Tag Archives: health

A body politic – the right to make live and let die

Most political geographers would get the allusion of the title. The first part is to the 17th century world of sovereignty, rights and social contract theory of Thomas Hobbes. For Hobbes peace would be secured when “a multitude of men, united as one person by a common power” choose to covenant their individual power to the ‘body politic’ by relinquishing some of their rights to a sovereign (the right to make war or take life for example) [see Hobbes 1640, Chp XIX, para 8].

The second part references Michel Foucault’s biopower where the claim to legitimacy by ‘the state’ is based on the guarding and fostering of productive life (see Foucault “Society Must Be Defended, Lectures 1975-76”, page 241) and the commensurate extension of state control over the biological. Foucault argued that in modernity man’s existence as biological (in contrast to legal or political) beings becomes the target of state strategies (biopower). He distinguished two forms of biopower: anatomo-politics and biopolitics – the former targeting the individual subject, the human body, the latter targeting man as a collectivity, the population as a body politic.

Donor Card

Concern with life and death of the individual and population comes to the fore in the questions around organ donation, revealing tensions between the body-politic and the politics of the body .

Defaults, organs and the state

Sadly it is statistically likely that three people in the UK died today awaiting a suitable donor.

As Rhys, Jessica and Mark noted in their article “Geographies of Soft Paternalism”, published earlier this year, “organ donation has become an intensive site for soft paternalist policy experimentation […] One classic tool of soft paternalism [that] has been controversially proposed as an ultimate solution to organ donation shortfalls: the re-setting of the organ donation default.” [draft for Geog Compass viewed here]

In the UK this default is based on the notion that the body is gifted, that is it is voluntarily made available for use after death through an act of conscious choice. So we have an opt-in system where people choose to enter their names on an Organ Donor Register. Doing so is simple, via phone, online or at various sites that we all visit such as the doctors surgery. Yet despite the ease and our consistent collective affirmation that organ donation is a good thing and we would like to be an organ donor in reality only about a quarter of us have done it. This coupled with increasing surgical advances, problems of organ compatibility, and the increase in demand (as life style related conditions like diabetes, liver and heart disease continue to rise) has seen year on year repeated headlines about soaring waiting list times.

Switching to a system based on ‘presumed consent’, (where the citizen is entered onto the register and has to opt-out of it) has been debated in the UK for years. It is common in much of Europe and seems to result in higher donor rates but local and cultural factors may be equally significant.

In nudge terminology this is changing the default option, a powerful tool for changing behaviour because the default position is what happens when you have a choice but choose to do nothing. The rationale for the presumed consent default is that numerous surveys show wide public support and a willingness to be entered on the register of organ donors but that that support is not reflected in the number who actually make the effort to place themselves on it. Why this is the case is varied, with the failure to follow through on stated preferences ranging from irrationality and insecurity – that doctors will not work as hard to save a patient, or an aversion to thinking about ones own death – to simple inertia – people are not motivated enough to enact their preferences by seeking out a means of entering their name on the donor register

But messing with the body, or more precisely the corpse, is a provocative act that turns the body into a site of contestation between state and citizen. In particular some argue that subtle changes in the default position like this reflects the over-reaching of the state and people’s loss of control over their own bodies following death. Indeed in the absence of actual consent the autonomy of the individual, the patient, is undermined. As such changing the default for organ donation raises fundamental questions about legitimate state action and personal freedom.

One of these was pointedly raised by the Archbishop of Wales in his Presidential Address to the Governing Body of the Church in Wales last month when he argued:

Archbishop Barry Morgan

There is, in presumed consent, a subtle or perhaps not so subtle change of emphasis in the relationship between the individual and the State.  That is, that unless we have opted out, our organs belong to the State and the State has the right to do with them as it wills.”

His comments, which echo those of a number of other faith leaders, came following the announcement by Health Minister Lesley Griffiths last month that Wales would introduce what they call a “soft opt-out” system (a White Paper outlining the proposals is imminent). This presumes consent unless the deceased has stated a contrary view or the family object.

This stands in contrast to the Coalition Government policy which has opted for Richard Thaler’s archetypal nudge of using ‘prompted choice’ to encourage organ donation. When you register online for a new drivers licence, you are required to complete a question about organ donation. The freedom of choice remains absolute (you can answer : yes, no or “not yet”) except in so far as the citizen is required to express a choice about organ donation in order to continue with their online driving licence application

In other parts of the world experiments with incentivisation schemes are being tested. For example, Israel and Singapore are experimenting with a ‘priority allocation’ system where those already on the organ donors register are given priority on the waiting list should they need a transplant. In similar vein the Nuffield Council on Bioethics has recently suggested the state might pay the funeral expenses of the deceased who donate their organs (and rejected changing the default to an opt-out scheme).  Spain, which has the highest rate of organ donation in the world (nearly 3 times that of the UK), also has a soft opt-out system. But a key factor in its effectiveness seems to be an emphasis on “procurement” with specially trained hospital staff who will always approach relatives of the deceased to ask about donation.

The body-politic is a complex beast. Changing the default is not necessarily a panacea in itself, indeed it is far to simplistic to look at a nudge policy (like opt-in/out) in isolation and anticipate or attribute a population wide outcome to its implementation.

And this debate about the use of behavioural insights to influence what we do with our decaying empty vessels also reveals something about the governmental rationality of this ‘nudging’ by the state. It has consequences that extend beyond the seemingly party politically neutral target of the intervention. In this case the choice of ‘nudge’ may shift in un-noticed but fundamental ways the relationship between the state and citizen.

For the body-politic the covenanting of rights after death to the ‘head’ of that body – the government – may prove an exercise in biopower, of making live and letting die that provokes some serious soul searching by both state and citizen.

Whilst personally on balance I find pragmatically I agree with an opt-out system for Wales I can’t help but be a little wary of what it means for the body politic. Does an opt-out system extend the reach of the state too far into our private lives and deaths? Does it force on us the relinquishing of further rights to the state? Does it, in Foucault’s terms, reconstitute the citizens body as a subject of the state?



Libertarian but not Paternal: Reflections on the UK’s New Public Health Service

For some time now we have had a strong sense that soft paternalism is less a distinct set of political practices and more a collection of tools for behaviour change that can be taken in very different political directions. Thus, while David Cameron and George Osborne’s pre-election statements clearly indicated that if elected they would deploy nudge-style techniques in their administration, it was far from certain exactly what type of politics this would lead to. As more and more statements and policy directives start to emerge from the Coalition Government it is becoming easier to discern what soft paternalism may come to embody in British politics over the next five years.

Perhaps surprisingly, it is Andrew Lansley, the Coalition’s Secretary of State for Public Health, who has been most active is revealing the key characteristics of the new government’s version of soft paternalism. In a recent speech to the UK Faculty of Public Health Conference on the 7th July 2010, Mr Lansley set out his vision of behaviour change policy in the field of public health. This speech confirmed two things. First that government clearly intends to deploy soft paternalist tactics within its health sector reforms. Second, that it has a very specific neo-conservative take on what soft paternalism means.

It is clear that Andrew Lansley, and like minded coalitionists, feel that the particular brand of soft paternalism practised by the previous Labour government (whether it be in the form of school meal reforms or the Change4Life programme) was simply too paternalistic. Ironically reflecting on the inability of his government to pass the “Elimination of Obesity Act 2010,” Lansley outlined a paradigm shift in health policy that would invoke the power of local communities to generate and sustain the structures cultural change that health reform really needs.

While there are many sensible suggestions made within Lansley speech, one cannot help but feel that it represents another, thinly veiled, assault on the welfare state.  The role of the state within health care provision is problematised by Lansley on at least three front: 1) in the wake of public sector spending cuts we can no longer afford a heavy-handed state bureaucracy meddling in public health issues; 2) that the “nanny state” is actually not very adept at changing personal health conduct; and 3) that sometimes state intervention can make the public health situation worse (the example used here is the way in which social marketing campaigns against drinking, smoking and obesity can actually normalize these problems not stigmatize them).

Taking these points in isolation, I have to admit that there are some important issues raised here. However, when they are placed alongside Lansley’s alternative behaviour change solutions to public health reform, anyone with a belief in “progressive” brands of soft paternalist (as I have) may start to feel a little queasy. In the wake of a failing state, we are presented with less public funding for healthy living campaigns (like Change4Life), the threat of disbanding the Food Standard Agency (Ramesh, The Guardian, 12 July 2010), and an increasing role for the food and drinks industry in public health support. Perhaps the most worrying insights into what the New Public Health Service may look like, however, came in related statements made by Lansley (reported in the Telegraph, but not documented in the official manuscript of his speech). We thus hear that:

“it is perfectly possible to eat a Mars Bar, or a bag of crisps or have a carbonated drink if you do it in moderation understanding your diet and lifestyle […] Then you can begin to take responsibility for it and the companies who are selling you these things can be part of that responsibility too” (Smith, Daily Telegraph, 8th July 2010).

Such sentiments open-up a worrying space between the corporation and the citizen, which has historically been filled by the state (see here George Monbiot’s reflections on the current round of state deregulation in the UK).

While it is always likely to be popular to talk about healthy eating in relation to choice and personal moderation, one of the reasons that soft paternalism first emerging within British health policy was because the food and drink industry had generated structures of food provision (whether it be vending machines in schools, or cleaver marketing ploys) that actually made it very difficult to eat healthily and responsibly in the first place. If the fiscally restrained state is incrementally removed from the public health sector my fear is that healthy choice options will decrease and the long-term cost of ill health will increase. It appears that British soft paternalism may be soft, but not all that paternalistic!


Thorntons and the corporate nudge

I had the expectation that the Easter vacation would probably enable me to escape well-intention nudges towards my eating habits – it is, after all, a time for the indulgent consumption of all things sweet! I was thus surprised (actually not all that surprised) to find some very interesting corporate nudging on my young daughter’s Thorntons “Girls Gift Parcel”.

On top of the box, which tantalizingly contained White Chocolate Buttons (40g), Milk Chocolate Buttons (40g), Milk Chocolate Raisins (40g) and Vanilla Fudge Cubes (40g), was a small picture of tooth bush brandishing mouse. The smiling mouse rather annoyingly states, “I know to brush my teeth twice a day!” As a parent, I have to admit that it is reassuring to think that every time my daughter reaches for a milk chocolate raisin or a fudge cube that she will be reminded of the importance to brushing her teeth.

But the cynic in me couldn’t help looking at thing differently. Isn’t it slightly strange that a chocolatier is promoting dental care? Isn’t this a little like McDonalds placing a statement on a Big Mac that reads “Ronald knows the importance of a healthy and balanced diet – and, by the way, you wouldn’t get anything remotely resembling that inside this box!”

My point is that when corporations nudge, it often serves to ethically cleanse their product of the potential damage it is doing to you. Perhaps an alternative strategy would be to supply information on the role of chocolate in accelerating dental decay. In addition, Thorntons’ teeth cleaning campaign feels somewhat patronizing when you are a parent – children know they should clean their teeth, getting then to actually do it is a different thing entirely. In a rather selfless act of hard paternalism I have thus been protecting my daughter’s teeth by assisting her consumption of her Easter chocolate mountain.


Social marketing and segmenting publics

The Department of Health’s White Paper, Choosing Health: making healthy choices easier (HMSO, 2004) sets out an agenda for enabling people to make ‘healthy’ decisions – presented as an appropriate route through the extremes of paternalism on the one hand and an unfettered market on the other. Choosing Health can therefore be understood as part of a wider move towards a self-consciously soft form of paternalism in UK public health policy. Public information, encouragement and shaping “the commercial and cultural environment we live in so that it is easier to choose a healthy lifestyle” are some of the means by which the UK Government defines its role in prompting behavioural changes regarding health.

from Department of Health (2008) Healthy Foundations. A segmentation model

This is not simply the promotion of ‘informed choice’, but involves explicit attempts to reconfigure the environment in which people make health-related decisions – whether conscious, habitual or emotionally-driven. The realisation of soft paternalism in health behaviours is enabled by the tools and techniques of segmentation and social marketing, which are used in “creating a demand for health choices”. The relatively new disciplinary area of social marketing (see for example, the Institute for Social Marketing, Stirling) draws on recent psychological and behavioural insights about the socio-cultural nature of the decision-maker, their tendency towards following social norms, their systematic biases, and their fallibility in the face of complex, long-term decision-making. Segmenting involves dividing the public into categories such as ‘discovery teens’, ‘younger settlers’, ‘older jugglers’ or ‘active retirement’. In addition to tailoring messages in this way, social marketing aims to use the ‘4Ps’, known as the marketing mix: product, price, place, promotion in order to achieve a ‘social good’ such as a changing damaging behaviours, breaking bad habits and changing attitudes.

This approach requires new infrastructures of governing. Research centres such as the National Social Marketing Centre (NSMC) deploy the very same tactics themselves in order to ‘socially market’ social marketing (French, 2008; Ambitions for Health, 2009). Corporate sponsorship is mobilised in order to extend the distribution channels for health promotion – for instance, within the ‘5 a day’ or ‘Change4Life’ campaigns. And Social Marketing advisors are now embedded in government departments such as DEFRA and the Department for Health, developing segmented approaches to government policy.

social marketing in UK health policy

Social Marketing is just one of the ways in which libertarian paternalist policies aim to shape decision-making environments. Its growth and potential impact requires sustained interrogation: what are the political implications of differentiating publics using segmentation models – does this create new forms of public value or constrain public solidarity and accountability in public services? Does social marketing constitute new governable subjects, seeking a more consumerist relation to the state and public services? Does this kind of psychological profiling reduce human character to the realm of socio-demographic modelling, limiting the range of alternative identities which can then be taken up? What about the irony that the rampant consumerism created through commercial marketing is now being utilised to counteract some of the problems that it produced? Or as author of VirtualPolitik, Elizabeth Losh, puts it, how can the government be both media-maker and regulator? And perhaps most critically, in transposing corporate methodologies into state practice and policy making itself, do we enjoy a more personalised debate about the delineation of public goods, or is this question sidelined by a concern instead for the differentiation of the public good for segmented publics?


Sticks, stones and lexical nudges

Government campaign, 1943 artist: weimer pursellWe have known for sometime that words have the power to radically change our patterns of behaviour and to potentially cause hurt to our personal lives and circumstances. The rise of commercial advertising during the nineteenth and twentieth centuries illustrated how the strategic deployment of catchphrases and media messaging could radically alter people’s patterns of consumption and brand preferences. The twentieth first century is, however, bearing witness to new forms of governmental intervention within the lexical worlds of advertising and promotion. The state is, of course, no stranger to the use of persuasive words in its own attempts to encourage changes in citizenly behaviour. Numerous public marketing campaigns have used powerful taglines to bring moral weight to governmental desires. Famously, for example, the British government’s fuel efficiency campaign during the Second World War was under-girded by the assertion that to ‘ride [one’s car] alone was to ride with Hitler.’ However, what we are seeing now is not the crude replication of such obvious ideological discourses by states, but an active recognition of the more subtle of enduring powers that reside in syntax. This is a form of lexical power that appears to reside much more in the adjective than the sentence as a whole.

photo by joan thewlis@flikrThe governmental deployment of Lexical nudges operates in two primary ways. First, governments have recently become much more proactive in regulating the adjectives that make unhealthy or financially damaging practices appear to be relatively healthy or benign. In the US, for example, the Family Smoking Prevention and Tobacco Control Act proposes inter alia to give the Food and Drug Administration power to control the marketing of tobacco products. In a nod to the persuasive potential of the adjective, it is thought that the FDA will use its new powers to prevent the rather misleading use of “lite” and “mild” qualifiers in naming of cigarette products (Economist, 2009 Vol. 39 no.8636:55).

A second approach to the lexical government of behaviour is suggested within the UK’s Institute of Public Policy Research’s recent report, Warm Words (2006). The IPPR commissioned the Warm Words report in order to provide a comprehensive analysis of the ‘linguistic landscapes’ that are shaping and informing British understandings of, and behaviours towards, climate change abatement. Produced by Gill Ereaut (qualitative research practitioner) and Nat Segnit (novelist and journalist), Warm Words identifies a complex and confusing set of linguistic repertoires used to describe the climate change threat by British newspapers, government departments, businesses and media outlets. Focusing on linguistic codes, routines of language, and tonality, Ereaut and Segnit identify three dominant linguistic representations of climate change in Britain: 1) Alarmism (characterized by ‘quasi-religious language tropes’ and adjectives such as “awful”, “terrible”, and “immense”); 2) Mockery and British Comic Nihilism (identified by the use of ‘blithe’ and ‘whimsical’ language); and 3) Pragmatic Optimism (focusing on the everyday language of ‘small changes’, ‘ease’, ‘convenience’, and ‘effortlessness’) (IPPR, 2006: 7-8). Outlining the confusing and ineffective nature of each language trope in promoting changing public behaviour’s towards climate change, Ereaut and Segnit claim that Britain requires a more shrewd and subtle approach to the linguistic framing of climate change (ibid: 8-9). According to Ereaut and Segnit, the words used to promote the government of climate change in Britain need to tap into a distinctively British linguistic tradition that invokes the ordinary hero of Dunkirk and Live Aid.

In the context of the broader debates that surround the normative potential of libertarian paternalism, it appears that the second approach to lexical nudging carries with it the greatest potential dangers. To control adjectives that are misleading, and potentially promote destructive behaviours, appears to constitute an important part of good government: namely not to deny the opportunity to pursue personal choices, but at the same time ensuring that these choices are not made under false pretences. It is the more comprehensive promotion of effective government-speak suggested in the Warm Words report that is more worrying. Its suggestion that the syntax of climate change government should be grammatically sealed within a psychological appealing narrative appears, in part at least, to be about the lexical closing-off of response options. Ereaut and Segnit admit as much when they assert that the presentation of facts about climate change should disappear from government rhetoric (their presence merely suggesting that the state has something to prove). The most important lesson of Orwell’s 1984 is that the control of language options is directly linked to the ability to determine how to think and choose in different ways. Language, in all of diversity, provides a varied matrix of freedom. Surely the role of the state should be to protect us from a varicious exploitation of lexical forms that lead to personal harm and not to circumscribe the freedom that we can all find in independent expression: win the argument, don’t close it off.


The burger woman and acts of citizenship

We’ve all become aware in recent years of Jamie Oliver’s crusade against unhealthy school meals and, indeed, his success in ensuring that Turkey Twizzlers – the staple diet of school canteens from Aberdeen to Aberystwyth and from Penzance to Penrith – have been consigned to the (recycling) bin. Another feature of Jamie Oliver’s campaign, of course, was the pictures of mothers of school-children selling items of (presumably) junk food to children through school fences or over the school gate. As a middle-class, educated and reasonably healthy academic, I was of course appalled by these guerilla tactics. Surely these mothers were guilty of the insidious crime of undermining their own children’s health or, even worse, the health of other children? burger by vanessa pike-russell @flikr

And yet, the work of Professor of Citizenship, Engin Isin (Open University) encourages us to think different about these parental practices. Isin argues that ideas of citizenship throughout history have been articulated through reference to those on the margins. It is these individuals and groups that can act as a kind of threat to us but it is these individuals and groups, too that are the source of our own security. We become assured of our own political identity by contrasting ourselves with these more marginalised people. I, as a well-behaved citizen of good character and reasonable diet, derive my own sense of worth and smugness from mothers such as these and their Turkey-Twizzler-eating offspring.

Isin goes further by suggesting that there are enduring ‘acts of citizenship’ that can emerge from these marginalised and disenfranchised groups, which can help to transform dominant ideas about citizenship. Is the act of passing or selling a burger over a fence to a child an act of citizenship? Will this act lead to different conceptions of what it is to be a British citizen? How do acts such as these lead us to question the extent to which the state can determine the diets of its citizens?


Hidden food and the nanny state in the kitchen

My mother tells a story of her childhood dislike of sprouts and my grandmother’s feeble attempts to disguise them as cabbage through a hastily conducted mashing-up process. Any parent can attest to the various culinary tricks, techniques and fables that routinely have to be deployed in order to encourage/force their children to eat more healthily: I, for example, am still waiting for my improved eye-sight and curly hair as just reward for my assiduous consumption of carrots and crusts!

pizza by wendalicious@flikrBut what was once an exercise in shrewd parental food repackaging is now becoming an arena of corporate action and state policy. On the 12th of May this year (2009) the British Food Standards Agency (FSA), in partnership with a range of popular high street restaurant chains, launched a new scheme for promoting healthy eating among Britain’s young consumers. The FSA’s ‘health through stealth’ approach to eating involves putting less salt in dishes, using lower-fat cheeses in pizza, and inserting ‘hidden vegetables’ in a range of menu options for children (FSA, 2009). Involving 400 companies and in excess of 2,000 restaurants (including Pizza Express, Pizza Hut, Frankie and Benny’s and Bella Italia outlets), the British government sees this new initiative as a significant act in public health improvement.

While the FSA’s ‘health through stealth’ approach to childhood nutrition reflects a broader series of attempts to restructure the ‘choice architectures’ that frame the consumption patterns of young people (including re-thinking school canteen provisions, the re-positioning of alco-pops in bars, and the movement of cigarette packs below the shop counter) there also appears to be something else going on here. Changing the hidden content of food appears to be less about making it easier for young people to choose to eat healthily, and more about making them do so without them realizing it. The choice here is all with the parents, in as much as they can decide to dine at Pizza Hut rather than McDonald’s, or Frankie and Benny’s as opposed to TGI Friday.

As a thoroughly paternalist policy then certain issues arise out of the hidden food agenda. While celebrated by government as a corporate commitment to public health, there is a danger that such policies could be self-defeating. So for example, despite improving the content of the food they offer is eating at Frankie and Benny’s really a healthy option? To what extent is a pizza really a healthy choice? My point is that this scheme could also be interpreted as a stealthy marketing ploy by partner companies to recast their image in the wake of the revolution in organic, slow and nutritious food? (Note for example that this scheme has coincided with the renaming of Pizza Hut as the much more nutritionally appealing Pasta Hut – whatever next, TGI’s becomes Thank God It’s Humus?)

Furthermore this policy initiative could also be counterproductive to the extent that rather than trying to educate children about the benefits of a healthy and balanced diet, it aspires to enable them to eat more healthy food in a completely unconscious way. This is hardly the “recipe” for developing a more culinary aware citizenry (and possibly contradicts the FSA’s own commitment to develop nutritional competencies among young people). While ‘health through stealth’ may not have people rushing for barricades in order to defend the gastronomic liberties of young people, it may thus prove to be an ineffective policy on its owns terms: my mother was never fooled by those sprouts you see, and she has never let us forget how she saw through the attempted dupe!