On regaining trust, avoiding self-satisfaction

Some first thoughts on restoring trust in the work of public health.

One of the reoccurring themes of these essays is the crisis of trust we face in working for health. The decline we have seen in recent years in the public’s trust in us poses a challenge to our capacity to create a healthier world. This suggests that it is on us to think self-critically about why this decline in trust, to reflect on how we conduct ourselves, on how our self-presentation may make the public more or less likely to embrace our efforts. Do we speak and act with humility or do we morally grandstand? Do we listen to others, including those with points of view with which we disagree, or do we just like to hear ourselves talk? Do we project optimism and a healthy self-confidence, or do we tip into the self-satisfaction that can put people off?

Each of these questions should give us cause for reflection, their answers of deep relevance to what we do. Lately I have been asked quite a bit: how do we rebuild trust in public health? I am not sure I have an answer, but I thought I would engage these ideas with a few essays on topics that relate to trust.

For today, I will address the challenge of self-satisfaction and what it means for our efforts to create health. I have been thinking a bit about whether we do indeed sometimes lapse into self-satisfaction, our successes occasionally going to our heads and causing us to forget the humility that should attend all we do. Let us start with how the Cambridge Dictionary defines self-satisfaction:

“the quality of being very pleased with yourself and accepting no criticism of yourself.”

This sounds right as a definition. It also does not sound particularly good. Few of us would feel comfortable admitting to a feeling of self-satisfaction, even as we are all liable to find ourselves self-satisfied from time to time. On one hand, we tend to feel self-satisfied because we have done something good. It is good to do good, something to which we should all aspire. And there is nothing wrong with a healthy sense of pride in our work. It can make us feel more confident, more willing to try new approaches and to be bold in how we engage with the world. But to be self-satisfied represents a less constructive version of the pride that supports confidence. When we are so pleased with ourselves that we tune out criticism, we risk becoming less effective versions of ourselves, to say nothing of the alienating effect self-satisfaction can have on others.

I often wonder about the relationship of what we do in health to the notion of self-satisfaction, and the implications of this for how we do what we do. Because what we do in health in some ways lends itself to self-satisfaction. In a recent essay, I wrote about the many reasons for optimism in our pursuit of health, reasons grounded in the incredible strides we have made towards creating a healthier world. Health is much better than it has ever been, and people live longer and healthier lives. We have made enormous progress in health, and if this is not a reason to be pleased with ourselves, nothing is. But when does pride in our achievements tip into a self-satisfaction that threatens the integrity of our efforts? I suppose it does so when it blinds us to advice, criticism, and the possibility that we are not infallible in what we do.

This suggests a second question: is there self-satisfaction in our ranks? Certainly, self-satisfaction has been attributed to those working in health, notably doctors. Fairly or unfairly, doctors have sometimes been characterized as smug and hostile to criticism. This has led to the trope of the arrogant physician seen in a range of cultural products, such as the television show House. It is perhaps not surprising that this trope should emerge. Doctors require high levels of schooling to do what they do, putting them in an elite professional class at the very start of their careers. When they are successful, it often means treating a disease or saving a life, a heady form of achievement. In our pursuit of health for all, we are in a similar position. Our success is nothing less than the creation of healthier populations. This can amplify the temptation towards self-satisfaction, a temptation we have not always done a good job of resisting in recent years. We saw, for example, a fair bit of triumphalism during COVID, which did not turn out to be entirely warranted. This was the case with the overly confident predictions we saw at the start of the pandemic about how COVID would likely unfold. In some cases, our confidence in our models was not always justified by subsequent developments, suggesting the importance of the humility that should always guide what we say and do.   

As an aside, I realize that there may be an element of self-satisfaction in the very act of writing about self-satisfaction. Just as there is a temptation to be self-satisfied about our virtues, there is a temptation to be self-satisfied about our capacity to be self-aware about our shortcomings. In this, as in all aspects of what we do, it is necessary to proceed with due humility, recognizing that we are fallible humans, unexempt from the follies and occasional failures this entails.  

So, yes, we have been, at times, self-satisfied. But does this matter? Why should we care about our occasional lapses into self-satisfaction? I would like to argue that, yes, it does matter, for three key reasons.

First, it matters because self-satisfaction is antithetical to the aesthetic and moral foundations of what we do in health. The work of creating health for all is not, should not be, about self. It is about service to community—about creating a healthier world for all of us. This work depends on a cohesive view of the architecture of health that paves the way for us to work with many to improve the health of populations. When we are self-satisfied, we turn inward, seeing ourselves when we should be seeing our community—the needs of the many and our capacity to work together to meet them. When our efforts are aligned with a collaborative vision for creating health, success means the success of all, not just one person or sector. We should seek to project, always, this collaborative spirit in our approach to health, inviting others to join our efforts and ensuring they feel welcome when they do.

A self-satisfied image does not serve such an approach. In writing about the moral and aesthetic case for health, I posed the question, “What are the sights and sounds of health?” The aesthetic of health should not be a look of smug satisfaction on the face of those working for health, nor should it be that of the lone expert working to apply her skills to the challenges of the moment. It should be an active, engaged, diverse community working with due humility towards the common good.

Second, we should care about self-satisfaction in health because it can blind us to when we are making a mistake. It is suggestive that the sample sentence for “self-satisfaction” in the Cambridge Dictionary reflects this danger: “I initially felt smug self-satisfaction, but within six months realized I'd made a mistake.” Such mistakes can be trivial, or they can be serious. I began this essay by mentioning doctors, whose self-satisfaction likely stems, in part, from their definition of success often being the saving of life. It is worth noting the other side of this, that their mistakes can mean the loss of life. The same is true of those who would create healthy populations. Just as the self-satisfaction of the 19^th century medical establishment caused them to resist handwashing in hospitals (in the belief that, as obstetrician Charles Meigs put it, “Doctors are gentlemen, and gentlemen’s hands are clean”), just as public health’s self-satisfied certainty in its own judgement allowed it to commit the grievous error of the US Public Health Service Syphilis Study at Tuskegee, our self-satisfaction can blind us to errors which can threaten the health of many. Avoiding self-satisfaction means doing a better job of avoiding such errors, allowing us to do our work more effectively by first doing no harm.

Third, we should be concerned with self-satisfaction because, frankly, no one will like us if we come across as smug and self-satisfied. This matters because we need capital with populations—we need people to like and trust us. And people typically do not like self-satisfaction in others. Self-satisfaction cuts off our connection to the populations with which we engage. When we are self-satisfied, we are just that—satisfied with ourselves. Rather than turning out towards the world, towards other people, we become fixated on what we see in the mirror, the image of our own imagined glory. This distances us from the engagement we need for our efforts to be fully inclusive and makes it less likely that the public will trust us our advice.

So, in the interest of a practical philosophy of health, one that is self-reflective, it seems reasonable to suggest that we avoid self-satisfaction, so that we can be ever better at what we do. How, then, can we avoid self-satisfaction? The obvious answer is to practice humility, something I have written frequently about. Humility does not, I should add, mean being self-abasing in our relationship to our abilities. Maintaining a healthy self-confidence is in many ways just as important as avoiding self-satisfaction. But healthy self-confidence and a sense of humility can coexist quite happily, helping us to be better at what we do. It can also make others likelier to want to share in our work.

What does humility in health look like in practice? Having singled out doctors for criticism early in this essay (as a doctor myself, hopefully I can be forgiven for doing so), I will close with the example of a doctor who in many ways exemplified humility in creating health. Many doctors would, of course, fit this bill, but I am today speaking of Anton Chekhov. Most famous for his plays and short stories, he was also a doctor. His literary output reflects an orientation to the world which is anything but self-satisfied. His characters are drawn with compassion, empathy, and curiosity about human behavior and the perplexities of the human condition. He once wrote, “The role of the artist is to ask questions, not answer them.” It is a statement which well captures the essence of an approach to life that avoids self-satisfaction in favor of humility and an openness to the world and all it can teach us.

This same spirit was present in Chekhov’s work as a physician. He was, by most accounts, an empathetic and attentive doctor, who listened to patients, cared for their mental and physical health, and applied his playwright’s eyes and ears to understanding the social context that shaped their wellbeing. At the same time, he understood the tendency of those whose business is health to become self-satisfied and ineffectual, often featuring in his stories doctors whose sense of compassion and humility fell far short of his own. He was also deeply interested in public health and the importance of prevention, remarking once to a friend, “The more experienced a doctor, the better he knows the power of hygiene and the relative weakness of treatment.”

Perhaps in our work, we can aspire to be like Chekhov, rather than like his less agreeable, self-satisfied characters.  One hopes that by avoiding self-satisfaction in favor of compassion and humility, we can support a vision of health based on truly seeing the world and the people in it rather than just seeing ourselves, and that such a view can contribute to the slow rebuilding of trust in the work of health that the moment calls for.

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Also this week.

I recently had the pleasure of joining Public Health On Call for a discussion about Within Reason with Dr. Josh Sharfstein.

I also enjoyed speaking with Jake Williams for the latest episode of The Wooden Teeth Show.