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Promoting Healthy Behavior: How Much Freedom? Whose Responsibility?
  1. Richard J Coker
  1. Health Services Research Unit, London School of Hygiene and Tropical Medicine, London

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    Edited by Daniel Callahan, Washington DC, Georgetown University Press, 2000, 186 pages, £32.50.

    When my family and I were hiking in northern New York state we got lost. I waved down a passing car and inside I could just about, through the haze of purple cigarette smoke, make out a couple of very obese people in the car; they looked like mother and son. They very kindly agreed to take us to our car, several miles away, and during the journey I asked them what had brought them to this remote mountain road. “We come here once a week to draw water from a mountain stream”, said the elderly woman. “Most people round here don't know how to keep healthy”, she and her son opined almost in unison.

    This experience, for me, captured many of the attitudes those of us in the West have towards health, health promotion, and disease prevention. This cameo shows how difficult it is to change unhealthy behaviour. Persuading people to give up smoking and reduce weight is more of a challenge than persuading them of the health-giving qualities of mountain spring water. In the West, and in particular in the United States of America, individuals are preoccupied with their health in ways not envisaged fifty years ago. In addition to recognising that we should take greater personal responsibility for our health we are acutely aware, also, of how the behaviour of others can affect our health. And it is in this realm, between the “right” to be free from state interference and lead one's life as one sees fit and the “right” to be unencumbered by unnecessary threats to one's wellbeing, where tensions arise. These tensions can be seen to play out in the realm of passive smoking, for example. The bans on indoor smoking in prisons in Vermont (and the subsequent lifting of these bans because of a thriving black market) and the US Supreme Court's decision that exposure of prisoners to tobacco smoke violates the eighth amendment (the right to freedom from cruel and unusual punishment) highlight Beck's “risk society” in ways which are sometimes difficult to navigate ethically.

    This excellent book, the result of a two-year research project conducted by the Hastings Center and the Stanford University Center for Biomedical Ethics, collects together a series of essays that reflect upon ethical, political and cultural issues surrounding the promotion of healthy behaviour. Perhaps not surprisingly, therefore, given the authors' North American origins, the book takes a US perspective. Although health promotion and disease prevention terms are used on occasion interchangeably with the promotion of healthy behaviour it is the latter, as the book's title suggests, that the collection focuses upon. This is interesting in itself and illustrates something of the strictures placed upon those in the US who ally social justice to public health. Ronald Labonte and Ann Robertson, the two non-US-based contributors, each provide papers which add breadth to the book and are superb. Meredith Minkler and Beverly Ovrebo have also produced impressive chapters, which highlight with clarity the ethical dilemmas which arise when trying to balance individual and societal needs and responsibilities. Ovrebo notes that: “While the debates are old, what is new is the context within which these debates are occurring” and it is these changing circumstances which make the book so interesting.

    The collection has, in my opinion, failed in two areas. Firstly, although the ethical and social tensions in changing behaviour are described well, little space is given to potential solutions. These, of course, are political. But if collections such as this are to have a lasting impact then they must provide argued political solutions. This is a lot to ask of a book but if an ocean liner of the magnitude of the American body politic is to change course it needs all the help it can get. Secondly, the health promotion consequences of the unravelling of the human genetic code are insufficiently explored. Over the next twenty years or so the knowledge which arises from this project will transform the ethical debates regarding the promotion of healthy behaviour.

    More than a quarter of a century after Marc Lalonde drew attention to the individual as an important focus for intervention to control risk factors for ill health, this book provides a timely reminder that changing behaviour continues to be politically, culturally and ethically challenging.