Spinoza,Liberation From Causation,and Community Health Promotion

Abstract

What sense does it make to say that a new program implemented in a community with roots as old as evolution caused an observed health benefit? Evaluation of community approaches has often sought to isolate the causal roles of interventions. Central to this is the assumption that there are causes to be proven and isolated. Benedict Spinoza (1632-1677) dismissed the concept of cause, arguing that all things, “substances,” are not caused but simply are. Actions of things in nature can influence each other, e.g., erosion of a mountain, but their substance, the mountains simply are. For Spinoza, satisfaction in life comes from realizing and acting in accord with our substance, but this requires communities that support such realization and action. Thus, communities and the vast influences they contain are central to human welfare. Interventions within them do not cause benefits but join with the history, culture, and numerous other features of the community in becoming part of how the community influences its members. Implications include a) expanding the social ecological model fully to embrace multiple influences – including innovative programs – and interactions among them, and c) varied research methods to identify practical lessons about how communities may adopt and incorporate innovations to engender change, rather than a catalogue of interventions that are supposed to change them.

Introduction

Community approaches to health promotion, including those in workplaces, have often promoted complex interventions to engage groups in programs, interact with and incorporate features of those communities and their surround, and achieve diverse benefits through varied pathways affecting different groups in different ways. Because of the hegemony of research methods from clinical medicine, however, these programs have been developed and evaluated too often among the strictures of controlled trials and standardization. These may suit objectives of evaluating pharmacotherapies independent of their surround but poorly suit the needs of vibrant, complex, adaptive, culturally and context sensitive community initiatives.

Behind the research folkways and dominance of clinical research, RCTs, standardization, and the like, are assumptions that (a) causes can be found and (b) the best way to identify causes is through a small set of experimental methods. What if the concept of cause were challenged?

Benedict Spinoza ¹ (1632-1677) argued that there is no such thing as causation, that, instead, things, “substances,” simply are, “…determined from a necessity of the divine nature, not only to exist, but to exist and act in a certain manner, and there is nothing contingent.” ^{2 p. 126} A succinct appreciation of Spinoza appeared in a New York Times piece on wilderness hiking by Nicholas Kristof, “... the mountains and rivers ... put us humans in our place. I understand Spinoza best not in the library but in the mountains.”^{emphasis added, 3} To join Kristof without venturing into the wilderness, look at this brief video from the North Carolina coast https://youtu.be/SORfH0hlXL8 and ask yourself what sense it makes to talk about one wave causing another, especially when considering that the Atlantic Ocean is 150 million years old.

Probably to appease the religious communities in Amsterdam (who still excommunicated him), Spinoza equated the “divine nature” and all of existence with “God.” His position is illustrated in his argument about why God, as creator, is not separate from all being. After all, if God created all existence, God would then be separate from that existence, meaning that there would be something that existed that God did not create, contradicting the premise. We are probably on safe ground, however, to substitute “nature” for “God.” ⁴

So, we all – you, me, they, and all the its around us – simply are, not caused, but simply are. Looking at the sky on a starry night and thinking about the relative fly speck that is our universe helps make this feel a bit more rational than at first blush.

Conatus and Community

If all existence simply is, if what we are is simply caused before our birth, foreordained, we might expect that all there is for us to do is to shuffle along for our allotted time and die. In contrast, Spinoza proposes the opportunity for wisdom and satisfaction in life through realizing and living in accord with our essence, what he called “conatus.”^{1, p 96} Conatus entails ideas and actions – living – to grasp, affirm and advance our essence as human beings. Thus, realization of our essence is not a “lifeless object”^{1, p 94} but a way of thinking and acting in correspondence with the essence of our substance. To realize and live according to our essence is the path to our greatest satisfaction.

Spinoza’s concept of conatus leads in an interesting way to communities. Individuals are not able to achieve conatus on their own. That requires a community in which all are supporting each other in realizing and acting in accord with their basic nature. The “strength of one man would barely suffice to ensure reason without men acting in concord with one another.” ^{2 p. 361} Thus, for Spinoza, conatus, realizing our essence, requires community. Community is not an optional strategy; it is essential.

Asserting the central role of community also constitutes a political philosophy in which individuals cede their own prerogatives to the goal that “all might conform to reason and human nature.” ^{2 p. 320} “A man who lives by reason lives better in a state which encourages this among all so that freedom and conformity to our essence is facilitated by, not opposed by the state.” ^{2 p. 351}

Social Influence

The ocean floor, the wind and tides may all influence waves, but do not cause them in oceans that are over 150 million years old. Denying “causes” is not to deny influence, but to frame it within a context of a huge number of other influences without privileging one or a few as causal. Individuals too can influence each other as in Spinoza’s observation that hatred “can be extinguished by love.” ^{2 p. 329} Spinoza identified a wide range of positive and negative influences but emphasized the possibility of human exchange of caring and support. Minds “are not conquered by arms but by love and generosity.” ^{2 p. 354} We should “apply our minds to those things which subserve concord and the establishment of friendship.” ^{2 p. 357}

The community that is essential to conatus includes many influences such as the broader culture, policies, economics, etc., reflecting the social ecological model.^5,6 This multitude and history of influences has real implications for how we view our work. To say that a particular intervention introduced into a community or system caused a particular change ignores the influence of human beings’ long and diverse histories with groups and systems. Note that this critique is counter to the tradition of 20^th century positivism and experimental design intended to isolate “causes” or more recent identification of “evidence based” interventions that are put forth with the questionable expectation that they may be effective almost regardless of context.

Free Will?

That all simply is and that we should cede our individual prerogatives to the community raise issues of free will and independence. For Spinoza, substances – who we are, what the Atlantic ocean is – simply are, uncaused. In that sense, determinism is not so much rejected as set aside. Nevertheless, things may influence each other. Although climate may lead to erosion of a mountain and humans may influence each other, these do not change the substances of the mountains or the humans.

Among the vast range of influences – others’ actions, situations, social determinants, genetics and early development, psychological and biological states, and on and on – individual behavior may be thought to be determined. Implications of this include questioning the utility of concepts like “freedom and dignity,” as with Skinner, ⁷ or questioning social and moral judgments such as achievement, responsibility, guilt, etc. that depend on an assumption of “free will,” as with Sapolsky. ⁸ Spinoza did not dwell on whether our choices – coffee or tea – are determined. Instead, he emphasized our substance being a given, our task of conatus being to realize and live in tune with that substance.

The philosophical or political assertion of free will may countenance restrictions on the individual, such as required vaccinations, as regrettable exceptions to a more fundamental and ideal autonomy. In contrast, Spinoza saw the interest of the individual as wedded to the interest of the community so that all may enable each to realize and act in accord with their essence. The dependence of the good of the individual on that of the community is not an exception to an assumed individual freedom. It is metaphysical, following from the assumption that we are not free but anchored in the necessity of our natures.

Ethics

Spinoza’s major work, from which the present quotations are drawn, was titled Ethics. That we all may advance to conatus only in concord with each other leads to an ethic that values actions according to whether they further that concord and its benefits. Consider policies that increase population health by constraining choice, e.g., requiring seat belts, motorcycle helmets, or vaccination of school children – or of adults during a pandemic.^9,10 How do we weigh health benefits against what some might consider the threat to conatus of state invasion of privacy, choice, etc. Spinoza does not eschew state influence. The mandate of the community is not to leave the individual alone, but to promote concord and thereby conatus among all. Questions may remain, however, about specific approaches, e.g., incentives for healthy choices vs regressive taxes for unhealthy ones.

Implications for Community Practice and Research

Denying causation does not eliminate data. Controlled studies – randomized, quasi-experimental, cluster randomized, etc. – have shown differences between communities that did or did not receive interventions, such as recent examples from this Journal.^e.g.,11-13 Such differences support the value of those interventions. Experimental studies in health promotion may also examine mediators and moderators in testing the effects of interventions.^e.g.,13,14 Although they may identify the influence of contexts, nevertheless they still focus on the intervention as causal, albeit mediated or moderated.

In contrast to focusing on the proffered causal role of the intervention, Spinoza might encourage placing the intervention not at the center but amidst the many contextual factors with which it interacts. Study might then examine beneficial changes as they are related to the many features of the intervention and setting. This moves attention from (a) how an intervention performs, albeit influenced by its context, to (b) how a community performs when an intervention is introduced into it.

Emphasizing communities and contexts recommends varied research methodologies – qualitative, mixed methods, case studies, natural experiments, and other methods such as those of implementation science, e.g., the Consolidated Framework for Implementation Research. ¹⁵ It might also include cluster or structural equation modeling approaches along the lines of the multivariate models in genetics that identify “signature” patterns of genes and their variants, with no single wild type or variant identified as “the gene.” ¹⁶ Examples include structural equation modeling of contexts and intervention features of a community program for asthma management among children from disadvantaged communities. ¹⁷

Focusing on complex interactions among contexts and interventions reframes development, implementation, evaluation, and sustainability of interventions, including, e.g.,

a) planning through community organization or worker based approaches

b) facilitating adaptability by “standardizing” interventions not by procedural details but according to their key functions or strategies ¹⁸ such as the “five defining elements” or “guiding principles” of Total Worker Health® ^{19 p. 1} or key functions of peer support^20,21

c) qualitative or mixed methods evaluations and other varied approaches to evaluation, as mentioned above

d) policies that acknowledge the complexity of implementation and favor adaptation and flexibility rather than mandating adherence to rigid standards or protocols

In short, pursuing a knowledge base that illuminates how interventions and their contexts interact to change behavior and health might enhance understanding and lessons about how communities and their inhabitants change rather than a catalogue of interventions that are supposed to change them.

So What? (Implications for Health Promotion Practitioners and Researchers)

What is Already Known on This Topic?

Spinoza rejects causation, thereby challenging assumptions underlying what research tells us and how it should be pursued.

What Does This Article Add?

Spinoza’s thinking leads to a complex and nuanced view of how changes occur and the metaphysical and ethical roles of communities in promoting change and wellbeing. This encourages a philosophical expansion of the social ecological model to embrace fully multiple influences, levels of influence, and interactions among them.

What are the Implications for Health Promotion Practice or Research?

Developing interventions with attention to nuance and complexity may do more to advance the good than what Spinoza might argue is a quixotic pursuit of interventions that purportedly cause change.