HEALTH PROMOTION Philosophy, Prejudice and Practice Second Edition David Seedhouse Auckland University of Technology, New Zealand and Middlesex University,London,UK HEALTH PROMOTION Philosophy, Prejudice and Practice HEALTH PROMOTION Philosophy, Prejudice and Practice Second Edition David Seedhouse Auckland University of Technology, New Zealand and Middlesex University,London,UK Copyright & 2004 John Wiley & Sons Ltd,The Atrium, Southern Gate,Chichester, West Sussex PO19 8SQ, England Telephone (+44) 1243 779777 Email (for orders and customer service enquiries): [email protected] Visit our Home Page on www.wileyeurope.com or www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1T 4LP,UK, without the permission in writing of the Publisher.Requests to the Publisher should be addressed to the Permissions Department, John Wiley & Sons Ltd,The Atrium, Southern Gate,Chichester,West Sussex PO19 8SQ, England, or emailed to [email protected], or faxed to (+44) 1243 770620. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the Publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Other Wiley Editorial Off|ces John Wiley & Sons Inc.,111River Street, Hoboken, NJ 07030,USA Jossey-Bass,989 Market Street, San Francisco,CA 94103-1741,USA Wiley-VCH Verlag GmbH, Boschstr.12, D- 69469 Weinheim, Germany John Wiley & Sons Australia Ltd, 33 Park Road, Milton,Queensland 4064, Australia John Wiley & Sons (Asia) Pte Ltd, 2 Clementi Loop #02-01, Jin Xing Distripark, Singapore 129 8 09 John Wiley & Sons Canada Ltd, 22 Worcester Road, Etobicoke, Ontario, Canada M9W1L1 Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Library of Congress Cataloging-in-Publication Data Seedhouse, David, 1956^ Health promotion : philosophy, prejudice, and practice / David Seedhouse. ^ 2nd ed. p. cm. Includes bibliographical references and index. ISBN 0-470-84732-8 (alk. paper) ^ ISBN 0-470-84733-6 (pbk. : alk. paper) 1. Health promotion ^ Philosophy. I.Title. RA427.8.S44 2004 613’.01^ dc22 2003057623 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 470 84732 8 ppc ISBN 0 470 84733 6 pbk Typeset in10/12pt Palatino by DobbieTypesetting Ltd,Tavistock, Devon Printed and bound in Great Britain byTJ International, Padstow, Cornwall This book is printed on acid-free paper responsibly manufactured from sustainable forestry in which at least two trees are planted for each one used for paper production. FORDEARHILARY,CHARLOTTEANDPENELOPE IN MEMORY OF MY BEAUTIFUL GRANDMOTHER, JESSIE SEEDHOUSE Contents About the Author ix Preface to the Second Edition xi Preface to the First Edition xvii Acknowledgements xxi Introduction 1 PART ONE: THE MAGPIE PROFESSION 7 Dialogue One Health Promotion on Offer: All Models Available 9 DialogueTwo Where’s the Beef? 17 Chapter One Glad to be Vague 27 Chapter Two Hollow Words – and How to Reveal Them 33 Chapter Three Evidence and Ethics 57 DialogueThree Progress so Far 73 PART TWO: PREJUDICE FIRST, EVIDENCE SECOND 77 Chapter Four What Drives Health Promotion? 79 Chapter Five The Political Tap Roots of Health Promotion 93 Dialogue Four The Outsider 127 Chapter Six The Outsider Problem 133 PART THREE: THE FOUNDATIONS THEORY OF HEALTH PROMOTION 161 Chapter Seven An Introduction to the Foundations Theory of Health Promotion 163 Chapter Eight Tough Questions 177 Dialogue Five The End of Illusion 191 Chapter Nine Ethics and Health Promotion 197 Chapter Ten Rational Field Health Promotion 215 viii CONTENTS Dialogue Six Time to Face the Music 229 Dialogue Seven Strategies for Health 239 References 283 Index 289 About the Author PROFESSOR DAVID SEEDHOUSE, BA (HONS), PhD (Manchester) David Seedhouse is a practical philoso- pher, intensely interested in health matters. He has written or edited 13 books and produced over 200 book chapters, journal papers and other articles. His most successful books are Health: The Foundations for Achievement and Ethics: The Heart of Health Care, both of which are in their second editions. His latest book is Total Health Promotion: Mental Health, Rational Fields and the Quest for Autonomy. Professor Seedhouse has researched and written extensively about: . The Philosophy of Health . Health Care Ethics . Medical Ethics . Health Promotion . Mental Health and Illness . Ethical Decision-making . Values-based Decision-making David is Professor of Health and Social Ethics at Auckland University of Technology, New Zealand (where he directs the National Centre for Health and Social Ethics www.healthethics.info). David is also a popular keynote conference speaker and visiting professor in 13 different countries, and is widely noted on the internet. Preface to the Second Edition CATEGORICAL AND HYPOTHETICAL HEALTH PROMOTION The first edition of Health Promotion: Philosophy, Prejudice and Practice is often read as arguing that conventional health promotion has so many theoretical and ethical deficiencies that it should be abandoned. But this is not the point. In fact conventional health promotion can be a good thing and there are many reasons why there ought to be more of it. Conventional health promoters (the Magpie Profession) want to eliminate or alleviate pain, disease and certain social obstacles in order to enable people to live safer and more fulfilled lives. These admirable ambitions are shared by foundations health promotion (the unconventional form of health promotion advocated in this text). There is a crucial difference, however: conventional health promotion assumes that its particular interpretation of health is the only correct understanding, while the foundations theory openly appreciates that there are different interpretations of health and many alternative ways to live a fulfilled life. Health Promotion: Philosophy, Prejudice and Practice is essentially a plea for tolerance. It makes tough criticisms of conventional health promotion’s academic inadequacies, and exposes a massive ethical crisis most conventional health promoters continue to ignore. But these objections are not meant to overthrow established health promotion. Rather they are made so that conventional health promotion can grow and flourish as a philosophically mature discipline. Most of conventional health promotion’s conceptual and ethical errors could be remedied overnight were the movement’s leaders to accept the intellectual and moral primacy of hypothetical over categorical health promotion. Categorical health promotion (the type advocated by all official health promotion bodies) presupposes that: 1. Health is an objective state 2. It is practically and morally good to behave in ways that create health 3. Given 1 and 2, health promoters can evaluate any given practice as either categorically good or categorically bad for health 4. It is ethical to promote health because health is a universally desirable goal. By contrast, hypothetical health promotion is based on the demonstrable facts that: 1. There is no objectively true understanding of health xii PREFACE TO THE SECOND EDITION 2. All categorical statements to the effect that practice A is good for health, practice B is bad for health and so on, are nothing more than logical extensions of unprovable assumptions about the nature of health 3. Different individuals and peoples hold different beliefs about how best to live. In the light of this social reality it is an unreasonable imperialism to claim that only those behaviours which conform to a particular health promoter’s idea of health are truly healthy. Assertions about ‘how people should live’ cannot arise spontaneously from the evidence; rather they must be chosen (knowingly or unknowingly) according to the asserter’s instincts, values, and ways of classifying the world (her prejudices, in other words). Take, for example, the apparently straightforward health promoting declaration many of us heard repeatedly as children: Eat your greens, young man/woman. You’ll never grow big, healthy and strong unless you do. There is evidence in favour of this assertion. Green vegetables are a good source of beta carotene and vitamin C, and there is research that indicates that eating broccoli (particularly the sprouted seeds) may help protect against some forms of cancer (see http://www.cancer.org/docroot/NWS/content/NWS_3_1x_Broccoli_and_Cauliflower _Help_Fight_Cancer.asp for example). But this does not make it categorically true that eating your greens is good for your health. All anyone can say is: If you want to grow up without vitamin C deficiency, and if you want slightly to increase your chances of avoiding bladder cancer as an adult, then you should eat your greens, young man/woman. I have chosen not to tell my own my children to ‘eat their greens’ because I do not believe that this approach is good for their health. When I picture my children’s health I see them standing on a stage that looks like roughly