A humanistic theory of human behavior: implications for health ...

1. A humanistic theory of human behavior: implications for health education David R. Buchanan, DrPH SOPHE Mid-Year Conference Seattle, WA June 9, 2007

2. Fact & Values:Empirical vs. normative analyses �If science is inquiry into general causal laws and explanation, ethics is inquiry into non-causal justification and general action-guiding reasons. . . The foundations of normative ethics will be prescriptive (or at least non-descriptive), for ethics is an action-guiding discipline that provides reasons for human action and that attempts justifications of moral claims. Science, by contrast, deals with the causes of events and with causal explanations of phenomena. The statements in the two domains thus display an unbridgeable logical difference: one is based ultimately on non-descriptive sentences, and the other on descriptive sentences. It is, therefore, logically impossible that the foundations of ethics find their roots (premises) in the foundations of science. Those familiar with modern ethical theory will recognize that this argument is merely a corollary of one use of the fact/value distinction.� - Tom Beauchamp, Knowing & Valuing, 1980

3. Fact & Values:Empirical vs. normative analyses �Ethical reasoning is reasoning which reasons out the good, as scientific reasoning is reasoning which reasons out the truth. The conclusion of a piece of scientific reasoning is a truth to be believed; the conclusion of a piece of ethical reasoning is a good to be brought about. By setting out my scientific reasoning I may explain why I believe a certain proposition; by setting out my ethical reasoning I may explain why I am performing a certain action. The point of ethical reasoning is the achievement of good, just as the point of scientific reasoning is the acquisition of truth.� -Anthony Kenny, Aristotle on the Perfect Life, 1992

4. Central Thesis To advance research and practice in health education, we need to develop a more coherent and comprehensive body of knowledge about human motivation and action, by taking into account an expanded view of the human condition that recognizes the ethical dimensions of human agency.

5. Overview Two Worldviews Scientific Model Validity in Research Ethics Humanistic Model: Implications for Health Education

6. Two worldviews:Scientific model The scientific worldview views human behavior as the product of antecedent factors that cause people to act in predictable ways. Behavioral research in the scientific model is thus directed towards verifying cause-and-effect relationships. Researchers test hypotheses in experimental research designs, towards the goal of developing the capacity to interrupt the causal chain of events that results in unhealthy behaviors.

7. Two worldviews:Humanistic model In contrast, the humanistic model sees human beings as endowed with a free will that enables them to choose between different courses of action. It is the ability to choose that provides the very foundation for ascribing moral responsibility. In this view, human action is guided by reasons, which enable people to act on felt desires -- or to choose not to act on them -- based on values and principles that they consider important. Research in the humanistic model is thus directed towards clarifying human values, good reasons for pursuing one course of action over another, and the moral considerations that support conclusions about the precedence of certain ethical principles over others.

8. Comparison of scientific and humanistic models

9. Scientific model History: Enlightenment; Boyle�s Law; positivism Goal Methods Relationship between theory & practice Overriding Values Limitations

10. Scientific model History: Enlightenment; Boyle�s Law; positivism Goal: identifying causes of behavior Methods Relationship between theory & practice Overriding Values Limitations

11. Scientific model History: Enlightenment; Boyle�s Law; positivism Goal: identifying causes of behavior Methods: testing hypotheses; RCTs Relationship between theory & practice Overriding Values Limitations

12. Methods:Hierarchy of knowledge Randomized Controlled Trials Quasi-Experimental Research Designs Prospective Cohort Studies Cross-sectional Studies Retrospective Case-Control Studies Case Series & Registries Cases Studies - Evidence-Based Working Group. Evidenced-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA, 268(17):2420-2425, 1992.

13. Scientific model History: Enlightenment; Boyle�s Law; positivism Goal: identifying causes of behavior Methods: testing hypotheses; RCTs Relationship between theory & practice: fidelity in implementation Overriding Values Limitations

14. Scientific model History: Enlightenment; Boyle�s Law; positivism Goal: identifying causes of behavior Methods: testing hypotheses; RCTs Relationship between theory & practice: fidelity in implementation Overriding Values: certainty; effectiveness Limitations

15. Scientific model History: Enlightenment; Boyle�s Law; positivism Goal: identifying causes of behavior Methods: testing hypotheses; RCTs Relationship between theory & practice: fidelity in implementation Overriding Values: certainty; effectiveness Limitations: capable of answering questions only about the direction and magnitude of cause-and-effect relationships

16. Research Ethics Goal: determining the most ethically sound course of action, what one should do Methods Validity Relationship between theory & practice Overriding Values Limitations

17. Research Ethics Goal: determining the most ethically sound course of action, what one should do Methods: search for good reasons, weighing, balancing, specifying Validity Relationship between theory & practice Overriding Values Limitations

18. Methods: Critical challenge One of the most, if not the most, crucial problems in ethics centers on the question of the nature and limits of justification in ethics. Perhaps the most central problem of moral methodology is how the justification of moral judgments (in contrast to the truth or verification of factual claims) can be established. When is a reason a good reason for a moral judgment? What reasons count, & how much weight should they be given? - Norman Daniels, Justice and Justification, 1996

19. Research Ethics Goal: determining the most ethically sound course of action, what one should do Methods: search for good reasons, weighing, balancing, specifying Validity: reaching reasoned consensus, coherence, resonance with lived experience Relationship between theory & practice Overriding Values Limitations

20. Research Ethics Goal: determining the most ethically sound course of action, what one should do Methods: search for good reasons, weighing, balancing, specifying Validity: reaching reasoned agreement, coherence, resonance with lived experience Relationship between theory & practice: choice, consent Overriding Values Limitations

21. Research Ethics Goal: determining the most ethically sound course of action, what one should do Methods: search for good reasons, weighing, balancing, specifying Validity: reaching reasoned agreement, coherence, resonance with lived experience Relationship between theory & practice: choice, consent Overriding Values: identifying rational basis for determining precedence of different values and principles, respect for integrity, promotion of autonomy and responsibility Limitations

22. Research Ethics Goal: determining the most ethically sound course of action, what one (or people, in general) should do Methods: treat like cases alike and different cases differently, weighing, balancing, specification Validity: reaching reasoned agreement, coherence, logical consistency, �resonance� Relationship b/w theory & practice: choice, consent Overriding Values: identifying rational basis for determining precedence of different values and principles, respect for integrity, promotion of autonomy and responsibility Limitations: less certainty

23. Humanistic model: Implications for Health Education Goal: promoting autonomy, enabling people to pursue their own life plans, to become clearer about (finding good reasons for choosing) what is most important to them Methods Relationship between theory & practice Evaluation Implications for funding priorities Limitations

24. Goal of humanistic health education �Autonomy is conceived of a second order capacity of persons to reflect critically upon their first order preferences, desires, and wishes, and the capacity to accept or to attempt to change these in light of higher order preferences and values. By exercising such a capacity, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are.� - Gerald Dworkin, 1988

25. Humanistic model: Implications for Health Education Goal: promoting autonomy Methods: public reasons approach, force of better argument, expanding civil society Relationship between theory & practice Evaluation Implications for funding priorities Limitations

26. Methods of humanistic health education �The aim of physician-patient interaction is to help the patient determine and choose the best health-related values that can be realized in the clinical situation. To this end, the physician must delineate information on the patient�s clinical situation and then help elucidate the types of values embodied in the available options. The physician�s objectives include suggesting why certain health-related values are more worthy and should be aspired to. The physician aims at no more than moral suasion; ultimately coercion is avoided and the patient must define his or her life and select the ordering of values to be espoused.� - Emanuel & Emanuel, 1984

27. Methods of humanistic health education �Like most of the elemental notions -- justice, integrity -- that guide our moral life, we do not have a sharply discriminating, operational definition ready at hand. Rather, we proceed by mutually intelligible intimations, affirming this, denying that, each claim suggesting an aspect of the whole that we vaguely discern but cannot readily grasp. . . This is what makes reasoned argument possible. We persist in trying to persuade our antagonists that there is some crucial element of the matter at hand that their case neglects, and we proceed in the good faith that, if we show them this perceptively, if we illuminate them, they may change their minds. And for our part, we presume that we may learn from the deliberation, which is to say, we keep open, and positively, the prospect that the case we are now earnestly making we will come to recognize as inadequate, because we will see a more significant, a larger truth in the matter.� - Anderson, Prescribing the Life of the Mind 1993

28. Humanistic model: Implications for Health Education Goal: promoting autonomy Methods: expanding civil society, public reasons approach, force of better argument Relationship between theory & practice: mutually informing and reinforcing Evaluation Implications for funding priorities Limitations

29. Theory & Practice in humanistic health education �The purpose . . . is not to produce or control anything but to discover through mutual discussion and reflection between free citizens the most appropriate ways, under present conditions, of living the ethically good life. . . It is precisely the point about praxis [social practice] that it has no extraneous product. It has an end, namely, the good of human beings, but that end is attained through itself, that is, through action or practice that is ethical and political. . . For �helping professionals�, this would involve toleration of high levels of uncertainty in trying to aid people to improve their own skills of practical autonomy, rather than categorizing them in terms of preconceived theories with resulting automatic formulas for treatment.� - Robert Bellah, �Social Science as Practical Reason,� 1983

30. Humanistic model: Implications for Health Education Goal: promoting autonomy Methods: expanding civil society, public reasons approach, force of better argument Relationship between theory & practice: mutually informing and reinforcing Evaluation: degree of clarity and satisfaction with decisions about how they choose to live their lives Implications for funding priorities Limitations

31. Evaluation of humanistic health education:Individual Level Awareness of alternative courses of action Ability to enumerate the advantages and disadvantages of the major alternatives Greater self-understanding of one�s reasons for choosing one course of action over another Greater satisfaction with one�s decision Greater reassurance that one�s decision better advances one�s own life projects

32. Evaluation of humanistic health education:Community Level Degree to which the community provides input and exercises control over research and community programs Degree to which community members feel their advice and suggestions are respected Degree to which participants feel their concerns have been addressed Degree to which community members trust health education professionals

33. Humanistic model: Implications for Health Education Goal: promoting autonomy Methods: expanding civil society, public reasons approach, force of better argument Relationship between theory & practice: mutually informing and reinforcing Evaluation: degree of clarity and satisfaction with decisions about how they choose to live their lives Implications for funding priorities: CBPR, Justice Project, �accountability for reasonableness� Limitations

34. Humanistic model: Implications for Health Education Goal: promoting autonomy Methods: expanding civil society, public reasons approach, force of better argument Relationship between theory & practice: mutually informing and reinforcing Evaluation: degree of clarity and satisfaction with decisions about how they choose to live their lives Implications for funding priorities: CBPR, Justice Project, accountability for reasonableness Limitations: precisely to the extent that history, philosophy, and literature offer meaningful knowledge

35. Conclusion:Two Cultures �I believe the intellectual life of the whole of western society is increasingly being split into two polar groups . . . Between the two, a gulf of mutual incomprehension�sometimes (particularly among the young) hostility and dislike, but most of all, a lack of understanding . . . It is all destructive. Much of it rests on misinterpretations, which are dangerous. The degree of incomprehension on both sides is a kind of joke which has gone sour . . . For the moment, I want to concentrate on the intellectual loss . . . When those two senses have grown apart, then no society is going to be able to think with wisdom.� - C. P. Snow (1964)

36. Afterword References Buchanan, David. Autonomy, Paternalism & Justice: Ethical priorities in public health. American Journal of Public Health, (in press). Buchanan, David. Tensions between Scientific and Ethical Criteria in Evaluating Public Health Interventions. Chapter 9 in Barbara Wallace (Ed.), From Health Inequity to Equity in Health: A New Global Approach to Health Disparities. Book contract signed with Springer Publishing Company, (in press). Buchanan, David, Miller, Franklin G., and Wallerstein, Nina. Ethical Issues in Community Based Participatory Research: Balancing rigorous research with community participation. Progress in Community Health Partnerships, 1(2):2007. Buchanan, David. Moral reasoning as a model for health promotion. Social Science & Medicine, 63(1): 2715-2726, 2006. Buchanan, David. A New Ethic for Health Promotion: Reflections on a Philosophy of Health Education for a New Millennium. Health Education & Behavior, 33(3): 290-304, 2006. Buchanan, David. Two Models for Defining the Relationship between Theory and Practice in Nutrition Education. Journal of Nutrition Education and Behavior, 36(3): 146-154, 2004. Buchanan, David. An Ethic for Health Promotion: Re-thinking the Sources of Human Well-Being. Oxford University Press, New York, 2000.