Excellent Traits in Public Health: Virtuous Structures and the Structure of Virtue

Abstract

MacKay’s Public Health Virtue Ethics offers a distinctive approach to public health ethics, with social structures at the forefront. MacKay’s helpful overview of the recent literature considers three distinct referents for ascribing virtues in public health ethics: (i) individuals, such as public health practitioners, (ii) social structures, such as public health institutions and policies and (iii) the communities affected by public health policy. While MacKay is interested in virtuous structures, I am interested in the structure of virtue as a precursor to this approach. In this commentary, I seek to unpack the structure of virtue itself, to delineate what various accounts of public health virtues offer, including MacKay’s new account. For such clarity, I turn to David Pears’ neo-Aristotelian essay on moral courage, in which he distinguishes external goals, internal goals and countergoals. Additional virtue vocabulary advances discussion of how the moral psychology of virtue traditions can be best adapted to public health professions, policy and practice.

Introduction

MacKay (2022) offers a distinctive approach to public health ethics, with social structures at the forefront. Applied ethics resources supporting public health introspection are timely; attrition and the low morale of the public health workforce suggest that the search for meaning and purpose within the profession is urgent. Questions of character are alive in a virtue ethics tradition, and pertinent amid the coronavirus disease 2019 (COVID-19) pandemic that is pressing public health professions to the limits of expertise, institutional capacity, and personal reserves. While MacKay is interested in virtuous structures, I am interested in the structure of virtue as precursor to this approach. In this commentary, I seek to unpack the structure of virtue itself, to delineate what various accounts of public health virtues offer, including MacKay’s new account. Doing so supplies those interested in virtue traditions with additional clarity, expanding this discourse at a time when public health institutions and practitioners are in dire need of moral support.

Promise and Pitfalls of Virtue Ethics

Let us first acknowledge that the language of ‘virtue’ and especially ‘vice’ sounds antiquated to our contemporary ears and likely has limited appeal to many in public health practice. Those who are more familiar with the tradition, especially practitioners who draw from Christian theology including Thomistic insights, might find themselves quite at home in a reinvigorated virtue tradition (Ip, 2019). A theological line of virtue ethics will be especially worth building out for those who, in parallel to Pellegrino and Thomasma’s (1993) approach, feel that public health work is a calling and perhaps best understood as a covenant of public service (Conrad, 2017; Telfair, 2018). However, many others will balk at a framework for guiding public health institutions and policy that is not just moral but smacks of moralizing. Especially given MacKay’s own analysis of stigma (p. 7), a virtue approach requires distinct attention to the pitfalls of ascribing ‘vice’ to practitioners, institutions, or communities.

However, the moral psychology at the core of virtue approaches is useful to public health. Its central question is often framed as ‘what sort of person should I be?’, rather than the dilemma-oriented conundrum of ‘what should I do?’ The analytic shift toward ways of being can sometimes be subtle: an emphasis on the trait of honesty or forthrightness, rather than the obligation to tell the truth—attention to our exemplars upon whom we model a life dedicated to justice, in contrast to the priority-setting schema of distributive justice frameworks. And as MacKay’s analysis emphasizes, public health virtues must address shared action, communal good and health policy justification. To do so, it is helpful to reframe the central question of public health virtue more socially, as ‘who do we want to be; what traits do we want our public health institutions to celebrate, safeguard, and instill?’

In addition, contemporary revived virtue ethics must also seek to address well-known weaknesses of character attribution. First, attribution errors are well-characterized flaws in causal reasoning, including the tendency of people to evaluate or explain the behavior of others as flowing from their character, rather than their context or extenuating circumstances (Ross, 1977). While normative theory is about justification, not causation, this bias can combine toxically with the language of vice. Virtue language can slip easily toward a rhetoric of heroism, blame, and moral outrage. Virtue ethics frameworks in applied ethics need to adjust for this common bias, emphasizing the elements of the tradition such as habituation and the central question of ‘can virtue be taught?’, which help direct moral assessment toward the social and cultural dynamics that shape moral attitudes, beliefs, organizations and policy formation. As MacKay depicts (p. 6), character traits do not emerge from a vacuum but rather are dynamically shaped by and, in turn, shape social contexts.

Second, virtue theory is often critiqued for not being sufficiently action-guiding (Cf. Hursthouse, 1991). As an ethical framework to apply to discrete public health challenges, the orientation of virtue traditions toward ways of being can make it a poor match for the policy- and decision-making crossroads in which pragmatic ethical guidance is often sought. In contrast, with its emphasis on learning and moral education, virtue theory is a strong resource for public health ethics education. Ethicists will need to develop concrete and useful analyses to demonstrate the practicality of virtue ethics in public health practices.

Three Approaches to Virtues and Public Health

MacKay’s helpful overview of the recent literature considers three distinct referents for ascribing virtues in public health ethics: (i) individuals, such as public health practitioners; (ii) social structures, such as public health institutions and policies; and (iii) the communities affected by public health policy. MacKay’s account shifts both the level of analysis to institutions and conceives of populations as collectives that cannot be reduced to individuals. When clarified, we are left with three versions of virtues in public health:

Type 1 (Rozier 2016): Public health institutions should encourage community attributes that are conducive to communal wellbeing.

Type 2 (Nihlén Fahlquist 2019): Public health professionals should cultivate professional attributes (e.g. compassion, responsibility, humility) to protect communities from the limitations of public health interventions.

Type 3 (MacKay 2022): Public health should support social structures that are conducive to social wellbeing.

However, throughout her account MacKay conflates two referents of her virtue approach: that is, to whom or what she ascribes virtue. She sometimes seems to wish to say that public health structures can be virtuous—which would permit statements like ‘X is a more compassionate public health policy’. In this case, the referent of virtue is public health structures (institutions, practices or policies). However, most of MacKay’s examples (compassion, justice, honesty) focus on social attributes—which would permit statements like ‘X is a better public health policy because it cultivates a more compassionate society’. In this case, the referent of virtue is society. Most of this confusion comes from her use of the phrases ‘virtuous structures’ and ‘virtuous societies’ as practically interchangeable. The move comes on page 3: ‘Thus, we attribute the virtue or the vice most enabled by institutional structures to the overall ethos of these societies’. This slippage ignores how social structures are not definitive of societies. Such conflation is unfortunate, as building an account of good public health structures is not the same endeavor as building an account of good societies.

The Structure of Virtue

To facilitate a consideration of public health virtues, additional virtue vocabulary can supply a more fulsome discussion of good traits and their relationship to public health goals. For such clarity, I turn to Pears’ (1980) neo-Aristotelian essay on moral courage, in which he distinguishes external goals, internal goals and countergoals.¹ By reflecting on classic examples of Aristotelian courage, Pears delineates how both victory in battle (an external goal) and nobility of courage itself (an internal goal) are motivating to the courageous. Fear, too, is a powerful motivator, as it reflects apprehension of the realities of potential injury or death (countergoals). Pears contends that these factors feature in the attitudes of the courageous, comprising their worldview of the threat and their course of action as they consider the moral question ‘How do I face this?’

For our purposes, these virtue terms help delineate an important way virtue approaches offer moral insight. The external and internal goals of virtues, as well as countergoals, help the virtuous compare and contrast ways of being. Consider each feature one at a time:

External goals : An external goal of virtue can be understood as the instrumental value the trait serves (Pears, 1980: 174). Honesty, for example is a trait conducive to the external goal of establishing and sustaining relationships founded on truth. Virtues are attributes that render the institution or individual in some way more prone to attaining external goals. Foot’s (1978) articulation of virtues as correctives adds to this picture, indicating that virtues are precisely those attributes that supply motivation to resist or counter common human failings. Similarly, the view that virtues are regulative ideals captures the ability of normative traits to shape behavior (Oakley, 1996). Stewardship is the capacity to safeguard the interests of future generations as well as the present (Cf. Lees, 2018). Trustworthiness is the tendency to deliver when counted on to take proper care (Potter, 2002). To delineate the external goal of a virtue, one need not embrace the Doctrine of the Mean, where vices are depicted as deficiencies and excesses. Rather, virtue attributes are forms of excellences and, when correctives, traits that pull us away from common failings. As an example, consider contemporary efforts to cultivate upstanders to serve the external goal of speaking up against a variety of social ills such as bullying and sexual exploitation. This social virtue approach is explicitly counter culture: i.e. a corrective effort to address common social predilections for deference and groupthink.

Countergoals : A countergoal is a context or factor that weigh against an external goal. Pears, for example, delineates pain and death as the countergoals of heros of ancient Greece, who must confront these to attain the goal of victory (Pears, 1980: 174). When considering whether to be honest, the potential for retribution, lost reputation, or hurt feelings serve as typical countergoals that motivate us (and institutions) to hide the truth. It is often easier to lie. Elsewhere in public service, the countergoal of corruption is seen as the primary threat to the virtue of integrity. For the potential upstander, the countergoal of avoiding confrontation provides a reason to defer; escaping the bully while his attention is directed at a different victim offers the countergoal of safety, if only temporarily. While the desire to give in to countergoals can be understood as temptation or vice, we can again seek to avoid such puritanical terminology. Countergoals are reason-giving. Pain and death are detriments to quality of life; it is often good for individuals and institutions to prevent and avoid them. Sparing others’ feelings is grounded in compassion; the virtuous can discern when tact crosses over into deception. Countergoals are the aspects of moral life that make Foot’s correctives necessary. The virtuous among us—individuals and institutions—are admirable in part because they consistently resist or confront countergoals rather than accede to their ability to give us reason to act differently.

Internal goals : Internal goals of virtue can be understood as their intrinsic value, and as the good provided to the virtuous. These are the values that are meant to be captured by the aphorism, ‘virtue is its own reward’. Examples include the clear conscience of those who speak honestly, rather than deceive; the sense of satisfaction (not indigestion!) of the temperate. Pears’ analysis delineates the internal goal of nobility that is attained by the courageous (Pears, 1980: 181). In addition, Pears notes that internal goals can be too vague to be action-guiding, especially in comparison to external goals. It is difficult to aim for ‘the noble’, but more obvious to try to be victorious. For the virtues of health professionals, the internal goals of virtues comprise what MacIntyre (1984) calls the internal goods of a practice. Internal goals comprise the goods that provide satisfaction, a sense of purpose, individual fulfillment or institutional high morale due to demonstration of epidemiological or public health excellence. Internal goods of the profession are achieved by doing the work that is distinctive to public health and doing it well. Sadly, it is the internal goods of the profession that many public health workers are reporting they are losing during the COVID-19 pandemic due to burnout, moral distress and public backlash (Bryant-Genevier, 2021; del Castillo, 2021).

Put together, these three features help us better understand the differences and similarities between the three accounts of public health virtues reviewed (see Table 1).

Discussion

Virtuous Public Health Structures and Virtuous Societies

As articulated, the strength of MacKay’s proposal is also, it appears to me, its weakness. By deriving virtues from the expansive goal of ‘social wellbeing’ and focusing on broad social structures as the level of analysis, we gain structural focus and collective emphasis—features desirable in any account of public health virtues. However, the resultant candidate virtues are correspondingly broad, such that they can also be attributed to any public institution or practice. Thus, while MacKay acknowledges that ‘it is not the role of public health to instill the virtue of compassion individual characters’ (p. 7–8), I push her further, to articulate how it is distinctively public health’s role to instill the structures of compassionate communities. There are two ways to do so: to delineate how public health uniquely knits groups together (has different external, internal and/or countergoals) or to delineate how the same virtue of compassion manifests distinctly in public health contexts (same goals, but specified and thereby more actionable). However, I worry that MacKay’s focus is better directed toward an account of public service or democratic virtues that are less distinctive of public health itself.

For example, it is unclear to me why public health institutions should seek to create inter-group compassion (p. 7) more than any other public or civic institution. Such compassion might be better understood as a civic or social virtue—the tendency for greater connectivity, inter-group cohesion or solidarity within a pluralist society. In this way, MacKay’s vision of public health echoes the concerns of Putnam (1995) in his analysis of declining social capital in the USA, capturing rapidly declining social intermingling within and between different groups. If this is the crux of the social problem, we can perceive that investment in adult education or public works (institutions more traditionally associated with cultivating civic virtues) might have greater or even primary responsibility for this social trait (Callan, 2000). Surprisingly, MacKay’s proposal appears to be the inverse of a ‘Health in All Policies’ public health approach [Health in All Policies (HiAP), 2014]: a kind of ‘social virtues’ in all policies approach, seeking to infuse social virtue throughout all public health structures.

How Do Collective Virtues Differ or Resemble Individual Virtues?

I am more excited about MacKay’s proposal that virtue theory for public health ought to direct more attention to collective forms of virtue. A main strength of virtue theory is its placement of moral psychology at the core of ethical analysis. With Rozier, MacKay aims to expand ethical analysis to the role of social institutions in shaping the conditions for a good life. One possibility for a virtue ethics of public health is to expand these insights to accommodate MacKay’s focus on collectives that cannot be reduced to individuals. What is the same and what is different about group or organizational psychology that helps us understand why some groups are oriented toward social goods, whereas others can be self-destructive? A virtue approach seeks a complex account of what motivates right action, what aspects of social and moral perception are apparent (salient) to the virtuous and how to acquire or learn the virtues. Collectivizing these dynamics will help improve understanding of how groups perceive and weigh external goals and countergoals, or whether collective virtues sometimes have an entirely different structure.

For example, much of public health policy seems to hinge not upon social trust but social reliance. Iodized salt systematically prevents goiters; fluoridated water assures better dental health for the entire population. It is a truism that public health works best when it is invisible, which is partly why communities often take public health benefits for granted. In these instances, I contend that most members of the public are not in a relationship of trust with public health. That is, they are not interested in the goodwill of public health institutions or professionals (Baier, 1986).² Rather, they are in a relationship of reliance. As Pettit (1995) argues, the difference between reliability and trustworthiness is that even inanimate objects can be counted on to be consistent: clocks dependably tell us the time and the sun rises every day. Humans, objects, and systems can be reliable. Reliability crosses over into trustworthiness when the motives of agents are needed to ensure consistency; we trust those who care enough about us to dependably safeguard our interests. Sometimes public health will need to demonstrate goodwill to earn trust or redress historical betrayals; there are other instances when reliability will suffice. Virtue ethics as a framework is at its best when it can help those in practice distinguish each context, justify why the virtues are needed and account for how either individuals or collectives can have such good traits.

The point here is not that collectives cannot have (un)trustworthy motives. Rather, the point is that current virtue accounts of trustworthiness are based on individual moral psychology, including external-, internal-, and countergoals, that need to be revisited for collectives if we are to ascribe the same trait. For example, when we say that we desire collective trust in public health, do we mean that public health institutions can be trustworthy in the same way as individuals? Or do we mean the kind of trust we need is the same as the figurative use of the expression, as in ‘I trust that the sun will rise tomorrow’ (i.e., I believe I can count on things to be the same)? Or do we mean that organizations are trustworthy in an entirely third way, distinct to institutions?³ Reliability is a virtue more easily ascribed to institutions or structures because it requires no organizational equivalent of motivation. With Nihlén Fahlquist (2022), I believe we should be deliberate about repurposing moral theoretic tools developed for individual character analysis for groups and institutions. We should supply analyses that clarify whether the collective trait always goes by the same name (and structure) as the analogous individual one. In doing so, the account is also more likely to avoid the pitfalls of virtue theory, including attribution errors and lack of actionability due to vagueness.

Conclusion

Virtue concepts, especially when fleshed out by the structure delineated here, provide what Williams dubbed ‘thick concepts’, or notions that combine evaluative and non-evaluative description and as a result can be action-guiding (Williams, 1985: 140). Thin normative concepts, like ‘wrong’ and ‘good’, need a lot more theoretical backing to become meaningful. Meanwhile, concepts like ‘trustworthy’ and ‘caring’ need less but often rely on social and contextual meanings that are built into the use of such concepts. Because Williams was following on the heels of philosopher Gilbert Ryle and anthropologist Clifford Geertz, thick virtue concepts connect to the notion of thick description (Väyrynen, 2021). The shared tradition has been picked up on in virtue ethics and the health professions before, suggesting potential consonance between naturalist virtue ethics and grounded theory approaches that seek accounts of regulative ideals in the lived experiences of health professionals (Oakley, 2018). Simply put, one way of deriving an account of social virtues and public health (à la Rozier) is to ask community members what social goods public health services provide. A way toward public health professional virtues (à la Nihlén Fahlquist) would be to explore what traits public health professionals view as central to achieving the mission of public health (e.g. Rogers, 2004). A way toward institutional virtue (à la MacKay) would be to ask public health leaders, workers, and communities to assess which policies are most functional. I, for one, am enthusiastic to see what these dually conceptual and empirical projects could yield.

Acknowledgments

The author would like to express her gratitude to the journal editors, Dr. Kathryn MacKay and Dr. Jessica Nihlén Fahlquist for their collaborative spirit and engagement on this topic.

Funding

The research to prepare this manuscript was partly supported by the Mayo Clinic Center for Individualized Medicine. The sponsor had no role in the writing of the report or the decision to submit the article for publication.

Conflict of Interest

None declared.

Endnotes

References