MATTERS OF INTERPRETATION: ON THE ENDS & MEANS OF HEALTH PROMOTION

David BuchananArts & Humanities Research Council Connected Communities WorkshopSeptember 19-21, 2011, Cardiff, Wales

Key questions

How should we think about improving the health of communities, or individual health? How should we think about changing people’s (unhealthy lifestyle) behaviors? Is it a scientific problem, the validity of which is to be assessed on the basis of effectiveness in producing behavior change? Or a moral and political problem, the validity of which should be assessed on the degree of moral consensus?

Does it matter which framework we apply?

Key questions

What should the goals of health promotion & education be? How should they be determined?

What methods should we use to achieve these goals?

Outline of talk

I. Contrasting assumptions: naturalistic & humanistic views on human nature

II. Health promotion goals, individual levelIII. Health promotion methods, individual levelIV. Health Promotion goals, community levelV. Health promotion methods, community level

I. Contrasting assumptions

Scientific approach to health promotion Based on the epistemological paradigm of naturalism

Assumptions of naturalism

Current research and practice in health promotion are based on the assumption that there is no essential difference between human nature and the laws of physics that govern cause-and-effect relationships in the natural world. Under the assumptions of the epistemological paradigm of naturalism, human behavior is determined by discrete independent antecedent factors.

Therefore, just as we can accurately predict the effects of the pull of gravity, and so design a rocket ship that can fly to the moon, so we can identify the forces that drive human behavior, and so develop interventions to modify them, to produce different outcomes, for example, reductions in cigarette smoking, or levels of obesity.

Assumptions of naturalism

Importantly, in this paradigm, the level of confidence that one has in truth claims is directly proportional to the rigor of the research design. Thus, the validity of claims about what might be the cause of behavior can be definitively determined to be true only by testing hypotheses, of the “If-then” form, by demonstration and proof in experimental research designs.

Scientific method

In this approach, researchers use the exact same research design that is used to test the efficacy of new AIDS medications, or hypertension or anti-cancer drugs

Identify problem State hypothesis Recruit sample population Randomization Baseline measures Run new treatment & comparison interventions Compare outcomes Draw conclusions

Hierarchy of knowledge

Evidence based medicine: The degree of confidence in validity of results is increased by eliminating various threats to the validity

Randomized Controlled Trials Quasi-Experimental Research Designs Prospective Cohort Studies Cross-sectional Studies Retrospective Case-Control Studies Case Series & Registries Case Studies

- Evidence-Based Working Group. Evidenced-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA,268(17):2420-2425, 1992.

Byproduct of scientific method

Whether by intent or not, the results of experiments give researchers the power to control and change the outcomes of the experiment. For example, according to the ideal gas law (PV=nRT), one

knows exactly how much the pressure will rise for every degree of temperature that a closed container is heated. One can predict and control the pressure however one wishes by raising or lowering the temperature.

In the case of health promotion research, the outcome of interest is human behavior.

Applied science of health promotion

Theory of Planned Behavior; see diagram next page In the scientific model, one designs interventions that will

change the independent variables in order to change the dependent variable under investigation, i.e., a given unhealthy behavior (e.g., smoking, overeating, low physical activity).

In the TPB, researcher test interventions to determine the results, e.g., if the intervention changes one’s attitudes or norms, then will it change their intentions and behaviors?

Proven interventions must be replicated with fidelity.

Theory of Planned Behavior

Attitudes

Norms

Intentions Behavior

Perceived behavior control

Outcome expectations

Outcome evaluations

Perceived normative belief

Importance of person

Community level

At the community level, the goals of health promotion are generally set by a utilitarian logic.

What are the leading causes of mortality? (Answer: heart disease, cancer, strokes)

What are the leading risk factors for heart disease? (Answer: smoking & obesity)

Therefore, the number one priority in health promotion is to reduce smoking, and obesity, through the most effective (and efficient) means possible, as determined by the results of scientific experiments.

Critique of scientific approach to health promotion

Following Max Weber, the Canadian philosopher, Charles Taylor sees the application of the scientific method to predict and control human behavior as another instance of the modern phenomenon of the rise of instrumental reason.

The German philosopher Jurgen Habermas expresses similar concern about the “colonization of the life world,” in which the aim of strategically manipulating people to do what you want them to do takes precedent over reaching common agreement about the best course of action.

Rise of instrumental reason

According to Taylor, the rise of “instrumental reason” is a “massively important phenomenon” underlying the perplexing sense of loss, malaise, and disintegration widely felt in modern culture. IR is the intellectual tendency to give precedence to thinking about means, rather than ends. Coined by Max Weber, the term “instrumental reason” refers to a pattern of thinking dedicated to the methodical expansion of human control and domination “by means of an increasingly precise calculation of adequate means.” Weber used the term to characterize the modern preoccupation with determining the most effective means to a given end, to the neglect of the evaluation of the ends themselves, a turn of events that he referred to as the “iron cage of modernity.” As Selznick states, “Reason is instrumental when it abdicates responsibility for determining ends and restricts itself to ways and means.”

Summary

My concern about the scientific approach to health promotion is that it reinforces the rise of instrumental reason, and in particular, how we think about our relation to our fellow community members, whether it is to figure out the most effective way to get them to lose 3-4 kilos, or whether it is to reach agreement about the kind of society we want to live in together. (Is a community in which no one has a BMI over 25 the most desirable state we can imagine, the goal most worth striving for?)

An alternative humanistic approach

There are many ways in which scientific and humanistic approaches to thinking about the human condition can be contrasted. (See chart next page.)

The most critical, essential difference turns on the question of free will, whether one assumes that human beings have the capacity to choose (or whether it is determined by discrete antecedent independent causal variables).

Chart of differences

Characteristic Scientific Humanistic

Central paradigmatic concern Is this true? Is this good?

Type of analysis Empirical Normative

Research objective Explain causes of phenomena; establish facts

Justify best course of action; clarify values

Question of interest Search for causes: What are the causes of x? Does A cause X?

Search for reasons: What is the best course of action? Should one do X?

Raw Data Observations Reasons

Goal of analysis Explanation Justification

Warrants of validity Experiments, hypothesis-testing, levels of evidence

Coherence, “wide reflective equilibrium,” consensus

On the question of free will

The question of free will is considered an open question by philosophers.

According to the American phil;osopher John Searle: “Our self-conception derives in part from our cultural inheritance, but mostly it derives from our own experience. We have a conception of ourselves as conscious, intentionalistic, rational, social, institutional, political speech-act performing, ethical and free will possessing agents. Now the questions is, How can we square this conception of ourselves as mindful, meaning-creating, free rational, etc. agents with a universe that consists entirely of mindless, un-free, non-rational, brute physical particles? . . . I see this family of questions as setting the agenda for the subject of philosophy for the foreseeable future.”

My position

The scientific model is powerfully (almost overwhelmingly) appealing because it is so effective in controlling forces in the natural world, for example, in the development of new drugs to control hypertension. For this, I am eternally grateful.

However, the scientific method is limited by the types of questions is can answer, only those of the “If-then” form.

It can tell us nothing about the meaning of different values by which humans choose to live their lives. What is the nature of the good society? The scientific method is mute.

Hence , we need a humanistic approach to understand the meaning, morality and motivation of human action.

My position

If it is an open question whether human beings have free will, then what would health promotion look like if we based it on humanistic assumptions?

It would require us to examine the ends and means of health promotion – and the relationship between ends and means –carefully.

II. Ends of health promotion, Individual level

Instead of uncritically accepting that the reduction of heart disease (and hence, smoking) is the most important goal for health promotion, we need to ask whether improvements in physical health indicators trump other potential values, such as the value of human well-being.

Developing compelling visions of human well-being is essentially and inextricably a humanistic research project.

Implications for Research

Instead of developing theories from which one can derive hypotheses, an alternative (humanistic) approach to developing theory might look as follows: “The point of developing theory is to outline and

define life situations so that people may have a clearer understanding of their world through meaningful clarification of basic social values, modes of living and social relations.”

- Herbert Blumer, 1970

Theories about the ends of health promotion at the individual level

Humanistic theories of human well-being Hedonistic, preference satisfaction, and objective

James Griffin’s objective account in his Well BeingHuman beings need five types of experiences of experiences to enjoy well being:

Autonomy Self-Understanding Accomplishment Enjoyment Deep interpersonal relationships

The ends of health promotion, Individual level

Please let me re-iterate that these issues are always matters of interpretation, about which we try to put forward the most compelling account that we can muster, recognizing that is will always be fallible, but the goodness of which can be seen in the degree to which others are inspired by the case we have made.

Only a humanistic approach to health promotion can tell us what it means to love a good life.

Individual well being

“Autonomy is conceived of a second order capacity of persons to reflect critically upon their first order preferences, desires, and wishes, and the capacity to accept or to attempt to change these in light of higher order preferences and values. By exercising such a capacity, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are.”

- Gerald Dworkin, 1988

Autonomy

In Taylor’s account, “It seems to be peculiarly characteristic of humans, however, that they are able to form . . . second-order desires. . . Our desires are classified in such categories as higher and lower, virtuous and vicious, more or less fulfilling, more or less refined, profound and superficial, noble and base.”

Research implications

What are the higher values by which we might judge our immediate felt desires to be beneath us, as not exemplifying the kind of person we are striving to become? Why shouldn’t I have another piece of cake? Why shouldn’t I sleep with my neighbor’s wife?

On what grounds do we choose to act, or not to act, on felt desires?

Implications for practice

Therefore, to promote health, the task before the field is to promote practices that enable people to excel in evaluating their desires. The good life is the life spent seeking clearer understandings of values we think important to realize and striving to live our lives more closely attuned to those values. The end of health promotion is, accordingly, the life of integrity.

“To have integrity is to be unmarred by distortion, deception, or other forms of disharmony and inauthenticity.” – Phillip Selznick

Challenges

Articulating meaningful values that can reasonably be defended is perhaps the greatest challenge of modernity.

Since Nietzsche decried the death of god, the project of identifying and defining values that matter constantly threatens to collapse into a state of nihilism, as recently described by a British political pundit (see next page)

Value of autonomy

Although I want to resist thinking about autonomy in instrumental terms, there is tremendous empirical evidence that the more people experience autonomy, the better their (physical) health.

What is autonomy? Is this a value that we want to promote?

The threat of nihilism, nothing matters

“Social problems that have been festering for decades have exploded in our face. Irresponsibility. Selfishness. Behaving as if your choices have no consequences. Children without fathers. Schools without discipline. Reward without effort. Crime without punishment. Rights without responsibilities. Communities without control. Some of the worst aspects of human nature tolerated, indulged, sometimes even incentivized, by a state and its agencies that in parts have become literally de-moralized.”

- David Cameron, Prime Minister

Self-understanding

The second experience that human beings must have to enjoy a sense of well-being is self-understanding.

Implications for research

How can we assist people in gaining a deeper self-understanding of the motives behind their actions?

How can we help people (and ourselves) creatively articulate the kind of person they want to become? In contrast to scientific assumptions (where behavior is seen

to be determined by past events), a humanistic approach sees that people can imagine different futures and seek to realize them.

Accomplishment

A third experience that human beings must have to enjoy a sense of well-being is a sense of accomplishment.

The opportunities that are open to individuals to achieve meaningful accomplishments is closely tied to our understanding of the nature of the just society.

Amartya Sen and Martha Nussbaum have attempted to enumerate the kinds of capabilities that people should be able to exercise to have lived a life worth living.

III. Means of health promotion, individual level

Dialogue Narrative Role of emotions Responsibility

Dialogue

Model of feminist consciousness-raising group

Dialogue

“Like most of the elemental notions -- justice, integrity -- that guide our moral life, we do not have a sharply discriminating, operational definition ready at hand. Rather, we proceed by mutually intelligible intimations, affirming this, denying that, each claim suggesting an aspect of the whole that we vaguely discern but cannot readily grasp. . . This is what makes reasoned argument possible. We persist in trying to persuade our antagonists that there is some crucial element of the matter at hand that their case neglects, and we proceed in the good faith that, if we show them this perceptively, if we illuminate them, they may change their minds. And for our part, we presume that we may learnfrom the deliberation, which is to say, we keep open, and positively, the prospect that the case we are now earnestly making we will come to recognize as inadequate, because we will see a more significant, a larger truth in the matter. “

- Anderson, Prescribing the Life of the Mind 1993

Implications for practice

“The purpose . . . is not to produce or control anything but to discover through mutual discussion and reflection between free citizens the most appropriate ways, under present conditions, of living the ethically good life. . . It is precisely the point about praxis [social practice] that it has no extraneous product. It has an end, namely, the good of human beings, but that end is attained through itself, that is, through action or practice that is ethical and political. . . For ‘helping professionals’, this would involve toleration of high levels of uncertainty in trying to aid people to improve their own skills of practical autonomy, rather than categorizing them in terms of preconceived theories with resulting automatic formulas for treatment.”

- Robert Bellah, “Social Science as Practical Reason,” 1983

Implications for practice

“The aim of physician-patient interaction is to help the patient determine and choose the best health-related values that can be realized in the clinical situation. To this end, the physician must delineate information on the patient’s clinical situation and then help elucidate the types of values embodied in the available options. The physician’s objectives include suggesting why certain health-related values are more worthy and should be aspired to. The physician aims at no more than moral suasion; ultimately coercion is avoided and the patient must define his or her life and select the ordering of values to be espoused.”

-Emanuel & Emanuel, Models of doctor patient interaction. 1992

Challenges

Can we reach reasoned agreement through dialogue?

When is a reason a good reason? What reasons count and how much weight should they be given?

On Narratives

Narrative refers to a particular type of discourse form -- namely, a story -- in which events and happenings are configured into a temporal unity by means of a plot. Narratives give us explanatory knowledge about why a person acted as s/he did; it makes another’s action understandable. The function of narrative analysis is to answer how and why a particular outcome came about.

On Narratives

Stories are concerned with human attempts to progress to a solution, or clarification of a situation. A story has a beginning, middle, and end. It relates the events in an individual situation in an ordered transformation from an initial situation to a terminal situation. It is more than a mere chronicle of events. A story retains the complexity of the situation in which an action is undertaken and the emotional and motivational meaning connected with it. The data describe when events occurred and the effect the events had on subsequent happenings. They include reference to when and why actions were undertaken and the intended results of the actions.

On Narratives

A plot is the narrative structure through which people understand and describe the relationship among the events and choices of their lives. When events are arranged in a plot, they are understood from the perspective of their contribution and influence on the specified outcome. Plots function to configure events into a story by: 1) delimiting the temporal range that marks the beginning and end of story, 2) providing criteria for the selection of events to be included in the story, 3) temporally ordering events into an unfolding movement culminating in a conclusions, and 4) clarifying or making explicit the meaning events have as contributors to the story as a unified whole. A plot relates events by causally linking a prior choice or happening to a later effect. Prototypical plots are comedies and tragedies.

Challenges

“Life now is completely different than the way it was then. Does your life approach anything like a linear narrative? Life seems to strobe on and off for me, and to barrage me with input. And that so much of my job is to impose some sort of order, or make some sort of sense of it. In a way that—maybe I’m very naive—I imagine Leo [Tolstoy] getting up in the morning, pulling on his homemade boots, going out to chat with the serfs whom he’s freed, you know. Sitting down in his silent room, overlooking some very well-tended gardens, pulling out his quill and…in deep tranquility, recollecting emotion. And I don’t know about you. I just—stuff that’s like that, I enjoy reading, but it doesn’t feel true at all. I read it as a relief from what’s true. I read it as a relief from the fact that, I received five hundred thousand discrete bits of information today, of which maybe twenty-five are important. And how am I going to sort those out, you know?”

- David Foster Wallace

Challenges

But as Wallace goes on . . .

“And yet I think our brain is structured to make linear narratives, to condense and focus and separate what’s important. Human beings are narrative animals: every culture countenances itself as culture via a story; every whole person understands his lifetime as an organized, recountable series of events and changes with at least a beginning and middle. We need narrative like we need space-time; it’s a built-in thing…. “

Role of emotions

Anger Envy Jealousy Anxiety-fright Guilt Shame Relief

Hope Sadness-depression Gratitude Compassion Happiness-Joy Pride Love

On responsibility

The philosopher Herbert Fingarette identifies two elements in the development of a sense of responsibility: “One is that of acceptance, of commitment, care, and concern, and of attendant elements of choice and the creativity of choice; the other dimension is that of the ‘forms of life,’ initially socially given and ultimately socially realized, which constitute the form and content of responsibility. Responsibility emerges where the individual accepts as a matter of personal concern something which society offers to his concern.”

Humanistic evaluation criteria at individual level

Humanistic criteria: The degree to which an individual has:

An awareness of alternative courses of action An ability to enumerate the advantages and disadvantages

of the major alternatives Greater self-understanding of one’s reasons for choosing

one course of action over another Greater satisfaction with one’s decision Greater reassurance that one’s decision better advances

one’s own life projects

IV. Ends of health promotion, Community level

Values that matter Justice Solidarity Tolerance

Justice

Tremendous interest in “social justice” in the field today, but . . .

“It is noteworthy that none of the most prominent contemporary versions of philosophical liberalism assigns a significant role to desert [agency] at the level of fundamental principle.”

- Samuel Scheffler, Responsibility and Liberalism in Philosophy and Politics, 1992

Challenges

Justice: at least six major theories of justice are available and commonly used in public discourse, however implicitly or unknowingly. Egalitarian Utilitarian Desert/merit Libertarian Capabilities Luck egalitarianism

Solidarity

Solidarity is bearing witness for the welfare of others. It is embodied in social practices that strengthen people’s dignity and autonomy. It is not a sentimental psychological attitude but based on moral commitments. It is not a feeling of vague compassion or shallow distress at the misfortunes of so many people in which one sees those in need primarily as victims. Solidarity involves a profound sense of moral responsibility, a determination to commit oneself to the good of all and of each individual because we are really responsible for all. Through solidarity, we see the ‘other’ not just as some kind of instrument but as our ‘neighbor’, a ‘helper’ to be made a sharer on par with ourselves of social and economic resources. Solidarity is the social practice of accepting responsibility for the well-being of fellow community members.

Challenges

Collapse of civil society, a la Putnam’s Bowling Alone, where the withdrawal into the private sphere is making us more calloused towards the needs of our neighbors and the common good.

Tolerance

We live in a pluralistic society, in which we recognize and respect that different groups hold different visions of the good life for human beings, and it is these differences that enriches our lives.

V. Means of health promotion, Community level

Community-based participatory research The justice project Institutional practices

Community-based participatory research

Misunderstandings about rationale for the use of CBPR Tacit acknowledgement of the ineffectiveness of

scientific approach

CBPR is a method of research that recognizes the rights of communities to determine the goals that they see valuable and the means for achieving them

Justice project

To improve the health and well-being of the population, contrary to the US Surgeon General’s recommendation of spending 30-45 minutes each day in vigorous exercise, I recommend that we spend 30-45 minutes each day discussing the kind of society that we want to create and we live in together.

Institutional practices

Most people most of the time do not reflect on and make conscious rational choices about quotidian ways of life. It is important to think about ways institutions can be

reformed to habituate people into practices (or to inculcate virtues) that do not burden individuals with the need to make thousands of choices every day about whether something is good for them or not.

Humanistic evaluation criteria

At the community level Degree to which community provides input and exercises

control over research and community programs Degree to which community members feel their advice and

suggestions are respected Degree to which participants feel their concerns have been

addressed Trust in researchers & Satisfaction with process

Conclusion

In a humanistic approach to health promotion, the goal of health promotion is to assist people in figuring out values that matter and the best ways of living in accordance with those values.

Telling people how they should live are ultimately moral and political concerns, and not a scientific problem to be solved.

Afterword

Global justice: The “bottom billion” – one in five human beings – lives on less than 50p per day (parity purchasing power). In the words of Stuart Hampshire, I look forward to the day when the toleration of poverty is seen to be the barbaric practice that it is today.