I read the article
The other day, I was recommended this article, Brown, R. C. H. (2018) Resisting Moralisation in Health Promotion. Ethical Theory and Moral Practice, 21:997-1011, by @ill-kidnap-all-the-stars about the moralisation of health through health promotion efforts. This recommendation came in the context of this op, on which I commented originally here and then here and in the replies, which I only say for context. It's a big topic, and I found the article an interesting read that others may find interesting as well. These are my thoughts on it.
First off, I want to say that going into it, I already agreed that health is a matter of personal wellness and not a matter of morality. What defines “health” can be relative to any individual’s personal biology and circumstances, and there is no such thing as attainable perfection in any context. I also disagree with messaging that says that people who don’t do enough for their health or make unhealthy choices are morally bad.
That said, let’s get into it. Under the readmore is almost 5k words of quotes and my reactions.
First/General Impressions
Initially, something that I found disorienting about the paper was the style. Maybe this is the norm for ethics/philosophy, but in my field, we do not speak in the first person or emphasize in professional publications. The frequent “I”s and emphasis threw me off, but I got used to it. There are also a number of typos and informal writing quirks “(!)” that look more at home in a tumblr post than a peer-reviewed academic publication in a professional journal. I also have a distaste for how often Brown repeats herself and the high overlap in points between the sections of the paper, as if she doesn’t trust the reader to remember what she said two pages ago.
What persisted was an uneasy sense about Brown’s convictions or lack thereof. She doesn’t state a lot about the moralisation of health as facts but frequently says things like “I suggest,” “I propose,” “I argue,” “I have sought to outline,” etc. The unsteady footing in her position comes most strongly in the final section, and ultimately, she is not saying that health education efforts inherently moralise health, just that it's a plausible outcome:
“Without claiming to have established any such mechanism, I suggest that a combination of conceptual reasoning and available empirical evidence indicates that such a process is at least plausible. … My concern is that, whilst informational / educational interventions appear to display the virtue of preserving (and, as is often claimed, empowering) choice, that very virtue may be the basis for objectionable effects in the form of moralisation. … In particular, I do not claim that informational and educational campaigns will generally be moralistic, since they tend not to suggest that those who fail to avoid unhealthy habits commit a moral wrong. Hence, I have focused here on establishing the plausibility of the suggestion that health promotion may contribute to the social process of moralisation, whereby health-related behaviours come to be seen as morally relevant.” (p. 1007-1008, emphasis mine).
1 Background: Public Health and the ‘Behavioural Turn’ in Health Promotion
In this section, Brown reviews the history of health promotion since the 1970s, pointing to a rise of “healthism” in that decade and the “behavioral turn,” in which a greater focus was placed on individual behaviors. She notes a shift in leading causes of mortality from infectious disease to chronic disease as lifespan increased. She describes how health promotion since then:
“...focuses less on prevention and eradication of disease, and more on reducing lifestyle risk factors for chronic disease” (p. 998). And then in Section 2: “The continued elevation of the value of health … redescribes ‘healthy’ as not merely (!) freedom from disease, along with complete mental and physical well-being, but now freedom from risk of future disease,” (p. 1000).
The first quote comes directly after describing the era of health promotion which saw a decrease in disease due to “improvements to living conditions and sanitation, alongside population vaccination programs.” And my response to that is, why are they different? If it was beneficial to improve conditions and develop vaccines to prevent infectious diseases, it follows that it is also beneficial to promote lifestyle improvements to prevent chronic diseases. I see no reason that increased freedom from risk of future disease should not be an aspect of health, since preserving wellbeing and quality of life and longevity in this way is not all that different from encouraging hand-washing and vaccination. It is great that the leading causes of death have shifted to reflect longer lifespans in cleaner conditions, and it makes sense for health promotion efforts to adapt to the needs of our current socio-medical climate for further progression of population wellness.
Later, Brown almost seems to defend moralist messaging around some aspects of public health (though her opinion on that is less than crystal), so what makes obesity and diet-related disease so immune in that framework? We shall see.
In this section, Brown describes health promotion policies that have faced public backlash:
“...regulating the sale of products or the permissibility of the behaviour itself. This includes increasingly restrictive regulation on the sale of tobacco and alcohol, the banning of trans fats from processed foods, and the outlawing of smoking in public places. Such policies are often described as coercive since they limit people’s freedom of choice, with the threat of legally enforced punishment for failure to comply,” (p. 998).
She states that this type of social manipulation is seen as coercive (which I think it is), and she aims to critique the alternative (healthy choice messaging/education) for potential ethical pitfalls in turn. Which is fine. I think examining the potential for ethical dilemmas, even in processes that seem preferable, is totally fair. Question everything! However, she concludes the section with:
“…if alternative approaches to health promotion (such as regulation and the use of environmental shaping to influence behaviour) avoid contributing to moralisation, there may be ethical reasons for preferring such approaches to health promotion,” (p. 999).
So, hold on there. Is she really saying that her critique of health education could conclude that the more coercive version of health promotion through regulation is better because it is less prone to moralisation? It sounds like her stance would be that limiting or manipulating the consumer's choice is ethically preferable over consumer education because that education might make people feel bad. This doesn’t even solve the real problems. If telling people why fast food is unhealthy and suggesting alternatives doesn’t work and leads to moralisation, why, in her mind, would regulating fast food and putting that stigma on it or limiting access be better? I think such regulations which place the burden on corporations, such as banning trans fats, are not without risk but far better than those which place the burden on the consumer, such as taxing certain goods or the recent ban on vape products in some states. At the end of the day, I'll be on the side of personal freedom and personal responsibility.
2 Healthism and the Promotion of Healthy Choices
In this section, it’s more of the same, and Brown defines two components of “healthism”:
“1. The tendency to view an increasing number of activities and domains of life in terms of the impact they have on health, and 2. the promotion of health to a ‘super-value,’” (p. 999).
I don’t think there is anything wrong with valuing health and looking at it with a holistic approach that takes all elements of lifestyle into account, as in component 1; health is more than diet or weight. I personally value my health and the health of my loved ones. I value the health of our global population in a much less personal sense and don’t claim any control over the behavior of strangers, but I am not going to be shamed out of saying that it would be good for humanity if we were all, on average, as healthy as we could feasibly be. Health is valued by most people to some degree, and many human rights concerns relate to the disparity of health between groups, such as malnutrition in impoverished regions or insufficient access to care for disease and disability. What she means by “super-value” and the downside of healthism is when health becomes the sole value by which any life is measured. I do agree with her argument for a multi-value outlook.
“Those who fail to value it properly, as demonstrated, for instance, by failing to take steps to preserve their own health, become seen as imprudent at best, reckless and deviant at worst. …health is a (perhaps the) dominant value which everyone should pursue. …broader concepts of health and/or those specifying health as a priority over other goods will align with healthism and foster moralisation to a greater extent,” (p. 1000, emphasis Brown’s).
I think this is fair. I have not always valued my own health (thanks, ana)*, but I am happy that I value it more now than I used to. I still engage in some unhealthy behaviors just because they’re enjoyable, and I don’t expect perfection from anyone. I don’t think every human is obligated to value their health above all else, and I don’t believe in shame-based health promotion or forcing anyone to value something they don’t. Just as more health-conscious people may think me imprudent, I may think overweight or obese people imprudent, but it still isn’t my life, body, or business. If people don’t value their own health, that is really their business, and no one owes health to anyone but themself**. Where I do draw a line is health denialism and misinformation. Adults can do whatever they want with their own bodies, but I should not be expected to tolerate misinformation* or child endangerment**.
*When I was at my worst with anorexia, I did not claim to be healthy nor care if I was. I think many people with that or other EDs may feel similar. In such spaces, there is no pretense. People may discuss harm reduction, but I haven’t seen anorexic people claiming that being severely underweight is healthier than being a normal weight. There are many facets to the disorder, and the psychology is more varied and complicated than most people think. On the other hand, Fat Activism promotes Health At Every Size (though hypocritically condemns the unhealth of underweight condition) and claims there are no health concerns that come with being overweight or obese, which is a dangerous lie. If they were honest about it, as some are, and said, “This is unhealthy, but I'm ok with that and the associated risks,” I would not have the same problem with it. I’m not speaking critically of people existing while fat. I’m speaking critically of Fat Activism and HAES rhetoric, which people of any size can promote.
**People who make the choice to become parents do have an obligation to their children, and providing the healthiest options they can access and teaching healthy habits actually is important there, considering childhood obesity comes with severe long-term health implications.
3 Moralisation
This is the section that describes what moralisation and moralism are and how they can be applied to health promotion. She introduces these concepts in the context of her field:
“...discussions of moralisation typically resist making any normative judgements about the process of moralisation itself. …‘moralism’ is generally applied in a pejorative sense…as a vice or criticisable in some way,” (p. 1001).
So, she’s saying social scientists try not to moralise moralisation, which is the reframing of previously amoral topics within a moral framework, but commonly, moralism is moralised. She then says:
“...moralism may occur in relation to something within a domain that is (generally) already considered morally-relevant,” with an example of recreational drugs, and, “[Moralism] is the application of contentious moral standards by some people upon the activities of other people. This might be because the standards themselves are contentious, or their particular application somehow raises controversy,” (p. 1001-1002, emphasis Brown’s).
I am interested by her emphasis on the contentiousness of the moral framework impacting whether something is moralistic or not. If it isn’t sufficiently controversial, it’s no longer moralism, just normal? She recognizes the importance of cultural context in that, and as we'll see later, it depends on whom those actions affect. The way she consistently uses examples of drugs and alcohol as potentially less contentious moral questions but holds dietary health separately does rub me the wrong way. Societally, we can agree that smoking and excessive alcohol or recreational drug consumption are things to limit or avoid for health reasons and moralise about that despite their obvious addictive natures. So why is it not ok to promote health in other, arguably more controllable, areas like diet and weight? More on that later.
“I have sought a compromise here by allowing that paradigmatic moralism (moralist, moralistic) should be disagreeable in some way, whilst moralisation need not be,” (p. 1002).
Why moralise moralisation, then? Why even raise the concern about moralisation in health promotion? What even is her point anymore, if this is the case? She clearly dislikes moralism, as most do, but while the rest of her field tries not to moralise moralisation, her tone and the thesis/title of the paper tell me she is saying this begrudgingly. I don’t think we should moralise health in a way that says people who don’t value it are not worthy of human dignity, and I thought she meant to agree with that, so why send this mixed message? To cover her ass professionally? It feels intellectually dishonest.
4 Moralising, Health and Responsibility
This section was a doozy. After describing historical religious moralisation of health, she says:
“Yet in another sense, the medicalisation of conditions is often associated with their removal from the moral domain. For instance, the classification of addictions (to drugs, gambling, and so on) as ‘diseases’ seems to discourage us from making harsh moral judgements about those who are addicted (rightly or wrongly),” (p. 1002).
“Rightly or wrongly”? For addiction? For someone writing 14 pages on the potential danger of moralising health with respect to dietary habits, Brown speaks more tolerantly of the moral judgment of people with substance abuse problems. Maybe she just doesn’t believe in behavioral addictions and meant the “rightly” to refer to gambling only, but it does sound weird.
Considering this, I wonder how she feels about the medicalisation of overweight and obese conditions, because she does not bring that up at all. Fat Activists say the word obese is a slur and rage against those who call obesity a disease. But with this in mind, should designating obesity as a disease not be a step in removing it from the moral domain and stigma? When health promoters speak about how the sugar and junk/fast food industries employ food science in order to make their products ultra-palatable and unfulfilling in order to get people to buy and consume more, creating what may be called “sugar addiction” or “food addiction,” or when they speak about binge eating disorder and its prevalence, Fat Activists say this language is unhelpful and stigmatizing. Supposedly, calling a problem an addiction or disease makes it a morally neutral medical concern rather than a personal moral failing. And yet, no one wants to speak in those terms because it feels moralising. Even Brown can’t win!
She then discusses the required conditions for moral responsibility: the Control Condition, “sufficient degree of control over her behaviour,” and the Epistemic Condition, “could reasonably be expected to understand the consequences of her actions,” (p. 1003, emphasis Brown’s).
What follows is a lot of theorizing about the level of control and understanding present in the average consumer and whether they qualify for a moral responsibility with regards to health. As a person who doesn’t think of health in a moral sense, I can still understand what she means. To me, it isn’t a moral responsibility, but it can become a personal responsibility, especially if the person claims to value health. Outside of any moral system, in a completely amoral sense, cause and effect still apply, and a person’s actions and choices, regardless of the freedom therein, can impact their health. How we manage that with consideration for the freedom of choice is the real question.
“There will be other factors important in judging the appropriate application of moral responsibility, such as assessments of the cognitive (and moral) capacity of the agent and how we might use moral responsibility as a way of shaping future behaviour,” (p. 1003).
Is she claiming here that people aren’t intelligent enough to make healthy choices? Not enough cognitive capacity? Interesting choice of words, to say the least. Especially given that her thesis is a critique of health education.
“...providing information and educating people about the harms of lifestyle-related risk factors encourages the perception that people are both in control of their behaviour, and that they understand the implications of their behaviour for future health. …it assumes that people have unhealthy lifestyles because they don’t know that they’re unhealthy; pointing this out to them will get them to change their behaviour.” (p. 1004).
Yes, understanding the implications is something health education is trying to do, and there's nothing wrong with that. The thing she is critiquing here directly acts on that second perception. As we'll see later, I suspect the unsaid point is that she is critical of diet education because it creates a capacity for responsibility in people, not that it gives the perception of responsibility as she claims.
I have seen Fat Activists say things to the effect of “I don’t need to be told my diet is unhealthy. I know.” Such statements come in response to people pointing out that it is unhealthy to be overweight or obese. And yet, it still looks like there is a knowledge gap when we have others in that community outright denying the health impacts of excess body fat. As I said before *, it’s that sort of health denialism that bothers me. If people know they’re unhealthy and don’t care, whatever. Plus, there are people out there who were never taught and don't really know the differences between their options.
For the first perception, control of behavior, she has much to say. Part of that is “environments and engrained habits (and often not under conscious control),” which connects to my earlier ** point about children. The habits we learn in our youth stick around, so if Brown is saying obesity can be explained by our unconscious, engrained habits if not conscious choice, then I take that to mean it is important for parents and youth caretakers to do what they can to teach healthy habits.
On the environment:
“...those who experience more social deprivation also tend to experience poorer health. …local food environment may influence dietary habits: Macdonald et al. (2007) have shown that deprived areas have a higher density of fast food outlets, plausibly contributing to people’s risk of developing obesity. Such structural factors may mean that, even if educational strategies can successfully raise awareness of behavioural risk factors, people’s capacity to change their behaviour in health-protecting ways may be severely limited by the environments they live in,” (p. 1004-1005).
Can we talk about how 13% of Americans live in food deserts, including the 6% who have “limited access to a supermarket” (2022)? If living in a food desert is a primary reason people become overweight/obese, why are >40% of Americans obese and an additional >30% overweight (2023)? I can see why a prominence of fast food outlets can normalize fast food within a local culture, but what’s normalized doesn’t need to be followed. People do have agency, even if it isn’t always easy to employ. Fast food isn’t all created equal, so even within it, there are still choices to be made. And it isn't even that cheap anymore. I see plenty of larger people doing What I Eat In A Day including take-out of exorbitant financial investment: stuff I wouldn't be able to afford regularly, and I'm not even poor. Eating more food costs more money. Crazy idea, I know. For the 7% who technically live in a food desert but have reasonable access to a supermarket, there are loads of recipes which are more cost-effective and healthier than fast food. The health education being critiqued here may provide such information. Maybe a person can’t access the healthiest diet, but they probably can manage a healthier diet if they so choose.
Fixing the environmental and economic barriers to healthy choices is something we as a society should be doing, but first, we must be able to openly recognize that it is unhealthy to be overweight or obese. Name the problem, fix the problem. If there isn't a problem, why fix anything?
On choice:
“…it is deeply intuitive as well as reassuring to believe that we are rational agents who respond well to reasons and who are in control of our behaviour. … This pushes a message that, through better understanding of the health implications of their behaviour, and given the tools to change that behaviour, people can (and should) adopt healthier lifestyles. …gives the impression that people are, or can become, well-informed and in control of their health. …creates the conditions for the attribution of moral responsibility,” (p. 1005).
No, I’m not going to agree with rhetoric that says a person’s actions are beyond their control. Here, Brown goes so far as to say that even with education and the tools to change, people won’t. To say we are simply beings of fate with no agency whatsoever is asinine and insulting. We all have our less-than-healthy habits and irrationalities, but overall, I do believe people are capable of making choices. Our choices reveal our values, and if someone doesn’t value health or just doesn't value it above all else, whatever; it’s their right not to, but it is still a choice. Does Brown think I have agency in how I speak on tumblr, if not how I eat? Does she believe in free will at all?
She doesn’t give any evidence to support her view that people aren’t in control of their own actions and choices; she only speaks in a way that implies the assumption of control is a flaw in health education. I would have been interested in why she thinks that. Despite her unsubstantiated claim, people can change their behavior; only whether they should or will is up to them.
“Although physical attraction is clearly deeply context and individual dependent, being overweight or obese is, in much of the world, widely seen as both unattractive and an outwardly visible sign of poor health,” (p. 1006).
No one owes you attraction. That isn't up for debate. She does (perhaps begrudgingly again) recognize the individual-dependence of that, but why even bring it up? Also, yes, weight can be a visible sign of poor health because people aren’t stupid. Most people know it isn’t healthy to be obese, and it serves no one to pretend it is. Other prejudices and assumptions about discipline aside, some degree of poor health is not an outlandish assumption given the medical literature.
Overweight/obese condition may be unique in that it is one of the most visible indicators of health. Call it a privilege that you can't always tell a person's full health status just by looking at them, and if a smoker or drinker or junk food eater is skinny, people may not make assumptions, but it is what it is. Once people discover how much a thin person smokes, drinks, or eats junk food, they're likely to make health judgements on that, too.
She speaks on weight discrimination, ascribing it a moral reasoning, and clipped a quote from another paper:
“One telling study found that parents of overweight children provided them less support for college than parents did for their thin children,” (p. 1006).
And I just had to flip this in my head. Fat Activists will talk all day about how poverty and mental illness and other physical health conditions can contribute to obesity. So here, would it not make just as much sense to say that due to the link between economic status and weight status, the parents of overweight children may not have as many funds available for college? Or the confounding variable of mental health on college admittance? Just a thought, since we’re looking at every perspective.
5 Against Moralisation in Health Promotion
So we are back to the pages I quoted in the beginning about her actual point and tying in her remarks at the end of Section 1. She then goes on to discuss the harm of stigma in smoking and alcohol consumption, saying it creates psychological stress and discourages people from seeking help. In that case, are we decreasing fat stigma so that fat people are more comfortable seeking help? Do they need help? What help would work? They don’t have a choice, according to Brown, and neither form of attempted behavior manipulation is free of ethical concerns. However, she does imply that the regulation method may be preferable due to coming with less stigma. Which, again, doesn’t make a ton of sense, as regulation can also stigmatize.
“Further, some health promotion will be moralistic. So called ‘social marketing’ campaigns make use of stark imagery and simplistic messages… Images of a foetus formed out of cigarette smoke, or inside an alcohol bottle with the title ‘too young to drink’; a revolver loaded with cigarettes; a young man and woman, apparently drunk, with the message “She’s never cheated on her boyfriend, until now”; a mannequin next to some text saying: “only dummies don’t wear condoms.” Such campaigns appear highly moralistic, equating as they do, specific behaviours (which they frame as health-related) with sinful, bad, undesirable and selfish behaviour,” (p. 1008, emphasis Brown's).
Dude. Is she saying it's ok to moralise in these areas? Because while she does speak of stigma, she doesn't challenge that such promotions "will be moralistic." While it isn't the clearest, Brown's tone suggests she accepts an aspect of moralism in these cases. Smoking and drinking aren’t healthy, especially when pregnant; alcohol can lead to regretful decisions; and condoms are good! Perhaps it's only moralism because the striking imagery feels contentious. As she touches on "drink (sic) driving," she says moralism is ok when it's critiquing actions which harm others, not just the agent. I get that. This relates to how I said it isn't immoral to be unhealthy but it may be immoral to promote health denialism and defeatism.
But the language is interesting, because it seems to come from her view of these examples more than the examples themselves. You don’t need the “sinful” label to agree that safer sex practices should be promoted for public health reasons. This gets at something I was trying to say in my comments on the post that got me here: is the messaging truly using a moral framework, or is that just how people perceive it? If a health promotion makes people aware of the unhealthiness or possible adverse effects of their choices, might they be reading more moralism than is really there because they feel attacked and defensive? Are anti-smoking campaigns (outside of those targeting pregnant women) really telling people it’s immoral to smoke or just pointing out how it can be unhealthy? This doesn’t need to be a moral issue, and I suspect the people who take offense at health promotion make it that way because they feel morally attacked, even if that isn’t the intention.
Brown gives no similar examples of the supposedly moralised diet- or weight-related health promotion this is warning against except the language used by a specific diet app. I was expecting more, but she did say it isn’t happening (just plausibly could).
“...product labelling on food, cigarettes and alcohol, can also be experienced as moralistic, using disgusting imagery and forcing individuals to be made aware of details about the health harms of the items they purchase, despite some people preferring to remain ignorant of such things,” (p. 1007, emphasis mine).
Oh, I see! Ignorance is bliss! Now she’s being honest. People don’t want to think about the unhealthiness of their choices. They don’t want to own it and say, “Yes, I smoke even though I know it’s unhealthy just because I like to do it.” They want the excuse of ignorance, and Brown’s critique of health promotion is defending that position specifically.
Her final conclusion, Section 6, is simply that health promotion through education may not be as benign as it seems, due to the risk of moralisation. She doesn't conclude that the regulation method is necessarily better either, just that the ethical risks of any health promotion method should be evaluated. She says she would support "methods of promoting health that are efficiently (sic)," but she makes no suggestions.
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Thanks for the rec. It was certainly something. To anyone who read this far, thank you too for joining me in this look at the article.
Final thoughts on agency: Bar special circumstances, no one is force-feeding anyone. No one is physically forcing 70% of the American population to eat 3,000+ calories a day. This denial of agency and personal responsibility is a security blanket for people who just don't want to be upfront about valuing other things over their health and don't want to be made aware of the unhealthiness of their choices. The denial of personal responsibility is defeatism that discourages people from making an effort. In the end, all it does is line the pockets of Big Food, Big Pharma, and Fat Activism influencers. I don't think being unhealthy is a moral failing, but I do think the intellectual dishonesty of Fat Activism is.
Healthline's tips for food desert nutrition.
