Morally Indigestible Listicles: Food, Experts, and the Burden of Choice

Never Eat

The Sydney Morning Herald (via the Telegraph, London) has published another “no-nonsense-straight-shooting-science-based” listicle of the foods YOU SHOULD NEVER EAT AGAIN! These lists seem to appear at least once every week on some form of news website.

This current list is prefaced with references to recent British Medical Journal studies that turned upside down “everything we thought we knew about eating and drinking healthily”. Instead of saturated fats being “the killer”, it turns out carbohydrates are!

Put down that bacon & egg roll and get yourself a KFC Double-Down sandwich!

Surprisingly the article doesn’t question why these new claims have a stronger knowledge base than previous claims or how we can be sure that in a week there won’t be another “nutritional revolution” that will turn this all on its head and finger protein as Grandpa’s real killer.

Leaving aside the science-base of these claims – not to imply this is unimportant – what is most disturbing about these articles (and this article in particular) is the emphasis on individual food choices as the determining factor of health. “Expert” claims that “every bacon sandwich you eat knocks half an hour off your life” reinforce ideas that my heart disease or your diabetes are reducible to that sandwich or chocolate bar eaten six years ago.

When these factoids are spoken by folks in white coats during times of austerity cuts to health services there is a real danger of compounding already existing public health policy problems by pretending that structural influences can be addressed via a nice social marketing campaign or a Jamie Oliver TV show that teaches people how to cook, garden and “never eat those foods again”.

In the UK (where this article originated) David Cameron recently flagged that sick benefits may be cut from people who are obese and do not lose weight. The rationale for this idea is that obese people can lose weight simply by making “correct” and “healthy” food choices. However, according to Cameron, they aren’t making these choices because life is too good on benefits. Hence, cut the benefits and healthy food choices will be made.

While these listicle articles may be dismissed as “not too serious” or “a bit of fun”, they depend on and reinforce a moralistic and biopolitical perspective on the relation between food, choice and health. This perspective is often used to justify budget cuts to health services due to the expectation that health is simply a matter of individuals making the right choices.

In an article for Public Health Ethics, my colleague Donald B. Thompson and I argue that this perspective is morally and scientifically unjustified. Below is the introduction. If you’d like read the whole thing but the pay wall gets in the way send me an email.

Is Nutritional Advocacy Morally Indigestible? A Critical Analysis of the Scientific and Ethical Implications of ‘Healthy’ Food Choice Discourse in Liberal Societies

Ethicists, politicians, journalists and health advocates use morally laden ideas of responsibility, obligation and justice to impel individuals to make ‘healthy’ food choices (Rozin, 1997; Saguy and Gruys, 2010; Holland et al., 2011; Rich, 2011; Rousseau, 2012; Spoel et al., 2012). From sensationalist advice that sugar is poison (Gillespie, 2008) or carbohydrates kill brains (Perlmutter, 2013) to official government dietary guidelines, the advocacy for ‘healthy’ food choices has become pervasive (Scrinis, 2013). Recent concerns over obesity and diet-related non-communicable diseases (NCDs) reinforce the characterization of ‘healthy’ food choice as an ethical obligation (Lang et al., 2009: 232ff).

Framed as a problem of individual choice and behaviour, the purported harm of obesity to society is used to argue that individuals have a responsibility to maintain their own health and thereby secure population health through ‘healthy’ choices (Singer, 2012; Callahan, 2013; Mayes, 2014). The idea that individuals demonstrate personal and social responsibility via food choice has subtly but persistently become part of the social and moral landscape in Western liberal democracies (Elbe, 2010).

Proponents of ‘healthy’ eating tend not to use explicitly ethical arguments, but imply them using the imperative mood. In liberal democracies such as Australia, Denmark, the USA and the UK, individuals are characterized as responsible for the harms of health-related choices on their own life and wider society (Petersen and Lupton, 1996; Goldberg, 2012; Larsen, 2012). The strength of ‘healthy’ food choice discourses to shape public understanding of food and health is drawn from and reinforced by what Brian Leiter calls ‘our untutored morality… the morality that infuses our culture’ (1997: 277). Ideas such as ‘do not harm others’ and ‘be responsible for your actions’ constitute a cultural morality that places implicit obligations on individuals to act in accordance with the advice of putative experts. Combined with developments in nutrition science and public health, this cultural morality can transform food choice into an ethical issue.

Robert Crawford describes the implied relation among morality, responsibility and health as ‘one of the most complex subjects facing medical sociologists and social historians’ (1980). A concept that helps to articulate these relations is medicalization, which describes the expansion of medical experts, terminology and interventions into areas of life that were previously considered outside of the medical sphere (Sobal, 1995; Verweij, 1999; Jutel, 2006; Conrad, 2007). Although medicalization can be purely descriptive, a number of scholars argue that medicalization implies unspecified moral considerations regarding consequences for individuals and society (Verweij, 1999; Purdy, 2001; Parens, 2013).

We argue that nutrition science has contributed to the medicalization of food choice, particularly in relation to diet-related NCDs. However, medicalization alone does not fully explain the moral imperatives surrounding health and food choice. A related, yet narrower and more obviously normative concept is healthism (Crawford, 1980; Skrabanek, 1994). Motivated by a concern over state interference, Petr Skrabanek defines healthism as the state’s use of ‘propaganda and various forms of coercion to establish norms of a “healthy lifestyle” for all’ (1994: 15ff). We argue that healthism has to be expanded to include the influence of non-state experts and authorities in encouraging individuals to conform to norms of health. Two features of healthism central to our analysis are: the characterization of the individual as the primary agent responsible for maintaining individual and population health, and the emphasis on the pursuit of health as the ‘paradigm for good living’ and an ‘end in itself’ (Crawford, 1980: 380–381). The spread of healthism discourse is problematic for moral and political liberalism, which seeks to remain neutral on matters of public morality (Charlesworth, 1993).

Nevertheless, the influence of healthism in liberal democracies positions health as a core moral value around which social consensus is established (Lupton, 1995; Fitzpatrick, 2001; Rose, 2001b; Halse, 2008; Metzel and Kirkland, 2010). In this context, health is increasingly framed as an end of individual freedom. Although freedom to choose can be in conflict with putatively ‘healthy’ choices, ‘unhealthy’ choices are increasingly reframed as non-free choices resulting from manipulation by industry advertising, biological addictions or self-deception. Put bluntly, the rhetoric of our cultural morality conflates nutrition advocacy and liberal moral theory to assert a cultural morality in which ‘healthy’ food choice has become an ethical act expected of all rational individuals.

The objective of this article is to question this conflation in two respects: to problematize the scientific conditions contributing to the medicalization of food choice and to describe some socio-ethical consequences of positioning ‘healthy’ food choice as a marker of the good life. The first part of the article outlines the scientific basis of putative links between food choice and biomedical health. We demonstrate that normative food guidance tends to simplify the science base of claims that individual food choices can secure health and prevent disease in an individual and thereby the population. In the second part we argue that biomedical health is only one of many important values associated with food. Food contributes to personal and social reality, social cohesion and well-being. We argue that those who use nutrition evidence to command individual food choices have an ethical burden to articulate why the biomedical value of food should be prioritized over and perhaps to the exclusion of values such as pleasure, comfort, belonging or well-being.

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