For over two decades, I have participated in an introductory course on “Medical Ethics” for second year students at Weill Cornell Medical College. In that capacity, I share leadership with a physician colleague in a small-group seminar that follows a lecture in each of the course’s eight sessions. The course material is case based and focuses upon end of life decisions, research ethics, pediatrics, obstetrics and gynecology, and surgery. I have come to recognize something about the course having relevance to both the editing and writing for this Journal. It is the idea of “reflective equilibrium” as articulated by the philosopher John Rawls in his A Theory of Justice (1971). There and elsewhere Rawls describes “reflective equilibrium” as a state of coherence arrived at through deliberation and negotiation among varieties of perspectives and points of view. It is a way of recognizing and deciding among paths of action and divergent views in matters of moral conduct where problems appear insoluble. Rawls’ believes that “reflective equilibrium” lies at the heart of the democratic process and the pursuit of justice. It provides a structure and context for dealing inductively with a wide range of concerns stretching from end of life issues to the cutting edge of biomedical research. Solutions in medical ethics are often provisional and contingent in character though embedded within them are significant and profound concerns with values and conduct related to the meaning of personhood and seeking after justice.

In historical studies, a contemporary reference to this process appears in John Burt’s acclaimed Lincoln’s Tragic Pragmatism: Lincoln, Douglas, and Moral Conflict. There the author explores the crisis of slavery and the manner in which both Lincoln and Stephen A. Douglas sought to address it in the years prior to the Civil War. He writes

Judgment and ideas refine each other in what John Rawls calls a process of “reflective equilibrium,” bringing out, under pressure of concrete political conflicts, implicit entailments of ideas, consequences of promises, we have already made but have not yet had to face. (Belknap, Harvard Press, 2013, p. 7)

The key words here are “under pressure” and “consequences” as they are inevitably present in conflict situations where there is moral complexity and much at stake.

In medical ethics, “reflective equilibrium” opens the way for looking at issues that may seem simple on the surface until examined at greater depth. We tell students that the resolution of ethical dilemmas has to do with the balancing of competing goods and that in this process “the perfect is the enemy of the good.” During a seminar session in this year’s course, one of our students stated “When I first looked at this case the answer seemed instinctive but then the more and more I looked it was really sticky.” I responded “sticky is good” and suggested that seeing the inherent complexity of the case at hand was a vital first step for arriving at any viable solution. The movement from “instinctive” to “sticky” to a resolution is what Rawls’ process aims for. Everyone in the class contributed. There were several different interpretations on what was going on and what was the fitting response to what was going on. All the stakeholders’ (patient, family, medical staff) interests were represented and recognized as having a voice and a claim in moving toward the eventual resolution. No one was left out.

Lest the above seem altogether quixotic, there is a point here to be made about the Journal’s construction and purpose. We strive, as has been said in other Editorials, for both variety and quality given the constraint of length for each issue. The result, if successful, represents an expression of a “reflective equilibrium” of voices and perspectives. In this issue, as in other issues, we must acknowledge those who have been on the online queue the longest. Some, but by no means all, must be included. Then, we must consider among more recent online publications a number of quantitative studies. They are prominent in this issue as they are in all issues of the Journal of recent vintage. In this issue, we include Jeff Levin’s piece on “An Agenda for the Surgeon General: Engaging the Faith Communities for Public Health Advocacy.” It reminds us of the place of religion in the public square particularly as it relates to matters of health promotion and health literacy for all persons. We have included in this issue three stellar book reviews on a wide variety of subjects that normally would not be grouped together. Mary Dunn’s article on Marie de L’Incarnation recalls the Journal’s historical roots in the creative use of psychoanalytic concepts, in this case Heinz Kohut’s writing about narcissism, as a tool for a deeper understanding of religious figures and religious experience. And Anne Miller and Stephanie Lyon bring into focus health issues in the Mormon community and the particular needs and character of psychotherapy with a group that deserves out attention. The Church of Latter Day Saints along with Christian Science, Pentecostalism, and Jehovah’s Witnesses are acknowledged to be the four most prominent indigenous religious denominations founded here in the United States though each has made successful efforts to expand beyond our borders. The better we understand them the better we will understand ourselves.

Finally, I believe that authors themselves engage in the formation of a “reflective equilibrium” of sorts in the process of preparing studies and essays for publication though I doubt many would call it that. They must select certain methodologies, data, language, and sources and exclude others. They must through a negotiation within themselves develop an authorial voice and style of expression congruent with the needs of their material, the demands of their discipline, and their sense of personal and professional integrity. All this requires a willingness to risk oneself in a public way that encourages scrutiny and criticism as well as praise or rejection. If the rewards did not outweigh the risks, then their formation of an inner “reflective equilibrium” would be hardly worth this effort in the first place. We are blessed and fortunate that all our authors create their own “reflective equilibriums” and are willing to take this leap of faith on our behalf.