TCS Daily

Health Uber Alles?

By John Luik - August 19, 2005 12:00 AM

The World Health Organization (WHO) has always had a rather expansive notion of what it means to be healthy. If one looks at the official definition it defines health as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." According to that understanding there isn't much that is not in some way connected with health. And for the health promoters at WHO's recently completed Bangkok conference that means that health is the supremely important value that trumps everything else.

After all, the health promoters argue, it is surely obvious that health is a necessary condition for any sort of life, so it must follow that for any truly rational person health must outweigh any other value that might conflict with it. But the "obvious" -- especially the obvious of the health promoter -- is often likely to be untrue. While it may be true that being alive is in some not very interesting sense necessary for having a life, it is not at all true that being "healthy," especially as defined by WHO, is a necessary condition for having a good life.

All of us make trade-offs between optimal health and other values all of the time. We travel by car for instance, for reasons of economy or convenience, even though we might recognize that statistically planes are safer. We smile at Alan Dershowitz's cardiac calculus where a patient chooses between ten years of inactive life and the risk of sudden death:

        "My doctor has made a prognosis/That intercourse fosters thrombosis/
        But I'd rather expire/Fulfilling desire/Then abstain, and develop neurosis."

We don't label immoral someone like Balzac whose excessive coffee-drinking was debilitating but necessary to his art. And what of those who risk their health for some person or cause? We surely don't wish to call them immoral. As the moral theorist Joel Feinberg observes:

        "Hangovers are painful and set back one's efforts, but careful niggling 
        prudence is dull and unappealing. Better the life of spontaneity, impulse, 
        excitement and risk, even if it be short, and even if the future self must bear 
        the costs. We all know that there are people who have such attitudes 
        and have them authentically."

This doesn't mean that health is not an important or even a central aspect of a good life, but rather that health is not the undisputedly cardinal value and individuals who do not measure up to the health promoter's frighteningly expansive definition of healthy might still lead rich and personally satisfying lives.

The problem with health promotion then is that it refuses to accept that there is a place for lives of purpose, meaning and satisfaction, good lives and civically responsible lives, outside of its notion of healthy. For instance, though the Bangkok conference and WHO are awash with references to the values of health promotion, there is very little attention given to the value of individual autonomy. And this is not an oversight, for health promotion is at bottom a fundamental menace not just to the unhealthy of the developing world and to science, but also to personal choice. This is because health promotion has always recognized that the lifestyle changes that it advocates as necessary for longer lives will not be voluntarily embraced. As Daniel Callahan of the Hastings Center noted in his book False Hopes:

        "...[A] sustainable medicine will require an effective continuum of programs of 
        public health, health promotion, and disease prevention, a continuum 
        ranging from education at one end of the spectrum, economic and other 
        incentives in the middle, and some frankly coercive policies at the other 
        end... Coercive programs will be necessary..."

And how are such "coercive programs" of health promotion justified? Or, more crucially, how are they justified in free and democratic societies? Cuba, for instance, is often cited as a model of health promotion, which is perhaps more revealing of the nature of health promotion than anyone at Bangkok would care to admit. One way is through the use of its extraordinarily broad definition of health, a definition that is truly totalitarian in that it seeks to bring not only all of an individual's but all of a society's behaviour and thoughts within its purview. If being healthy is read not in its traditional sense of being free from disease but instead as a "state of complete physical, mental and social well-being" than it is possible to bring quite literally everything -- beliefs, habits, character, pleasures, lifestyle -- under the power of health promotion. In effect, health promotion offers a definition of being human where human is seen primarily and almost exclusively through the perspective of health. Where traditional medicine was interested primarily in curing illness so that individuals could live their lives, health promotion seeks to use its idea of health to define and shape individual lives. Medicine for the health promoter is no longer the servant of autonomous persons, but their shaper and in some sense their master. It is difficult to find a space for a life of one's own within such a suffocatingly broad notion of health.

And in just what does such coercion consist? It consists primarily in the state collectivizing risk, so that an individual's judgements about those trade-offs between health and other values are replaced by those of the state. In effect it is the government assuming the function, under the guise of promoting healthy living, of deciding what are acceptable and unacceptable risks. This is not some minor encroachment on individual autonomy, but a full-scale assault, under the guise of health, on an individual's capacity to define his life. Our choices about risk for instance, are a major component of what we mean when we talk about having a life of one's own. Because virtually everything that we do entails risk, the idea of risk provides at least one dimension against which we can plot what we mean by a good life. Chocolate yes, smoking no, hang gliding no, travel by car yes, working in a high rise yes -- such small personal decisions about risk come together in a personal and personally chosen pattern that is uniquely mine and are at the center of what we mean when we talk about my idea of right living.

But the health promoter, as the ultimate social engineer, sees this messy individuality as a threat to healthy living. These individual choices about risk, these tradeoffs in which pleasure is often chosen in preference to health, are unacceptable. At the end of the day, Bob's values, tastes, beliefs, and decisions about risk and pleasure are less legitimate than the health promoter's grand vision of what a healthy society should be like and Bob needs the state's help to both realize this and change. Though it is ostensibly Bob's body that the health promoter is after, in reality it is his soul. Whereas in the past the state had no hesitation in enforcing religious beliefs, it is now similarly unashamed of enforcing the new religion of health. Rather than allowing individuals to make their own decisions about the place of health in their lives, the health promoter wishes those decisions to be made by a health establishment and bureaucracy that frequently misrepresents scientific findings, issues health advice that is purely arbitrary and often wrong and proposes solutions that are without intellectual, moral or practical rigor.

All of these menacing aspects of health promotion -- its menace to the world's poorest, its menace to science and its menace to individual liberty -- come together in one of the centerpieces of the Bangkok conference -- the WHO Global Strategy on Diet, Physical Activity and Health. Already the health promoters, fresh from their work on the Global Tobacco Treaty, are talking about setting in motion a similar treaty to deal with what is increasingly called Big Food. Never mind that the science suggests both that being overweight or even moderately obese do not shorten life and that interventions around diet to prevent chronic diseases do not generally work. Never mind that malnutrition -- not obesity -- has a role in 50% of all childhood deaths in the developing world. Never mind that what people eat or don't eat is widely recognized as a personal, not a state decision. WHO's health promoters intend to use the "obesity epidemic" as a way to define what counts as good food and bad food, healthy food and unhealthy food, what food can and cannot be marketed and advertised, what food will be subject to sin taxes, what food will be controlled, what food will be denormalized.

In one sense, none of this should be surprising. The seemingly exclusive preoccupation with the values of health and longevity over the last decades of the 20th century appears to have deadened us to the fact that there are other values that are equally, perhaps more important to a full and good life. So taken are we with the religion of health that we seem prepared to defer to any regimen, surrender virtually any pleasure and compromise any liberty so long as it gains us a deferral of death. For instance, the proposal to impose a "sin tax" on certain books, plays, ideas, or associations in order to change people's behaviour and improve their mental "health" would not survive a moment of serious consideration. Yet the same proposal applied to something like food and advanced by the health promoter appears to be uncontroversial precisely because it is "only" about health.

For all its menace to the world's poor and sick, and to science, health promotion's worst threat is to autonomy and to democracy. At the end of the day the Bangkok vision of health promotion presumes a nursery world full not of rational and self-governing individuals, but of docile infants too uncertain of their own values and how best to realize them to be left to make their own way in the world. As de Tocqueville noted of such a state enterprise:

        "It gladly works for their happiness but wants to be sole agent and judge 
        of it. It provides security, foresees and supplies their necessities, facilitates 
        their pleasures, mangers their principal concerns.... Why should it not entirely 
        relieve them from the trouble of thinking and all the care of living?"

The great rebuke of democracy to health promotion and its great compliment to human dignity is that through it we entrust to ourselves, not a health bureaucracy or a government, however well intentioned, the task of making, for better or for worse, ourselves. And that compliment makes all the difference.

John C. Luik is writing a book on health policy. He lives in Canada.


TCS Daily Archives