PETER ALLMARK: 

 Abstract This article claims that health promotion is best practised in the light of an Aristotelian conception of the good life for humans and of the place of health within it. At least two philosophical criticisms are made of health promotion practice. The first is that some such practice offends against Mill’s liberty principle, that coercion should not be used against someone for his own good. The second is that health promotion promotes an ascetic rather than a good life.

I suggest that health promotion practice is vulnerable to these criticisms because of its flawed, objective view of health concepts, a view in which health judgements are taken to be facts about people. In fact, health is not a fact but a judgment. However, this should not lead us to adopt an entirely subjective view. I suggest that judgements of health can be grounded in Aristotelian views about the function of the parts of the human organism and ultimately in the function of the organism as a whole. That function is to live the life of a fully rational animal.

I defend the plausibility of this view and work through its implications for health promotion. These are that there may be occasions when beneficent coercion is justified (where an activity severely undermines the human function) and that health promotion can be practised in a way that promotes a good life.

Introduction:

This article claims that health promotion is best practised in the light of an Aristotelian conception of the good life for humans and the place of health within it. I begin by dividing health promotion practice into two main categories, persuasive and coercive. I then set out some criticisms that have been made of health promotion. Many of these are empirical; health promotion is founded on inadequate evidence. However, there are at least two philosophical criticisms. The first is that coercive health promotion offends against Mill’s liberty principle, that coercion should not be used against someone for his or her own good. The second is that health promotion promotes an ascetic rather than a good life.

These philosophical criticisms, particularly the second, provide support for the idea that health promotion needs to attend to conceptions of a good life. The article moves next to an examination of Aristotle’s conception; the good life for humans is one in which they function well. The human function is to live as a fully rational animal; this requires living in accordance with moral and intellectual virtues. This virtuous life is good human functioning and would be the best, happiest life to lead. I defend the plausibility of this account against three critical questions. The first is, why we should accept that humans have functions; the second, why we should accept that the human function has anything to do with what are customarily deemed virtues; and the third is
why we should accept that a virtuous life would be a good one for the individual. If an Aristotelian account of the good life is plausible, then the philosophical criticisms of health promotion amount to saying that health promotion does not help people to live such a life. Judging this claim requires first that we analyse the notion of health that is implicit in health promotion; what does health promotion promote? I suggest that it promotes an objective notion of health, one in which judgements of health and illness are taken to be facts about people.

This objective notion is very problematic. In line with others, I argue that health is not a fact; it is a judgement on the facts. However, this should not lead us to adopt a completely subjective account of health. An Aristotelian account of health is possible in which attributions of health, illness and so forth are judgements based ultimately on good human functioning. For example, someone is in good health when the various elements of their body perform their function well and thus contribute to the good functioning of the whole organism. I argue that this avoids problems with both objective and subjective accounts.

With an Aristotelian account of health and happiness in place, it is possible to turn to the philosophical criticisms of health promotion. The first criticism is that health promotion should never be coercive. I argue that good human functioning requires that people are able, in the main, to act in accordance with their rational choice. Even where their choices are flawed, people may move towards virtue through reflection upon them. In general, therefore, the Aristotelian account would support Mill’s principle.

However, there may be some choices that so undermine the human function that it would be best to prevent people from making them. The second criticism is that health promotion does not promote a good life. I argue that there is warrant in this criticism. A glut of epidemiological information results in its being possible for people’s choices to become focused on, for example, the health effects rather than the pleasures of food and sex. Someone focused in this way would seem to be displaying a vice (hypochondria or “healthism”). Furthermore, someone who lived entirely in accordance with health promotion advice would be living a lowrisk life. For many, such a life would be unsatisfying.

Health Promotion and Its Critics

Health promotion is generally considered an important element of health care and part of the role of health professionals; as well as returning people to health and palliating symptoms we should also be maintaining health, preventing people becoming ill in the first place. This seems sensible, particularly given that preventing illness is likely in general to be cheaper than treating it and that the suffering of being ill is avoided.

Health promotion practice can be divided into two main types, the coercive and the persuasive. Coercive health promotion exists where legislation enforces certain behaviour; this can be for the sake of society in general or for the sake of the individual subject to the legislation. Examples of the former include health and safety legislation protecting employees and legislation concerning disposal of waste. Examples of thelatter include drug legislation (prohibiting the use of some recreational drugs and limiting the use of other drugs to doctors’ prescription only), seat belt and crash helmet legislation, and fluoridation. Persuasive health promotion also takes many forms.

It may involve advertising and informing people about healthy diets, services such as “stop smoking” and screening clinics. It may also take the form of cajoling: for example, each time a smoker visits his doctor the latter may remind him of the wisdom of giving up. The criticisms made of health promotion policy can also helpfully be divided into two main types, the empirical and the philosophical. The empirical criticisms are based upon the belief that many interventions performed in the name of health promotion are either of dubious benefit or of uncertain harm-benefit balance [1]. Skrabanek complains that “preventive medicine” is performed in an “ethical vacuum” wherein its interventions are not scrutinised as they are in the rest of health care [2]. However, my concern is with two philosophical criticisms of health promotion policy; these criticisms remain even where the policy is empirically well grounded.

The first philosophical criticism relates to coercive measures, particularly those that coerce the individual for her own good (for example, by preventing her taking some recreational drugs). Such measures clearly violate Mill’s liberty principle, which states that “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant” [3]. From this standpoint, critics say that adults should be free to choose what risks they
take with their lives. Thus, if, say, they choose to ride motorbikes without crash helmets and so forth that should be up to them [4]. The second philosophical criticism is rarely stated explicitly [5] although it is inherent in jokes about how miserable it would be to follow all health promotion advice (“You wouldn’t live longer but it would feel that way”). In other words, health promotion promotes an ascetic rather than a good life.

Taken together, the philosophical criticisms give purchase to the idea that health promotion policy should have an eye to what constitutes a good human life and the place of health within it, particularly its place when set alongside other things of value, such as liberty. In the Nicomachean Ethics Aristotle develops one account of the good life for humans. Aristotelian virtue ethics has undergone a renaissance since the publication of Anscombe’s well-known article in 1958 [6] and has since been turned to areas of controversy in bioethics [7]. This gives credence to the attempt to turn an Aristotelian eye to the philosophical criticisms of health promotion. The first step in this process is to set out Aristotle’s account of the good life.

Aristotle’s Account of the Good Life

At the heart of Aristotle’s conception of the good life is the idea that the morally good life is also the life that is best for the individual. To modern eyes this seems odd. Most of us would have little problem conceiving of a wicked individual who leads a life that is good by his own lights (such as a successful gangster). However, this is not simply amodern (or post-modern) idea. Aristotle’s conclusion may well have seemed strange to the Greeks. Consider the following statement: I say that justice or right is simply what is in the interest of the stronger  party . . . in enacting . . . laws they [the government] make it quite plain that what is ‘right’ for their subjects is what is in the interests of themselves, the rulers, and if anyone deviates from this he is punished as a lawbreaker and a ‘wrongdoer’ [8].

This was said not by Nietzsche but by Thrasymachus in Plato’s Republic. Aristotle was well aware of the view that living morally has nothing to do with living well and he engages with these views. In particular, he tackles the view, widely held in the modern world, that the good life consists in a life devoted to, and successfully attaining, pleasure. Aristotle’s starting point is that when human beings choose to act they see some good in the action. This good is either intrinsic (as when choosing to eat chocolate) or instrumental (as when travelling to work) or a combination (as when playing a sport both intrinsically for pleasure and instrumentally for health). If there were some overarching good at which all these choices ultimately aimed then it would be helpful to know what
it was. Aristotle claims that there is one such overarching good, happiness (in the sense of a happy, flourishing life) [9]. All of us choose what we do with the ultimate end of a happy life in view.

 

Thus, we may eat chocolate because we view that as constitutive of a happy life, we may go to work because we view it as instrumental to one. However, this does not take us far. Happiness is agreed as the final end in nominal terms only; there is widespread disagreement as to what it consists in. Some candidates, such as making money, can be dismissed because they can only be instrumental ends. But a number of plausible candidates remain. Perhaps the most common view is that happiness consists in a life containing as much pleasure and as little pain as possible
(hedonism). A less common view is that it consists in a life devoted to morally good works (such as charitable activity) or in a life of study and understanding. A fairly common view is that a happy life will be one that combines a number of ends-in-themselves.

To try to take the argument further, Aristotle switches tack. Instead of asking what is a good life for people to lead he asks what makes something a good example of its kind. This leads him to the function argument [10]. For things with a function it is clear what makes them a good example of their kind; they possess qualities that enable them to function well. For example, a good flautist will possess musicality, perseverance and dexterity. These qualities are termed virtues. A good flautist’s (qua flautist) life will be one in which he performs this function well. It follows that if people were things with a function then a good human life would be one in which they functioned well, that is, a life in which they exercised human virtues. Now it happens that we already possess the idea of a good person and of human virtues. Thus we might say someone is a good man because he is kind, courageous, thoughtful and so forth. So perhaps we may conclude that the good life for
humans is the one lived by virtuous people. Aristotle concludes the function argument saying, “the human good turns out to be activity of the soul in accordance with virtue” [11].

This looks implausible for at least three reasons. First, why should we accept that people have functions? Second, even if people were things with a function, why shouldwe accept that the qualities we have come to term virtues have anything to do with that function? Third, why should we think that living in accordance with virtue would be a
good life for the person who lives it? Let us take these in turn.

i) Are People Things with a Function? We can make sense of Aristotle’s argument if we draw upon arguments from the wider Aristotelian corpus [12]. Human beings are natural kinds (like plants and other animals). We understand the behaviour of natural kinds teleologically. In other words, we understand them as having within them a source of change and staying unchanged. For
example, we understand an acorn in terms of some of the changes it may undergo.

Now, of course, an acorn can undergo many changes; it can become food, mulch and so forth. Very rarely will an acorn develop into an oak tree. Yet this is the change in terms of which we understand it. An acorn contains within it the potential to become an oak tree. Thus, of all the things an acorn can become, we identify this potential as its defining potential. Aristotle termed this its essential potential or property. Hence we understand natural kinds in terms of their essence. And the function of a natural kind is to realise its essential properties (as the function of an acorn is to become an oak tree). Viewed in this way, a human being is a natural kind with essential properties and, therefore, the function of realising them. What, then, are humans’ essential properties? To answer this, Aristotle uses an eliminative argument from uniqueness. He looks for the properties possessed by humans but not by other natural kinds. He says that what defines humans is that they are rational animals.

Hence they grow (like plants), have appetites (like animals) but have rational desire (uniquely). Thus, the essential properties of a human being are the changes he goes through in becoming and living the life of a fully rational animal; and the human function is to live the life of a fully rational animal. If this were the human function then the virtues would enable us to fulfil it. This leads us to our second question.

ii) Why Should We Accept That the Qualities We Have Come to Term Virtues Have Anything to Do with Our Function?
Aristotle argues that what we term virtues do indeed enable us to fulfil our function. He does this by discussing a number of virtues case by case and showing how they exemplify good reasoning. He says that there are two types of virtue, moral and intellectual. Moral virtues are to do with our ‘animal’ side. Like animals we desire food, warmth, drink and so forth. The moral virtues ensure that we desire these to the right extent as determined by reason. The intellectual virtues are to do with our essentially human side, that is, reason itself; they ensure we reason well. The key intellectual virtues are practical wisdom, which is concerned with right action, and intellectual wisdom, which is concerned with right beliefs and understanding. In that we possess the intellectual virtues we shall be fully rational; in that we possess the moral virtues too we shall be fully rational animals. Whilst it is obvious that intellectual virtues are necessary for one to live as a fully rational animal, an example might help show how the moral virtues do so also. Courage is concerned with the emotion of fear and the related desire to avoid danger. We tend to think of this virtue
simply as being displayed in someone who is willing to take risks with his well-being.As such, the connexion with reasoning is not obvious. However, consider a situation where a driver sees a young child running around the central reservation of a motorway. He stops and runs across the motorway to take hold of the child. Such an action seems courageous. Consider a second situation where a driver stops and runs across the motorway in order to retrieve a newspaper he has just seen there.

This action seems foolhardy, not courageous. Yet this driver has taken exactly the same risk with his well-being; however, he has done so for a trivial reason. This shows us that courage is not simply about taking risks, but about taking risks for the right reason. In a similar way, temperance is not about avoiding bodily pleasures but rather about enjoying them appropriately; the enjoyment of wine is not incompatible with a good human life, but alcoholism is. Thus when we have virtues we act in the right way for the right reasons, that is, as practical wisdom dictates.
This is why moral virtues are (very closely) linked to our function of reasoning well.

However, it might be said, courage can harm our well-being. The courageous driver may be hit and killed. The cowardly driver will live to enjoy his life. This takes us to our third question. iii) Why Should We Think That Living in Accordance with Virtue Would Be a Good Life for the Person That Lives It? A critic might accept Aristotle’s account thus far but object that the good life
he defines will not necessarily be subjectively good. An individual might be better advised to forget virtue and pursue pleasure if he wishes a happy life. We know that, for example, there may be such a person as a “good prostitute” [13] who possesses prostitute-virtues; but we would certainly not think it morally good for her to possess these virtues or to live the “good prostitute” life. Thus, it is not necessarily morally good for someone to be good at performing a function.

However, the prostitute example is telling. It is not good for the prostitute to be a good prostitute precisely because such a life is a bad life for a human; the role of being a prostitute conflicts with her human function, it is not the life of a fully rational animal. Furthermore, Aristotle does believe that life will, for the most part, go well for the virtuous agent; it will be the most pleasurable life open to her. This is for two reasons.

The first relates to the role of pleasure in animals. Things that are pleasant for animals are, in general, instrumental to, or an intrinsic part of, their good functioning. Animals desire food, for example. However, in humans this sometimes breaks down. The prospect of pleasure tempts us into wrong-doing, such as over-indulgence in food and alcohol, or infidelity. This breakdown occurs because human beings can have two types of desire that may conflict. For example, they can have non-rational desires for excessive food but a rational desire to maintain a healthy weight. Possession of the virtues ensures that this conflict does not occur; the virtuous agent desires only what accords with reason. A life without such conflicts is likely to be more pleasant than one
that has them.

However, a hedonist may object here; why should it not be rational to desire excess? It seems perfectly possible to enjoy a life of over-indulgence in one or more of the so-called vices. This leads us to the second reason that life will generally go better for the virtuous agent: because of the unity of her desires. We have already seen that thevirtuous agent will not suffer the conflict between rational desire and non-rational desire that many of us do. The hedonist has responded that he will not suffer this conflict either; he will desire excess because he believes it right to do so. He will aim only for what pleases him, with no thought to morality; will not this be a happy life? However, Aristotle suggests that such a person “wishes these things had not become pleasant for him; for bad people are full of regret” [14]. The problem for the hedonist is that there is no reason to expect his non-rational desires to form a unity. He may have an appetite to eat to excess, and to be excessively promiscuous, and to drink too much.

He may also want to do this over a full life and so make rational choices to defer current pleasures in order to protect future ones. All such non-rational desires could lead in different directions. The obesity and illness caused by eating and drinking too much may sabotage plans to be promiscuous; the non-rational desires for pleasure now could sabotage desires for long-term pleasure. And in both cases the sabotage could work the other way; the vicious agent may have to give up drink to pursue sex, for example. The point is that he has no basis for deciding between competing desires or on which to develop a coherent set of desires.

A vicious agent could realise that he suffers these conflicts and decide to reduce the number of non-rational desires that make up his vision of the good. He could prioritise making money and drinking, say. But this agent seems to have developed a bizarre form of stoicism in which he has minimal desires and, therefore, the minimum risk of conflict between desires and of the non-satisfaction of desires. This ascetic criminal is a rather comic figure because the rational basis for his choice of life-style is in conflict with its original source. He sought satisfaction of non-rational desires, yet the only way to achieve this consistently is to forego them. Thus, whether the vicious agent is the controlled ascetic, or the uncontrolled hedonist, he will suffer conflicts and regrets.

I conclude, therefore, that Aristotle’s advocacy of a life of virtue as being the best life for humans is not implausible; for the most part, our lives will go best if we develop the human virtues.
We may now turn back to the philosophical criticisms of health promotion with which this article is concerned. These criticisms can now be reformulated. They are that health promotion does not promote the life of a fully rational (virtuous) agent and that coercive health promotion inhibits choices that would in some way enable people to live such a life; health promotion measures either inhibit a happy life or promote one that is not happy. Tackling these criticisms requires a deeper look at the notion of health inherent in health promotion and at its place in a happy life. Here we are seeking the answers to two questions: first, is the notion of health upon which health promotion is founded a sound one and, second, does health promotion promote health to the right degree, that is, does it place the correct value on health vis-à-vis other components in a good life?

Health: Objective, Subjective and Aristotelian Accounts

Accounts of health, illness and disability (henceforth, “the health concepts”) can be broadly categorised as either objective or subjective. Objective accounts view health concepts as facts about a person; someone is ill or disabled in the same way he may be blond-haired or have certain sized feet. Attribution of a health concept, such as illness,is a matter of discerning the relevant facts rather in the way that a mechanic can diagnose a problem with a car [15]. By contrast, subjective accounts suggest that value judgements play a large part in the attribution of health concepts. Someone with identical physical or behavioural characteristics might be deemed ill in one situation but not in another; the difference will lie in the value judgements of those making the attribution.

Subjective accounts can be political in nature, emphasizing the power of some people over others in making these attributions (particularly in relation to ‘disability’ and ‘mental illness’). They may also be ‘holistic’, emphasizing the importance of taking into account the subject’s own view when attributing a health concept to her. In general, objective accounts of health hold sway amongst health care professionals [16]. They view health and illnesses as facts and themselves as experts in discovering (or diagnosing) these facts. Most doctors would feel it entirely appropriate to reach a
decision that there is ‘nothing wrong’ with a person who claims that there is.

This objective view is reflected also in health promotion policies. Health promotion is founded on the idea that there is such a thing as health that can be attributed to someone with low blood pressure, psychological stability and so forth. It is also founded on the idea that the population can be made ‘healthier’ through policies. However, objective accounts of health concepts are seriously flawed [17]. They are based on the idea that the various elements of the body have functions. For example, the red blood cells have the function of tissue oxygenation, the white cells are part of the immune system. Illness occurs where something occurs causing failure of function of some part: “illness is centrally a matter of biological dysfunction” [18].

Disability exists where some functional element is absent, such as a limb or the sense of hearing (although the border between illness and disability may not be always clear-cut). Health is negatively defined as the absence of illness or disability. There is a suppressed assumption in the objective accounts that there exists such a thing as normal functioning of the elements of the body. Human beings differ greatly in the way their bodies function, such that it is only possible to talk of normal functioning in terms of a range. This idea is familiar to health professionals in blood test
results; these are sent from the laboratories with a ‘normal range’ alongside — we are  concerned only when the result falls outside this range. However, what is it that makes a range normal? An objective account seems committed to the idea that it is some kind of statistical normality; for example, that 95% of people will fall within this range. But there are many objections to this.

i) Some functioning that is statistically abnormal is welcomed rather than called illness or disease. For example, we welcome hypolipdaemia but not hyperlipidaemia. Both are abnormal but only the latter is termed an illness; similarly, very low intelligence is termed a disability, very high intelligence is not.

ii) Some normal functioning is treated as an illness; tooth decay and male hair loss are statistically normal, but are treated nonetheless.

iii) There is controversy over whether some abnormal functioning should be treated as illness. Homosexuality has been termed a mental illness in the past. There are also those who claim that disability is not a flaw in the function of the individual but rather a flaw in the way the individual is viewed by society. For example, mental illness has been dismissed as myth [19] and deafness has been claimed to be a different culture mislabelled as disability [20].iv) At the very least, some elements of illness are irreducibly subjective and unrelated to proper functioning. If someone is suffering chronic pain then she is ill whether or not there is a biological explanation for this.

These objections seem devastating to objective accounts; illness and disability are not facts about someone but rather a value judgement on the facts. This gives purchase to subjective accounts that emphasise the social construction of health concepts. Very often the evaluative element in the attribution of health concepts is missed because the values are very widely shared. For example, lung cancer is associated with things all of us disvalue, such as pain, breathlessness and a shortened life span. As such, there is no controversy in terming this an illness; but this should not blind us to the fact that it is, nonetheless, a judgement based on values.

The key problem with the subjective accounts is that they leave the diagnostic process rudderless. There does seem some truth in the idea that, say, a dearth of white blood cells is a serious malfunction that is appropriately deemed illness. If we move entirely to the subjective position then where there is disagreement over whether or not someone is ill there seems no solid basis from which to settle this. Thus if someone is nominally severely depressed but denies this then how are we to justify treating him? Or, if a woman wants to have IVF to select a deaf child, or wants to take medication in order to render a hearing foetus deaf, why should we deny her this choice?

However, an Aristotelian account of health concepts can be given that does not fall foul of the problems with either the subjective or objective accounts [21]. This Aristotelian account centres on his concept of the function of natural kinds. We have seen that, for Aristotle, the function of a natural kind is to realise its essential properties and that the human function is to live the life of a fully rational animal.

From their embryonic stage, humans may become babies, then children and then adults. During that time they may develop their rational capacities and they may develop the virtues; they will enact plans, react to events and develop understanding. In doing this they will, to a greater or lesser degree, realise the essential properties of a human and, therefore, fulfil the human function. In realising this function, the elements of the human will also have their functions; for example, the function of the eye is to see. Illness or disability will exist where the elements do not perform their
function either properly or at all. On the face of it, this looks like the objective accounts. The difference is that the objective accounts state that the elements have a function per se. Such accounts miss the evaluative element involved in, say, deeming a condition an illness. The Aristotelian account grounds the function of body elements in the overall function of the
human. Thus, red blood cells have the function of oxygenation and this serves the function of living as a fully rational animal; their failure to perform this function impedes such a life.

(Good) health exists where the various elements of the human being perform their function in such a way that they present no impediment to that person performing her function. Illness and disability exist where there is failure of one or more element fully to perform its function. Disability is usually a matter of the absence of some functioning part whilst illness is impediment of some functioning part. This does not fall foul of the problems that attach to objective accounts, since the ultimate ground upon whichthe attribution of health concepts is based, that is, happiness or a good human life, is evaluative. We judge what such a life consists in. Thus we can see that hyperlipidaemia threatens happiness and hypolipidaemia does not. Neither, though, does the account
fall foul of problems that attach to subjective accounts. Take the case of a manic person who says that on her judgement she is happy, she is fully rational.

 

An Aristotelian would respond that this evaluation is wrong; it is possible to be mistaken in one’s value judgements. Only a virtuous agent leads a fully rational life; a vicious agent doesn’t because of character faults; a manic agent cannot because of a serious problem in the functioning of some bodily element, a mental illness. Many people will balk at this [22]. Who is the Aristotelian to say that one person is correct and another not in the realm of value judgements? There are at least three Aristotelian responses here.

i) In the first place, there is a wide range of value judgements that are almost universally shared. Death is abhorred unless there are overwhelming grounds to embrace it. Similar points can be made in relation to many health related concepts such as pain, breathlessness, immobility, nausea, emotional pain and so on. As Megone (citing Roger White) puts it, in the absence of some special reason it is better not to be ill [23]. Someone who denies this can reasonably be thought in error.

ii) We do impose our value judgements on others; in effect we declare them to be in error. Mental health is an example. The manic person described above may have treatment imposed upon her. She may also be absolved from responsibility for her actions whilst ill. Subjective accounts are forced to conclude that such treatment is unreasonable (as Szasz believes), but this will be unacceptable to most. Objective accounts are untenable. Thus it is only the Aristotelian account, which says there is such a thing as correct evaluative judgement in relation to human functioning, that can explain why forced treatment is sometimes reasonable.

iii) Asserting that there are correct value judgements does not imply that there is a body of people who know the truth to whom the rest of us must acquiesce. Whilst Aristotle thought that most people were not fully virtuous he did think that most of us have a handle on what is good [24]. The development of our values includes a process of discussion. There is a wide range of areas of agreement on values. There are also controversial areas. Whether or not deafness is a disability would be one such area. However, whereas subjective accounts can only say there is a difference
of values here, with no further method for resolution, the Aristotelian is able to describe the turf a little better. Essentially, the key question will be whether or not deafness is per se an impediment to living the life of a fully rational animal.

At this point it might be objected that this account describes only mental illness and disability. It is perfectly possible to be physically ill and yet live a fully rational life. At least two responses are possible here. The first is that serious physical illness does impair living a fully rational life: pain and nausea impede our ability to engage in activities that fully engage reason. The same applies to a degree to lesser physical illnesses, such as headaches. The second is that the function of the various parts of the human organism is to contribute to the function of the whole: the fact that an individual might be able to compensate for a malfunction of a part (such as the loss of a limb) does not obviate the fact that the part is not making its proper contribution to the whole. (For this reason, I am inclined to the view that deafness is a disability.)A further objection might be that this “impediment to function” definition of illness
would declare too many things to be illnesses. For example, wouldn’t serious poverty and hunger impede the fully rational life, or possession of a vicious character? Are these illnesses too? In response, Aristotle would accept that serious poverty might indeed impede the fully rational life: a virtuous but seriously poor person could be rendered unhappy by that poverty [25]. However, the poverty is not a malfunction of some part of the organism of the agent who suffers it: that is why it is not an illness.

Turning to vice, Aristotle would certainly accept that this impedes the fully rational life. However, this is a malfunction of the whole person, not a part of it. And, whereas illness is something that lands upon someone against her will, vice is something she freely chooses. As such, a vicious agent could be perfectly healthy — there are no barriers to her good functioning save her own character: vice is not an illness, it is a character fault.

At the end of the previous section, two questions were asked. The first was whether the notion of health upon which health promotion is founded is a sound one. In that it is based on an objective account of health, it is not. As such, health promotion policies will tend to discount the evaluative element in the attribution of health concepts. Health promotion proceeds as though health were a factual state that it is the job of health professionals to create in as many people as possible. I have suggested this is problematic. Health is an evaluative state founded ultimately on our judgements about what is a good life. To ignore this is to risk seeing health as a state isolated from the whole of human well-being and to leave oneself vulnerable to the philosophical criticisms with which we began. This becomes clearer when we consider the second question asked at the end of the previous section: does health promotion place the correct value on health vis-à-vis the other components of a good life? In other words, does it promote happiness?

Does Health Promotion Promote Happiness?

This brings us back to our two philosophical criticisms of health promotion: that it sometimes violates Mill’s liberty principle and that it does not promote happiness. The liberty criticism is, in fact, an element of the happiness criticism. Mill is a utilitarian and from that viewpoint the importance of liberty lies in its contribution to happiness.

Liberty enables the individual to perform experiments in living. Through these, he is able to find his true self (what Gray terms, the individual’s quiddity [26]) and what is satisfying to that true self. Attempts to coerce the individual for his own good, beneficent coercion, are likely to diminish his happiness for two reasons. The first is that coercion diminishes the individual’s scope for experimentation; the second is that those doing the coercing will almost never have the insight into someone’s quiddity that the individual himself has.

For Aristotle, the value of liberty (or, better, autonomy) lies in the way that through its exercise one may either be or become virtuous. Virtue involves doing the right things for the right reasons. Thus, if someone foregoes getting drunk not because he sees the value in sobriety but only because he is unable to get drink then he is not acting virtuously. It follows that coercion is unlikely to help the non-virtuous to become virtuous. Aristotle believes character change to be possible [27]. He repeatedly stressesthe importance of habituation in moral development [28]. To become virtuous the agent must learn habitually to choose well and to take pleasure in that choice.

One method of habituation might be repeatedly to force the agent to do the right thing. The problem with this is that repeatedly acting well faute de mieux is not the same as repeatedly choosing well. Reason is not involved in the former, therefore full rationality may not develop. Forced training undermines the very capacity for critical self-reflection that is required for someone genuinely to change.

Thus, for both Mill and Aristotle, coercion is unlikely to promote happiness. The liberty principle is sound. However, there are possible exceptions to this general rule from an Aristotelian perspective. In the first place, both Aristotle and Mill would permit the use of force to prevent one person’s harming another. This might justify some health promotion measures, such as health and safety legislation, road safety laws and banning smoking in public buildings. However, this leaves a number of coercive measures that seem to be aimed specifically at helping the person coerced; fluoridation and drug legislation are examples. These seem clear violations of the liberty principle. There is, I believe, a possible Aristotelian justification for some of these measures.

For Aristotle, the good life consists in living as a fully rational animal. In general, this requires autonomy so that one may develop and exercise moral and intellectual virtue. However, some autonomous action may be so undermining of rational activity and, therefore, happiness that society may be justified in preventing it. Examples may include the suicidal gestures of young jilted lovers and the ingestion of highly toxic and addictive drugs, such as crack cocaine. Society may also be justified in banning activities whose risk greatly outweighs any plausible benefit, such as riding motorbikes without wearing crash helmets. Such beneficent coercion will always be controversial.

Doubt may be expressed over whether some activities are indeed harmful enough to health or happiness to justify a ban: prostitution and the use of soft drugs are examples. The point is that an Aristotelian approach explains the grounds for such a ban. In doing so, it also describes the ground for discussion of whether such bans are appropriate [29].

Fluoridation is a different type of intervention. Here a collective decision must be made; either there will be fluoride in the water or there will not. Some people desire it; others do not. It follows that one group is bound to impose its will on the other. This seems to be a matter of justice, of how one should choose between conflicting claims in society. As such, it is beyond my scope here.
Let us turn, then, to the second criticism, that health promotion does not promote a good life. In other words, would someone who followed the edicts of health promotion be contributing to her own happiness in so doing? Much health promotion that is focused on individual behaviour concerns activities related to bodily pleasure. It enjoins people to refrain from things they may find pleasant, such as sex, drinking alcohol, taking drugs, sun tanning, eating, smoking and indolence, or to do things they may find unpleasant, such as exercise and eating vegetables. The virtue concerned with bodily pleasure is temperance. One can fail to be virtuous in two ways in this realm.

The first is over-indulgence, or intemperance; the second is under-indulgence, or asceticism. From an Aristotelian viewpoint, the second criticism implies that health promotion advice promotes not the virtue of temperance but the vice of asceticism. However, thisdoes not seem to be the case. Temperance involves enjoying bodily pleasures to the right degree and for the right reasons:
. . . things that are pleasant and conducive to health or vigour [the temperate person] desires in a moderate way, as is right, and other pleasant things as well, as long as they are not incompatible with health or vigour . . . [30].

An ascetic would not enjoy moderate alcohol and so forth, but a virtuous agent would. And this seems to be precisely what health promotion is advocating. However, a note of caution is warranted. In Aristotle’s day there would have been little epidemiological information; the vast majority of day-to-day activities would have been “not incompatible with health or vigour”. That is no longer the case. It would now be possible to make many life choices with a view to their effect on long-term health. What we eat, drink (alcohol, caffeine, etc.), what job we do, where we live,
whether we marry, whether we wear a shirt in the sun, how and where we choose to travel; all such choices can be informed by epidemiological information. Arguably, though, were we to make choices in this way, with health as a primary focus, we would not live a happy life, for at least three reasons.

First, if one’s choices concerning, say, food and alcohol, are made primarily with a view to health then one is no longer enjoying these things as pleasant, but rather experiencing them as medicine. Second, someone who behaves in such a way is probably not displaying the virtue of temperance but rather the vice of hypochondria (which is, perhaps, a form of cowardice). LeFanu describes this as “healthism …a medically driven obsession with trivial or, more often, non-existent, threats to health” [31]. Third, Aristotle tells us that if we are to be happy we should develop virtue.

However, it seems reasonable to think, in line with Mill’s notion of quiddity, that each virtuous agent will find enjoyment in different ways. Both rock climbing and chess require great intellectual involvement and thus fit the notion of a higher (intellectual) pleasure; but the former is not consistent with the “low risk” strategy of health promotion. Some people will take a different view on risk and will find happiness in activities that are inconsistent with health maximising. I suggest, then, that some ‘one size fits all’ health promotion advice is flawed. For example, it would not be unwise (that is, incompatible with virtue) for an agent, faced with the information that eating a diet low in fruit and vegetables doubles her risk of bowel cancer, to decide, nonetheless, to persist in doing so. Nor is it necessarily unwise to indulge in rock climbing or other dangerous sports. On the other hand, it is probably unwise to drink, say, 100 units of alcohol a week, or to be addicted to crack cocaine, as these seem incompatible with living the life of a fully rational animal.

Conclusion

Those who say that health promotion does not promote a good life have some justification. Much of the problem arises from the objective view of health on which health promotion policies are founded. This leads to a view that insofar as people are rational they will have similar attitudes to the place of health in a good life. A contrary, subjective view would deny this, but at the cost of losing any notion of reasonable behaviour in relation to health at all.

The Aristotelian account of health and happiness retains the objectivist notion of the good functioning of bodily elements as intrinsic to health but grounds it in the evaluative notion of happiness. As such, it is able to allow that there will be disagreement at the edges over the appropriate balance of risks in a happy life whilst also allowing that there is a generally agreed notion of what constitutes good health. It is upon this notion that health promotion policies can reasonably be grounded. In general, such policies should be informative only; rarely, coercion too may be justified.