If you are superstitious, it may seem unwise that this Friday's feature of the OHPE focuses on thirteen ethical dilemmas in health promotion. Nurit Guttman's (1995) review of dilemmas in health communication are easily adapted to health promotion practice, so here they are, summarized and posed in question format for Friday reflection. Following these interesting questions are some ideas from others such as Coveney, (1998), Seedhouse (1998), and Yeo (1993).
Maybe it is only if you don't take the time to think about these kinds of questions your luck may be affected...
B. THIRTEEN ETHICAL DILEMMAS IN HEALTH PROMOTION (
adapted from Guttman, 1995)
I. Dilemmas Concerning Strategies
1. The Persuasion Dilemma
To what extent is it justified to use persuasive strategies to attain the intended health-promoting effects of the campaign, even if the use of such strategies might infringe on individuals' rights? (e.g. the
degree of paternalism)
2. The Coercion Dilemma
To what extent is it justified to promote restrictive policies or regulations on individuals' behavior in order to achieve the health goals? (i.e., when should we intervene - only when one's behavior needs to be restricted to protect others?)
3. The Targeting Dilemma
Whom should the program target? Should the program devote its resources to target populations believed to be particularly needy, or should those who are more likely to adopt its recommendations be targeted? (i.e., balancing the need to be effective with the need to provide equity in programming)
4. The Harm Reduction Dilemma
To what extent should a health promoter engage in strategies that support behaviors that are not socially approved or seen by some as immoral, in order to prevent further harm to certain populations?
II Dilemmas Concerning Inadvertent Harm
5. The Labeling Dilemma
To what extent, by forcefully telling people that they have a certain medical condition that puts them at "risk" does the program effort label them as "ill" and to what extent does it stigmatize certain
individuals by "vilifying" certain health-related conditions they have?
6. The Depriving Dilemma
To what extent might the program goal, while aiming at risks associated with certain behaviors or practices, in fact serve to deprive people of pleasures?
7. The Culpability Dilemmas
a)To what extent should a person be culpable for ill-health outcomes associated with their behaviors and to what extent should the social environment be seen as responsible.
b)To what extent should certain "risky" behaviors be socially approved and socially desired while others should be disapproved of, thus identifying those who practice them as irresponsible?
c)To what extent should one be responsible for the behavior of significant others?
III. Dilemmas Concerning Power and Control
8. The Privileging Dilemma
When focusing on specific health problems or particular ways to address them, to what extent does the program privilege certain stakeholders or ideologies?
9. The Exploitation Dilemma
When involving community or other voluntary organizations in the interventions, which might support values of participation and empowerment, to what extent does this involvement in fact serve to exploit these organizations?
10. The Control Dilemma
When providing health-promoting programs and services, to what extent might the programs' and services' utilization serve to control organizational members? (e.g., workplace initiatives)
IV. Dilemmas Concerning Social Values
11. The Distraction Dilemma
By emphasizing the importance of certain health-related issues in personal, organizational and societal agendas, to what extent does this emphasis serve to distract people from other important social issues? (some argue that the health agenda distracts from the significant problem of economic equity)
12. The Promises Dilemma
Do health campaigns, when they urge people to adopt particular practices and behaviors and say this will make them healthier, make promises that might not benefit certain individuals or society as a
whole? (Guttman cites Callahan, 1990, who says raising expectations for health is at the core of the increase in demand for expensive medical programs.)
13. The Health as a Value Dilemma
By making health an important social value that should be pursued by the public, do community health programmers in fact promote a certain moralism that might not be compatible with other values? (sometimes at the expense of connectedness and caring?)
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C. MORE THINKING ON ETHICS
Seedhouse (1998) asserts that the key ethical question for health workers is "what is the relationship between work for morality and work for health?... "Whatever health is taken to mean, work for health has to involve intervention in human lives.....it is possible to make a difference to people's lives....[this] is a key to morality: moral philosophers are concerned about human thought and action because, and
in so far as, this has social consequences." p. 47-48)." This emphasis on the individual/social relationship points to the public health paradox.
Yeo's (1993) paper "Toward an Ethic of Empowerment for Health Promotion" identified the notion that the process of health promotion, the "enabling," transcends the possible conflict between individual vs
community. Different from saying "you are responsible, you got into this mess, now get yourself out" this perspective is premised on the idea that people need know how, resources and power to assume greater control. The community and individual shape each other.
Coveney (1998) builds on this notion. He focuses on nutrition as an example, summarizing the history of nutrition strategies in the last century. He identifies published accusations of practitioners of
staying too focused on a disease model - taking scientific discoveries about nutrition and translating them into appropriate behaviors. Others say a more humane and effective approach is to work with
everyday concerns that people have about food and eating. Health professionals and community members focus on a problem and develop an understanding of it to help decide on an appropriate approach. But these criticisms are not confined to nutrition, and the conflict between a social model and a "medical" model is not in its approach, but in its ethical underpinnings.
Coveney argues his point succinctly and agrees with Yeo that the two models are more similar than different (both require a "self-reflective, self-problematizing subject" (p. 465) to address the problem. In the former model one does it as an individual and in the latter model one does it collectively. By fostering the means by which individuals (alone or collectively) become self-reflective we can ensure more ethical practice. "Health promotion - whether it be individually or socially oriented - provides for us an ethics: a means by which we can assess our own desires, attitudes and conducts in relation to those set out by expertise." (Coveney, 1998 p. 466). This idea of the health promotion process is consistent with the WHO definition of health promotion, (1996) which, as a central aspect requires fostering increased control (of the subjects). Coveney urges health promoters to expose our assumptions about these "subjects," our community members, as well as clarify the ideological assumptions about the strategies that we choose, before we act.
Coveney, (1998). The government and ethics of health promotion: the importance of Michel Foucault.
Health Education Research. 13(3), p. 459-468.
Guttman, Nurit. (1995). Ethical dilemmas in health campaigns. Unpublished paper, presented at the 1995 Annual Conference of the International Communication Association.
(available through the Health Communication Unit (416) 978-1188 fax: (416) 971-2443 or
Seedhouse, D. (1998). Ethics: the heart of health care. 2nd Ed. Toronto: John Wiley & Sons.
Yeo, M. (1993). Toward an ethic of empowerment for health promotion. Health Promotion International. 8(3), p. 225-235.
Note: Please see OHPE 79.2 for additional resources related to ethics.
Submitted by Lorraine Telford, The Health Communication Unit,
Centre for Health Promotion