Public Health 123 (2009) 514516

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Public Health
journal homepage: www.elsevierhealth.com/journals/pubh

Short Communication

On idiocy or the plea for an Aristotelian health policy

I. Devisch*, K. Dierckx
Department of Medical Philosophy and Ethics, Ghent University, De Pintelaan 185, 9000 Gent, Oost-Vlaanderen, Belgium

a r t i c l e i n f o
Article history: Received 24 October 2008 Received in revised form 21 March 2009 Accepted 28 April 2009 Available online 12 June 2009

Smoking For many years, it has been clear that it is very difcult to get people to give up smoking. Every day, policy makers, medical ethicists and a wide variety of other professionals contemplate the following question: how do we stop people from smoking? Despite innumerable campaigns, highly-explicit warnings on packets, and references to death and cancer, many people persist with their smoking behaviour. Taxes on tobacco could be raised even more and people prohibited from smoking in restaurants and pubs all over the world. Nevertheless, many continue to smoke. They know that smoking is risky and bad for their health, but they keep on doing it. Why? This question bothers everyone who is involved in preventive anti-smoking campaigns and public health, both at the level of policy making as well as in academic research.1 For the sake of the argument, let us broaden the horizon of this question. Smoking, and its disastrous health consequences, is not an isolated case. It is just one example of an unhealthy lifestyle in which nutrition, physical activity and other aspects also play a signicant role. Let us assume that individuals are well informed about their behaviour which is, of course, not always the case, but this article is concerned with that category of person yet continue to smoke. What does that tell us? They, or let us say we, know that such behaviour is harmful, but behave as if we do not know that it is. In the case of nutrition, one could claim that unhealthy food can taste great, but in the case of smoking, particularly cigarette smoking, it is difcult to defend the claim that these also taste great. Of course, smoking is addictive, but many remedies are currently available to help people to quit smoking. Some people use

such remedies, but many do not. Therefore, the following general conclusion would seem to be quite plausible: smokers are idiots!a Although this may sound rather unethical, the expression is perhaps justied, but not for the reasons one might expect. The question is: what do we actually mean when we stigmatize smokers as idiots? In most cases, idiocy is used as an insult, without any further thought. But as we shall see below, a closer examination of the term provides some interesting reections, particularly in a public health context. Instead of attempting to make another contribution to the endless debates on smoking, which predominantly centre around the arguments of my freedom versus harm to others, a closer examination of the term idiocy might offer a more fruitful approach. Some insights from Plato and Aristotle, two of the greatest philosophers in ancient Greece, may enable the question to be addressed properly. Akrasia In Platos universe, only intelligent or stupid persons exist. Intelligent persons are those who have perfected their intellectual virtues and therefore have an understanding of the world, whereas stupid persons are those who lack insight. Plato rmly believed in the view that wisdom an understanding of the world as it is will inevitably lead to sensible action. According to him, it would be impossible for an intelligent man to act in a stupid manner, since intelligence was synonymous with intelligent behaviour. As Socrates states in Platos dialogue Protagoras: Then, I said, no man voluntarily pursues evil, or that which he thinks to be evil. To prefer evil to good is not in human nature; and when a man is compelled to choose one of two evils, no one will choose the greater when he may have the less.2 In this dialogue, the words of Socrates cannot be much clearer: he who prefers evil, acts in a stupid manner. Contrary to Plato, however, Aristotle took into account the problem of what is referred to as akrasia in Greek: the fact that

* Corresponding author. Tel.: 32 4 9857 4801. E-mail address: ignaasdevisch@scarlet.be (I. Devisch).

a This slogan is widely used between individuals, as well as in everyday live and on weblogs. A few examples are listed below, as accessed on 05/11/2008: http://room101.blog.co.uk/2007/02/07/smokers_are_idiotsw1697478?comment_ ID2988075&rtc1; http://www.gpforums.co.nz/showthread.php?s&threadid 221488&pagenumber5; http://ardeb.blogspot.com/2007/06/smokers-are-idiots. html; http://www.youtube.com/watch?vaMp-a9kugtI; http://www.facebook.com/ topic.php?uid11175946268&topic4788&start150&hash79b3c5cf1da4836a86c 10b172e55c186.

0033-3506/$ see front matter 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2009.04.009

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someone knows something, but still does not act according to such knowledge. In other words, Aristotle was aware that people may have a perfect and clear understanding of their stupid behaviour, knowing that they would be better off not doing certain things, but who are nevertheless still unable to stop themselves from doing evil.3 As a result, Aristotle examines human character traits which are not as blameworthy as vices but not as praiseworthy as virtues. Although akrasia, which literally means a lack of mastery, goes against reason as a result of some pathos or emotions in the broad meaning of the word, Aristotle does not bluntly categorize it as plain stupid or unintelligent.b To Aristotle, akrasia is, as Landrum describes so well, acting against ones better judgment.7 An akratic person makes deliberative and rational decisions but, for some reason, his will to carry out these decisions fails. Akrasia, therefore, is not the result of mere irrationality or idiocy, but the result of someone not being able to transfer his rational decisions into reality. Romaioli et al. wrote: We think that peoples beliefs and desires should be consistent with their actions8; in fact, this is not the case. Considering this, the notion of akrasia provides a rational explanation why people thanks to their rationality and not despite it are still unable to act in the way that they decided. An Aristotelian health policy In 1993, McKnight mentioned the akratic agent to recognize the possibility of what he called incontinent action to distinguish: between a rational agent who sometimes acts irrationally and a nonrational agent who is incapable either of rational or of irrational action. Declaring an akratic agent autonomous classies him together with an ordinary non-akratic agent; declaring him nonautonomous involves putting him in with non-rational beings such as animals, comatose patients and those in advanced stages of Alzheimers disease. Neither classication is comfortable.9 McKnights akratic agent overlaps with our category of the idiot, although we prefer the vaguer and more descriptive notion of the idiot because: (1) the problem is well over weak-willing people; and (2) we explicitly want to deal with the negative connotations associated with akrasia. The idiot is someone who can be very sensible or intelligent, but who does not act according to his or her intelligence or understanding. The idiot, and this is a crucial difference with stupidity, knows that he or she acts like an idiot, but does not change such idiotic behaviour.c An idiot expresses his or her idiocy because he or she realizes that such behaviour is perhaps not the wisest thing to do, yet still fails to change it. Let us therefore revisit the problem of akrasia in Aristotles work in order to elaborate in more detail on the slogan smokers are idiots. Why should a public health worker be interested in a reection upon the category of idiot? And in what way is it helpful to use the term idiot in a deliberate manner, rather than

b The literature on akrasia is impressive, given the fact that we are dealing with an ancient ethical and philosophical concept: more than 100 references were found on the Web of Science on 15/02/2009, many of which are not recent, although they are still informative in a way. As is also the case with other concepts, not all literature deals with the same phenomenon: sometimes akrasia is used as a very broad notion to stipulate the weakness of the will or irrational behaviour in general; sometimes it is described within the work of one single philosopher or writer; and in other contexts, akrasia is the signier for pathological or disorder behaviour in a strict therapeutic sense. For an elaborative description of akrasia as a character disorder, see Rorty (1997)4; for a recent overview of akrasia in Greek philosophy, see Lefebvre (2008)5; for a model of decision making based on akrasia, see Kalis et al. (2008).6 c For those who might be interested in calling themselves an idiot, a ash-site exists that continuously repeats the phrase you are an idiot until you.. see http:// piv.pivpiv.dk/.

a mindless abuse or uncritical moralising condemnation? Or perhaps: would public health see any improvement if based on an Aristotelian rather than a Platonic perspective? In terms of examining the problem of smoking or risk behaviour in general, Aristotle would perhaps be more useful in helping us to understand the difculties facing smokers today. The problem is this: people know that smoking causes lung cancer and other diseases, yet they continue to smoke. Is this not a textbook example of the Aristotelian notion of akrasia? As discussed previously, Aristotle allows us to see that clever people can behave like idiots, despite perhaps even as a result of such cleverness. If numerous individuals who are well informed continue to smoke, they are probably not idiots as such, but only behave as idiots from a certain point of view. Such people probably know very well that it would be better not to smoke, but these individuals take other matters into account which they associate with smoking, i.e. comfort, rest, consolation, socializing, etc. The question therefore is not whether or not we act rationally, but what takes part in the motivation of our acting, and from what philosophical perspective we look at human beings. A motivation of an act or decision can be very rational, e.g. to prefer the pleasure of smoking above the psychic stress of not being allowed to smoke; it can be irrational, e.g. a diabetes patient who knows he will be very sick if he does not stop smoking but refuses to do this, despite the passionate pleads of his family; it can be based on the incapacity to bridge thinking and acting; our motivations can differ in time and context; etc. Therefore and above all, we do not want to limit the problem of akrasia to irrational behaviour or character disorders. In other words, if we actually use the cliche that human behaviour is quite a complex issue, involving a range of motivations of which intelligence and understanding are but a few examples, as conclusive evidence in relation to the prevention of risky behaviour, should a carefully planned public health policy not consider such matters more profoundly? For instance, many public health campaigns are still conducted on a mere Platonic approach where the government provides the citizen with information. From that moment, they expect the people to be either clever and do the right thing (when they listen to the information) or to be stupid and continue to do their own thing (if they ignore the message). Rather than push on for conclusive evidence for the costs or prots of the prevention of risky behaviour, a more profound reection of this contemporary public health policy is needed. There currently exists an abundant literature on the topic of empowerment or on how to enhance ones capability to make the right decisions.10,11 Nevertheless, plenty of work remains to be done, for instance with the integration of a theory of desire in public health discourse. The important role played by desire in our lives is one of the basic conditions of modern man. From earliest childhood, others ask us: What do you want? What do you like? A great part of our lives is centred on the issue of how to satisfy our desires, what type of people we should be friends with, etc. Look around us: every commercial is about stimulating our senses and desires. Despite the fact that we are dealing with a serious recession right now although, in a way, this recession was not caused by less consumption but by consumption we could not later afford the reason why a capitalist free market usually works so well is not because we have become indoctrinated, but rather because this market is able to seduce or entice us all the time with new products that we do not need, but sometimes still desperately desire.d

d This is why the French philosopher Jean Baudrillard talked about implosion.12 Today, it is not so much a question of a rebellion against capitalism, but rather the excessive use thereof. In its performance, such risk of an implosion is more of a threat to this economic system than a revolt from the outside (explosion) can ever be.

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Conclusions and practical implications What can we conclude from the reections above? The most important conclusion would be that an ethical public health policy should need to take account of human desires. Rather than punishing people for their risky behaviour, a policy that is based upon an Aristotelian perspective would be more suitable for dealing with the prevention of risky behaviour. However, this by no means justies our human desires. Not only would such a thing be completely unrealistic, it is also undesirable. Conversely, an Aristotelian health policy could prove to be useful in fostering a better understanding of our idiotic behaviour and try to rene public health policy on the basis of such understanding. And once we know this, would we not be idiots if we did not take such knowledge into account? Practically, if we translate Aristotles theoretical framework into contemporary society, what lessons can be learned in a public health context? As the idea of empowerment embodies, public health did and does start from the autonomy of the individual. Its scope is to empower the individual in such a way that its autonomy enhances, and to increase the chances of deliberative and reasonable decisions which are right from the perspective of health. The following statement carries out the core business of public health: more autonomy means more rationality and thus better health choices. Although many nuances can be made and have been made, autonomy remains the focus. At most, public health discourse substitutes a strong concept of autonomy with the idea that we are not always rational, and other motivations social, psychological, cultural etc. can play their role in decisions. As Gillon concluded in his editorial of the Journal of Medical Ethics from 1993: we are all less than fully autonomous, all less than fully informed, all less than fully wise, clever and determined, and that we all manifest, at least intermittently, akrasia, incontinence or weakness of will.13 Unmistakably, the triad autonomyrationalityhealth is one of the a prioris of public health which goes back to 18th Century enlightenment that started from the idea that if humans would lay down their chains of religion, human behaviour and thus society would make a gesture towards more rational acting. Obviously, this is not necessarily the case. Postmans famous slogan we amuse ourselves to death is, in more than one way, a perfect summary of modern society.14 Apparently, although there are plenty of opportunities to live our lives in an autonomous way, many heteronomous motives are at work at the heart of this autonomy. These are more than just disturbing factors of autonomy. In fact, thanks to these disturbing factors, there is public health. Let us be clear: there is nothing wrong, as such, with autonomy and empowerment; we certainly do not claim that more rationalization would be a mistake. Nevertheless, the question remains whether this is the starting point that public health needs to get a grip on, or at least to understand, human behaviour. What could be the case if we would shake this presupposition upside down? What if akrasia is more than an accident of individual autonomy, but a crucial characteristic of it? What if public health started from the idea of heteronomy rather than autonomy? What if human actions and rational decisions are not merely based in autonomy but in the intertwining of autonomy and heteronomy? If akrasia or heteronomy overall are to be situated at the heart of human actions, risk behaviour becomes much more comprehensible, and idiocy becomes a needless category when used in

a unison negative way. Would this way of looking at human actions not result in a more realistic encounter to public health interven tions? As Gervas et al. wrote: When risk behaviour is viewed as a balancing act on the part of patients, it becomes easier to appreciate that many patients take risks not because of ignorance, but after weighing rewards against risk. Even if benets could be guaranteed (which is never the case), risk compensation may explain why the obvious potential of many preventive activities (such as use of seat belts or condom promotion) is never fully realised.15 An Aristotelian-based health policy frames akrasia into a broader political context and conceptualizes it as more than simply a personal failure.4 As long as risk behaviour is understood as a sin, like defective motivational structure due to the weakness of will, we will never be able to understand why people act like idiots. As the history of science and philosophy teaches us, if a hypothesis seems to be exhausted, sometimes we have to step back and question the framework from which we are thinking and acting, and ask ourselves: is this the most suitable paradigm to deal with the problems we want to solve? As far as we are concerned, akrasia throws down a major challenge to public health. Funding None declared. Competing interests None declared. Ethical approval None required. References
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