>> After the outbreak of SARS-CoV-2 (corona virus), contact and exit restrictions, minimum distance between people, hygiene rules, mask requirements and other measures were introduced to protect public health and to prevent the healthcare system from being overwhelmed. These measures have an impact on economic, social and cultural life.
Long-term high numbers of infections result in increasingly longer-lasting measures. Politicians are making a name for themselves with statements in favor of further tightening restrictions, closures and curfews. The effectiveness of these measures is critically discussed in science, and the relationship between costs and benefits is not transparent.
This article is not about the question of whether a specific spectrum of measures promises success or not. Rather, the aim of this commentary is to show that policies that do not reflect citizens' preferences are doomed to failure. Measures to contain and combat the corona virus are only successful if the decisions are accepted and politicians can count on the compliance and consent of a majority of the population.
We all try to weigh up the desired and undesirable effects when making decisions. There is no reason this should be any different when dealing with the health risks of the pandemic.
The stress test for politicians is concretized in the weighing of the effects: Are citizens prepared to accept economic losses in order to contain the pandemic, and if so, to what extent? Conversely, are they willing to accept a certain excess mortality rate in order to stabilize the economy? Do you accept the sharing of personal data through a Corona app if this can reduce the risk of infection? Is the deprivation of individual civil liberties tolerated in order to protect vulnerable population groups?
Delegation of decision-making authority
In December, according to the ZDF political barometer, 83% of those surveyed supported the extension of the measures. In addition, night-time curfews in urban and rural districts with high infection rates were tolerated by almost ¾ of those surveyed. Why such high approval ratings? It can be assumed here that the belief in the information advantage and the competence of politicians and authorities is deeply anchored in large parts of the population and that there is therefore a great willingness to give up decision-making powers. Politicians take decisions on their own by arguing that information asymmetries that become visible raise doubts about the decision-making authority of citizens. The extent to which this argument also applies to Parliament is another matter.
In addition, in times of crisis, the argument is repeatedly made that collective needs take priority over individual goals in this crisis situation and that quick action is necessary. This gives collective goals clear priority over individual goals. It remains unclear over what period of time this argument is supposed to be valid. As a result, decision-making authority is delegated to political or regulatory decision-makers.
Even if the decision-makers are legitimized by elections or expertise, the question remains to what extent the affected citizens support the measures taken and to what extent they are prepared to accept economic and/or health consequences. Because it is the citizens who are affected in their economic, social and cultural lives. The complexity is also that these sacrifices cannot (contrary to common parlance) guarantee health, but only reduce the probability of being infected by that particular virus, possibly having to go to the hospital and perhaps dying.
Subjective value judgments versus population preferences
Despite a high level of uncertainty about the effects of measures to contain and combat the corona virus, political decision-makers must act - always based on the evidence that is currently available. In addition, they always have to make compromises. Maximum control of the health risk would in itself require that public transport be shut down because many people meet in a small space. This is what the “Zero Covid” initiative (https://zero-covid.org) calls for, for example. But then many healthcare workers can no longer get to their workplace. The complete isolation of residents of old people's and nursing homes would also be advisable, but with the result that their mental health (and often that of their relatives) would suffer. Scientists are now calling for an incidence rate below ten under the confusingly similar term “No Covid” and want to allow green zones with more freedom where this is successful. But, whether zero or zero: There is an inevitable weighing up of benefits and (not just economic) costs, which is currently made on the basis of value judgments without making them transparent.
With such fundamental strategies that drastically restrict civil and personal freedoms, it must be openly discussed whether the decision-makers as administrators take the citizens' preferences into account in the best possible way when making this assessment. In other words: Are political decision-makers free to follow their own subjective preferences when representing the affected population? Because: Whether legitimized by elections or specialist knowledge, it is always purely subjective value judgments of individuals that decide on the compromises between public health, civil rights and the economy.
Regardless of the answer to this question, one can assume that the acceptance of all political decisions depends largely on whether the citizens affected understand and support the weighing of the advantages and disadvantages.
Acceptance and dissatisfaction with
political decisions
The acceptance of political decisions is largely determined by the individual weighing of the advantages and disadvantages by those affected. If the preferences prevailing in the population are not taken into account or if the value judgments underlying the political deliberation processes are not transparent, it is to be expected that there will be dissatisfaction among the population.
In most democracies, this dissatisfaction can only be vented in the next elections, although it almost always remains unclear why exactly representatives or parties are losing votes. They are not voted out or confirmed because of a single decision, but because of their decisions in several areas (health, environment, infrastructure, internal security, etc.). Recent experiences in particular – for example the riots in the Netherlands in January – also show that this dissatisfaction can lead to violent protests.
These considerations boil down to the hypothesis that political decisions that contradict citizens' preferences are ultimately doomed to failure. Ultimately, poor decisions or a lack of transparency about value judgments also pose a danger to democracy itself.
Methods and future measures
For this and future pandemics, there is a need to develop tools and methods to analyze population preferences and develop supportive decision-making tools. Ways must be found to incorporate population preferences into political decision-making processes.
The good thing is: they already exist! Methods of preference measurement to be used here have been developed and refined by various scientific disciplines in recent years. These procedures can easily be transferred to the health care system or health policy. A further presentation of a study: http://www.coronapreferences.info/.
Non-pharmaceutical measures of the corona pandemic can also be transferred into a decision model. Figure 1 shows the most important characteristics of a lockdown, which describe the benefits, costs and risks of political interventions.
To present potentially conceivable alternatives, the characteristics of the individual measures are varied over the course of the experiment in order to find out which attributes are important to the respondents and which are unimportant. By making choices about constantly changing alternatives, the structure of the consideration processes can be analyzed and preferences can thus be documented. A risk of infection of 15% (see the blue dots in the “risk of infection” image) may not be enough for some people to choose an alternative with a personal loss of income of 10% - a first indication that maintaining their income is relatively important to this person .
If the same person sticks to his decision against an alternative in which the risk of infection is increased to 20%, but the loss of income is reduced to 5%, then preserving income is obviously particularly important to him. Another example is the sharing of health data: someone may reject an alternative that involves sharing if the excess mortality is three percentage points (i.e. 0.90% instead of 0.87% of the population). If this person continues to reject an alternative with just one percentage point excess mortality (i.e. 0.88% instead of 0.87%), then data protection has a very high weight in their preference structure.
In this way, population preferences can be determined from the voting process using econometric methods. The heterogeneity of different population groups can also be analyzed and documented in relation to how they deal with non-pharmaceutical measures. Information on preference studies: http://www.coronapreferences.info/.
With this data, governments have the chance to align their measures with the preferences of their voters and thus improve their acceptance. There is also the possibility of communicating the connections between the deliberation processes with the help of choice experiments. A step towards an informed debate and the chance to create transparency about value judgments.
potential for improvement
The current pandemic is not only a stress test for the healthcare system, but also for political decision-making processes. It is undisputed that non-pharmaceutical measures require the participation of the population. However, this can hardly be achieved sustainably without taking population preferences into account. The box below shows the significance of this thesis with a practical example in Switzerland. This makes it clear that political decisions can fail if citizens' preferences are not met.
It should also be remembered that the country's welfare depends on everyone being able to achieve their personal benefit-cost ratio (as best as possible). Politics is there to make this possible; on the sole condition that this endeavor may not cause damage to third parties. This means that any necessary restrictions must be designed in such a way that they correspond to citizens' preferences as much as possible.
But even then, unfortunately, there is no guarantee of success for political decision-makers. They always act with incomplete information, which also comes from experts who also pursue their own goals (prestige in the professional world, attention in the media, career opportunities). The failure of measures should therefore not be blamed on the responsible politicians and authorities. Conversely, however, capturing citizen preferences can help reduce such failures.
In summary: It is not about demanding one or another political decision; Rather, it is about demanding decision-making processes that enable citizen-oriented politics. The comprehensibility of value judgments is part of democratic processes and has an influence on the satisfaction of those affected. <<
Swiss experiences of direct democracy
The failure of decisions that are remote from citizens is confirmed by an experience from Switzerland, a country with direct democratic institutions that allow a statement to be made on individual legislative proposals. However, the example concerns healthcare and not a specific health risk related to a pandemic. A choice experiment carried out in 2003 (of the type presented here) looked at citizens' preferences with regard to aspects of so-called integrated care (IV, English Managed Care). By integrating service providers into a network, the IV promises a reduction in health care spending, which is reflected in lower health insurance contributions as a result of competition. The price for this is a more or less extensive restriction of the freedom to choose a doctor. However, the election experiment showed that the “hard” variant, in which the health insurer would compile the list of doctors based solely on cost criteria, would have to be compensated with up to 38 percent of the national average premium at the time.
However, the Swiss parliamentarians did not take note of this research result. In an effort to relieve the public budget of rising health care costs, they passed a law with a large majority in 2011 that intended to make IV the standard in social health insurance; Anyone who wanted to maintain their free choice of doctor had to accept an increased contribution. Conversely, the law did not provide for any compensation (whether through lower insurance premiums or through a reduction in taxes). The 50,000 necessary signatures for a referendum were promptly collected, and in June 2012 it was approved with 76 percent of the vote. The failure of the bill would have been foreseeable if it had taken into account the previously collected citizen preferences and included compensation for the restriction on the freedom to choose a doctor.
