What is "Ethics"? I. Beyond Rules and Principles: The Importance of Ideals

Since many of my reflections in this "Mortal Matters 2.0" blog will be framed in terms of "ethics", it may help if I start off with some reflections about what "ethics" is – or should be -- and how to think about "ethical" questions.

When someone poses an "ethics" question, it is often a question about a specific decision or action: "what should I (or we) do?" or "What is the right thing to do?" or "Is doing X ethical?"  

"Ethics" questions framed in this way then often turn into philosophical discussions about the right "ethical principles" or "rules", and/or practical discussions about how to "apply" those principles to a specific situation.  When we hear or read about someone being "unethical", for example, it is almost always framed in terms of that person having done something that violated some ethical rule or principle.   

Principles and rules are of course very important.  But by themselves they often leave our moral reflections impoverished, and far less powerful than "ethics" should be. 

A different starting point is to think of people we admire the most, people we consider inspirational moral examples. 

When I think of the physicians I admire most, the ones who most fully embody the moral values that characterize medicine at its best, the ones I wish I could be more like, I don't usually think in terms of any specific "decisions" they made – did they get that patient’s “code status” right?  And while they are almost always people I would describe as “highly principled”, it isn’t exactly the "principles" or "rules" they use that I find most inspiring, and wish to emulate.  They seem to me to consistently embody something much higher (or deeper?) than words like "rules" or “principles” can capture. They frequently go beyond, sometimes far beyond, anything most people would say is their "ethical responsibility”.  Words like "excellence" and “exemplary” come to mind.   

But even "excellence" doesn't seem to me to capture adequately what makes these people such important and powerful role models.   In the language of grades, even a "straight A" wouldn't quite convey what makes them special.  They seem to be aiming for, and motivated by, something different, something that is simultaneously higher than any “rule”, and anchored in something deeper than any “principle”.  

At this point, I find myself hampered by trying to find the precise words to capture what I mean. Like many lofty words -- "beauty" and "goodness" come to mind -- when finding the right language to define them is hard, illustrating in examples can help.

Mahatma Gandhi (1869-1948)

When I and many others think of shining "moral examples" of the 20th century, several names regularly come to mind -- three are Mahatma Gandhi, Martin Luther King, and Nelson Mandela. Each showed us, and still shows us, what it can mean to lead a profoundly moral or ethical life.  Not one was or is a perfect role model in every aspect, or every period,of his life.  But when we think of the ways in which they are moral examples to us, how each showed us with unusual power what "ethics" in practice can be, we think of their passionate dedication to high ideals, aspiring to a vision of what an ethics-centered life can be, and of what being part of an ethics-based community can mean for each of us.

Dr. Martin Luther King, Jr. (1929-1968)

Nelson Mandela (1918-2013)

Each of these people embodied an extraordinary commitment to “justice”, but that commitment was not simply to “principles of justice”, or at least not the way those are described in most “ethics” books.  Each was a moral visionary, driven by a commitment to an ideal of justice that went far beyond what most of their contemporaries even imagined. And each of these moral heroes not only broke many “rules”; each also spent substantial time in jail.  

Of course, most of us work in organizations, or live in communities, whose rules are far more ethical than the caste system in India, or Jim Crow laws in the U.S., or apartheid in South Africa.  But even if the rules we live under, or live by, are as ethical as it is possible for rules to be, I suspect that most of us still admire people morally the most not because they never break a rule, and not even because they always adhere to ethical principles, but rather because they live by unusually high ideals.

Since ideals are sometimes thought of as either “too abstract”, or “unrealistic”, I will close here with two quotations from another moral hero of the 20th century, Dr. Albert Schweitzer.  He too, spent time in jail, or at least in a prisoner of war camp, after he and his wife Helene were arrested at the hospital they had founded in Lambarene, Gabon just before World War I broke out, imprisoned for the crime of being German citizens in a French colony.  So their hospital was forcibly closed, and they were shipped back to France as prisoners of war, freed only after the war ended.

On the subject of ideals and so-called “realism”, Schweitzer wrote:

I place at opposite extremes the spirit of idealism and the spirit of realism.  The spirit of idealism means that men and women…arrive at ethical ideals through thinking, and that these ideals are so powerful that they say “We will use them to control reality.  We will transform reality in accordance with these ideals.”  The spirit of idealism desires to have power over the spirit of realism.  The spirit of practical realism, holds it false to apply ideals to what is happening.  The spirit of realism has no power over reality.  If a generation lives with these ideas, it is subject to reality.  This is the tragedy which is being enacted in our age.  For what is characteristic of our age is that we no longer really believe in social or spiritual progress, but face reality powerless.

And in this spirit, when Dr. Schweitzer spoke to young people he stressed that one of the most important things a young person can do is to:

Grow into your ideals, so that life can never rob you of them.

Welcome Back to "Mortal Matters" (version 2.0)

Just over 2 years ago I wrote my last "Mortal Matters" blog post, "The Miracle of Candice", not realizing that The Boston Globe and boston.com had decided to stop hosting their "Community Voices" blogs. I had never thought of myself as a "blogger" kind of person, but looking back I find I have missed offering occasional blog-length reflections on medicine, ethics, and other topics.

I am currently in a reflective mood, as I wrote last month to my many cherished colleagues at Beth Israel Deaconess Medical Center:

This month [June 2016] I celebrate 30 wonderful years at BIDMC, and with BIDMC as a wonderful home base for many other things, sometimes far beyond our campus.  I have decided to celebrate by taking time away from July 1 to October 1 to reflect on the past 30 years, and on goals for the next phase of my work life.

A larger context for this is that my wife Susan and I became "empty nesters" two years ago -- three of our four wonderful children have now graduated from college, and our youngest daughter will likely do so in May 2018.  Sometime after that, Susan and I are considering whether we might do very different things with our lives -- the most radical change might be splitting our time between a US home base and periods of international work together.  Of course, it is also quite possible that we will not make any major changes at all.  In any case, since last year I have been telling people that my goal is that by 2018 or 2019 any of my current major work-related projects that are important to me will either have been completed, or will have become institutionalized or largely led (or at least easily could be) by others, so that they are no longer heavily dependent on me.   

To succeed in that means I need to become clearer than I currently am about what work-related things truly are most important to me, and why -- so I will be using this "Mortal Matters 2.0" space to reflect on those questions.

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My current plans for this blog, which will no doubt evolve in unpredictable ways, are to focus my initial "Mortal Matters 2.0" entries on a few very general "30,000-foot" themes that I find myself regularly coming back to when I reflect on more specific topics in "medicine" and "ethics".  These include thoughts on topics like:

What is "Ethics"?

What are -- or should be -- the "goals of medicine"?

Who was Albert Schweitzer, and why do I think his legacy remains so important for the world?

What is "Good Work" in medicine?  What sustains it?  What undermines it?  

After these initial high-level reflections, I currently expect to write mostly about narrower and more concrete topics.  While occasionally a posting will be sparked by recent news or current events, I will likely usually be writing on more timeless subjects (What is "hope"?  What is "healing"?  How can we support them?), often reflecting on experiences I have had over the past 35 years with individual patients, their families, and professional colleagues.

As I write about these and other topics, I will also frequently be thinking, writing about, and paying tribute to some of the people who have most influenced me.  On the last "30,000-foot" topic listed above ("Good Work" in medicine), for example, I am deeply indebted to to Howard Gardner for his pioneering explorations of these issues, initially in professional work, now in all of life. 

Finally, since most of what I know and value I have learned from other people, I am hoping that at least some of my blog entries will spark others to comment so that we can reflect and learn together -- so please do!