Freedoms, functionings and the aims of health promotion: A conjoint analysis

The capabilities approach (CA), developed by Amartya Sen, is a normative framework for assessing individual wellbeing, social arrangements, and the design of policies. The CA posits that policies should focus on removing obstacles so that people have more freedom to live the kinds of lives that they have reason to value. It is an integrative account, conceiving of freedom and wellbeing as two distinguishable but linked aspects of human life. CA scholars are divided on the question of whether or to what degree freedom matters to health. Some argue that what matters most for health are achievements, namely health outcomes; that freedom of individuals or groups is of secondary concern. Other scholars endorse Sen's view that freedom is a crucial component of achieving wellbeing, arguing that when freedom is constrained something of value is diminished, even if good health outcomes are realized. Health promotion policies and interventions, which range from value-free information provision to sanctions and coercion, provide a useful lens through which to examine these tensions. Using a discrete choice method known as conjoint analysis, this study examines how two groups of laypersons – prospective jurors in Baltimore, MD and a national, internet-based sample -- trade off elements of freedom (including incentives and sanctions) and achievements (understood as individual- and population-level health outcomes) in choosing between various types of health promotion interventions. The analysis has implications for how we evaluate health promotion activities that impose conceptions of ‘the good life,' use coercion, or are paternalistic in character.