On Friday I was in Ware talking to various local government leaders about behaviour change. I used the opportunity to elaborate on cultural theory and its four paradigms for social relations: the hierarchical, the egalitarian, the individualist and the fatalist.

To what extent, I asked, do behaviour change strategies in areas such as obesity, alcohol abuse, anti-social behaviour engage with these ways of seeing the world and acting upon it? Behaviour change as a concept is hierarchical, being as it is about people in authority deeming a behaviour to be unacceptable and then maintaining that, through the use of expertise and authority, they can solve it. But how, if at all, do these strategies engage individualism, egalitarianism and fatalism?

We discussed the ban on smoking in public places, which is widely seen as a success. I suggested that it had worked – in the sense that it has been accepted – because the hierarchical authority of health experts and policy makers had reinforced the egalitarian demands of non-smokers (made more powerful by evidence of the effects of passive smoking). Individualist pressures were balanced between smokers and non-smokers while fatalist smokers would stand out in the rain resigned to their status as social outcasts rather than mounting the barricades in defence of their habit. Whether the ban will work in its wider aim of reducing smoking is less clear. With pubs closing every day and, presumably, more people drinking and smoking at home it could be that the mixture of wilfulness and passivity among smokers will leave smoking levels only marginally reduced.

This discussion took place on the same day as the UK Organ Donation Task Force announced that it had decided against recommending ‘presumed consent’ for organ donation. Among the reasons given was the concern that this might lead to a backlash against the policy and doctors administering it. In cultural theory terms the argument here is that presumed consent could create egalitarian momentum as patients came to believe that they were vulnerable to being exploited by doctors.

Cultural theory argues that each of the four views of social relations gains its energy from its opposition to the others. Doctors have largely escaped the loss of public esteem and trust that has affected other authority figures. The legitimacy accorded to the medical profession means that their authority is not perceived as a hierarchical imposition so it has not generally provided the context for the emergence of an egalitarian or individualist opposition (although there have been critiques of medical practice from particular communities of patients). Given the mixed evidence of the actual impact of presumed consent on donation levels, the task force clearly felt that trust was too big a price to pay.

Gordon Brown seems to be considering overruling the recommendations but in recognising the limitations and vulnerabilities of policy based on hierarchical authority, and in urging greater commitment to the ‘clumsier’ solution of organised voluntarism, the Task Force may be offering wise counsel.

2 Comments on Smoking bans and presumed consent

west2 on Sun, 23rd Nov 2008 3:58 pm


“Behaviour change as a concept is hierarchical, being as it is about people in authority deeming a behaviour to be unacceptable and then maintaining that, through the use of expertise and authority, they can solve it. ”

Yet do they solve it? You mentioned the smoking ban. How has success been judged and by whom?

If you look at a history of smoking bans they are a failure. People still smoke and contrary to a possible marginal decrease in smoking as you say, in some countires with bans (Ireland for example) there has been an increase. What this lead to is calls for more draconian measures from the ‘authorities’ to justify their pronouncements.

Once the authroity changes so do the other aspects you mention.

So using your prisms, the hierarchical, the egalitarian, the individualist and the fatalist.

The hierachical maintains its view only as long as they remain powerful and in control.

The egalitarian can no longer claim that people are being treated equaly. The authority does try to invoke the message ‘level playing field’ which of course it isn’t. Not for business, where choice is restricted, people lose their jobs and pubs close. People are treated differently depending on ‘life style choice’. Clearly the egalitarian can no longer claim that individuals have the same rights.

The individual wants to avoid a criminal record and fines. Interesting that those in the illegal drugs market are not so concerned. They accept their place outside the law. The smoker is generaly law abiding and does fear being labeled a criminal.

The fatalist will adapt
Your comments about about the medical profession are interesting. Remembering in times gone past they too supported controlling governments and yet are seen as benevolent and apart. What will be the affect of this changing?

‘Presumed consent’ could well affect this. Though I suspect their reputation is declining anyway because of the support for measures to ‘help’ people make the ‘right’ choices.

The medical profession are advisors not policy makers and as such should tend the sick and leave politics alone, their ultimate reputation depends on it.

west
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Fritz Lickint on Sun, 23rd Nov 2008 9:07 pm


The smoking ban is widely seen as a success? I suppose if people listen to ASH it’s seen as a success. They always are successes for ASH. For the smokers who stopped going to pubs the ban was not a success. For the communities it broke up it was not a success either. But their voices and their opinions don’t count. They were not consulted.

And in what way are the demands of nonsmokers egalitarian? They wanted a ’smokefree’ environment, and that was necessarily a ’smokerfree’ environment as well. They – or rather the antismokers – set to out to expel the smokers, and to remove the equal rights they had formerly enjoyed. That’s hardly egalitarian.

And what evidence is there against passive smoking? There is none! It is a complete fraud. Most of the passive smoking studies showed insignificant near-zero risks. The medical establishment wasn’t really concerned about the ‘risks’ of passive smoking. They wanted to ‘denormalise’ smoking through a coercive piece of social engineering.

In the long run, the losers in this are going to be the anti-smoking medical establishment, as they come to be identified with a coercive healthism that first made its appearance, along with antismoking research and public bans and even passive smoking’ in – guess where? – Nazi Germany.

http://www.bmj.com/cgi/content/full/329/7480/1424

http://www.adl.org/Braun/dim_14_1_nazi_med.asp

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