Some of the best instances of bioethics are applications of ethical conceptual analysis to real-world cases that is done in a way that prompts both reflection on the part of the practitioners involved in the real-world case and reflection by the bioethicist on the way in which the field of bioethics understands the concept in question.

Buth et al’s paper in this issue is a fine example of just this ( see page 299 ; Editor’s choice). Their paper brings together three important concepts that straddle the worlds of politics and ethics and are to some extent under-theorised in applied settings. These three concepts – moral narcissism, moral complicity and dirty hands – raise particular problems for the activities of researchers, aid workers and others from richer countries working in poorer or conflict-torn parts of the world.

Buth et al set out a general account of these concepts and their relationship. Their focus is substantially on complicity largely because Médecins Sans Frontières (MSF) have been accused of it in each of the three cases they go on to discuss. These three cases involve MSF interventions in Myanmar, Libya and on the border between Syria and Jordan. Each are importantly different: from the involvement of MSF with the wrongdoers varies from not speaking out and continuing to operate in other parts of the country (Myanmar) to being used as a coercive pawn providing aid (Syria/Jordan border). The situations are complex and, in the end, Buth et al see the analysis of them in terms of complicity as a useful first step but that is all.

There are some important nuances embedded in the paper that are worth bringing out.

First, moral narcissism as they define it, comes about at the point at which “an appropriate concern for one’s own moral integrity turns into moral self-indulgence” or a concern for the preservation of the agent’s self-image, as Bernard Williams describes it.1 Interestingly it’s as though how I appear, how I seem, in performing an action comes to matter more than what I do and its rightness.

One thing to notice here (as Buth et al do) is that there is a balance to be struck between being indulgent and being unreflective. This is slightly different way of understanding the idea of moral narcissism and distinct from Williams’ context where he wants to contrast the consequentialist position with the integrity of the agent in acting – a contrast between the importance of what happens as a result of what the agent does and the importance of the nature of what the agent does.

Being reflective (in the sense that being overly reflective can be self-indulgent) is related to recognising and being aware of the place that an agent has in the context of action – being aware of how they are viewed, what is expected of them, what their values are in relation to those around them and how the proposed act or acts are expressive in the context. We can imagine at one extreme an agent who is naïve and unaware, blundering into a situation with the best of intentions but completely missing the context. At the other extreme, and this is the moral narcissism, we can imagine an agent who is completely hamstrung by what others will think and how they will be judged seemingly if they do anything at all. At this extreme, the agent is too concerned with the politics of the situation and their role in it if they act: to be an agent here would be to become embroiled in the politics.

These extremes map neatly onto certain kinds of objectivism in ethics at one end, contrasted with a kind of relativism that is often tempting in the face of value and contextual difference at the other. The self-image focus of the moral narcissist is sometimes the product of the idea that there is nothing else for me to be concerned with but what I value. At the other end of the spectrum, the kind of blind objectivist has things right and immediately sees the demand to act on the unambiguous demands of the context.

This is a slightly different take on the idea of moral narcissism as discussed by Buth et al but it is most definitely in line with Williams’ concerns related to integrity. But what is striking here is the way in which these issues a become a peculiarly acute problem for those from outside inserting themselves into, and hence acting in contexts of extreme hardship, poverty, violence or emergency. These are precisely the contexts described in the examples given by Buth et al. Organisations like MSF as well as individuals who venture abroad into difficult circumstances to provide help and ‘do good’ are often caught on this sliding scale. Being too humble or being too naïve is on this scale and seems clearly connected to self-reflection and self-awareness. And very definitely difficult to navigate safely. MSF and other INGOs have a good deal of experience at this, which doesn’t make them immune but gives them an advantage.

The context of choice makes a significant difference: being removed from that context and judging others brings with it its own risks. It is reasonable to disagree or to ask questions about particular choices (like those made by MSF) and those making the choices should reasonably be able to explain those choices. But the judge here has precisely the same set of challenges as the INGO: judging is an ethical exercise too and it is all too easy to forget that condemnation can be unreflective and quick. One would hope that INGOs (and individuals) have serious internal tension about how to be agents in these contexts. One might also hope that those outside of these institutions are similarly conscious of their own positions as judges when they use labels such as ‘moral complicity’ in these circumstances.