Fictional city of the future. Portrait of a Utopian society.

When Crafting Public Health Policy, the Perfect Shouldn’t Be the Enemy of the Good

By Daniel Goldberg

The nirvana fallacy “is the informal fallacy of comparing actual things with unrealistic, idealized alternatives.” Practice and policy guided by the nirvana fallacy discourages any action at all short of a perfect solution.

Sound familiar? It’s one justification for pandemic policy inaction in a nutshell.

For example, public health officials at virtually every level have resisted implementation or reinstatement of mask mandates in part by arguing that either some percentage of the population will not mask or that mask mandates alone will be ineffective. Note that the error in these justifications is not necessarily that they are wrong, although both claims are false or misleading in important respects (as to the claim of unwillingness, regional and national polling consistently report that majorities favor mask mandates at least during pandemic surges. As to the claim of ineffectiveness, there is more than enough evidence by ordinary epidemiologic standards to license the conclusion that mask mandates are an effective intervention for pandemic response and control).

Rather, the more important mistake is that these propositions are actually the warrant for mask mandates. The fact that some percentage of the population will refuse to wear a mask is literally a reason to implement a mask mandate — to capture those portions of the population who are willing to wear a mask but might not do so in the absence of a mandate.

Similarly, the fact that mask mandates alone may have real but less-than-desired impact is literally a reason to implement a mask mandate. The fact that a bundle of interventions is needed for adequate pandemic response and control is beyond dispute; the fact that mask mandates have some positive effects for pandemic response and control is the justification for their implementation rather than a reason to dispose of the effort!

In an earlier post on Bill of Health, I documented a similar example of the nirvana fallacy regarding the possibility of temporary closures of high-risk contexts such as bars and indoor dining. One objection to such an intervention is the notion that it might “contribute to new problems that require intervention (i.e., closing bars could, in theory, increase the likelihood of private gatherings, which are harder to control via public health law responses).” But rather than standing as a reason to avoid the public health action, the fact that some high-risk contexts are largely unreachable via public health law interventions is a reason in favor of its implementation! In the post, I noted Lindsay Wiley’s explanation that

preventing transmission from one household member to another is a downstream approach at a point where there are fewer effective & feasible govt interventions … So the approach used in some cities in 1918, during polio outbreaks, & in the 1st 2 waves of 2020 was to break the transmission chain before it reaches so many households, by intervening upstream at workplaces & commercial & institutional indoor gathering places.

I summarized the argument as such: “In other words, the very fact that some factors intensifying the pandemic are less ameliorable via public health law is an excellent reason for addressing the factors that are more ameliorable.” Although I did not realize it at the time, the objection I was critiquing in that post exemplified the nirvana fallacy.

The persistence of the nirvana fallacy in public health contexts is even more puzzling inasmuch as it rather obviously contravenes basic axioms of harm reduction, a general conceptual approach for public health practice and policy. Although harm reduction ethics can be complex, there is general consensus among public health ethicists that harm reduction ethics in general has a sound footing and provides a sufficient warrant for a wide variety of practices and policies.

The entire premise of harm reduction rests on the idea that the perfect ought not be the enemy of the good. It would be peculiar indeed to respond to a claim that “X intervention reduces harm and is therefore ethically justified” by stating that “X intervention is not ethically justified because some harm persists even after X.” In fact, such a rejoinder almost qualifies as a non sequitur. The justification for harm reduction is literally based on the idea that harm elimination is either impossible or undesirable, but that reducing harm is a powerful means of advancing health justice and reducing stigma and is therefore well-justified ethically and empirically.

We live in a non-ideal world and public health interventions must be designed and implemented with such imperfections in mind. Utopian ideals are important insofar as they frame the state of play between our current world and the destinations that we are trying to reach. However, the map is not the territory; clinging too much to a plan even when real-world conditions frustrate the ideal journey may leave travelers lost in the wilderness.

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