Health Education Research, Vol. 17, No. 1, 134-138,
February 2002
© 2002 Oxford University Press
BOOK REVIEW |
An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being
Professor David Buchanan Oxford University Press, New York, 2000 232 pp. ISBN 019 513057X (hb)
1 Wake Forest University School of Medicine
2 University of Pittsburgh School of Nursing
In An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being, Professor David Buchanan provides readers with a far-reaching, highly stimulating philosophical critique of our approach to addressing public health problems. This is not a book to read quickly. Rather, it raises many deep questions about commonly employed public health strategies and tactics, and thus is best read slowly, deliberately and with an open mind. Throughout the book, we found ourselves pondering single sentences for several minutes (and occasionally for several hours). Kudos to Buchanan for writing a book that stops you in your tracks. Even if you disagree with his perspective, you can't dismiss the insightful analysis and thought-provoking theses that leap from nearly every page. Buchanan does not shy away from attacking the philosophical pillars of public health. Here's an example of his unabashed perspective:
Thinking in the field of health promotion is currently framed by the scientific terminology of morbidity and mortality rates, risk factors, randomized control trials, independent and dependent variables, null hypotheses, cost–benefit analyses, and effective behavior change techniques. This book recommends a new direction marked by the concepts of well-being, integrity, virtues, autonomy, responsibility, civility, caring, and solidarity. (p. 3)
While the field of health promotion and health education has increasingly embraced theories of empowerment, social learning and behavior analysis, Buchanan challenges the usefulness of paradigms such as these that include power, mastery and control as key underlying constructs. In critiquing empowerment theory, for example, Buchanan asks:
Why has empowerment assumed such prominence in the field these days? Of all the different candidates that could possibly be contemplated, why has the interest in power become so predominant? Why not caring, or compassion, or dignity, or love, morality, respect, harmony, responsibility, or some other significant human aspiration? Why has the pursuit of power captured so much attention? (p. 81)
While health education has focused much attention on the science of changing unhealthy behavior, Buchanan suggests that `the scientific method undermines the most fundamental understanding of ethical human relationships' (p. 4). He argues that health promotion should focus substantially more attention on the validity of values, the visions of a good life and the ideals that drive the way that we live. At the book's essence is the notion that the effectiveness of scientific and technological interventions is compromised by the lack of attention to the political and moral context in which science and technology exists. He's not the first to raise such criticism. In fact, some proponents of empowerment theory (a theory Buchanan criticizes) write about how empowerment can be used to promote social, political and structural change. In an aptly titled first chapter, `Disquietudes', Buchanan attacks mainstream public health with intellectual spears that are sharp and unrelenting. We believe that some of these spears are on target, while others miss the mark.
Our dependence on the scientific method, Buchanan asserts, comes from our dependence on instrumental reason, which is defined as `the kind of rationality we draw on when we calculate the most economical applications of a means to a given end' (p. 10). In contrast, Buchanan argues for practical reason, defined as `centrally concerned with clarifying goals and deciding which goals are most worthwhile' (p. 88). From his perspective, the field's emphasis on instrumental means (rather than on reflection about the end result of actions), combined with the emergence of the empirical experimental sciences, has resulted in a problem-solving paradigm that is problematic on a number of fronts. Buchanan suggests that this approach to problem solving was effective when the primary public health concern was communicable disease. However, he posits that this paradigm is not particularly effective in dealing with people's behavior, which is the primary source of many contemporary health problems: `My contention is that scientific knowledge offers little help for health promotion specialists to do their jobs well. On the contrary, almost all their actions require the exercise of practical reason' (pp. 93–94). His criticism has broad implications for how we approach modern systems such as managed care:
...the field of health promotion is becoming further caught up in a system of thought, a way of looking at the world, that stresses a calculative and instrumental stance toward others. The rise of managed care presses toward developing more effective and more powerful techniques in the way people live, with few and precarious safeguards restraining their application. (p. 44)
He suggests further that an ethical pitfall of our current approach is `in terms of trying to figure out how to get others to do what we want them to do, rather than in terms of trying to reach common understandings about the good life for human beings' (p. 62). Continuing a few pages later, `...the presumption is that we know what is in people's best interests better than they do themselves' (p. 69). In discussing the different implications of instrumental versus practical reasoning, Buchanan raises questions that cause one to pause and reflect and for which he notes that there is no correct answer. What is well-being? How does one square biological fitness with social well-being? What are the values that should guide our lives? What are the individual and societal costs of encouraging people to comply with health provider recommendations? What impact do our interventions have on individual autonomy, dignity and personal responsibility? He also issues well-conceived calls for revising the curricula of our training programs so as to expose students to ethical decision making, moral reasoning, philosophy, justice and politics.
At times, Buchanan falls into the trap of throwing the baby out with the bathwater. Behavioral theory is alleged to have little explanatory power. In a statement that he admits is heretical, he writes:
I do not think that lowering heart disease rates is the most important goal of health promotion. On the contrary, I think most people are drawn to the field because they want to be part of forging social and political conditions in which we all can live together decently. Nonsmoking, a strict diet, and regular exercise are really rather trivial parts of any broad understanding of social well being, but that is where all of the field's resources are now directed. (pp. 14–15)
Although it is hard to object to the importance of social well-being and the promotion of positive social and political conditions, try telling one of the nearly 61 million Americans with active cardiovascular disease (CVD) or one of the nearly 1 million Americans who die each year from CVD that reducing CVD risk factors should not be a primary focus of public health. We suspect that few people dying of heart disease want to hear us talk about the social and political conditions that contributed to their ill health. Rather, they want to know what medicines they can take, what behaviors they can engage in and what cognitive/spiritual directions they can adopt to increase their quality of life. Likewise, try telling researchers and practitioners in the tobacco control movement, many of whom are trained in health education and promotion, that their efforts to change the landscape of tobacco prevention and control through environmental/advocacy work is not forging new social and political conditions.
Buchanan suggests that individuals who engage in what we deem unhealthy behaviors (e.g. smoking, eating a high fat diet, failing to exercise, etc.) do so because they do not share the same values as public health professionals. Second, he worries that our efforts to modify risk factors will seriously threaten individual autonomy, dignity and social responsibility. Third, he wants the field to focus attention on values (e.g. which ones are important to us and why). Buchanan believes that our health goals will only be met when moral, ethical and political factors are front and center. We agree that clarifying and pursuing values would help advance the field. However, the argument carries less weight when presented as a dichotomous choice: risk factor modification versus tackling ethical and political questions. The problems are large enough and the field big enough to employ multiple perspectives. We agree that instrumental reasoning is more commonly embraced than practical reasoning, and that a more balanced allocation of resources and effort would yield important dividends. Let's be careful, however, not to promise a panacea. Frankly, it's uncertain whether, at the end of the day, practical reasoning will move our field forward, improve health (however health is defined), and clarify political and ethical dilemmas.
Throwing the baby out with the bathwater is also evident in Buchanan's selective review of the effectiveness of health education interventions: `...it is simply an indisputable fact that studies of behavioral health problems have not been able to produce results even remotely comparable to those found in biomedical research' (p. 8). One wonders what biomedical literature Buchanan reads. Certainly it's not the Institute of Medicine report estimating that between 44 000 and 98 000 deaths are caused each year by medical errors (ironically, Chapter 4 of the book is titled, `Iatrogenesis in health promotion', and presents the case that social learning, social marketing and empowerment theories promote harmful ideology). It can't be the literature on the thousands of deaths among individuals participating in clinical trials, and it probably isn't the large literature documenting failed or largely ineffective surgical and medical interventions. On the other side of the coin, while there is no question that behavioral health interventions could be more effective, to conclude that these interventions are ineffective is hyperbole.
Buchanan also criticizes current population-based health promotion efforts by the fact that they require manipulation of the behavior of others. This action, says Buchanan, violates the personal autonomy of the recipients of these actions, by removing their individual choice. He claims that the focus on involuntary participation has much potential for coercion. Buchanan also raises the concern of the potential for misuse of the behavioral sciences by managed care—to identify and target those with undesirable behaviors likely to result in excessive health care expenditures. However, the reader needs to keep in mind that protecting individual autonomy is not the only good worth striving for. Protecting personal decision-making autonomy may actually be harmful if we unquestionably honor people's preferences. And although we should certainly be careful that information about behavior not be used to exclude people from health insurance coverage, striving for distributive justice often requires limits on personal choice. It does not seem unreasonable for an HMO provider to try to change a behavior (e.g. smoking) that has costly health consequences. Although Buchanan presents his thesis as an `ethic' for health promotion, he fails to consider the fact that many (maybe most) public policies require a balancing act in which we have to determine how much autonomy we are willing to trade in order to achieve fairness or better health for our citizens. While we agree with Buchanan that `Science cannot tell us which goals are more worthwhile than others, which ways of living more valuable. It cannot tell us how we should live' (p. 168), we also believe that science can help seed dialogue about these issues.
Buchanan criticizes the instrumental approach as being tied into economic thinking. He states that health promotion is not being done because it is a good and right thing to do, but because it is cost-effective. Economics seems to have become a dirty word in health care, especially now as politicians and newspapers take swipes at managed care, as Congress takes on the challenge of creating a Patient's Bill of Rights. We need to come to grips with the fact that our seemingly infinite demand for health care services cannot be met with the limited resources that are available to us. We also need to face the fact that access to health care is not fair and that some effort needs to be made to re-distribute resources in a more equitable manner. Cost-effectiveness analysis is not just a technique for determining the cheapest way to provide health care. Rather, it is a technique for showing us how to maximize the benefits to patients, given the resources that are currently available. The promise of economic analysis is that it can help us identify inefficient resource use, and permit us to redistribute those resources in a more efficient and more equitable manner. Buchanan might respond that economic analysis is of limited value to a society that has not clearly articulated what it values or how such resources should be distributed. We would agree with this observation. The fact that 43 million Americans have limited access to health care due to lack of insurance is a national shame. That the US spends more on health care than any developed country, but ranks quite low on many measures of public health demonstrates a need to rethink our approach to health. Policies regarding resource allocation would be enriched by efforts to develop consensus regarding these and other issues. However, this does not preclude economic analysis from being used to help us choose between competing demands. As long as health care must be paid for and health care resources are limited, economic considerations must be addressed.
Finally, Buchanan's thesis mirrors the meta-ethical debate of deontologism versus teleologism. According to the deontologic perspective, we should evaluate the ethical validity of an act in terms of the nature of the act itself. (Was the act itself something that we would consider to be ethically justifiable?) The teleological perspective, on the other hand, claims that we should evaluate the ethical validity of acts in terms of their consequences. (An act can be justified based upon the good that it produces.) Buchanan's practical reasoning approach is deontologic by nature, in that it stresses the importance of means rather than ends in promoting health. He points to the importance of such principles as justice, caring, civility, trust and responsibility in our attempts to promote individual and community well-being. Although he does not deny the importance of outcomes, he criticizes the instrumental reasoning (teleological) approach as focusing too much on the achievement of established health goals, cost-effectiveness concerns and the use of means that discourage the application of these deontologic principles. The reader can identify deontologic–teleologic debates in just about any clinical ethics case book. Consider the current controversy regarding cloning technology—the key ethical dilemma being whether the tremendous potential of the technology justifies the necessary destruction of human embryos. In health promotion, as in most clinical ethics cases, it is evident that both perspectives must be considered. Otherwise, we can do the right thing and end-up with terrible consequences or we can trample what we value in our attempt to achieve good ends.
As evidenced by our comments, we found Buchanan's analysis to be highly engaging, educational and thought provoking. This book would be a valuable addition to the bookshelves of researchers, practitioners and students alike. Indeed, the book should be required reading for all graduate students in health education/health promotion. While we take exception to some of Buchanan's conclusions and the occasional selective review of the literature, there is no question that this is one of the more important health promotion books published in recent memory.
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