Principles – Andrew Appleton MD

Breaking bread (not bad).

An interesting observation of human behaviour during the COVID-19 pandemic is to make note of which shelves in the grocery store are empty. We’ve all heard the meme about toilet tissue. Clearly a necessity, but an odd one to hoard. What I find more intriguing are the bare shelves of flour and yeast. It would seem that everyone has suddenly started baking. Where does this urge come from?

During ordinary busy life, eating, let alone cooking, has become a matter of convenience and efficiency. We have so many things to do, that how we nourish our bodies has become an afterthought. We tend to cram in meals between other things. Worse still is that we often miss the rich opportunity to dine together, sharing stories of our days, learning from our families.

Well, now we have the time. We are home with our families. We are dining together again. So, we bake. Making bread takes time and care. A level of attention that simply wasn’t available until now. This is an opportunity to connect with our loved ones through making something together. I see those bare shelves as a sign of real humanity in the midst of crisis.

I have previously written about the importance of identifying moments that matter. Sitting down to break bread together is one of those moments. My wife and I make a priority of doing this with our children. We have an ongoing joke when we sit down across from one another by saying, “Well, here we are again.” This makes light of the routine nature of the act, but within it there is comfort. We know that no matter what we have experienced that day, how challenging it may have been, we will always return to this place.

Following the pandemic, my hope is that we can all slow down a bit, taking the time to cook and dine together more often. No one regrets having more dinners with the people they love. So, go stock up on flour and yeast. Along with your bread, may your well-being rise.

Be well.

On Being Disappointed in Oneself

We’ve all experienced disappointment in many forms. Disappointment is the feeling of displeasure when something doesn’t turn out as expected. Perhaps the most insidious form is self-disappointment. It’s insidious because it occurs within the privacy of our own minds, subject to our inner monologues, badgering us relentlessly. I find the notion of being disappointed in oneself fascinating. Are we not supposed to know ourselves better than anyone? How is it that our expectations can be so routinely misaligned with reality that we feel sad when we miss the mark? I believe the fundamental problem has to do with our overextending the concept of personal agency, or free will.

Everyone has said something that they regret. Often this happens during an emotionally charged exchange. Whatever was said probably came out within a fraction of a second of its preceding thought entering consciousness. There was literally no stopping it. If asked to explain why what was said was said, there truly is no satisfying answer. Feelings were hurt. Self-disappointment follows. The explanation, however, while unsatisfying to the recipient of the regretful utterance, is interesting to explore.

All things that we say or do are a product of our conditioning and present context. Our conditioning stems from our predisposition – genetics and human instinct – and all of our life’s experiences to date. Context is the present state of everything going on around us. Where conditioning meets context, actions ensue. If the context is such that there is no time for metacognition – thinking about what you’re thinking – then the role of personal agency is drastically diminished. We act on conditioning alone. This is the case for most spontaneous conversations, sports, driving, and so on.

If we mainly act on conditioning, then why should we be disappointed in ourselves for things we had no chance to plan? I don’t believe we should. The only possible internal conflict with a given outcome, then, would be its discordance with a deeper set of principles we ascribe to ourselves. To be kind, for example. Am I always kind? Of course not. Yet, there is nothing to be gained from being disappointed in myself when circumstances arise in which I am not kind. I did not fulfill my aspirational value in a given moment. What I got was a product of who I was in a specific context at a specific time. Principles, by their nature, are general. They may guide thinking and conduct in the general sense but cannot determine how we will act in any particular circumstance.

What, then, should we do when we feel that twinge of self-disappointment? Be aware of the feeling, but don’t stop there. Consider whether what occurred could have been anticipated and mitigated in the exact context within which it happened. Chances are it could not, especially since much of our context is beyond our control. Next, we should become curious about how to begin shaping our future conditioning, so as not to act the same way when presented with a similar context. Taking a future-oriented problem-solving approach, guided by our principles, should be a successful treatment for the disappointed self.

Be well.

Be kind. Be curious. Be useful. And create.

My children are too young to have nuanced conversations about philosophies of life. Yet, I often think about the type of advice we should be giving them on how to live a meaningful life. While they may not recognize advice for what it is, at this point, I am mindful that we are already modeling the values and behaviours we believe most important. The result of my thinking on this is a simple and foundational list of recommendations:

Be kind. Be curious. Be useful. And create.

I see this as both a starting and ending point. Before starting anything, if you commit to being kind, curious, and useful, you will stand to make the most of it. When you’ve come to the end of a project or phase of life, no matter the outcome, and you can honestly say that you were kind, curious, useful, and that you created something, then you have succeeded.

Be kind.

Kindness is giving others the benefit of the doubt, listening to their stories, or stepping in when help is needed. We are dependent on so many people for so many things, but often take this for granted. Everyone has a story when the kindness of a loved one, neighbour, or stranger helped them in a time of need. No reciprocation expected. We are at our best when we have mutual respect for one another. We shed the weight of suspicion, hate, unnecessary competition. When we are kind, we allow others to flourish. We grow along with them. It starts early with our children. They see how we treat others. We must show them and tell them what it means to be kind.

Be curious.

One of the great joys of being human is our ability to learn. Children embody this for us. They have an incredible sense of wonder. A deep desire to explore everything. My four-year-old asks questions that I don’t know how to answer. “Why do we dream?” “Where does the wind come from?” What an amazing opportunity to learn together. This never has to stop. But it does. Something happens in adulthood. We become entrapped by the lives we have created for ourselves, with rigid schedules and rules. There’s no time to explore. But we must. Our children need to see the same joy in us, when we learn something new, that they experience themselves. Education, innovation, and progress depend on our insatiable curiosity.

Be useful.

To live in a vibrant and productive society we need people to put skills into action. Look around you. Everywhere you go there is evidence of peoples’ work. Children need to have this pointed out. How was our house built? Who put these roads here? How does that airplane fly in the sky? The answer, in each case, involves people coming together to do useful things for our mutual benefit. At some point, our children will have to decide where to focus their efforts. This will depend on their natural and learned abilities over time. We must help them know that there are more ways to contribute than one can think of. But above all, whatever you do, be sure that it’s useful. When we do something useful, we know that our work is valued and that we have given back to the society on which we depend.

And create.

Note that I have not said “Be creative.” I believe when people think of creativity as something that you are, rather than what you do, their view quickly narrows to the arts. While the arts are a beautiful manifestation of what people can produce, we can also create in other ways. Create friendship and community. Create love. Create joy. Create suspense. Create a new perspective. Create a car out of Lego. The possibilities are truly endless. The only limit is imagination, and our children should be encouraged to use theirs’ extensively. The peak of human achievement is when we have created something, together, that generations before would never have thought was possible. This is the power of humanity and a pillar of our sense of meaning and fulfillment.

These recommendations work together. Being kind forges strong relationships and opens doors before you. Curiosity brings you to the brink of what has not yet been created. Being useful develops your skills to contribute to the progress of society. Creating something for others brings us together and moves us forward.

If you’re looking for advice to give your children on how to be, I hope you find these simple recommendations of use. Discuss it with them. Model it for them. Grow together.

Redefining Health and Well-Being – How the WHO has it wrong

What is health? Nutritious food and exercise quickly come to mind. Being healthy makes us think of doing something. We have a healthy diet, lead a healthy lifestyle, have healthy relationships. “Healthy”, the adjective, is easily understood as a good way of doing something. It’s more difficult to define “health”, the noun. Presumably doing healthy things brings us health. Why else would we do healthy things? The reasons, and hence the “health” being sought, differ from person to person. Enter “well-being” and the subjectivity amplifies. The two are intimately linked. Perhaps not in the way we’ve been sold.

Let’s start with a definition. I know, I am breaking 10^th grade English dogma – don’t start your introduction with a definition! My purpose is to show you how a widely accepted definition is not only wrong but is not actionable. The World Health Organization definition of “health”:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

I appreciate the inclusion of “physical, mental and social” as necessary components of health. The utility of this definition ends there for me. Starting with the second clause the WHO suggests that the presence of “disease or infirmity” (read: disability) negates the achievement of a state of health. Can one not have health while living with chronic disease or disability? Rhetoric aside, I don’t think I need to expand further.

Back to the first clause, “Health is a state of complete […] well-being”. I’ve removed the part I like to reveal the absolute nature of this statement. If you broadly apply the WHO’s definition of health, you would be hard pressed to find any human being who meets the criteria of clause one alone. Let’s give the WHO the benefit of the doubt – their definition is aspirational. It’s meant to inspire nations and their policy-makers to reach the highest possible heights of health, equity, and productivity. I’m skewering their definition to make the point that health, to the individual, must be cast in a different light. What of well-being?

In the philosophical sense, well-being is how well your life is going for you. There is debate about how to quantify this. One has to know the constituents of well-being and how to determine what makes them good for the individual. There are three leading theories, Hedonism (balance of pleasure over pain), Desire-satisfaction (fulfillment of desires), and Objective list (constituents of well-being outside of pleasure and desires). I will not dive into these here, suffice it to say that each has its limitations. Given the theoretical equipoise, I feel I have license to propose my own definition, albeit leaning in the direction of Objective list theory. Let’s first address the relationship between health and well-being.

According to the WHO, health cannot be achieved until you have well-being. For those policy-makers trying to bring health to their people, the problem of defining well-being becomes eminently vexing. If defining health is the Mona Lisa, defining well-being is the ceiling of the Sistine Chapel. My main contention, however, is against the assertion that health is secondary to well-being. I argue that the opposite is true.

Argument from First Principles

You are a biological being. You have physiologic systems that require inputs and produce outputs. An ideal state of health, then, could be considered providing the precise quantity and rate of inputs your systems need to perform effectively and efficiently. Nothing more, nothing less. Inputs may include nutrition, sleep, physical activity, mental stimulation, and so on.

Now imagine a scenario where someone has completely engineered your life for you. They have designed a way to provide all inputs, tailored to your biological and genetic profile – proper food, eight hours of sleep per night, physical training, exemplary education, even socialization. Everything is controlled. Even though you could be in perfect physical and mental health, you would not be surprised to find yourself completely miserable.

How can this be so? Because whatever we do to be healthy is ultimately being done to prepare us for something else. That something else is conscious experience. I do not wish to invoke any arguments about dualism here. Regardless of how you think about the nature of consciousness, its existence is undeniable.

Consciousness presents the world to us. It is within consciousness that we do or do not achieve well-being. An ideal state of health gives us our best chance to achieve well-being but does not guarantee it. Well-being is achieved when our consciousness perceives that our internal and external states are aligned and complimentary. If I am in pain and I do not think I should be in pain, I am suffering, and my well-being is under attack. If I have a set of beliefs but others are forcing theirs upon me, there is conflict, and my well-being is under attack. If I love the natural world and have time to go for long hikes (and the physical health to do so), I feel fulfilled, and my well-being is sustained.

Argument from Evolution

From an evolutionary standpoint the healthiest, strongest, fittest people had an advantage. This includes mental health and intelligence, requirements to succeed in a group. In a hunter-gatherer tribe, most waking hours would be spent on activities to promote survival. Good health would allow individuals to contribute more and pass on their genes. Well-being doesn’t emerge as something with which one has to be concerned until you can do something more than simply survive.

Well-being requires time, with which one can turn their attention to or think about whatever they choose. It requires time to experience a sense that what you’re doing is worthwhile.

Well-being became possible once we had larger societies with economies and adequate resources. Once you can purchase or trade for what you otherwise would have spent your time acquiring, you have time to learn, travel, care, volunteer, socialize, play, and more. These are things with which we associate meaning or purpose. Plato and Aristotle were able to think extensively about well-being, virtue, and the like, because they lived in a society that valued knowledge and was able to support a number of citizens who did not contribute to the production of physical resources.

One could point out that we would not be able to conceptualize or experience well-being were we not adapted for it. While true, this does not negate my argument. Before modernity the major selective pressures would have primarily favoured characteristics that promoted survival. In keeping with the story of evolution, it is generally only known what characteristics conferred an advantage in hindsight. The emergence of consciousness and ability to reason are clear evolutionary advantages, allowing ancient peoples to develop language and band together in complex societies. These events needed to occur prior to the ability to articulate and reflect on what is now being considered as well-being. Hence, I contend that the notion of well-being is an interesting development that came along for the ride while humans evolved to become the primary dominant species that we now are.

Conclusion and New Definitions

To bring this full circle, two questions help underscore the fact that health precedes well-being and not the converse:

Can you have good health without well-being? Yes, without a doubt.

Can you have well-being without good health? Unlikely.

Notice I haven’t answered ‘No’ to question two. Health is an important (likely the most important), but not sole component leading to well-being. If you are a Buddhist Dzogchen master and have become enlightened, unencumbered by a sense of self, you could have well-being without good health, because there is no self that requires it. You would still require some degree of health, though, to hold the body upright and have clarity of mind enough to meditate.

Also note that within my questions ‘good health’ does not ascribe to the WHO’s “absence of disease or infirmity”. Health is a product of the individual within whom is resides. With that said, here are my suggested new definitions for health and well-being:

Health: A state of optimal physical, mental and social functioning that gives one the best opportunity to live well.

Well-being: A state of consciousness in which one’s internal and external experiences are aligned to create feelings of happiness, fulfillment, meaning and/or satisfaction, over the course of one’s lifetime.

Within the definition of health, I have used the word “optimal”. This allows anyone to optimize their physical, mental and social functions to fit their current state, be it free of disease and disability, or not. The definition also tells us that health is a foundational state. If we have health, we are on solid ground. Health is the jumping-off point for us to live our best lives.

Well-being is less tangible. While not the only route, health is the major conduit to well-being. As the definition states, your internal and external states must align. This means that your physical, mental and social functioning, as well as your environment, occupation, goal structure, expectations, and more, must converge to create the feeling of fulfillment. By its nature, well-being is transient, but can be kept closer at hand with deliberate attention.

As a final thought, I have designed the definitions to be actionable. Getting to an optimized state, modifying, and optimizing some more, is achievable. Getting to “complete […] well-being” is not. Reflecting on your internal and external experiences to assess their alignment can also be done. Keep these definitions close at hand as we continue to explore ways to empower your pursuit of health & well-being.

Guiding Principles

When thinking about matters of health and well-being it’s helpful to have a set of guiding principles. Ultimately, we are always trying to inform our actions by deciding what is good or bad for us. The impossibility of this effort stems from the constant barrage of information and opinion about how we ought to conduct ourselves. I use the following principles to help find the signal in the noise:

1. Autonomy.

Decisions about one’s health and well-being must be made by the individual, so long as they have the capacity to do so. As a doctor, I carry the responsibility to help my patients make the best decisions for themselves, guided by my expert knowledge and experience. They may ultimately make a decision with which I do not agree. I must respect their decision, because it is theirs to make.

Similarly, as a society, we have a responsibility to make available the best knowledge of the day, so that each of us may use it to decide how to conduct our lives. What is best for one individual can be at odds with what is best for society. Nevertheless, good societies uphold the individual’s right to autonomy, especially regarding personal health and well-being. Limits should only be considered when there is clear evidence that an individual’s choices could result in appreciable harm to others.

2. Equal opportunity.

Society should be tasked with creating equal opportunities for each of its citizens. None of us chose when, or where, or to whom we were born. The random event of our birth, and the situation into which we were born, should not adversely affect our opportunity to achieve our full potential. A good society recognizes this and works toward removing unnecessary barriers to opportunity. This is especially so for the opportunity to realize good health and well-being. Once presented with opportunity, however, it should remain up to the individual to decide if and when to act.

3. Evidence-informed reasoning.

The scientific method is to be respected and celebrated. We should always look first to ‘the evidence’ to inform our actions. Not everyone is armed with skills to appraise science, however. For this, we will always have to rely on experts. Unfortunately, in matters of health and well-being, there are plenty of charlatans. So, in areas we are not expert ourselves, we must retain skepticism, asking what any self-proclaimed expert may have to gain from their machinations.

If one’s skepticism is piqued, a simple strategy is to ask for references or data upon which conclusions have been made. If produced, one then has an opportunity to appraise it for themselves or seek a second opinion. This effort is not in vain, for once we leave the land of evidence, we find ourselves afloat in the sea of opinion.

4. Embracing uncertainty.

I often remark to my trainees, “The only thing we know for certain is that we can know almost nothing for certain.” After speaking so highly of evidence-informed reasoning, we must address the reality of context. Scientific studies are necessarily narrow in scope and conducted in a rigorously controlled setting. This is the only way to validly test a hypothesis. But it creates a problem when we then apply findings to the real world. The context of our present scenario is almost always different than experimental conditions. Enter uncertainty.

Uncertainty makes people uncomfortable. Our minds are put at ease when we know exactly how things will transpire. In medicine, this is seldom the case. Hence the frustration that ensues when patients ask if a given treatment will work. More often than not, we just don’t know. However, we can certainly offer a well-reasoned guess based on evidence.

In matters of health and well-being, be skeptical of anyone who claims they know anything for certain. Instead, find someone who embraces uncertainty, for they will likely retain the curiosity to seek further understanding.

5. Open and respectful dialogue.

Far too much time is wasted on unnecessary debate between opposing ideologies. Outrage abounds these days, even for matters that are trivial. The only remedy is open and respectful dialogue. This occurs when each party is seeking to learn and expand their understanding. If we approach dialogue in this manner, we all benefit. If you disagree, great! Explain why and how your perspective is different, or possibly better. We would not learn anything if we all agreed about everything. Exploring differences of perspectives or discordant scientific findings is how we progress knowledge. No offence necessary.

6. Accepting that what we currently think might be wrong.

This is directly related to principles 4 and 5. Believing oneself right all the time and having to defend it can be quite stressful! It also creates unnecessary conflict in defence of ideology, rather than rational thought. History is full of examples of how prevailing practices of the day turned out to be wrong. And that’s okay, because we learn and change our ways by applying new evidence. If we approach matters of health and well-being with an acceptance that we might be wrong about current practice, we stand to progress far more than by embracing dogma.