A humanistic theory of human behavior: implications for health education

1
A humanistic theory of human behavior
implications for health education

• David R. Buchanan, DrPH
• SOPHE Mid-Year Conference
• Seattle, WA
• June 9, 2007

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Fact ValuesEmpirical 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

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Fact ValuesEmpirical 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

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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

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Two worldviewsScientific 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.

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Two worldviewsHumanistic 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.

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Comparison of scientific and humanistic models
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Scientific model

• History Enlightenment Boyles Law positivism
• Goal
• Methods
• Relationship between theory practice
• Overriding Values
• Limitations

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Scientific model

• History Enlightenment Boyles Law positivism
• Goal identifying causes of behavior
• Methods
• Relationship between theory practice
• Overriding Values
• Limitations

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Scientific model

• History Enlightenment Boyles Law positivism
• Goal identifying causes of behavior
• Methods testing hypotheses RCTs
• Relationship between theory practice
• Overriding Values
• Limitations

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MethodsHierarchy 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.

CONFIDENCE
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Scientific model

• History Enlightenment Boyles Law positivism
• Goal identifying causes of behavior
• Methods testing hypotheses RCTs
• Relationship between theory practice fidelity
  in implementation
• Overriding Values
• Limitations

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Scientific model

• History Enlightenment Boyles Law positivism
• Goal identifying causes of behavior
• Methods testing hypotheses RCTs
• Relationship between theory practice fidelity
  in implementation
• Overriding Values certainty effectiveness
• Limitations

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Scientific model

• History Enlightenment Boyles 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

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Research Ethics

• Goal determining the most ethically sound course
  of action, what one should do
• Methods
• Validity
• Relationship between theory practice
• Overriding Values
• Limitations

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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

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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

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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

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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

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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

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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

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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

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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

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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 patients
  clinical situation and then help elucidate the
  types of values embodied in the available
  options. The physicians 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

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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

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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

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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

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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

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Evaluation of humanistic health
educationIndividual Level

• Awareness of alternative courses of action
• Ability to enumerate the advantages and
  disadvantages of the major alternatives
• Greater self-understanding of ones reasons for
  choosing one course of action over another
• Greater satisfaction with ones decision
• Greater reassurance that ones decision better
  advances ones own life projects

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Evaluation of humanistic health
educationCommunity 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

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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

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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

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ConclusionTwo 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 incomprehensionsometimes (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)

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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.