1. MATTERS OF INTERPRETATION:
ON THE ENDS & MEANS OF
HEALTH PROMOTION
David Buchanan
Arts & Humanities Research Council Connected
Communities Workshop
September 19-21, 2011, Cardiff, Wales

2. 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?

3. 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?

4. Outline of talk
I. Contrasting assumptions: naturalistic & humanistic
views on human nature
II. Health promotion goals, individual level
III. Health promotion methods, individual level
IV. Health Promotion goals, community level
V. Health promotion methods, community level

5. I. Contrasting assumptions
 Scientific approach to health promotion
 Based on the epistemological paradigm of naturalism

6. 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.

7. 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.

8. 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

9. 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.

10. 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.

11. 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.

12. Theory of Planned Behavior
Outcome
expectations
Attitudes
Outcome
evaluations Intentions Behavior
Perceived
normative belief
Norms Perceived
Importance of behavior
person
control

13. 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.

14. 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.

15. 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.”

16. 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?)

17. 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).

18. 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; Justify best course of action; clarify
establish facts values
Question of interest Search for causes: What are the Search for reasons: What is the best
causes of x? Does A cause X? course of action? Should one do X?
Raw Data Observations Reasons
Goal of analysis Explanation Justification
Warrants of validity Experiments, hypothesis-testing, Coherence, “wide reflective
levels of evidence equilibrium,” consensus

19. 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.”

20. 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.

21. 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.

22. 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.

23. 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

24. 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 Being
Human beings need five types of experiences of
experiences to enjoy well being:
 Autonomy
 Self-Understanding
 Accomplishment
 Enjoyment
 Deep interpersonal relationships

25. 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.

26. 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

27. 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.”

28. 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?

29. 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

30. 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)

31. 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?

32. 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

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

34. 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.

35. 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.

36. III. Means of health promotion, individual
level
 Dialogue
 Narrative
 Role of emotions
 Responsibility

37. Dialogue
 Model of feminist consciousness-raising group

38. 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 learn
from 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

39. 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

40. 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

41. 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?

42. 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.

43. 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.

44. 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.

45. 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

46. 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…. “

47. Role of emotions
 Anger  Hope
 Envy  Sadness-depression
 Jealousy  Gratitude
 Anxiety-fright  Compassion
 Guilt  Happiness-Joy
 Shame  Pride
 Relief  Love

48. 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.”

49. 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

50. IV. Ends of health promotion, Community
level
Values that matter
 Justice
 Solidarity
 Tolerance

51. 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

52. 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

53. 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.

54. 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.

55. 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.

56. V. Means of health promotion,
Community level
 Community-based participatory research
 The justice project
 Institutional practices

57. 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

58. 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.

59. 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.

60. 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

61. 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.

62. 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.