Previous sections have outlined parallel approaches to examining the determinants of diet – structural and those couched in terms of responsible behaviour by the general public. I now explore approaches to public health practice and the concept of ‘behavioural justice’ (Adler & Stewart 2009) to link these themes. Diet, obesity and health outcomes differ by socioeconomic groups, with those who are most disadvantaged most at risk of having poorer outcomes. Reducing the prevalence of diet-related ill health (or at least retarding its increase) and ironing out demographic differences are targets of public health in the UK and across much of the world.
Key reports on the social determinants of health in both the UK and the US have recognized that a range of actors must be engaged, and the food system must be changed in order to tackle diet-related disease prevalence and health inequalities (McClellan & Rivlin 2009; Marmot 2010). Considering relationships within the food system is fraught with tension – each actor negotiating the various demands of ‘responsible’ behaviour. Dietary choice by the general public within today’s food system consequently raises questions of justice given the differential economic, spatial, cultural, educational and other resources that people possess, as well as the contrast with what corporations and policy-makers have at their disposal: “both the hedonic cues and the pricing and availability of unhealthy foods make it more difficult for people to behave in healthier ways. More problematically, the medical model assumes a level playing field for the populations making these choices” (Adler & Stewart 2009,
p.60).
Approaches that focus solely on social determinants of diet and health are, however, in danger of ignoring significant issues: individual-level determinants are inescapably enmeshed with social ones, and it is not a given that structural changes lead to behaviour change (Forde & Raine 2008). Additionally, aspects of public health practice are contentious. Firstly, its normative nature i.e. that health inequalities should be addressed, carries the risk of identifying and potentially stigmatising the socially disadvantaged people it aims to help most (Carter et al. 2011). Secondly, it is based on the premise that good health is intrinsically ‘good’ and by extension behaviours that can lead to poor health are fundamentally ‘bad’. This is not to consider the possible benefits that some may gain from such behaviour such as immediate gratification from eating a so-called ‘unhealthy’ food.
What is more, governments are aware of the fine line between social
responsibility and personal liberty. The seminal Lalonde report presented this predicament thus: “the ultimate philosophical issue… is whether and to what extent the government can get into the business of modifying human behavior, even if it does so to improve health” (Lalonde 1974, p.36). In the 2010 UK Public Health White Paper, the government reiterated the dilemma: “it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live. Recent years have proved that one-size-fits-all solutions are no good when public health chone-size-fits-allenges vary from one
neighbourhood to the next. But we cannot sit back while, in spite of all this, so many people are suffering such severe lifestyle-driven ill health and such acute health inequalities.”28
A hundred and fifty years ago, John Stuart Mill rejected ‘nannying’, or
28
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1 27424.pdf page 2, accessed 19/06/11
paternalism –interfering with any member of society’s freedom of action with the aim of conferring benefit on that person. A key counter-argument is one of broad utilitarianism, whereby interference is justified because of secondary costs which, in the case of health in the UK are borne by the NHS, and indirectly by the public who contribute to its funding through taxation. More recently, some have advocated ‘libertarian paternalism’ (as described in section 2.1.1).
Social justice, however, sets out to create as level a ‘playing field’ as possible, upon which the general public has the option and opportunity to exercise their autonomy. Research has shown that those who exercise more autonomy have better health outcomes (Wilkinson & Marmot 2003; Buchanan 2007).
Buchanan is careful to point out the difference between ‘autonomy’ and
‘liberty’: while the latter suggests freedom to do as one pleases as long as it does no harm to others, autonomy is based on “the integration of freedom and responsibility” (Buchanan 2007, p.3). He highlights the reciprocal relationship of each member of society to the social by advising against prefacing justice with
‘social’ too readily lest agency is omitted. Indeed, a social justice perspective is not to suggest that members of the public take no responsibility for their own dietary actions; it is important to “recognize the less tangible but morally and psychologically important values of free choice and the assumption of
responsibility, both of which are essential for personal development and for the management of one’s life course” (Wikler 2002, p.58).
While members of the public ultimately do make choices about their own dietary (and other) behaviour, contextual influences on whether those decisions are ‘responsible’ health-wise or not must be taken into account. Indeed, the Marmot Review of health inequalities in the UK, Fair Society, Healthy Lives implicitly embraces social justice, stating in its conceptual framework that it is necessary to “Create an enabling society that maximises individual and
community potential” in order to “Enable all children, young people and adults to maximise their capabilities and have control over their lives” (Marmot 2010, p.19). The general public can only be expected to do this and to eat
‘responsibly’ for health in relation to a food system that presents them with a fair food environment, free from undue economic constraints, from disparities in the availability of foods, from unclear and excessive information about food itself and from the dominance of commercial interests over those of the consumer.
Yet the association between social inequalities and the prevalence of obesity and diet-related illness suggests that “the economic benefits of flexible and open markets, such as they are, may be offset by costs to personal and public health, which are rarely taken into account” (Offer et al. 2010, p.306).
Additionally, Finegood is explicit that despite the complexity and
interconnectedness of the environment within which eating is enacted, the role of each person is not lost, rather “Of particular importance is the need to match the complexity of people’s tasks to their capacity to act, and the tasks of the individual actors in the obesity system vary considerably” (Finegood et al. 2010, p.S15). The same could be said of other illnesses related to diet and similarly, policies must account for each person’s “varying degrees of power over their lives, and varying ability to change behaviour. The extent to which they are able to act depends on many factors, from personal capabilities to deep social structures, from economic markets to community social norms” (IPPR/Lewis &
IPPR 2007, p.8). In other words, a person’s dietary behaviour, ‘capacity’ and responsibility for health must be contextualised in the food system and other actors’ behaviour within it.
A framework for examining inequalities in diet-related disease and obesity prevalence within which to encompass both issues of social justice and a person’s autonomy is therefore required. One such possibility is presented by Adler and Stewart’s (2009) notion of ‘behavioural justice’, which suggests that personal responsibility can only be expected in conjunction with collective responsibility. This corresponds with the optimal outcome in Foresight’s
‘Scenarios’ projections (see Figure 2.1). Adler and Stewart insist that members of the public “should be held responsible for engaging in healthy behaviors only
when they have full access to the conditions that enable those behaviors. This places the primary responsibility on society to provide equal opportunities for all people to be able to make the healthier choices” (ibid p61).
A behavioural justice approach to curbing prevalence of diet-related disease goes some way to accounting for Forde and Raine’s suggestion that “a solely social approach to better health is poorly aligned to the realpolitik of
contemporary policy trends in health and social care” by acknowledging the relationship between individual and social determinants of health (2008, p.1694). Additionally, it offers a model of public health practice that reduces normative elements. A model that aims to level the playing field – either by narrowing socioeconomic inequalities or by according responsibility
proportionately within the food system – would also allow for differences in the ability and inclination to take up health promotional messages; these would otherwise have the potential to widen health inequalities given that population groups with the poorest health outcomes are those least likely to take up educational information (Walls, Peeters et al. 2011). Behavioural justice allows for each person to make choices – either with expediency or reflexively, which promote their health or damage it – in relation to social factors and other actors in the food system.
2.7 Summary and research aims: exploring responsibility in the food