If a person suffers from a fatal illness for which there is inadequate treatment, what degree of risk would be considered ethically acceptable in a clinical trial? This is a question faced by physicians, scientists, institutional review boards, courts, and of course, our patients every day as we seek to advance our therapeutic armamentaria for glioblastoma, amyotrophic lateral sclerosis, and many other illnesses. In the absence of an objective anchor on which to base our decisions, we are driven by our moral sense. Morality is critical for the practice of medicine and for guiding research. Perhaps surprisingly, we can begin to understand the origins of morality within the construct of human creativity that I have discussed in each edition of this column this year:

Motivation. Fairness and the punishment of unfairness activate reward centers in the brain (Science 2004;305:1254-8). Evolutionary psychologists believe this rewarding behavior is an instinct that supports the survival of social groupings ("Evolutionary Psychology: A Primer." 1997). The uniquely large size of human social groupings – defined in terms of cities, states, countries, and even a global community – requires social cooperation for which these motivational anchors of fairness and its enforcement exist.

Perception. In any social grouping, we occasionally perceive situations involving inequality or unfairness (especially within our social niche). If I am at a restaurant with my neighbor, and we both order the same chocolate ice cream dessert, I will feel unfairly treated if he gets twice as much as me, or if his comes with sprinkles and a cherry and mine does not. I perceive this inequality, but I envisioned (expected) equality. The difference between what I envisioned and what I perceive provides the motivational voltage that leads me to act.

Action. I now formulate a plan. I will call the waiter over, point out this obvious difference, and ask that I receive the same serving of ice cream as my neighbor. Enactment of this plan requires me to account for and conform to the context. Though internally my motivation is clear, externally, I am among polite company in a public place and the injustice is of rather small import, even if it is unfair in principle. So, in acting out the formulated plan, I do not yell obscenities or threaten the waiter’s life, but rather tactfully wave him over when I catch his eye and then politely point out the difference.

Temperament. Although this is not a long-term issue, the restaurant is busy, and it is more than a few minutes before I am able to signal my waiter, so I am waiting. In waiting, my impatience palpably grows, fueled by the indignation of the unfairness in front of me and the gradual melting of my ice cream, which I’d rather be enjoying instead of waiting to replace. But I must be patient for my plan to be effective. I miss the waiter once or twice, so I must persevere. It would be a mistake to lose my temper and yell or jump up impatiently, as it would only make me look bad.