Holiday Review
The appeal of the coin toss that it is a simple, seemingly
unbiased, method of deciding between 2 options. Although
the outcome of a coin toss should be at even odds, the outcome
may well not be. Historically, the toss of a coin before a
duel reputedly decided which person had his back to the sun
— an obvious advantage when taking aim! In medical trials, a
simple statistical manipulation can have a dramatic effect on
the treatment a patient receives. Our hypothesis is that with
minimal training, the outcome of the toss can be weighted
heavily to the call of the tosser, thus abolishing the 50:50
chance result that is expected and allowing for manipulation
of an apparently random event.
Methods
We included 13 otolaryngology residents from the University
of British Columbia who verbally consented to participate.
We excluded any residents who had a hand injury that
would prevent them from tossing a coin with their dom in -
ant hand.
The participants were told about the purpose of the study
several weeks before the trial. The investigators instructed the
residents and demonstrated the toss. The residents were
allowed to practise tossing the coin in a consistent manner for
a couple of minutes. Each resident then performed 300 coin
tosses in which they tried to achieve a heads result each time.
The results were recorded by an observer to avoid the possibility
of cheating. The 2 participants who achieved the greatest
manipulation of the results (i.e., the highest proportion of
heads) were given an incentive (i.e., $20 and $10 coffee
vouchers). We felt that the use of an incentive would reproduce
real-life situations.
Statistical analysis
Because our null hypothesis was that the coin-weighting was
unbiased, we assumed that 50% of the tosses would result in
heads. We used 2-sided binomial testing because we could
not assume that if we were trying to increase the proportion of
heads, we would not instead reduce this proportion. For a
change of at least 10%, we calculated that 263 coin tosses per
participant would be required to achieve 90% power to detect
this difference with a significance level of 0.05.
We performed a comparison of proportions. The statistical
calculations were performed on the basis of how many coin
tosses an individual would have to perform to show a significant
manipulation. Therefore, any participant who achieved
this level would have a significant result. We did not use
group statistics for this reason.
Results
Each of the 13 participants tossed a coin 300 times. All participants
tried to achieve a heads result. Each participant successfully
achieved more heads than tails results; this difference
was statistically significant for 7 participants (Table 1).
The participant who was most successful at manipulating the
outcome achieved a proportion of heads of 0.68 (95% confidence
interval 0.62–0.73; p < 0.001).
Interpretation
This study shows that when participants are given simple
instructions about how to manipulate the toss of a coin and
only a few minutes to practise this technique, more than half
can significantly manipulate the outcome. With devoted training,
more participants would probably be able to achieve this
figure, and the magnitude of the manipulation would prob -
ably be increased.
With respect to the use of a coin toss to randomly assign
patients to a treatment in a clinical trial, our results could be
considered clinically significant if only 1 participant in this
study had achieved a nonrandom result. We have shown that
a person tossing a coin may have the ability to manipulate the
toss and significantly bias the results to their liking. Given
that we would never know the manipulation skills or motivation
of the person tossing the coin, this method seems unsuitable
for randomization procedures in experiments in which
bias needs to be minimized.
Research by Diaconis and colleagues2 has suggested a
dynamic bias to coin tosses. They suggest that, for natural
flips, the chance of the coin landing as it started is about 0.51,
with a number of assumptions or required conditions. Diaconis
states that, for a fair toss, the coin must be caught in the
palm of the hand and not allowed to land on a surface and
bounce, because the latter often incorporates a degree of spinning
on the coin’s edge. Because catching a coin in one’s
palm and turning it onto the back of the opposite hand allows
for manipulation with sleight of hand, the coin must be
allowed to just land in the palm of the hand.
Diaconis and colleagues2 assumed that when tossed, the
Table 1: Results of coin tosses in which 13 participants
attempted to achieve a “heads” result
Outcome
n = 300
Participant Heads Tails
Proportion of
heads (95% CI)
p
value*
1 162 138 0.54 (0.48–0.60) 0.18
2 175 125 0.58 (0.53–0.64) 0.005
3 159 141 0.53 (0.47–0.59) 0.37
4 179 121 0.60 (0.54–0.65) 0.001
5 203 97 0.68 (0.62–0.73) < 0.001
6 168 132 0.56 (0.50–0.62) 0.043
7 170 130 0.57 (0.51–0.62) 0.024
8 160 140 0.53 (0.48–0.59) 0.27
9 192 108 0.64 (0.58–0.69) < 0.001
10 167 133 0.56 (0.50–0.61) 0.06
11 154 146 0.51 (0.46–0.57) 0.69
12 153 147 0.51 (0.45–0.57) 0.77
13 176 124 0.59 (0.53–0.64) 0.003