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Courage: Its Various Forms

Daily we have brought to our attention, acts of courage performed by health care workers during the ongoing COVID-19 crisis. It also shows an advanced social empathy that the courage of the multitude of unheralded workers who carry on their work for the public good, despite the real danger to themselves, is also at times recognized. The janitorial workers in hospitals, ambulance drivers, spring to mind. This was beautifully acknowledged by the recently released song by Alicia Keys.

Courage therefore is an interesting subject to discuss. All forms of courage are valuable...and brave... and most be heralded and recognized to perpetuate that impulse. of our better angels. Courage often involves not only words but essentially actions.

Courage is certainly not unique to humans, although in humans it may be more complex. The courage ofcourse of our canine companions, may be unmatched in the extent of the number of members who are prepared to be brave.

There are basically two general categories of courage: reflexive and premeditated.

Some of the most dramatic and poignant examples of courage brought to our attention are acts of reflexive courage, made all the more impressive when it involves non-family members. There are accounts of men who have rescued other people's children from bodies of water: ocean, raging rivers, and the child survived and the rescuer perish. Most pertinent to our modern US age, the school teachers, or close associates (often the boy-friend shielding girlfriend), who shield school children from being shot be rampaging gunmen. My opinion is, of the forms of courage, this may be the most innate in the majority of humans.

Pre-meditated courage can be divided into courage that directly impacts the individual and that which does not (altruistic). Further categorized into courage that follows a community of activists (which is often oppositional to the prevailing culture), and that which is purposefully. oppositional to the common culture and solitary in nature/origin.

Pre-meditated courage that follows the flow of broadly sanctioned conduct is best illustrated by health care workers and COVID-19 - especially individuals who have flown to New York to help in the epicenter of the COVID crisis. These brave individuals, and ofcourse the larger community of local nurses, physicians, technologists, knowingly put their lives at risk to benefit others. Repeat that again to yourself. This is remarkable, and yet also not rare in humans. Some of these people die helping others.

Over recent years, the courage that entails speaking up to protect the individual themselves, or the community they identify with, has also come to the fore. One of the great values of these individuals being publicly documented/recognized is that , as with bad behavior, good behavior also is subject to being copy-catted. For example, Gretchen Carlson, coming public on sexual harassment at Fox news, opened the door/ gave courage, to other women victims in the media/entertainment industry to speak up, not uncommonly for crimes done to them that occurred decades earlier. This has created a massive movement of women victim activism. Brave individuals who have spoken up for their self-identified group have justifiably achieved immortal fame. In antiquity, Spartacus for the underprivileged class, Mahatma Gandhi for India in the mid 20th century, Martin Luther King Jr for black Americans. The greatest of them have also given us lasting quotations from their philosophy (Gandhi: be the change that you want to see in the world; Martin Luther King: I had a dream speech). The most remarkable of them had sought peaceful change (Gandhi, King), others more violent activism (Spartacus, Robespierre). The #Me Too//#Stand up movement and Black Lives matter movements are the two most recognizable current courage-based movements that speak up for justice. The most effective strategy ultimately is probably the recognition of their similarities, and bringing together of all these movements, and incorporating less visible/publicized groups (Dreamers). These are essentially movements against Abuse of Power. Unity would be the strength: too fractionated groups and their voices are easier to drown out, cover up. Climate change activism is an example of blended self-related and non-related courage. The poster child for climate change activism courage is the young Swedish girl Greta Thunberg. I wish I could give a speech as powerful as hers to the UN assembly. Many of these courageous actions become copycatted behaviors... which is a critically important human behavior- copying what others have done before. In this setting extremely positive. Courage breeds courage.

Courage that goes against the grain and benefits others (non-related) is perhaps the most uncommon form of bravery. Perhaps the most famous example of this form of courage is Oskar Schindler. Schindler was a Nazi, and yet he became the great savior of thousands of Jewish people during the terrors of the Holocaust. Diametrically opposed to the culture he was in. There was no association he had with Jews, and yet he risked his life to save them, and not only his, but the lives of his family. Presumably this stems from a profound sense of Right and Wrong. This altruistic bravery is so rare because it not only is courageous to assist unrelated individuals, does not follow the flow of a community of courageous individuals, it is usually quite solitary.

So all forms of bravery contain a tremendous amount of personal risk, including death. Likely as with many human conditions there is likely a genetic component to it. Using health care as the comparison model: reflexive courage, such as wisking a non-related child out of the way of a moving car, is remarkable, but likely relatively common, maybe 20- 50% of individuals have this impulse.

Pre-meditated courage for the individual's issues, is well shown as speaking up against their abuser (famously Larry Nasser's victims). This often blends courage for issues pertaining to the individual with courage that benefits a community. Frequently when women describe why they have been silence breakers, their rational includes and may be primarily to protect other women in the future from experiencing similar mistreatment. Courage which is based on the individual's circumstances is rare, perhaps in 1% of individuals. Importantly it can be fostered by pre-existent examples. There are different underlying psychological components to speaking up as an individual compared to speaking up for a community. Courage that is part of a community but benefits non-related people or entities (the planet) is relatively common, to initiate the movement requires remarkable courage, maybe 1 in 1 million have this, to be part. of the movement, still extremely impressive, perhaps 10% of individuals have this. Nonrelated altruistic courage that goes against the grain of the community is the rarest form of courage. In general any activity that is solitary is more challenging then an activity in which the individual is part of a group. Schindler is the example of this type of courage. Perhaps 1 in 10 million people have the genetics for this courage, because almost by definition it opposes the strongest biological force of self-survival.

All forms of courage. are remarkable and should be fostered in the individual and the community. The most impressive are the courages in which the risk is losing your own life, and this can happen with all of them. Risk of loss of life is the greatest intensities of these individual courages. In the media, we are aware of perhaps thousands of individuals who have shown reflexive courage: risking/losing their life to save others not related to them (I think of the teachers at New Town). Premeditated self-focused courage rare and benefits enormously from prior examples (current in the media, victims of male OB/GYN physicians in California and New York). Premeditated courage which benefits others but is part of a community is also rare but benefits from the community is relatively common (health care workers and COVID, UN Peace-keeping forces, positive military actions in general). The blend between courage benefitting the self and the community is relatively common, and the best examples are great philosophers.

Premeditated courage that benefits non-related individuals and goes against the grain and is solitary, is the rarest form of all courage, and I suspect (like GDD) is genetic in nature, as it goes against the primary biological force of self-survival (Schindler). As with other forms of bravery, it likely benefits enormously from prior examples to spur action. In many respects it is the ultimate expression of the Stoicism of Marcus Aurelius - the pursuit of virtue: being the best individual you can be for the qualities that you are possessed of.

Without difficulty, aided by searching the media, it is straight-forward to come up with the names of physicians who have committed egregious acts against patients (Nasser perhaps the most famous example) and males in the privileged group who have sexually molested women (Harvey Weinstein, Roger Ayles, Bill Cosby, and atleast 2 presidents, the most recognized). Many of the victims are also recognizable who have spoken up. The one group in which there appears to be no/extremely few prior examples are individuals who are not victims but who speak up to protect others. I certainly know one person who has done this, but not only for Gd, but also as yet not described, to benefit patients in general. I am certain this has to be genetic, this individual has an ancestor who was a Lutheran minister who was killed at about the age of 40, breaking up a fight between two men. If non-victim bystanders or non-victim peers do not speak up, then it is hard to imagine that significant lasting change can be made with justice for victims. It is also fascinating that this courage is often not greater than the others, in fact oftentimes less intense. In the modern age in Western countries to report misconduct of colleagues the downside is almost never death, but loss of reputation or loss of career, or both, and yet this bravery is much rarely than those who are prepared to risk their lives treating COVID patients. Of the tens of thousands of courageous doctors who go into hospital to treat COVID patients, how many are prepared to speak up if their colleagues commit terrible abuse, probably extremely few to none. This seems inexplicable, but it relates to several factors: it is at present without examples to copy; is not part of a community of ethics-warriors; is solitary and creates further isolation; and not supported by a community.

Perhaps the greatest present day example of the premeditated solitary oppositional bravery is from China, yes China. Li Wenliang was the first physician to speak up about/ whistle blow, on COVID and who was retaliated against by governmental agencies, and who ultimately died of the disease. He is a great hero for China but also for all of us. In Valhalla he joins the company of other great physicians of the past: Boerhaave, Sir William Osler, Louis Pasteur, and many unknown warriors for patient safety. Li Wenliang is a great hero. A problem though with trying to stimulate other patient safety warriors is that: there is no money in it; no recognition; often vicious opposition from members of the status quo (Schoppenhaur's 3 stages of truth); and many of the individuals who are the beneficiaries do not understand that the intention is deliberately to benefit them and they also form part of the opposition (lack of wisdom-sense). This all has to change for safety practitioners to increase in number, and not only be formed of the 1 in 10 million with the genetic defect of putting the welfare of others ahead of themselves, but to include the greater number of individuals who are simply interested in patient welfare and fully understand what primum non nocere entails.

This change must continue, more people must speak up. This will also stimulate copycats: individuals who then gain the courage to speak up themselves because they have the model of someone else to follow. Why did no one speak up against Nassar or all the other physician-criminals? Fear of losing their job and their reputation, not their life. Shameful. We are better than that. I follow the principle to be the change one wants to see in the world.

Courage breeds courage - if the outcomes of positive courage are publicized.

Richard Semelka MD Consulting Stay tuned on the latest advancements:

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