Richard J. Severson

This is chapter seven of my book, Medicine, A Phenomenological Inquiry.

Symbols, Virtues, and Spiritual Awakenings:

Consciousness isn’t only a private experience of the self.  The feeling of a feeling also represents the appearance of a world that we care about.  The mind is a symbolic construction attuned to the emotional signals of the body, yet we live outward and forward into the world as moral agents.  What would be the point of consciousness if we weren’t able to leverage its strengths in order to improve our own existence?  Morality evolved to enhance the cooperative capabilities of small bands of hunter-gatherers.  As Darwin pointed out, moral communities outcompete nonmoral ones because they work together more efficiently.1 Couldn’t the same thing be said regarding the evolution of consciousness?  Our distant ancestors used their minds to outthink their adversaries.  Success or failure depended upon how they performed mentally.  In that sense, their fate was always in their own hands.  The feeling of a feeling, I suspect, is probably akin to a moral sentiment.  Regret is a good example.  We feel regret, or disappointment in ourselves, when we fail to achieve a goal.  To be held accountable for our own actions—to feel the pang of censure—is the meaning of both morality and consciousness; it is one of the burdens of self-awareness.   

Symbols have a moral thickness that extends them beyond the confines of the mind’s internal structures.  Falling down, for instance, is a symbol of sickness that also represents a diminished world of opportunities.  Confined to bed, we feel incapable of meeting our normal obligations.  We try to go to work, but we can’t.  Even the ability to take care of ourselves becomes an exercise in futility.  Instead, we must rely upon the assistance of others to feed ourselves, bathe, and so forth.  To care about the welfare of someone else is the epitome of both morality and medicine.  It is a healing symbol that is also a moral virtue that binds us to the fate of others.  Symbols are to the inner life of the mind what virtues are to our worldly activities and concerns.  Symbols and feelings give rise to virtues just as they give rise to thoughts; consciousness would be incomplete without all of our mental attributes working together.    

According to Aristotle, virtues are settled dispositions to act and feel a certain way.2 Summarizing ancient Greek practical wisdom (phronesis), he mentioned 10 different moral virtues: courage, generosity, magnificence, high-mindedness, gentleness, friendliness, truthfulness, wit, tact, and justice.  He thought justice summarized them all.  Centuries later, in conformity with his Christian vision of reality, St. Augustine said that caritas, or love, is the epitome of all virtues, including justice.3  Every culture develops its own distinctive symbols and myths that expound an overarching worldview.  Likewise, every culture cultivates its own customs and virtues that demarcate normative behavioral patterns.  They go hand in hand. 

We acquire moral virtues by habit or by practicing them.  It is never easy, as the many tragic conflicts of human history attest all too well.  “Anyone can get angry,” Aristotle said, “or can give away money or spend it; but to do all this to the right person, to the right extent, at the right time, for the right reason, and in the right way is no longer something easy that anyone can do.”  The practice of virtues is a difficult enterprise.  So is the prospect of controlling our own feelings, as therapists continually proclaim.  Yet it is our responsibility as self-conscious beings to express our feelings and behave in an appropriate—virtuous—manner.  It’s how we go about the business of managing our affairs.  To be virtuous is the ultimate purpose of consciousness.  Or, as Aristotle concluded, a happy life is a life in conformity with virtue. 

Aristotle was no Stoic.  He did not believe that virtue could inure one to every form of suffering.  To be stricken with a debilitating injury or illness would necessarily diminish the prospects of happiness, even for the most virtuous person.  For a true Stoic, on the other hand, virtue is unassailable by the vicissitudes of life.  I think it would be fair to say that the virtues of medicine are in alignment with Aristotle’s perspective on suffering.  Paramount amongst them is caring for those in need of assistance.  Sickness is an incapacitating condition, capable of rendering moral virtues irrelevant and meaningless.  What we can’t do, not what we ought to do, overwhelms our moral horizon.  It is not a cause for happiness to feel as if the world has abandoned us to a miserable fate.  Like a curled wood shaving on a carpenter’s floor, pain and suffering turn us inward upon ourselves and away from the world.  That’s where medicine comes in.  It picks us up and restores us, or tries to, when our own virtues and hopes are of no use at all.      

Until recently, virtues have been out of favor in modern ethical theory.  That’s true in biomedical ethics as well.  It wasn’t until the last decade of the 20th century that Pellegrino and Thomason championed the practice of virtues as an alternative to the standard model of principled medical ethics.4  They mention fidelity to trust, compassion, phronesis, justice, fortitude, temperance, integrity, and self-effacement.  That’s a demanding list of praiseworthy characteristics for health professionals to live up to.  Ironically, Beauchamp and Childress began including their own list of medical virtues in the 7th edition of their influential textbook regarding principled decision making in the clinical setting.5  Everybody who has ever taken a medical ethics class probably knows about their deliberative method for weighting the relevance of four core principles—respect for autonomy, nonmaleficence, beneficence, and justice—in order to resolve the ethical conundrums that beleaguer modern medicine.  For instance, how can an organ transplant program be equitably administered when demand greatly exceeds the supply of donor organs?  The beneficence of helping the lucky few who receive new organs would seem to create a harmful injustice for those who don’t survive long enough to reach the front of the queue.  Less well known are the virtues Beauchamp and Childress recommend to health professionals, in addition to their widely accepted principles.  They include caring, compassion, discernment, trustworthiness, integrity, and conscientiousness.  What’s interesting about this list compared to the Pellegrino and Thomason list is that they prioritize the virtue of caring.  All the other virtues represent refinements of that one foundational medical virtue. 

Another interesting point of comparison is that Pellegrino and Thomason include justice as a virtue, whereas Beauchamp and Childress treat it as a principle.  Is there a real difference between principles and virtues, or is it just a matter of splitting hairs?  I think there is an important difference between them.  Principles are rational tools that we use to impose order on our thoughts and behavior.  Like Kant’s moral law, they are theoretical constructs that must be universal in their application.  John Rawls made the quintessential argument for why justice is such an important principle for a liberal society.6  He said that we must imagine not knowing anything about our own personal condition in life—rich or poor, happy or wretched, male or female, etc.—and on the basis of that hypothetical “veil of ignorance” build a society where everybody is treated exactly the same.  Without such an abstract application of fairness across the board, it would probably be impossible for a modern democracy to function at all.  Conversely, virtues transform our self-identities from within, even changing how we feel about things.  When rightly practiced, the virtue of justice engenders a sense of fair play within our character, thereby leading to changes in how we live.  Principles are more abstract, externally imposed, and rule-like than virtues; they are ethical constructions, virtues much less so.  Long before the invention of ethics, our Stone Age ancestors practiced their own distinctive moral virtues.  Chief among them were humility and generosity.7  As part of our moral character, virtues are more closely aligned with our instinctual feelings, and therefore not as beholden to the ethical reasoning associated with principles. 

Most of us use the terms morality and ethics interchangeably.  (I suspect the same thing could be said about virtues and principles.)  When we do make a distinction, usually we think of morality as being more personal, ethics more theoretical.  Morality is a human universal.  Every archaic society studied by anthropologists has shown ample evidence of a moral life.  No one doubts that it is part of human nature to be moral.  The same can’t be said about ethics.  It’s not necessary to be skilled at ethical reflection to be a moral person.  That’s a point that is often overlooked, particularly by philosophers and theologians who have been attempting to domesticate and improve our moral instincts for thousands of years.  I agree with the point of view that ethics has limited value in resolving many of the moral problems we face, particularly in medicine.8  There is no doubt that ethical analysis can help clarify our problems, but that doesn’t necessarily engender the moral wisdom required to make good decisions.  Virtues are more helpful in that regard.      

In recent decades, moral psychologists have done extensive research on the instinctual moral feelings that govern our behavior.  What they have found is that we make instantaneous judgments about moral issues based upon our affective reactions to them.  Even newborn babies are capable of moral discernment.  By the time they reach six months of age, they are actively watching how people behave toward one another; they show a definite preference for nice people.  This capacity to evaluate behavior instantaneously is universal and unlearned.  It is only afterwards that we try to justify our moral reactions by offering reasons for what we did.  But our reasons have little to do with what actually motivated us.  Thinking is usually an afterthought rather than a guide to our behavior.  It is our instinctual morality that is in the driver’s seat, not ethical reflection.  As one moral psychologist put it, “Moral judgment is not a purely cerebral affair in which we weigh concerns about harm, rights, and justice.  It’s a kind of rapid, automatic process more akin to the judgments animals make as they move through the world, feeling themselves drawn toward or away from various things.”9              

Moral psychologists are not the only ones who have expressed skepticism about the abstract methods of modern ethics, however.  Following an essay by Elizabeth Anscombe in 1958, many philosophers began to look elsewhere for a fresh start in ethics.10  The long-disregarded virtue tradition caught their eye.  The reprise of virtues helped restore the importance of moral character to ethics.  Being a certain kind of person is more important to the moral life than the use of reason, rules, and principles to resolve often contrived dilemmas.  The focus on character also lines up well with modern psychology, which has challenged philosophy as the leading voice in moral theory.  What made virtues most appealing, however, is that they don’t slight the significance of feelings the way rational principles tend to do.  Our mental capacities work together, not separately, as neuroscientists have demonstrated with fMRI studies of the brain.  It is probably closer to the truth to say that our feelings and thoughts represent different aspects of the same mental experiences.  Granted, feelings are less subject to conscious manipulation than thoughts.  We don’t construct feelings like we do thoughts.  Yet, thoughts have the potential to influence our feelings, just as our feelings almost always influence our thoughts.  Isn’t that what talk therapy is all about?  We talk about what is bothering us, and in the process we disentangle the knot of thoughts and feelings that has gotten us down.  Virtues work in the same general way.  When we practice them, they discipline our minds, putting our thoughts and feelings into proper order.         

Emotions and feelings provide a two-way communication system between our minds and bodies.  The symbolic healing of shamans, as we saw in the last chapter, entailed the exploitation of that communication system.  The shaman’s job was to convince the patient that her/his feelings could be mapped to a symbolic myth that was then manipulated in order to induce the mind to restore the body to its rightful state.  But symbolic mind-to-body interventions represent only one of two possible avenues of communication between mind and body.  It works the other way around as well: from body-to-mind.  In such instances, it is the body that influences the mind’s symbolic and moral structures.  When breathing foul air, for example, we tend to make harsher moral judgments.  That’s because the insular cortex, which processes smells in mammals, also lights up when we observe something that is disgusting, or unfair.11 Instinctively, we sniff our noses at immoral behavior.  It’s an indication that the body is communicating information to the mind via affective signaling channels.  How we feel is a strong indicator of whether we will like something or not. 

Body-to-mind affective communication influences our symbolic sense of purity, which plays a crucial role in our moral habits and virtues.  When washing our hands, for instance, we feel more disgusted about “dirty” things such as pornography.  Zhong and Liljenquist called it the Macbeth effect in reference to the eponymous Shakespeare play.12 After convincing her husband to kill the Scottish king, Lady Macbeth vainly attempted to wash away her own guilt.  “Out, damned spot!  Out, I say!” she screamed.  The act of cleansing ourselves actually increases the desire to guard against impurity.  A clean body naturally goes hand in hand with a pure heart.  When living in their traditional ways, Native American men spent time in a sweat lodge before embarking on a hunting trip.  It was a purifying ritual, meant to make them worthy of the task that lay ahead.  In hunter-gatherer societies, taking the life of an animal for food was a moral issue.  The animal’s spirit had to be mollified, which required the purification of the hunter’s intentions.  What I am suggesting is that all moral behavior—all virtues—share in the body’s quest for purity that is part of what’s been called the behavioral immune system.       

Many animal species engage in behaviors that reduce their exposure to pathogens.  Keeping their dens and nests clean is one obvious example.  According to Mark Schaller, the Homo sapiens behavioral immune system is linked to the instinctual feeling of disgust.13 Even the appearance of contamination in our food, or the smell of it, disgusts us.  It’s an involuntary response of the body.  Were we to eat something that had spoiled, we would gag and expel it automatically.  The list of things that disgust us is extensive: vermin, feces, oozing sores, filthy clothing, rotting teeth, disfigurement, maggots, yellow liquids, etc.  Women in the early stages of pregnancy are especially prone to disgust responses due to the vulnerability of their developing fetuses.  Violations of moral codes and taboos also elicit disgust.  Sexual promiscuity is often viewed with disgust because it’s a risky behavior that actually exposes the participants to infection.  The behavioral conventions in traditional societies have always had health implications.  They are like prescriptions for avoiding infections.  Disgust is a moral sentiment that erects a prophylactic barrier against disease. 

An instinctual aversion to infection risk has infiltrated the practices of everyday life even in modern societies.  We prefer to marry people with symmetrical faces, for instance, because an asymmetrical face could be a sign of prior infection.  We stigmatize entire categories of people, including the elderly, sick, obese, and disabled.  Xenophobia is probably linked to this ancient behavioral immune system as well.  We don’t want to mingle with strangers, or “dirty” immigrants.  We prefer that people conform to our norms of beauty and behavior because it makes us feel safer.  Obsessive-compulsive disorders are often related to issues of cleanliness and purity.  An overactive sense of disgust is probably an important contributing factor. 

As I am writing this chapter, we are in the midst of the Covid-19 pandemic.  Stay at home orders and social distancing precautions have stirred up deep seated feelings of aversion and vulnerability.  Are we safe from this insidious virus?  Since there aren’t enough test kits to go around, and no vaccine as of June 2020, it’s hard to say.  All we can do is hunker down, keep our distance, wear a mask, and be vigilant about hand washing.  There are reports of aggression against those who don’t comply with these new social taboos.  There are also reports of aggression against those who do comply.  It is a confusing time.  When I take daily walks on the forested trails that wend through my neighborhood, I notice that I am looking down as I pass people going the other way.  In normal circumstances, I would smile and say hello.  Now I am more concerned about giving them a wide berth.  If they neglect to reciprocate my efforts to social distance, I feel an urge to scold them harshly for not respecting my 6 feet of quarantine space.  Fortunately, I have been able to resist that kind of censorial outrage.  I confess it has not been easy.  The behavioral immune system that works in concert with our instinctual morality is very powerful.

The scope of shamanic healing wasn’t confined to the manipulation of mythic symbols alone.  Their symbols and myths were peppered with taboos and warnings about how to behave and what to avoid.  A common etiology of Stone Age sickness was the breech of a social taboo—eating a forbidden fruit, for instance.  An important aspect of the healing séance was the moral admonishment of the entire community.  It usually went something like this: Adhere to the strict behavioral guidelines of the community, or suffer the bitter consequences!  As I said earlier, healing symbols also functioned as virtues at the same time.  Take purity for example.  As a symbol of shamanic healing, it indicated that health is something which must be restored through the elimination of impurities.  As a virtue, however, it represented a moral quest pertaining to the real life problems of infection and hygiene.  Symbols of healing are of a more abstract nature, their virtuous manifestations more behaviorally specific.  The distinction between the two is very dynamic and fluid; like other mental phenomena—feelings and thoughts, for instance—they are similar yet distinct.  To push things one step further, the moral extension of our healing symbols also  represents the birth of those spiritual practices—the singing of the Navajo haatali, to pick one example—that embody the desire to reach beyond the harsh realities of existence.  The virtuous practices of the healing arts blazed a trail that our spirits could then follow.  The desire to heal and be healed is the primordial act of transcendence.  That is the gist of my argument.     

Even the early use of herbal medicines was probably associated with virtuous behavior that served a prophylactic purpose.  Let me make a brief detour to explain what I mean by that.  According to one ethnopharmacologist, the medicinal use of herbs arose out of the need to restore our gut chemistry to its original prophylactic vigor.14  Our ancestors evolved from primates whose digestive tracts made use of defensive allelochemicals from their leaf-eating diet.  Plants created the chemicals in the first place to ward off herbivorous insects, and the primate gut repurposed them to fight off their own parasitic infestations.  This chemical symbiosis was refined over millions of years of evolution, and it contributed to the overall health of our great ape ancestors.  Early hominids continued to follow a similar leafy diet until they began eating meat on a regular basis approximately two million years ago.  That dietary change had a profound effect on their gut chemistry.  Eventually, it led to the deliberate supplementation of their diet with herbs and other plant substances, including bark, which can be toxic to vegetarians. 

In the case of our own species, two other significant changes caused further compromises to our inherited gut chemistry.  The first was the outmigration from Africa to every continent and major island on earth except Antarctica.  It began approximately 70,000 years ago.  Those early migrants settled down in new environments with completely different food sources, and unfamiliar parasites to which they had no natural immunity.  It meant that more extensive medical and moral practices became necessary in order to stabilize the digestive system and fight off infectious agents.  According to an old Tibetan legend, indigestion was the first disease.  That’s probably not far from the truth. 

The second big change that caused difficulties in our gut chemistry was the invention of agriculture.  It forced us to rely almost exclusively on a few domesticated grains for our entire diet, supplemented with small portions of meat and other animal products.  As a result, sickness became more and more common, and medical intervention became a necessity of life.  It helps explain why we have become so accustomed to the idea that we need to be under a doctor’s care in order to remain healthy.  Even before agriculture severely curtailed our diet, however, our Stone Age ancestors had been actively supplementing their food with teas and herbal extracts in order to maintain a healthy digestive system.  What is the natural state of health for humans?  It seems that restorative healing practices—at first instinctive, then gradually becoming more intentional—have played a critical role in establishing the norms of health from the very beginning of our existence.  It all began with the behavioral immune system that we inherited from our primate and hominid ancestors.  

A plausible hypothesis, I believe, is that the challenge of maintaining the prophylactic capabilities of our gut chemistry as we drifted apart from other great apes was one of the key adaptive pressures that led to the development of consciousness.  We needed to be more deliberate and careful about what we ate in order to maintain our own health.  That required the ability to plan our lives more efficiently, which in turn dictated the need to create meaningful cultural systems to safeguard our existence.  In short, we needed to find a new way to live in harmony with a more complex world.  It was because we left our great ape ancestors behind that we learned to think on our own two feet.  Our adventurous, risk-tolerant temperament pressured us to become more cunning and mentally adaptive.  This is the broad biological context within which time-travel, consciousness, morality, medicine, culture, spirituality, and all the other distinctively human characteristics emerged.  It was the shamans, the first doctors, who helped us to expand our mental capacities so that we could become the most eusocial, collaborative primate on earth.    

All symbols convey meaning that is relevant to our being in the world.  But not all symbols are virtues because they don’t all engage us in moral actions.  We do what we care to do, and our worldly engagements are an expression of that primordial virtuousness.  Recall that one of the hallmarks of phenomenology is the notion of intentionality.  Every feeling and thought expresses a concern about something—it has an intentional object—as does every symbol and virtue.  The intentionality of symbols pertains to the edifice of the world as a whole.  That means symbols are concerned about how the world hangs together, whereas virtues are concerned about how to get on in the world (instead of how it is constructed).  Unlike symbols, virtues convey a sense of shared intentionality because every act of human caring is a form of social engagement.  The original purpose of morality and virtues was to enable small groups of hunter-gatherers to work as collaborative hives in order to survive the challenges they faced.  A world without collaboration and companionship is, for Homo sapiens, an empty world—a geography without a purpose.  As a moral species, we can’t fully care about life unless and until we have others to share it with.  Friendship is not a luxury for us.  As the culmination of our shared moral intentionality, caring is the virtue of all virtues.  

According to Michael Tomasello, humans achieved their unique capacity for ultra-cooperativeness, or shared intentionality, in two evolutionary steps.15  The first one occurred approximately 400,000 years ago when early humans were forced to collaborate more effectively in order to survive the dramatic climate changes of the Pleistocene ice ages.  They achieved joint intentionality, or the ability to share their individual perspectives.  It enabled them to work together more effectively, and communicate with gestures.  They developed strong sympathetic feelings, and an ability to govern their own behavior according to what others might think.  The second evolutionary step occurred approximately 150,000 years ago with the emergence of our own species.  Our ancestors experienced tremendous competition from other hominid groups, as well as a need to form tribal alliances due to increases in population density.  These challenges led to the development of a whole new level of collective intentionality, wherein the norms of the group became the objective standard by which people governed their own thoughts and behavior.  This hive-like group mindedness became the cultural engine that eventually enabled us to create the vast civilizations that we are familiar with today.   

What’s unique about Tomasello’s evolutionary perspective is that he applies it to child development theory.  He claims that the two evolutionary steps that differentiated humans from the other great apes are repeated in the psychological development of each child.  By 9 months, children are capable of cooperating with others on the basis of joint intentionality; they achieve the capacity for collective intentionality at around 3 years of age.  Finally, by the age of 7, children have acquired all of the psychological capabilities that are unique to adult humans.  But that is not the end of their social tutelage.  On the contrary, it is just the beginning of a long process of cultural learning that will extend well into adolescence.  By contrast, other great ape youngsters are on their own in terms of finding food and learning about the world after they are weaned.  The human pattern of ontogeny entails the early acquisition of necessary psychological skills followed by a long period of adaptation to a cultural way of life.  It takes a long time for children to master the social skills necessary to become well adjusted adults.  The capstone of human ontogeny is normative self-regulation according to Tomasello.  That means growing up is a drawn out process of acquiring a conscience.  When watched by others, humans share more and steal less whereas chimpanzees behave the same whether they are watched by other chimpanzees or not.  Humans have acquired a sense of “we,” or shared intentionality, that chimpanzees haven’t.       

If a chimpanzee could talk, what would it say?  “I am hungry,” perhaps?  This has been a topic of fascination to psychologists for nearly a century.  Viki was a chimpanzee raised by humans who coaxed her to speak a few words.  “Mama” was about as far as she got.  In another famous case, Washoe learned to sign 250 different words.  A gorilla named Koko managed to do slightly better than that.  The problem is these primates were being taught to mimic human speech, which isn’t the same thing as talking.  No great ape has ever invented its own words.  Why not?  For one thing, you don’t need words to report about your own hunger, for instance, when a gesture or a grunt would suffice.  Humans didn’t acquire symbolic minds in order to comment on their emotional states.  Emotions represent the language of the body well enough as it is.  Humans acquired the ability to speak so that they could collaborate with others.  Consciousness represents the capacity for sharing intentions which are always about something more than just our own feelings.  Or, to put it a little differently, our feelings always pertain to our moral engagements with others.  When I am angry, for instance, what is it about?  Usually, it’s a response to the inappropriate behavior of somebody else.  It’s why anger can be considered a proto-virtue.  We practice virtues in order to educate our feelings and intentions so that we can behave in a socially acceptable manner.  Virtues, in that sense, are the practices of a healthy conscience.  They are an extension of the symbols that represent a mind designed for sharing—talking—with others.  If a chimpanzee really could talk, there’s nothing it could say because the chimpanzee mind is not designed for sharing moral tales.  Symbols and virtues are not words, though they make the use of words possible.  Words are the expression of our shared moral intentions.  “I’m sorry that I disappointed you.”  Now that is something worth talking about.     

I want to return briefly to the topic of moral virtues in medicine.  I already mentioned two different lists of medical virtues.  Pellegrino and Thomason offered seven for consideration, including fidelity to trust, compassion, phronesis, justice, fortitude, temperance, integrity, and self-effacement.  On the other hand, Beauchamp and Childress argued that caring is the overarching medical virtue that animates all the rest, which, in their case, included compassion, discernment, trustworthiness, integrity, and conscientiousness.  I agree with the primacy of caring as a medical virtue.  As Heidegger suggested, caring is the meaning of our being in the world.  What he meant is that the world represents the locus of our cares; there is no world until we care to interact with it.  That is the primordial intention of our moral existence.  It is the primary intention of every healing symbol as well.  Armed with care for the suffering of others, we find ourselves able to be compassionate, trustworthy, and all the rest of the medical virtues.  There can be no medical healing without the suffering of others as the grand avenue of our caring.  The essence of every medical virtue is found in the ability to care for somebody else.  To help others is the reason for our being when there is no need for such reasons.  Virtuous behavior is something undertaken for its own sake; it is the definition of authentic existence.  That is the epitome of medicine as well.  In many ways, medicine itself represents the embodiment of human virtue, which is embodied in the primordial intention of caring.  How could there be compassion without caring?  That’s like asking how words could exist without the ability to convey meaning.  If we didn’t care, we couldn’t express our compassion; nor could we talk if words didn’t communicate what we meant by them.  It is our moral cares that determine the intentions that we pursue and hold dearest.  

In this chapter, I have been focusing on the primordial aspects of symbols and virtues because I am interested in the intimate connections between morality and medicine that reach back into the Stone Age.  It’s an issue that biomedical ethicists rarely pursue.  After all, they are professional ethicists, not moral anthropologists.  They focus on issues relating to clinical problem solving because that is their purpose—to serve the needs of the health care professions.  Nevertheless, there are serious moral problems pertaining to the unvirtuous practices of medicine itself that need to be addressed.  To pick an obvious example, the health care industry generates tremendous amounts of toxic waste that contribute to global warming and the deterioration of the earth’s ecological systems.  The great irony is that medical disregard for the earth has actually been undermining the long term health prospects of human beings.  That wasn’t the case in the Stone Age, obviously.  Shamans believed that maintaining harmonious relationships with the natural world was the sole basis for human health and well being.  It’s a sensibility that we are beginning to appreciate once again though we are finding it hard to match.  I think it represents a moral crisis for the ages that will transform civilization as we know it.           

Environmental medicine has been a medical specialty for decades, though its primary focus has been on poisons and other toxic chemicals that threaten human life, not the ecological consequences of medical practices themselves.  There are a number of newer organizations dedicated to the greening of medicine, however, including Health Care Without Harm.  It was founded in 1996 after the Environmental Protection Agency identified medical waste incineration as a major source of toxic pollutants, including dioxin and mercury.  (It generates other pollutants as well.)  Dioxin is a known carcinogen.  Specifically, it is the burning of flexible plastic tubing used in medicine drips that is the source of dioxin pollution.  According to one of the cofounders of Health Care Without Harm, the number of medical waste incinerators in the United States has been sharply reduced because of their advocacy efforts.16        

For most humans, the Stone Age ended with the invention of agriculture.  It enabled our hunter-gatherer ancestors to settle down into permanent communities that occasionally grew into great cities with tens of thousands of inhabitants.  Our instinctual morality didn’t prepare us to live in such crowded quarters.  Instead, it evolved to help us work cooperatively within small groups.  The typical hunter-gatherer band consisted of 20 to 50 people.  How do you get along with strangers in a big city when your own xenophobic instincts tell you that they should be avoided because they are not part of your tribe?  This is the great moral crisis that every budding civilization faced.  The hierarchical institutions that we are so familiar with today—religions, monarchies, governments, militaries, courts of law, police forces, prisons, and so on—were invented to help overcome our moral tribalism (and other inadequacies).  The earliest ethical manuals, often embedded in sacred texts, were meant to encourage people to treat others as they would their own family members.  Friendship was a virtue highly prized by ancient civilizations.  One of the oldest literary texts ever recovered by archaeologists is the Epic of Gilgamesh.  It’s no accident that it is a story about an unlikely friendship between a king (Gilgamesh) and a wild man of the forest (Enkidu).  The transformative message was that we are all capable of getting along with strangers—even glaringly uncivilized ones, like Enkidu—when they become our friends.   Friendships and marriages were sought after alliances that became the glue of kingdoms.                     

I think we have been preoccupied by the unprecedented experiment of human civilization for about seven thousand years.  That is the time span within which great empires, institutional religions, and the traditional medical systems of China, India, and Greece came into being.  It is also the time span within which the majority of humans lost touch with wild nature as the primordial grounding for their self-understanding.  With growing regularity, they looked to their own anthropocentric perspective as the principal framework for interpreting the world.  Animals were no longer viewed as equals or kin; instead, they became soulless beasts of no inherent worth when compared to our own flattering ontologies.  We even doubted their ability to feel and suffer, vainly believing that only human suffering matters.  Rivers and forests became mere resources to be exploited and repurposed.  Even the seemingly infinite stocks of oceanic fish have been depleted by human predation.  In short, we are the proud creators of the Anthropocene.  It isn’t yet an official geological epoch, but the International Commission on Stratigraphy is expecting a formal proposal to make it official in 2021.  The beginning date of the proposed epoch is unsettled.  One likely candidate is 1945, the year when the first atomic bomb was detonated.  Perhaps it would be the most fitting date because our continued existence is now a matter of our ability to restrain ourselves from the use of such weapons ever again. 

Can we refrain from our own self-destruction, be it from all-out warfare or ecological catastrophe?  Perhaps it’s a moot point because we will soon have the capacity to quicken our own obsolescence by tinkering with our genes and neurobiology.  Could we possibly re-engineer our moral character with “virtue implants” that forbid unsavory behaviors?  It sounds silly, but not completely so.  For thousands of years, we have been looking to virtues as the best means for improving ourselves.  There have been some successes along the way, yet here we are facing these problems of global enormity.  The archaea, bacteria, and other microscopic life forms are probably safe from the ecological consequences of our bad habits.  The same can’t be said for the living creatures of noticeable size to us.  As one biologist observed, we have been steadily eating our way down the food chain, beginning with the largest mammals first (many of them extinct as a result).17  Virtues seem like such paltry tools for changing human behavior in the face of potential global disasters.  Which will come first—our commitment to stop burning fossil fuels one nation at a time, or the deadly acidification of the oceans as they absorb more and more carbon dioxide that is released into the atmosphere from burning fossil fuels?  Will the 80 or so cetacean species that ply the oceans in dwindling numbers continue to exist?  What about the magnificent blue fin tuna that is on the brink of extinction now because we can’t resist a taste for sushi?  There are no human virtues that address such issues.  Even Dante didn’t envision a place in hell for our species-centered transgressions.    

What would be the epitaph of humanity if we were to disappear from the earth?  “Here lie the bones of Homo sapiens, the species that foresaw its own demise but couldn’t prevent it?”  Actually, it’s not that easy to summarize what our existence represents as a whole.  So much of our story is unprecedented.  No other large animal has ever achieved a world population of seven billion members.  No other species has taken control of its own evolution.  No other species has pondered the meaning of existence, or hypothesized about the enormity of the universe.  No other species laughs and cries and loves like we do.  The list of our unique attributes is seemingly endless.  It is also vain and pedestrian because we are not that unique.  We are animals, almost identical to the other great apes in most of our biology.  Maybe it would be fairer to say that our differences are both gigantic and minuscule at the same time.  It’s a paradoxical mixed bag, not a slam dunk for human exceptionalism.  We had a natural humility for most of our time on earth.  It is probably imperative for our survival, and the survival of untold numbers of other species, that we somehow reinvent it.  I think the period of our own self-absorption has come to an end.  We are facing a new kind of moral crisis that ancient ethical manuals could not have imagined.  

Facing dire environmental circumstances was not something unfamiliar to our Stone Age ancestors.   We are not unique in that sense.  Instead of global warming, they had to cope with the Ice Age.  (They weren’t responsible for the Ice Age, as we are for global warming.)  Starvation and malnutrition were common realities.  So was intense competition from other hominid species.  The survival pressures that they faced were so severe that extinction was a real possibility.  As we know, the Neanderthals didn’t survive.  What made the fate of our ancestors different?  I think they survived by improving their mental capacities.  I also think shamans played a key part in what amounted to a symbolic revolution of the mind. 

Shamans were daring experimentalists, time travelers whose determination to help their sick patients expanded the scope and dexterity of our imaginations.  We survived when other hominids didn’t because of the strength of our mental virtues.  Yet those virtues didn’t exist prior to the desperation that led to their invention.  Soul loss was the great scourge of that time.  It is a sickness that undoubtedly shares some of the symptoms of starvation.  When the mind is malnourished, it wanders even to the point of experiencing out of body hallucinations.  By projecting their own spirits into the maelstrom of that bewildering condition, shamans created new mental pathways for others to follow.  Their journeys etched lasting symbolic milestones into the shared consciousness of their people.  The mythic interpretations of their journeys served as homing beacons for lost souls.  The tools of the shamanic trade were ecstatic out of body experiences that became the precursors of ordinary time-consciousness as we experience it today.  They were risky feats of the imagination in the beginning; for us, they are the subconscious routines of remembering the past and anticipating the future.   That’s what happens when we acquire a virtue: it becomes part of our character, a pattern of behaving that is automatic and routine.  

How do you acquire a virtue such as courage when you don’t have any to begin with?  As Aristotle observed, you do so by imitating what a courageous person does.  That seems reasonable enough.  But how do you acquire a virtue that doesn’t exist yet?  How would imitating somebody be of assistance in that circumstance?  Aristotle had no answer for that novel experience; in fact, he didn’t even conceive of it.  That’s what shamans faced—a dire situation where the necessary mental capacities to respond hadn’t been fully developed yet.  They were forced to develop new mental virtues by experimenting with their own imaginations.  Essentially, they re-imagined themselves.  That’s what the invention of new virtues means.  We call that kind of self-transcendence a spiritual awakening.  In many ways, we are facing a similar kind of spiritual crisis today.  We need a new set of moral virtues that will enable us to meet the challenges that are unique to our times. 

I am not suggesting that we must become like our ancient forebears.  We can’t recover the past, nor should we want to do so.  We live on the other side of the great reversal of time-consciousness.  The future is the horizon of our dreams, not the past.  Shamanistic spirituality is not our destiny.  They were animists, the inventors of the soul and everlasting life.  We, on the other hand, are scientific materialists.  We interpret out of body experiences as hallucinations of the mind, not spiritual visitations from other realms of existence.  Our medicine is tied to our biology, not to journeys of imagination.  The fact that we are confined to just one physical body doesn’t mean that we can’t transcend ourselves.  Our spiritual awakening is both biomedical and ecological in its significance.  There are potential new virtues on the horizon that could help us to recover our proper place in the natural world.   

I think the spiritual awakening that I have in mind has three distinct ecological meanings.  The first one pertains to our unreserved openness to the future.  Unlike our Stone Age ancestors, who always looked to their mythic origins for guidance, we embrace new possibilities.  We don’t want to repeat the past; we want to leave it behind.  Self-identity, for us, has become part of a more nuanced and complex ecology of possibilities.  The transgender movement is indicative of this shift.  Many of us no longer feel confined to old binary categories that dictate who and what we are.  The biological palette of our sexual identities is much more intricate than we ever imagined.  It’s also much more manageable through medical intervention: We can modify and rebalance the levels of testosterone and estrogen in our bodies, for instance.  Our experience of the future is actually different from that of our ancestors.  Their future was strictly limited by traditions, while ours is more open to evolutionary changes.  We embrace a future that enables us to become the agents of our own personal evolution.  There are a plethora of ecological niches to satisfy the emergence of individual variation.  I don’t think the medical principle of respect for autonomy is strong enough to capture the meaning of what we see unfolding around us.  Openness to personal deviation from the biological norm is an apt though wordy description of the kind of virtue that seems operative here.

The second ecological meaning of our spiritual awakening pertains to the breakdown of the self as a real phenomenon.  Previously, I discussed the concept of world zero, and the necessity for creating the illusion of having a self-perspective that cannot be overturned.  Without a stable world zero perspective, it would be impossible to keep all of our different points of view straight.  Is the experience of typing this chapter real or imaginary?  How would I know if I didn’t privilege the present events that my “self” is experiencing?  I believe this is why early humans fell prey to soul loss—because they didn’t yet have a strong sense of world zero.  They were easily confused by different perspectives of time and place.  We rarely if ever lose our orientation in time and space like that.  But we have discovered something almost as uncanny: we’ve managed to peak behind the curtain and see that we are not the “selves” we thought we were.  Instead, we represent the public face of a virtual reality machine that our brain has generated as a tool for keeping our perspectives in order.  It’s a shocking discovery if being no one is our true fate.  It’s also an opportunity to re-imagine what being a self really symbolizes.  What does it mean to be an embodied self?  I think the truth is that we are more like a matrix of collaborative communities than a singular person.  Our bodies are made up of cells and organ systems that have intentionally joined forces to become a unified corporation.  It is often said that the intestinal system or gut represents a second brain because it has more neurons that any other part of the body except the brain.  I think it is even more significant that the gut represents an experiment in collaborative living between billions of microorganisms.  We have ignored the communal ecology of our own embodiment.  The self of my own identity is and always has been a living “we,” not an “I.”  What kind of virtue does it require to acknowledge the community of selfhood?  Respect for the web of life comes to mind.

Finally, the third ecological meaning of our spiritual awakening pertains to the worldly nature of existence.  We live outward and forward into the world.  That means we are not isolated creatures.  The world that we inhabit is a shared world.  For too long we have ignored and belittled the intrinsic value of other organisms that share the world with us.  We thought that caring for ourselves alone was enough to secure our place in the world.  We were wrong about that.  It is the diversity and multitude of other life forms that secures our place in the vast ecosystems that safeguard life on earth.  To separate ourselves from that deep ecology creates an imbalance that will eventually lead to our own misery.  That seems to be what we are facing right now.  Above all else, we need a virtue that decenters our own self-importance.                                          

I am convinced that medicine is the epitome of our caring nature as well as the most authentic expression of our moral consciousness.  I think that is true in our time just as it was in the Stone Age.  As such, it is the fountainhead of our virtuous aspirations.  That is why it is impossible for medicine to ignore the ecological threats to our health and well being.  It is inevitable that ecology will become part and parcel of our biomedical efforts to heal the sick.  The suffering of all creatures will become an ultimate concern for us because life is a shared experience.  It cannot be isolated by species or any other arbitrary boundary. 



  1. Charles Darwin, The Descent of Man (John Murray, 1882).
  2.  Aristotle, Nichomachean Ethics (Liberal Arts Press, 1962). 
  3. St. Augustine, “On the Morals of the Catholic Church,” in Augustin: The Writings against the Manicheans and against the Donatists (Hendrickson, 1994). 
  4. Edmund Pellegrino and David Thomason, The Virtues in Medical Practice (Oxford University, 1993). 
  5. Tom Beauchamp and James Childress, Principles of Biomedical Ethics 7th ed. (Oxford University Press, 2012). 
  6. John Rawls, A Theory of Justice (Belknap, 1971). 
  7. Christopher Boehm, Moral Origins: The Evolution of Virtue, Altruism, and Shame (Basic Books, 2012).     
  8. R. L. Holmes, “The Limited Relevance of Analytical Ethics to the Problems of Bioethics,” Journal of Medicine and Philosophy 15, no. 2 (April 1990), 143-60. 
  9. Jonathan Haidt,  The Righteous Mind: Why Good People are Divided by Politics and Religion (Pantheon, 2012), 61. 
  10. Elizabeth Anscombe, “Modern Moral Philosophy,” Philosophy 33, no. 124 (January 1958), 1-19. 
  11. Jonathan Haidt, The Righteous Mind.
  12. Chen-Bo Zhong and Katie Liljenquist, “Washing Away Your Sins: Threatened Morality and Physical Cleansing,” Science, New Series 313, no. 5792 (September 8, 2006), 1451-52.
  13. Mark Schaller, “The Behavioral Immune System,” in The Handbook of Evolutionary Psychology 2nd ed., Vol. 1, 206-24 (Wiley, 2016). 
  14. Timothy Johns, With Bitter Herbs They Shall Eat It: Chemical Ecology and the Origins of Human Diet and Medicine (University of Arizona, 1990). 
  15. Michael Tomasello, Becoming Human: A Theory of Ontogeny (Harvard, 2019). 
  16. Charlotte Brody, “Thinking Like a Girl is Good Medicine,” in Ecological Medicine: Healing the Earth, Healing Ourselves (Sierra Club Books, 2004). 
  17. Edward O. Wilson, The Future of Life (Alfred Knopf, 2002).

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