Want Healthier Americans? Shift the Focus from “Personal Choice”

Popular narratives centering on “free choice” and “personal responsibility” might contribute to high rates of ill health and poor well-being in the United States, suggests a recent article in Perspectives on Psychological Science. The authors, Cayce J. Hook and APS Fellow Hazel Rose Markus (Stanford University), propose shifting to a narrative emphasizing that: (a) health depends on the individual and the environment, (b) health has impacts beyond the individual, (c) individuals can help cultures to support health, and (d) behavior-change policies can benefit health.  

“A culture-wide emphasis on personal choice and personal responsibility is harming Americans’ health and well-being,” write Hook and Markus. Estimates by the Centers for Disease Control and Prevention (CDC) indicate that up to 40% of deaths in the United States caused by chronic “lifestyle” diseases—heart disease, cancer, chronic lower respiratory disease, diabetes, and stroke—could be prevented. Despite constant calls for people to take responsibility for their health, Americans die younger and experience more illnesses and injuries than their counterparts in other high-income countries. 

Hook and Markus explain that health might not improve as long as messages such as “our physical and emotional well-being is dependent on measures that only we, ourselves, can affect” and “personal responsibility is the key to good health” (US Department of Health and Human Services, 1991) pervade policymaking, media, and social norms. First, these messages ignore the role of social and environmental factors that are beyond personal control in shaping health. After all, a single individual can hardly affect pollution, public safety, inequality, affordability of healthy foods, and quality health care. Second, these messages promote stress and worry over health, can lead to blame and stigmatization of the unhealthy, and hinder the adoption of policies that could make everyone healthier.

Narratives about freedom of choice and fears of government control in health matters are perpetuated throughout a “culture cycle,” the authors propose. According to this model, individuals are simultaneously products and producers of their cultures. In the United States, contemporary approaches to health are shaped by four levels of influence that interact with one another: (a) individuals and their attitudes, (b) interactions with others, (c) institutions (e.g., government, health organizations), and (d) the ideas of freedom of choice, personal responsibility, and individualism. 

The emphasis this cycle places on the individual, and the resulting resistance to governmental interference, also overlooks the role of environmental factors in supporting healthy choices. 

Everyday environments promote sedentary behaviors and unhealthy food choices. Moreover, “personal choice” has been used to support a health care system that leaves the United States “alone among rich capitalist nations in not guaranteeing basic universal health coverage” and has allowed food, tobacco, and alcohol industry groups to resist regulation that would limit sales, Hook and Markus explain. 

Although it is undeniable that health can be influenced by individual choices, it is fundamental to understand that physical, social, and cultural environments shape these choices too, the researchers continue. Other research indicates that an effective way to improve health in the United States might be to “adopt policies that change everyday environments in ways that make healthy behaviors easy to do,” write Hook and Markus. They call for broader narratives that improve the understanding that healthy choices do not depend solely on the individual and do not exclusively affect the individual. “Individuals’ health choices can have profound effects on their families, friends, and broader communities.” 

This broader narrative supports the idea that individuals can be social influencers who can help to change their communities and cultures for the better. It also supports the implementation of policies that make healthy choices more accessible than unhealthy choices. “Psychological science can play a major role in shifting narratives around health that are currently serving as barriers to change,” Hook and Markus believe. “If appeals to choice and personal responsibility are making us sick, one path forward is to work toward creating more supportive environments that afford responsibility and make healthy choices available and easy to choose.”

Reference

Hook, C. J., & Rose Markus, H. R. (2020). Health in the United States: Are appeals to choice and personal responsibility making Americans sick? Perspectives on Psychological Science. Advance online publication. https://doi.org/10.1177/1745691619896252