Editorial--health education and health promotion.

SIR As pointed out in your recent editorial (1) my contribution to the 1984 'controversy' defended not health promotion in all its many guises, but rather one particular interpretation of it (2). I was suggesting that there is a model of health promotion (elaborated upon elsewhere (3) which included health education at its best (no doubt of the type of which Gill Williams 'approves'), and where there is little (if any) place for a 'hard sell'. This model has gained a high degree of acceptance in many places, has, I understand, promoted agreement and collaboration between different professional groups (notably community physicians and health education officers), and has also given direction to what had become a sterile semantic debate. Moving on to the question ofpersonal autonomy in health-related decision-making, I am somewhat confused by the statement that my referring to 'the illusory nature of free rational choice may strike a certain chill'. This can be interpreted in two ways: firstly, that you agree that the concept of free rational choice is illusory, and you find this disturbing; or, alternatively, that it is the denial of the existence of free rational choice which chills you. On balance I take the latter to be the intended meaning. In any case, since your statement might well be taken that way by your readers, it is necessary for me to clarify my standpoint. I am very much in favour of free choice, but my argument that freedom of choice is currently limited is based on recognition that health-related decisions do not take place in a vacuum. Health choices are made in a social environment heavily loaded in favour of unhealthful behaviour, due to the existence of many powerful influences, such as: the false images created by advertising and promotion, and otherwise by mass media; the associated social pressures (including peer pressure) to be 'cool', 'sophisticated', 'smart' or 'macho', rather than being rejected as a 'wimp' or 'wally'; the relative prices and availability of products; and socioeconomic status (with its important bearing on opportunity and motivation). Even disregarding these factors (as many people all too readily do), it has to be acknowledged that unhealthful practices are often habit-forming or addictive. To quote Thomas McKeown (4), 'Our habits commonly begin as pleasures of which we have no need and end as necessities in which we have no pleasure'. Also, '...it is said that the individual must …