Smoking bans and presumed consent

On Friday I was in Ware talking to various local government leaders about behaviour change. I used the opportunity to elaborate on cultural theory and its four paradigms for social relations: the hierarchical, the egalitarian, the individualist and the fatalist.

To what extent, I asked, do behaviour change strategies in areas such as obesity, alcohol abuse, anti-social behaviour engage with these ways of seeing the world and acting upon it? Behaviour change as a concept is hierarchical, being as it is about people in authority deeming a behaviour to be unacceptable and then maintaining that, through the use of expertise and authority, they can solve it. But how, if at all, do these strategies engage individualism, egalitarianism and fatalism?

We discussed the ban on smoking in public places, which is widely seen as a success. I suggested that it had worked – in the sense that it has been accepted – because the hierarchical authority of health experts and policy makers had reinforced the egalitarian demands of non-smokers (made more powerful by evidence of the effects of passive smoking). Individualist pressures were balanced between smokers and non-smokers while fatalist smokers would stand out in the rain resigned to their status as social outcasts rather than mounting the barricades in defence of their habit. Whether the ban will work in its wider aim of reducing smoking is less clear. With pubs closing every day and, presumably, more people drinking and smoking at home it could be that the mixture of wilfulness and passivity among smokers will leave smoking levels only marginally reduced.

This discussion took place on the same day as the UK Organ Donation Task Force announced that it had decided against recommending ‘presumed consent’ for organ donation. Among the reasons given was the concern that this might lead to a backlash against the policy and doctors administering it. In cultural theory terms the argument here is that presumed consent could create egalitarian momentum as patients came to believe that they were vulnerable to being exploited by doctors.

Cultural theory argues that each of the four views of social relations gains its energy from its opposition to the others. Doctors have largely escaped the loss of public esteem and trust that has affected other authority figures. The legitimacy accorded to the medical profession means that their authority is not perceived as a hierarchical imposition so it has not generally provided the context for the emergence of an egalitarian or individualist opposition (although there have been critiques of medical practice from particular communities of patients). Given the mixed evidence of the actual impact of presumed consent on donation levels, the task force clearly felt that trust was too big a price to pay.

Gordon Brown seems to be considering overruling the recommendations but in recognising the limitations and vulnerabilities of policy based on hierarchical authority, and in urging greater commitment to the ‘clumsier’ solution of organised voluntarism, the Task Force may be offering wise counsel.