have to look far to find contemporary illustrations, from tobacco executives aghast someone dared accuse them of making a deadly product to the notorious Ford Motor Company indifference to safety in designing the Ford Pinto. The people involved weren’t trying to be unethical or immoral; they were in the grips of denial triggered by the Semmelweis Reflex. This denial was strong enough to make them ignore or trivialize evidence that in retrospect appears conclusive.

There was a dramatic reaction against Semmelweis and his theory by the medical establishment, both in Vienna and elsewhere. Puerperal fever is now known as the “Doctor’s Plague,” because it was a case in which medical treatment made things worse — a lot worse. Semmelweis himself was terribly shocked and depressed to realize that it was his own actions that had resulted in the deaths of many women. And if Semmelweis was shocked, one can only imagine the reaction of other healers to being told that they were in practice, if not in intent, killers.

 Semmelweis continued to make things worse by attacking those who criticized his work. He accused his fellow physicians of murder and worse, and his own behavior became increasingly erratic. Showing increasing signs of mental illness and breakdown, his wife committed him to an asylum in 1857, where he died under mysterious circumstances.

Rembrandt, The Anatomy Lesson

Managing the Impossible Project: Inertia and Friction

Semmelweis succeeded in his “impossible project” to determine the basic cause and treatment of childbed fever, but failed to win widespread support for his ideas at the time. It would not be until the latter part of the 19th Century that the germ theory of disease became widely accepted.

If we consider Semmelweis’s project to be identifying the cause and treatment of childbed fever, he was a remarkable success. As noted, he was much less effective in gaining widespread acceptance for his ideas.

The natural human resistance to new ideas and the role of persuasion and influence management in achieving change are a constant source of frustration — and sometimes despair — for leaders of all stripes. It may help to extend our scientific metaphor and describe the obstacles in light of physics: people and organization, no less than other objects in the real world, are subject to inertia and friction.

Whatever the etiology of the Semmelweis Reflex, the idea of resistance to change is well established in management literature, and it’s just inertia under another name. A body at rest tends to stay at rest until acted upon by an outside force. The good news is that if you can just get the motion started, inertia changes from your enemy to your friend and helps sustain the motion.

Friction, of course, is one of those “outside forces” that hamper inertia. Moving parts have friction, and friction results in the degradation of useful energy. In the human sphere, we’ve all witnessed the results of friction in every human encounter. In mechanics, one way to lessen the effects of friction is through lubrication. The discipline of emotional intelligence, good manners, politeness, and office politics all work to lessen the friction in organizational interaction. It’s just as much a part of the job as the technical work, and leaders ignore it at their peril.

Rashomon Reality (Part 18 of Cognitive Biases)

Our 18th installment of Cognitive Biases covers the self-serving bias, offers a new interpretation of the Semmelweis reflex, and looks at the two sides of the serial position effect.

Self-Serving Bias

A self-serving bias occurs when people attribute their successes to internal or personal factors but attribute their failures to situational factors beyond their control: to take credit for success but to shift the blame for failure. It also occurs when we are presented with ambiguous information and evaluate it in the way that best suits our own interest.

Several reasons have been proposed to explain the occurrence of self-serving bias: maintaining self-esteem, making a good impression, or sometimes that we’re aware of factors outsiders might miss.

The bias has been demonstrated in many areas. For example, victims of serious occupational accidents tend to attribute their accidents to external factors, whereas their coworkers and management tend to attribute the accidents to the victims' own actions.

When the self-serving bias causes people to see Rashomon reality, the ability to negotiate can be dramatically impaired. One of the parties may see the other side as bluffing or completely unwilling to be reasonable, based on the self-serving interpretation of the ambiguous evidence.

In one experiment, subjects played the role of either the plaintiff or defendant in a hypothetical car accident case with a maximum potential damages payment of $100,000. The experiment used real money at the rate of $1 real = $10,000 experiment.

They then tried to settle in a fixed amount of time, and if they failed, the settlement amount would be charged a hefty legal bill. On average, plaintiffs thought the likely award would be $14,500 higher than the defendants. The further away the perceived “fair” figures were from each other strongly correlated with whether they could reach an agreement in time.

The self-serving bias, interestingly, seems not to exist in our struggles with personal computers. When we can’t get them to work, we blame ourselves rather than the technology. The reason is that people are so used to bad functionality, counterintuitive features, bugs, and sudden crashes of most contemporary software applications that they tend not to complain about them. Instead, they believe it is their personal responsibility to predict possible issues and to find solutions to computer problems. This unique phenomenon has been recently observed in several human-computer interaction investigations.


Semmelweis Reflex

Dr. Ignatz Semmelweis, assistant to the head of obstetrics at the Vienna General Hospital in the 1840s, discovered that his clinic, where doctors were trained, had a maternal mortality rate from puerperal fever (childbed fever) that averaged 10 percent. A second clinic, which trained midwives, had a mortality rate of only four percent.

This was well known outside the hospital. Semmelweis described women begging on their knees to go to the midwives clinic rather than risk the care of doctors. This, Semmelweis said, “made me so miserable that life seemed worthless.” Semmelweis started a systematic analysis to find out the cause, ruling out overcrowding, climate, and other factors before the death of an old friend from a condition similar to puerperal fever after being accidentally cut with a student’s scalpel during an autopsy.

Semmelweis imagined that some sort of “cadaverous particles” might be responsible, germs being at that time unknown. Midwives, after all, didn’t perform autopsies. Accordingly, Semmelweis required doctors to wash their hands in a mild bleach solution after performing autopsies. Following the change in procedures, death rates in the doctors clinic dropped almost immediately to the levels of the midwives clinic.

This theory contradicted medical belief of the time, and Semmelweis eventually was disgraced, lost his job, began accusing his fellow physicians of murder, and eventually died in a mental institution, possibly after being beaten by a guard.

Hence the Semmelweis effect: normally described as a reflex-like rejection of new knowledge because it contradicts entrenched norms, beliefs or paradigms: the “automatic rejection of the obvious, without thought, inspection, or experiment.”

Some credit Robert Anton Wilson for the phrase. Timothy Leary defined it as, “Mob behavior found among primates and larval hominids on undeveloped planets, in which a discovery of important scientific fact is punished.”

I don’t agree. I think there’s something else going on here.

The Semmelweis effect, I think, relates more to the implied threat and criticism the new knowledge has for old behavior. Let’s go back to Semmelweis’ original discovery. If his hypothesis about hand washing is correct, it means that physicians have contributed to the deaths of thousands of patients. Who wants to think of himself or herself as a killer, however inadvertent?


The Semmelweis reflex is, I think, better stated as the human tendency to reject or challenge scientific or other factual information that portrays us in a negative light. In that sense, it’s related to the phenomenon of reactance, discussed earlier.

In this case, Semmelweis’s own reaction to discovering the mortality rate of his clinic might have been a tip-off. He was “so miserable that life seemed worthless.” In his own case, this drove him to perform research, but these other doctors can only accept or deny the results. It’s not unreasonable to expect a certain amount of hostile response, and calling people “murderers,” as Semmelweis did, is hardly likely to win friends and influence people.

You don’t have to look far to find contemporary illustrations, from tobacco executives aghast someone dared accuse them of making a faulty product to the notorious Ford Motor Company indifference to safety in designing the Ford Pinto. The people involved weren’t trying to be unethical or immoral; they were in the grips of denial triggered by the Semmelweis reflex. This denial was strong enough to make them ignore or trivialize evidence that in retrospect appears conclusive.

When you’re accused of fault, watch for the Semmelweis reflex in yourself. The natural first impulse is to deny or deflect, but the right practice is to examine and explore. Depending on what you find, you can select a more reasoned strategy.



Serial Position Effect


The serial position effect, coined by Hermann Ebbinghaus, refers to the finding that recall accuracy varies as a function of an item's position within a study list. When asked to recall a list of items in any order (free recall), people tend to begin recall with the end of the list, recalling those items best (the recency effect). Among earlier list items, the first few items are recalled more frequently than the middle items (the primacy effect).

One suggested reason for the primacy effect is that the initial items presented are most effectively stored in long-term memory because of the greater amount of processing devoted to them. (The first list item can be rehearsed by itself; the second must be rehearsed along with the first, the third along with the first and second, and so on.) One suggested reason for the recency effect is that these items are still present in working memory when recall is solicited. Items that benefit from neither (the middle items) are recalled most poorly.

There is experimental support for these explanations. For example:

• The primacy effect (but not the recency effect) is reduced when items are presented quickly and is enhanced when presented slowly (factors that reduce and enhance processing of each item and thus permanent storage).
• The recency effect (but not the primacy effect) is reduced when an interfering task is given; for example, subjects may be asked to compute a math problem in their heads prior to recalling list items; this task requires working memory and interferes with any list items being attended to.
• Amnesiacs with poor ability to form permanent long-term memories do not show a primacy effect, but do show a recency effect.

More next week.

To read the whole series, click "Cognitive bias" in the tag cloud to your right, or search for any individual bias the same way.