Ethical Issues in Health Promotion and Communication Interventions
Summary and Keywords
Health promotion communication interventions invariably raise ethical issues because they aim to influence people’s views and lifestyles, and they are often initiated, funded, and influenced by government agencies or powerful public or private organizations. With the increasing use of commercial advertising tactics in health promotion communication interventions, ethical issues regarding advertising can be raised in health promotion communication when it applies techniques such as highly emotional appeals, exaggerations, omissions, provocative tactics, or the use of children. Key ethical concerns relate to infringing on people’s privacy, interfering with their right to freedom of choice and autonomy, and issues of equity (such as by widening social gaps, where mainly those who are better off benefit from the interventions). Interventions using digital media raise ethical issues regarding the digital divide and privacy. The interventions may have unintended adverse effects on the psychological well-being of individuals or groups (e.g., by inadvertently stigmatizing or labeling people portrayed as negative models). They can also have an effect on cultural aspects of society (e.g., by idealizing particular lifestyles or turning health into a value) and raise concerns regarding democratic processes and citizens’ consent to the interventions.
Interventions can have repercussions in multicultural settings since members of diverse populations may hold beliefs or engage in practices considered by health promoters as “unhealthy,” but which have important cultural significance. There are also ethical concerns regarding collaborations between health promoters and for-profit organizations. Identifying and considering ethical issues in the intervention is important for both moral and practical reasons. Several ethical conceptual frameworks are briefly presented that elucidate central ethical principles or concerns, followed by ethical issues associated with specific contexts or aspects of communication interventions.
Introduction: Why Are Ethical Considerations a Pivotal Part of Communication for Health Promotion Interventions?
The process of health promotion communication involves various types of communication approaches and strategies to encourage people to adopt recommended health practices. This process often entails the articulation, development, testing, and dissemination of practical suggestions, claims, and persuasive messages within various communication formats and media channels (including social networks) for the purpose of promoting the health of individuals and the public as a whole. Clearly, because this process aims to influence people’s views, beliefs, preferences, relationships, social norms, and lifestyles, it raises a variety of ethical issues and dilemmas related to the persuasive and influence strategies used. Ethics and morals both concern precepts or principles for what governs or should govern people’s voluntary behavior, in terms of what is considered right or wrong, in particular when it could have an impact on others. Some scholars make a distinction between ethics and morals, with ethics referring to mainly to the guiding principles and morals to the more practical and social and cultural context (Johannesen, Valde, & Whedbee, 2008).
Ethical theories aim to identify and justify the moral norm that can serve to guide and evaluate the morality of the conduct or policy (Beauchamp & Childress, 2001). Ethical dilemmas emerge when a particular ethical principle (e.g., respecting people’s privacy) conflicts with another principle or moral obligation (e.g., protecting someone from harm) when planning a health promotion communication intervention (Guttman, 2000). Because various health issues have raised ethical issues concerning healthcare professionals’ decisions and practices since ancient times, philosophers and medical practitioners developed a body of literature and guiding principles, often referred to as medical ethics, that specifically pertain to health-related issues but draw on the more general principles in ethical theories (Beauchamp, 2009). Currently, with advances and developments in biomedicine that can affect individuals and society, the term bioethics has been introduced to refer to the study and practice of ethics in the wider healthcare context. Scholars note that it is also a more critical and reflective activity that is concerned not only with ethical precepts and codes, but also with understanding the issues and pointing to policy implications (Khuse & Singer, 2001).
Health communication interventions may also have unintended adverse effects on the psychological well-being of individuals or groups (e.g., by inadvertently stigmatizing or labeling people who are used to portray a negative model) (Cho & Salmon, 2007). Further, health promotion communication interventions could have an effect on cultural aspects of society (e.g., by idealizing particular lifestyles or turning health into a value) and raise concerns regarding democratic processes, citizens’ consent to the intervention (Ayo, 2012), and the role that they place in the appropriation of the political, social, and moral realms of the public consciousness and discourse.
Despite the obvious role played by ethics in health promotion communication interventions, communication researchers note that they are seldom discussed in daily health communication practice and are mainly raised only after critical questions are raised by others (Bouman & Brown, 2010). Therefore, practitioners and scholars concerned with ethical issues in health promotion note that it is imperative that ethical issues regarding the intervention should be identified and addressed already at the outset of the intervention, and that it could be assumed that additional ethical issues may emerge during the implementation (Brenkert, 2002).
Moral and Practical Reasons
Identifying and considering ethical issues in the health promotion intervention is important for both moral (adhering to ethical principles or cultural conceptions of what is right and wrong) and practical (producing the desired impact) reasons (Carter et al., 2011). From a moral perspective, one compelling argument is that since health promotion aims to promote a social good and since its goals are for a “noble” cause, the means to achieve them must be ethical as well (Holden & Cox, 2013; Kirby & Andreasen, 2001; Rothschild, 2001). Health promotion interventions are laden with moral concerns because the behaviors that they aim to influence typically relate to intimate aspects of people’s lives, their relationships, culture, and social values. For example, food is a symbolically and socially central aspect of human life. Therefore, interventions to change people’s food habits essentially intervene into their culture, habits, preferences, and personal and work relationships (Carter et al., 2011; Mayes & Thompson, 2014). Such interventions can have repercussions in multicultural settings since members of diverse populations may hold beliefs or engage in practices considered by health promoters as “unhealthy,” but which have important cultural significance to them. Thus, interventions might address sensitive topics or challenge people’s deeply held beliefs and moral judgments.
Another reason for considering ethical issues is that health promotion interventions increasingly rely on advertising campaigns and marketing strategies, which enhance their persuasive potential. Further, health promotion interventions increasingly use digital media, and this use also raises ethical issues regarding the digital divide and privacy. In addition, there are ethical concerns regarding current and potential collaborations between health promoters and for-profit organizations. Finally, with the increasing adoption of commercial advertising tactics in health promotion interventions, ethical issues that are raised regarding advertising can be raised in health promotion communication when it applies techniques such as highly emotional appeals, exaggerations, omissions, provocative tactics, or the use of children.
From a pragmatic perspective, if the intervention is to be perceived as doing things that are unethical, it would lose its credibility. Further, the consideration of ethical issues can help health promoters avoid using communication tactics that could be ineffective because they might be insensitive to the values of the intended population and cause people to respond negatively.
Types of Ethical Concerns Regarding Health Promotion Communication Interventions
Key ethical concerns in health promotion include issues related to infringing on people’s privacy, interfering with their right to freedom of choice and autonomy for the sake of promoting the health of individuals or society as a whole. Further, ethical issues in health promotion interventions raise concerns regarding unequal or unfair treatment or provision of services, referred to as equity, and distributive justice, which expands the term to include unequal distribution of risks or burdens or of fair opportunities to attain health goals (Daniels, 1985). For example, communication interventions might serve to widen social gaps when mainly those who are better off benefit from these interventions.
Another particularly contentious issue concerns the emphasis on personal responsibility in health promotion interventions. It raises ethical concerns regarding whether interventions that aim to promote healthier lifestyle choices might invariably result in putting the burden of being healthy on the individual. Other types of ethical issues are related to tactics and strategies. For example, strategic decisions regarding which population should be the target of the intervention, and which will not, or what kind of persuasive arguments and visual appeals should be used. Overall, the range of ethical issues in health promotion interventions is as broad as the types of issues addressed and the types of tactics used. Ethical issues can be found in each component of the intervention, from the conception of its goals, from the way it considers (or not) the issue of informed consent or participation of the intended population in the design of the intervention, to the assessment of its outcomes (Guttman & Salmon, 2004). These issues are further elaborated in the sections that follow.
In some cases, the ethical issues that emerge in health promotion activities are explicit and elicit a debate, while in other cases, pertinent ethical issues may be more difficult to recognize in the wide range of health promotion activities. Therefore, it is important to identify and elucidate them. For this purpose, the following sections will briefly outline several ethical conceptual frameworks that elucidate central ethical principles or concerns, followed by ethical issues associated with specific contexts or aspects of communication interventions.
How to Identify and Consider Ethical Issues: Drawing on Ethical Frameworks and Precepts
Because health communication interventions are intended to serve health-promotion goals, the discussion of ethical issues can be informed by the medical or bioethics (Beauchamp, 1996) and health promotion ethics literature (Buchanan, 2000; Buchanan, 2008; Callahan & Jennings, 2002; Cribb & Duncan, 2002; Dawson & Grill, 2012; Mittelmark, 2008; Seedhouse, 2001), from the communication and social marketing literature (Andreasen, 2001; Truss & White, 2010; Guttman, 2000), as well as from critical and cultural theories that point to ethical issues related to broad moral issues related to culture and democracy (Foucault, 1984; Lupton, 1993). Current discussions on ethics in health promotion emphasize two broad questions that they propose should be asked regarding the ethical base for the health promotion issue: first, does it indeed promote people’s health (e.g., is it based on reliable evidence); and second, whom does it actually benefit (e.g., is the benefit distributed fairly, and does it contribute to equity) (Carter et al., 2011; Holden & Cox, 2013). These two questions encompass some of the major ethical concerns in health promotion that directly or indirectly refer to the obligations of doing no harm, doing good, justice and equity, and effectiveness. These are among the central ethical principles specified in formal ethical frameworks, briefly noted next.
“Doing No Harm”
A series of precepts or moral obligations of healthcare practitioners that draws on this literature (Beauchamp & Childress, 1994) is briefly summarized in this section. One important obligation is that when one aims to better people’s health one needs to avoid doing them harm (nonmaleficence) (Beauchamp, 1996). This moral obligation is considered by some ethicists as the foremost ethical maxim for healthcare providers since the days of Hippocrates. The obligation to “do no harm” causes ethical concerns when an intervention of any kind, including a communicative activity, might directly or indirectly harm individuals or communities, whether on a physiological, psychological, social, or cultural level. For example, as a result of health promotion interventions, some individuals might become particularly anxious because of certain risk messages, or communication interventions might inadvertently stigmatize certain populations by using a derogatory depiction of their medical condition.
One example of potential harm elicited in health promotion communication interventions concerns initiatives that focus on body weight and obesity prevention. Health promotion interventions aimed at body weight are associated with ethical concerns because people’s identities are influenced by their body image, and thus messages about their bodies essentially concern their self-image and personal worth. People might also be affected by such interventions by viewing themselves more negatively, by having others see them in a more negative way, such as by being blamed for their presumed lack of willpower or character, regardless of economic, social, genetic, or psychological factors that affect their body weight and food consumption (Carter et al., 2011). This can serve as an example of situations in which people find it difficult to change their health conditions because of not having appropriate opportunities, support systems, or supportive environments, and might not succeed in their attempts to change, which could create or reinforce a cycle of self-blame and helplessness.
A second obligation that could be seen as the flip side of doing no harm is the obligation to “do good” (beneficence), which is considered a basic tenet of the helping professions. This obligation is supposed to be carried out by actively pursuing means to help individuals and communities to reach a positive state of health or by preventing them from being endangered by risks and potential harm. The obligation could involve the protection and promotion of people’s health on the individual level, as well as the family, community, and societal levels (Beauchamp, 1996). Numerous dilemmas emerge when interventions aim to “do good,” but other factors might be involved that raise concerns regarding the means applied in the intervention. For example, to reach male youth who are typically uninterested in health information, health promoters might seek to employ computer video games. However, in order for these games to be attractive to the youth, they might consider using images that are violent or sexist. Other concerns and examples are presented in the sections that follow.
Respecting People’s Privacy and Their Autonomy to Make Free Choices and Not to Be Manipulated
Two central obligations rooted in liberal Western philosophy and democratic theory, which are related to each other, are to respect people’s right to autonomy and the obligation to protect their privacy. These are based on the premise that individuals have an intrinsic right to make their own decisions on matters that affect them, so long as such decisions do not bring harm to others. This precept places high importance on individual choice regarding both political life and personal development. It underlies democratic forms of government and self-determination of individuals, communities, and nations, and it has been the foundation for the development of important medical care codes such as patients’ rights, informed consent, and confidentiality. Ethical issues associated with respect for autonomy and privacy typically concern the use of persuasive arguments that might be considered manipulative, or the use of graphic material such as mutilated bodies or human suffering that might offend people or expose them to issues or sights to which they do not want to be exposed (Hastings, Stead, & Webb, 2004).
One of the main criticisms of ethical frameworks that prioritize the importance of autonomy is that it represents mainly a Western approach to the conception of moral issues, draws too much on assumptions of individualism and universalism, and does not reflect diversity in moral reasoning (Makau & Arnett, 1997). Another criticism, which has particular relevance to health promotion ethics, is that an emphasis on persuasion and manipulation as threats to people’s autonomy presents a narrow conception of autonomy that does not take into consideration the social and relational context of human choices and behavior (Bouman & Brown, 2010; Owens & Cribb, 2013). For example, people’s health-related behaviors are done in the context of their family relations, and it might be very important to them to adjust their behavior so that it would fit the cultural traditions of their close relatives.
Another criticism addresses the actual potential to realize one’s autonomy, whether on the personal or collective level. It adds a stipulation to autonomy in health promotion that people should have the capacity not only to choose, but be able to act upon their choice (e.g., have the opportunity to eat healthier food at work, or walk to work instead of drive). The stipulation to ensure that people have the capacity to act upon a healthier choice can be articulated as an important condition to meet both ethical considerations of autonomy and equity or justice, which are referred to in the sections on justice and equity (Lee, Rogers, & Braunack-Mayer, 2008). This stipulation corresponds to one of the central guiding principles in social marketing: namely, the main goal of an intervention is to identify and reduce barriers—whether social, physical or psychological—in order to facilitate people’s ability to engage in the promoted health-related practice (Lefebvre, 2013; Hastings, 2007). However, these stipulations should not be used by decision makers as a justification to avoid communicating about issues when the intended population does not have the means to act. In such cases, for example, the discourse can focus on what is needed and how to create the necessary means, or on what kind of actions could be adopted even partially to address the health challenges.
Ethical Issues in Choosing Issues and Obtaining Consent
In the medical care context, it has become an ethical and often a legal requirement to obtain people’s consent to perform a medical intervention on them or on their dependents and to inform them about the procedures and possible risks or adverse consequences (Olufowote, 2008). Because health promotion activities are often viewed as relatively unobtrusive or educational, and because they are mainly implemented in the context of populations or through the media, the question of whether informed consent is required is often not even considered. Further, because health promotion interventions are a result of the initiatives of government agencies or not-for-profit organizations that aim to promote the health of the public, it is taken for granted that the public approves of them. Yet, health promotion interventions, by definition, intervene in people’s lives, and their topics are often chosen by the government or influential public and commercial organizations (Eagle, 2009). This raises the question of what should and could be the standards or procedures to ensure that informed consent is obtained on behalf of diverse populations. On a national scale, health promotion may reflect policies formulated as a result of a political democratic process, but on the local or organizational level, the question might be raised as to who represents the community residents. The issue is of particular importance when programs serve as so-called social experiments, to prove the efficacy of one type of health intervention over another. There are various participatory methods to involve different stakeholders relevant to the intervention, and they could be considered part of the design of the intervention.
Obligation to Promote Health Effectively and Efficiently
Another ethical obligation concerns designing and implementing health promotion interventions so that they will benefit most people and will be conducted in the most efficient and effective way of using public resources. This approach draws on a teleological perspective in moral philosophy and focuses on consequences as the main criteria for determining moral worth. This is indicated by the word telos, which means “end.” This approach is associated with utilitarianism (though some refer to it as a separate approach) that assesses the worth of actions on what was or will be the most beneficial to most people or society as a whole, and by doing so with a consideration of effectiveness (Hiller, 1987).
One of the underlying premises for this type of justification is also that society has limited resources, which should be utilized to maximize their effectiveness. This obligation can influence decisions about how to choose the intended population for a health promotion intervention by drawing on a utilitarian basis rather than needs (Christians, 2007). However, it should be noted that utilitarian approaches that are employed in health promotion typically include considerations of equity and justice, which are embedded into the overall ethical framework. A teleological approach is often referred to in terms of “the ends justify the means,” and is used by practitioners to justify the use of particular persuasive strategies, which might offend, disturb, or even harm (e.g., stigmatize) certain members of the population. In such cases, arguments drawing on the importance of utility are presented in order to override concerns regarding privacy, autonomy, or causing harm to certain individuals or groups. These issues are further discussed in the section “Using Provocative Appeals and Strong Negative Emotional Appeals”.
Justice and Equity
An important guiding principle in democratic ethical frameworks refers to equity and justice. These are broad and contested issues that encompass obligations associated with distribution of resources, opportunities, benefits, and risks. Health promotion activities are typically committed to the moral obligation to promote equity in terms of health promotion opportunities across social groups. Overall, disparities in health have been linked to social and economic determinants and many health promotion interventions aim to address these disparities. However, paradoxically, health promotion activities that have achieved significant improvements in the adoption of healthier practices among large populations may inadvertently serve to reinforce, rather than reduce, existing social disparities.
It has been found that large-scale programs that aim to influence lifestyle behaviors, including the prevention of heart disease, smoking cessation, and increased physical activity or early cancer detection are more likely to have an impact on populations with greater economic resources (Viswanath & Ackerson, 2011). This has raised concerns regarding equity. Thus, several important ethical issues regarding justice and equity as they relate to public health communication interventions have been noted both conceptually and in empirical studies. These concern knowledge gaps, addressing barriers, digital media, targeting, and the issue of trust.
Equity and Knowledge Gaps
A recurring concern in the past two decades that concerns equity is that health promotion interventions may inadvertently widen health and social gaps by benefiting mainly those who are better off socially and economically. Communication scholars point to research findings that indicate that despite the promise that mass media campaigns could disseminate health promotion materials more equitably, such campaigns in fact were found to increase social gaps. A considerable social gap was found in the acquisition of, and the capacity of people to act upon, pertinent health information according to their socioeconomic backgrounds. This gap has been referred to as “the knowledge gap,” and its occurrence has been found regarding various health issues, including cancer, heart disease, and breastfeeding (Kulkla, 2006; Viswanath et al., 2006). Consequently, health promotion interventions may inadvertently serve to reinforce existing social disparities.
The emphasis on justice is particularly relevant because less economically well-off groups are typically more severely affected by chronic and infectious diseases than the well off because they are less economically equipped to prevent or control them. Thus, social inequalities in people’s health and welfare can be exacerbated (Lee et al., 2008). To address such knowledge gaps, the assumption is that what is needed is to ensure that all people should have ready access to accurate, up-to-date, and easily understood and relevant information about how to prevent or reduce risk and promote their health. Further, the communication should be tailored to overcome obstacles faced by members of disadvantaged groups in accessing such information.
Equity and Addressing Barriers
In the discussion of autonomy earlier in this article, it was noted that critics maintain that in order for people to make autonomous decisions regarding health practices, they must also have the capacity to recognize these choices. A similar stipulation could be made regarding equity is ensuring that there are equitable solutions to barriers that people may face when they want to adopt health promoting practices. Providing solutions to barriers is a central guiding principle in social marketing and highly relevant to considerations of equity (Lefebvre, 2013).
Communication interventions that do not provide relevant solutions for the specific problems or barriers that prevent people from adopting the recommended health practices raise a central ethical concern regarding the communication intervention as a whole (Brenkert, 2002). If people at whom the communication is aimed to promote their health are not provided with solutions to barriers that they must overcome to adopt the recommended action, they will be reluctant to adopt it and benefit from it or protect themselves. For example, people who work long hours and do not have affordable fresh fruit and vegetables in the vicinity or time to prepare meals need solutions for these problems. Another example comes in the context of public health emergencies, in which people are asked to evacuate their home or business immediately. People might ignore directives to evacuate their property if no assurances are given that their property will be protected (Lee et al., 2008). Another example concerns the promotion of smoking cessation treatments. Critics maintain that clinical smoking cessation programs have been presented by healthcare professionals as the most effective means for smoking cessation compared to unassisted smoking cessation. They argue, however, that this communication could be both ineffective and harmful when promoted in nations with mainly economically disadvantaged populations because the medical products are inaccessible to them and it could discourage personal efforts (Chapman & Mackenzie, 2012).
Another example that demonstrates issues of equity as they relate to the ability to realize health information concerns menu labeling. Researchers argue that menu labeling may preferentially influence the welfare of those who are healthier and wealthier and have the opportunity to make choices. An additional ethical concern is that focusing the responsibility on people to make choices might shift the focus away from the institutional changes needed for people to be able to make the healthier choices, such as ensuring that healthier foods are available to the public at a reasonable cost (Carter, 2015).
Digital media offer opportunities to widely disseminate health promotion information in various formats and have become the main source of health information for many people. However, their use also raises ethical concerns regarding equity and the so-called digital divide (Hargittai, 2002). People with limited digital literacy or who lack physical access to computing facilities, as well as relevant skills and competencies, are less able to access or use health information distributed online (Viswanath & Kreuter, 2007). One example is the information gap that occurs in public health emergencies that use digital media channels to reach the public. In such situations, some of the most vulnerable groups in society, including the aged, the homeless, recent immigrants, rural residents, and the poor, are more likely to be at risk if digital media serve as the main route for information provision (Lee et al., 2008). To meet the obligation of equity, various health promotion programs seek to develop ways to increase access and enhance digital literacy among populations for whom the use of digital media for the purpose of health promotion is less accessible (Ginossar & Nelson, 2010; Kreps, 2005).
Equity and Strategic Segmentation and “Targeting”
Designing health promotion programs to focus on particular segments of the population is accepted as both a practical and ethical strategic approach in health promotion. It is considered a more ethical and effective approach because it requires the provision of equivalent but culturally appropriate messages to populations with different sociocultural backgrounds and levels of literacy (Hornik & Ramirez, 2006). It is also considered efficient because interventions that are developed according to the social norms and values of the particular population, and which draw on metaphors and symbols that they are familiar with or prefer, will likely be more effective in reaching its health promotion goals.
Ethical issues that concern justice and equity are also related to these strategic decisions regarding which populations should be the “target” of the intervention and which will not. However, the mere decision to “segment” a population according to certain parameters and to allocate limited resources to adapt particular health promotion activities to certain populations raises ethical issues regarding equity as well as utility. Decisions regarding “targeting” are often made on the basis of utilitarian or efficiency considerations. For example, it might be recommended by social marketing professionals to “target” those who are already in a state of readiness to adopt the recommended health practice by contemplating or engaging in it (Lee & Kotler, 2015). Alternatively, it may be decided to focus the efforts on those with the greatest need, who are considered “hard to reach” and less likely to adopt the recommendations, thus raising concerns associated with utility and the inefficient use of limited resources that are available to health promotion, as well as not addressing the needs of other groups (Newton, Newton, Turk, & Ewing, 2013).
Equity and Trust
Health promotion scholars concerned with ethics raise an interesting point regarding equity and the issues of trust, particularly in public health emergencies. Some populations do not obtain health information that could be beneficial to them because they do not trust the sources. Thus, there is an ethical obligation regarding earning legitimacy and trust from populations believing they have been discriminated against, stigmatized, or marginalized in the past. Otherwise, their lack of trust in the authorities will serve as an unfair barrier, and thus, they will not benefit from the health promotion initiative (Lee et al., 2008).
Ethical Approaches of Caring and Connectedness
Some ethical frameworks introduce an overall approach to connectedness and caring rather than focusing on particular principles of justice. One such approach is referred to as narrative ethics (Tong, 1998), which stresses the importance of understanding people by learning their perspective. A related approach is the ethic of care, which draws on feminist studies and focuses on the importance of maintaining relationships, connectedness, and attachment between people, on receptivity, and a person’s responsiveness to others (Nodding, 1990; Veatch, 1998). Similarly ethical approaches found in cultures referred to as traditional (Cortese, 1990), as well as in the communitarian approach, also emphasize caring and a sense of community (Etzioni, 1998). These ethical perspectives have implications for both health promotion interventions that take place in community settings and the development of a discourse that raises issues of caring for others and mutual obligations in health promotion (e.g., mutual obligations for reducing alcohol consumption, helping others quit smoking, or encouraging physical activity). Another ethical framework has been noted as central to the communitarian approach, which stresses social relations and interdependence, kinship, and a sense of common purpose and tradition among members of the community. This framework prioritizes values such as generosity, compassion, peace, stability, solidarity, sympathy, and reciprocity. Thus, people’s choices take into consideration the way that they live within a community (Bouman & Brown, 2010). This can have implications for health promotion interventions, which means that drawing on this approach could emphasize adopting health promotion practices or social norms as a means to help others in the community or emphasize mutual support, instead of focusing on individual responsibility.
Communication Stipulations for Ethical Communication: Truth, Completeness, Sincerity, and Inclusion
The literature on communication ethics also provides stipulations that can be used to identify and guide the consideration of ethical issues in health promotion interventions. Ethical issues are inherent in any instance of communication between humans; this is the case whether or not the communicators seek to present information, facilitate others’ decision making, persuade people about important values, or advocate particular solutions. Even in an open discussion or dialogue, people may seek to influence others’ views and opinions. According to philosophers and ethicists, an ethical perspective regarding influence in communication must be practiced in a noncoercive, nonmanipulative manner, which respects other people’s free choice and individuality (Johannesen, 1996). This is also explored in the work of Jurgen Habermas (1987), in his framework referred to as the Ideal Speech Situation, in which he outlines stipulations for a communication interaction that is as free from coercion as possible.
In the context of health promotion interventions, it is particularly important from an ethical perspective to avoid manipulation and coercion for several reasons. One important reason is that the interventions often take place in diverse and pluralistic social contexts, and in situations where there are significant power differences. The choice of the intervention goals might serve those who have more authority and power. Another reason is that much of health promotion communication aims to persuade people to change their practices. Therefore it is important to have guidelines to help ensure that the persuasion process is not coercive. This does not contradict policy regulations that are based on public discourse and democratic processes that might restrict people’s actions, such as regulations regarding mandatory safety devices or prohibitions in using certain chemicals. The stipulations outlined in the framework of the Ideal Speech Situation include truth, correctness, sincerity, comprehensibility, and inclusion. Each of these stipulations can contribute to the design of communication interventions or to the identification of potential ethical issues. The following sections briefly explain each of these as it relates to health promotion interventions and has been adapted for this purpose.
Stipulations as to the Truth of Health Information
Being truthful is one of the tenets of Western morality that is assumed to be shared universally. Concealment or misrepresentation of what is believed to be true, even for what is considered a good cause, is considered an infringement on the ethical principle of respect for autonomy (Beauchamp, 1996). However, in different cultures, the notion of autonomy differs as it relates to telling the truth or conveying all the information about a health issue when certain people do not choose to hear it. Thus, considerations of culture might be relevant in certain situations or among people of various cultures (Cortese, 1990).
In health promotion interventions, inaccuracies or exaggerations are often represented in slogans or visual images. It is also argued, particularly by practitioners, that it is more effective to disseminate simple and clear messages, and that for the purpose of effectiveness in message design, giving more detailed information should be avoided. However, these assertions could be contested on both ethical and practical grounds.
The following guidelines can serve to develop more ethical health promotion communication interventions:
• Do not imply that the expertise of those who are cited in the intervention is the only legitimate authority to make the health recommendations. By implication, this could entail allowing or acknowledging alternative conceptions or engaging in a dialogue about them.
• Avoid using jargon and technical language and relying on privileged sources of data. For example, when promoting diagnostic preventive tests, explain the risks of not taking these tests in understandable language.
• Allow alternative ways of framing and prioritizing health issues. For example, sexual health of adolescents could be framed in different ways according to culture and social norms.
• Ensure that the health issues that are promoted are truly relevant to the intended populations and not made to seem relevant because they are important to the interventionists. One example of this would be focusing on a particular issue when community members would prefer to look at another one, such as women’s health issues (McLeroy et al., 1995).
Stipulations as to Correctness and Reliability of Health Information
Health promotion often involves providing information that is intended to convince people that they should adopt particular health promoting practices. For example, having certain diagnostic procedures for early detection of diseases or changing their diet. However, the correctness or reliability of this type of information could be contested: It might not always be up to date, might be tentative or incomplete, or might be subject to different scientific and cultural interpretations. Over time, new studies and new modeling technique recommendations related to the benefits and risks of particular foods or medical treatments have changed as new research findings emerge. For instance, recommendations have changed on the use of female replacement hormones, how to reduce the risk of infant crib death, and the consumption of cholesterol in food, among other topics. Scientific backing for health recommendations thus, may be tentative, and the benefits and risks of adopting certain recommended practices may have a degree of uncertainty.
According to the stipulation of correctness, health promoters should avoid asserting certainty in their health claims when tentativeness or degrees of probability would be more accurate. However, this requirement raises concerns regarding efficiency and effectiveness because information that is presented in a tentative way or in probabilities might deter people from adopting the health recommendation, which could be beneficial to them. The stipulation of correctness also implies that health promotors should refrain from exaggerating negative or positive consequences, the magnitude of the problem, or the degree of the expertise of the authorities upon which it relies, even when such a presentation is believed to be more persuasive and serve the purpose of the intervention (Johannesen, 1996).
Stipulations as to Comprehensibility, Clarity, and Completeness
Information that is meant to promote people’s health clearly needs to meet the stipulation that it will be understood by those who are meant to use it in order for it to be beneficial. Drawing on ethical obligations associated with equity, this stipulation points to the importance of presenting the information in a way that people with limited competencies in literacy and numeracy can understand. Further, based on the findings of studies on risk perception, it is important to present risks to people in ways that are relevant to them, or they will not relate to the information (Rossi & Yuell, 2012).
These stipulations point to an additional challenge: Trying to present health promotion information that is both easy to understand and complete and serve to encourage people to adopt the recommended health practice might be difficult. As noted in the section “Stipulations as to the Truth of Health Information”, it is a common assumption among practitioners that it is more effective to disseminate short, simple, and clear messages and to refrain from giving more detailed information for the purpose of effectiveness in message design,. However, this approach does not enable conveying unbiased information to the public (McCartney, 2010). Further, in matters of health, oversimplification of health information infringes on the obligation of respecting people’s autonomy and their right to make informed decision based on complete information. It might also not be efficient because people might want to understand the rationale for the health recommendation and consider its pros and cons.
Further, if the decision is based on comprehension, they might be more committed to following through on it (e.g., according to the theoretical conceptions of the Elaboration Likelihood Model and the empirical evidence of studies that use it) (Petty & Cacioppo, 1984). The ethical standard of completeness also suggests that it would be unethical to present a one-sided argument, selecting only favorable supporting evidence. In addition, these stipulations imply that potentially undesirable consequences of the recommended practice should not be hidden or misrepresented. However, providing complex information, including information on the tentativeness or limitations of the scientific evidence, which is the basis for the health recommendation might deter people from adopting it, although it could be beneficial to them.
Stipulations as to Sincerity: What Are the Actual Goals?
The reasons for the communicative initiative for changing health need to be made clear, including the goals and implicit agenda of sponsors and the identity and motives of stakeholders who are likely to benefit from the outcomes of the intervention. This type of obligation is particularly important when the health promotion intervention concerns members of diverse groups who may feel that they have been exploited in the past or that there are hidden agendas in the intervention that are meant to serve the purpose of others rather than themselves.
Stipulations as to Inclusion: Participation and Deliberation
Health communication activities are often initiated by agencies or organizations that come from outside the intervention community or represent only particular sectors. According to the inclusion stipulation, the communication process should include respect for others’ point of view, beliefs, and suggestions. This is particularly important for members of diverse groups who, by definition, may hold diverse views of the issues and have different capacities to address it. This stipulation is also associated with the moral obligation to respect people’s autonomy and self-determination, as well as with democratic values such that people should be given the opportunity to participate in decisions that affect their lives (Brenkert, 2002). Involving people in the design and implementation of health promotion interventions could be important for utilitarian reasons as well because it can help create a sense of ownership and is more likely to meet the needs of the people for whom the intervention is intended (Castleden, Garvin, & Huu-ay-aht First Nation, 2008).
The stipulation for inclusion could be expanded to participative and deliberative communication, which can enable individuals and groups to articulate their values and to consider choices between competing obligations rather than to approach them with predetermined prescriptions (Dutta, 2011). Participative and deliberative strategies for message production are increasingly adopted in health communication interventions, particularly in the context of community programs (Papa & Singhal, 2006) and more recently in the use of digital media (Korda & Zena, 2013; Neiger et al., 2012). Health promotion interventions that employ an entertainment-education format have also been using dialogue, narrative, and plot as means to elicit critical reflection and different perspectives or value orientations (Slater and Rouner, 2002; Sood, Menard, and Witte, 2004). Further, they can involve population representatives in the articulation of ethical issues. Yet the use of entertainment education raises its own slew of ethical concerns as well (Bouman & Brown, 2010).
Ethical Issues Related to Appeals to Personal Responsibility
Personal responsibility is commonly used directly or indirectly in many health promotion interventions. For example, people are urged to make prudent and more responsible choices when they consume food or beverages, when they engage in sexual relations, and when they make choices regarding transportation or which kind of games their children play. However, personal responsibility is a highly contentious issue in health promotion interventions, and its use as a persuasive argument raises several important ethical concerns on the individual level, as well as political and cultural levels (Guttman & Ressler, 2001; Turoldo, 2009). One important assumption related to the use of personal responsibility as a positive motivator in health promotion draws on the notion of the right to autonomy, which is based on the assumption that individuals should be free to make their own choices about many health-related practices, so they should be encouraged, but not forced, to make responsible ones.
An emphasis on personal responsibility from this perspective could be viewed as an effective means to promote desired behaviors and to enhance people’s sense of efficacy and autonomy. A related conception of personal responsibility is that it can serve to empower individuals and populations and promote a sense of agency. Similarly, it can emphasize people’s ability to help others. From this perspective, an emphasis on personal responsibility plays a strong positive role in promoting the lives of individuals and communities. Researchers have found that although messages on personal responsibility were associated with increased intake of fruit and vegetables, those that emphasized the importance of social responsibility appeared to be more motivating (e.g., Williams-Piehota et al., 2004). For example, parents might be more willing to change what their children eat for lunch at school when the change is framed as a collective effort by all parents.
One example of ethical issues that emerge with the emphasis on personal responsibility can be seen as it relates to nutrition. With the increasing emphasis in health promotion on the prevention of obesity and cancer through better nutrition, interventions urge the public to make “healthy” food choices. Communicating about the importance of healthier food choices is often couched in the language of moral “obligation” and “responsibility” to adopt these healthier choices. Critics of this type of approach raise concerns that this emphasis can serve to burden families for whom the healthier choices are not easily available, causing them to feel that they are not fulfilling their obligations, while denigrating the pleasure and comfort that they derive from communal meals that they are told are not nutritious (Mayes & Thompson, 2014). Further, people’s food choices are highly dependent on the options made available to them in terms of access and cost, as well as social and cultural factors, such as social norms and the influence of commercial advertising and marketing strategies, particularly as they influence children and youth. This has implications for health promotion interventions that relate to public policy (Kotler, Shiffman, & Hanson, 2012; Story & French, 2004; Anjali, 2010; Cairns, Angus, Hastings, & Caraher, 2013).
Personal Responsibility, Accountability, and Blame
One important concern in the use of personal responsibility in health promotion interventions is that focusing on it might carry negative connotations reminiscent of ancient exhortations to overcome vices such as gluttony, sloth, and lust (Berkman & Breslow, 1983). A related concern is that it could serve to blame individuals and populations for the emergence and spread of infectious diseases and pandemics (Nelkin & Gilman, 1991).
Similarly, some health promotion interventions imply that illness or disability results from the failure to adopt a so-called responsible lifestyle and that irresponsible individuals are responsible for the adverse outcome. However, ethicists maintain that in the health context, people can be held accountable only when their actions are completely under their volition or control. Attributing blame to those who do not adopt the promoted health practices could inadvertently become “victim blaming,” or holding them accountable for the consequences of behaviors and circumstances that led to these behaviors over which they have had only limited control (Wikler, 1987). This corresponds to the previous discussion on autonomy that pointed to the limitations of autonomy when people cannot overcome barriers and obstacles, as well as to the discussion on justice and equity and the existence of social gaps where those who are better off can more easily adopt health practices than those who are less economically and socially well off. It is important, therefore, to make a distinction between blaming people for their medical/health problems and encouraging them to have a sense of agency to try to change circumstances and practices in a way that can promote their health.
According to ethicists, for people to be held responsible, they need to have the ability to exercise their own will, they need to have the capacities to make moral choices, they should be able to actively interpret what is happening, and they must be knowledgeable about the potential consequences of action or nonaction. Thus, for individuals to be truly responsible, they would need to have “response-ability.” This has practical implications as well. The stipulation of having the capacity to make choices corresponds to the previous discussion on stipulations of capacities to exercise one’s autonomy. By implication, people should not be blamed for not being responsible if they do not have the capacity to make what health promoters or society consider responsible choices.
Beyond Personal Responsibility
Even when health promotion messages do not explicitly blame people for taking full responsibility for their health, they might frame the notion of responsibility for disease or injury prevention as if it were primarily under individuals’ control. This can deemphasize the role of structural and institutional factors such as the work environment, housing conditions, or pollution in the etiology of many health-related problems. Historically, personal responsibility is a central notion in discussions of justice, ethics, and social regulation of behavior. From a political, cultural, and social perspective, scholars note that responsibility is a core concept for understanding how people and governments can sanction and try to control people’s conduct (Crawshaw, 2012).
Responsibility for Others
Many health promotion interventions refer to responsibility for others. For example, people may be called upon to promote or protect the health of significant others (e.g., children, spouses). Thus, on the one hand, appealing to people’s sense of obligation can help reinforce moral commitments such as caring, solidarity, and compassion. On the other hand, it might serve to reinforce particular gender roles or cultural stereotypes and also place a burden on people who have limited control over others’ behavior (Guttman & Ressler, 2001).
Harm Reduction Approaches and Health Promotion
Numerous health promotion programs apply, often inadvertently, what has been called a “harm reduction” approach, described by some of its advocates as “compassionate pragmatism.” The harm-reduction approach justifies health promotion interventions that aim to help people avoid serious harm, while not urging them to change other practices associated with it. This approach is based on an ethical conception that prioritizes the obligation to protect people from greater harm, while not aiming to stop the lesser harmful practice. Proponents of this approach often refer not only to the obligation to help people with special needs to avoid serious harm, but also to the utility of this approach. They explain that it helps enlist the trust of particularly vulnerable populations, and that if they did not ignore the lesser harmful practice, the people at risk would not adopt their recommendation for the one that is most harmful. Further, they argue that this promotes trust in the relation between the health promoters and members of these hard-to-reach populations as a basis for the development of health promotion interventions in the future. This approach has been applied in the prevention of substance abuse and sexually transmitted infections among young adults, or in syringe-exchange programs for injection drug users to prevent HIV infection, and more recently regarding alcohol consumption (Howard, Griffin, Boekeloo, Lake, & Bellows, 2007).
Harm Reduction and Corporate Interests
The use of this approach in programs in the road safety context raises additional ethical concerns. For example, programs that promote the use of a designated driver mainly focus on encouraging people to rely on a driver that does not consume alcoholic beverages, and do not refer at all to the harm of consuming a large amount of alcohol. In fact, many of these initiatives are sponsored by alcohol companies (Dejong, Atkin, & Wallack, 1992; Ditter et al., 2005). Further, health promotion in workplaces might also be seen as adopting a harm reduction approach when they basically promote practices that fit into the corporate work schedule. The lifestyle associated with long workdays are not beneficial to most people’s health and well-being. For example, it does not enable many people to spend much time with their families or to develop a healthy and self-actualizing and meaningful life. Health promotion interventions mainly focus on particular aspects that can be changed, but not the overall institutional context that affects people’s well-being. In fact, these programs might simply help people to adapt better to current constraints of work schedules rather than reduce work hours.
Ethical Issues in Adopting Marketing Approaches for Health Promotion
Commercial marketing strategies have been shown to be hugely successful in influencing people to purchase various products and services and to adopt particular lifestyle trends. This has prompted many health promotion programs to adopt methods and tactics used in commercial marketing as a means to enhance the reach and impact of their programs. The application of commercial marketing strategies to health promotion interventions raises a host of ethical concerns. These include (a) the ethics of using slogans and simplistic messages, which are not likely to meet the stipulations of completeness and reliability; (b) appealing to strong emotions, which might infringe on respect for people’s autonomy and privacy or cause people emotional harm; (c) employing celebrities and advancing commercialism (for example, by using prizes and incentives). Because these tactics have become the staple of many health promotion interventions, they often appear to be ethically “neutral” or morally justified because of their presumed effectiveness (drawing on the assumption that “the ends justify the means”). Because of this presumption, it is important to scrutinize each communication and marketing tactic used in health promotion interventions for potential ethical concerns.
Labeling, Shaming, and Stigmatization
A prominent concern in health promotion interventions is that by presenting members of certain groups that are at risk for serious diseases, or that people who engage in particular practices are responsible for a specific health problem, this may inadvertently label these individuals or groups in a way that can negatively affect their identity, cause them to feel shame, or even stigmatize them. It should be noted that despite the sophistication of current scientific understanding of the etiology of diseases, people might adopt moral frameworks and social stereotypes when aiming to explain health-related conditions of diseases (Douglas, 1994). Indications of adverse societal-level effects of stigmatization can be found in the tendency of people who hold stigmatizing views to support coercive measures and discrimination against individuals with these conditions. It is suggested that health messages that warn against the risk of contracting a stigmatized medical condition may inadvertently serve to reinforce prejudice and damage the self-esteem of those who have these conditions (Glick, Crystal, & Lewellen, 1994). Even school-based programs for weight loss have been found to stigmatize children. Similarly, messages depicting the horror of being confined to a wheelchair because of drunk driving or the use of guns were perceived by individuals with mobility disabilities as devaluing them and attacking their self-esteem and dignity (Wang, 1998).
Not only stigmatization, but also labeling, has been shown to affect the identity of individuals or groups. Persuasive messages can influence the way people see themselves or their sense of identity (Foucault, 1972). For example, labeling people by connecting their persona to their medical condition may lower their self-esteem or place them in an almost constant state of anxiety (Barsky, 1988). Even humorous uses of presumably harmless stereotypes in health messages need to be scrutinized for ethical implications. Similarly, the use of shaming has been used as persuasive means in various health promotion interventions, whether portraying smokers, drivers, or parents as stupid, hateful, or ridiculous, or even using sexually insulting metaphors. The use of stigma has been a contested issue because proponents argue that it is an effective approach that draws on social norms (Bayer, 2008). However, opponents argue that it is not ethical, and that it is an important challenge for health promotion interventions to avoid labeling, stigmatizing, or shaming (Brennan & Binney, 2010). Further, these types of appeals serve to distance people and, rather than elicit compassion and social connectedness, they contribute to what scholars describe as othering (Thompson & Kumar, 2011).
Ethical Issues in Using Scare Tactics and Graphic Appeals
It is widely believed among communication practitioners, researchers, and the public, although also strongly contested, that an effective way to influence people to adopt practices that will protect them or those they care for from risk is to elicit strong emotions of fear, anxiety, and even disgust (Lupton, 2013). Proponents argue these tactics are justified because they work. The dilemma of whether to use highly graphic or provocative appeals is particularly vexing when members from the intervention’s population suggest that they should be used, or when studies report that people indicate that these types of messages are the ones that are more likely to influence their intentions to adopt the recommended practice. On the one hand, it could be argued that these types of findings could be construed as indicating people’s consent. On the other hand, there are both theories and empirical evidence that counter claims regarding the effectiveness of using graphic images of mutilated bodies and other similar types of appeals. In addition, the studies mainly report on intentions or, when behavioral changes are found, the interventions include other factors (e.g., enforcement or support measures).
Further, from the perspective of ethics, several compelling arguments can be made why their use raises serious ethical concerns. These include that strong emotional appeals deny people from engaging in autonomous decision making; such appeals can create anxiety and distress, and people continue to see the images regardless of the risk message; these appeals may contribute to inequity because people in vulnerable populations are more likely to feel that they can do little about the risk about which they are warned, and it may generate in them a sense of ineptness or even fatalism (Hastings, Stead, & Webb, 2004).
Using Provocative Appeals and Strong Negative Emotional Appeals
One of the communication tactics to gain audience attention and to raise issues to the media and public agenda is to use provocative and shock tactics (Vezina & Paul, 1997), which might include graphic, violent images of acts such as self-mutilation (Donovan, Jalleh, Fielder, & Ouschan, 2009), or images considered disgusting (Lupton, 2015b). Clearly, provocative ads can elicit discussion, put an issue on the public agenda, and enhance people’s memories regarding the ad or the brand (Wu & Morales, 2012). However, researchers note that provocative ads might not achieve the intended effects, and often their effects are limited to gaining attention rather than achieving long-term goals (Brown, Bhadury, & Pope, 2010; Dahl, Frankenberger, & Manchanda, 2003).
These types of communication tactics tend to raise objections, as in the example of complaints registered to the British Advertising Standards Authority (ASA). In this case, two of the top 10 ads that received complaints concerned health promotion. One such ad was from the British Department of Health’s antismoking campaign, which showed smokers having a fish hook pulled through their cheeks, representing their craving for cigarettes (BBC, 2008). Another example is the Australian White Ribbon Day 2006 campaign on the topic of family violence, which was severely criticized by mental health professionals and those working in the family and domestic violence sector because of depictions of suicide and self-harm in the television advertising and accompanying promotional materials. However, the organization rejected the requests of concerned groups, claiming that the violent imagery used was necessary to attract men’s attention (Donovan et al., 2009).
Another critique of provocative ads is that the strong emotional impression that they create might overshadow other types of discourse and social values. Further, studies find that the response of people from vulnerable populations to public health campaigns using negative emotional appeals were anger, retreat, guilt, passive helplessness, and despondency, rather than empowered decisions to act (Lupton, 2015b).
Ethical Issues Regarding Cultural Sensitivity and Moral Relativism
An important tenet is respect for cultural heritage and sensitivity to cultural beliefs and customs. Often, health promotion programs incorporate cultural values, symbols, and themes into health messages, which can reflect cultural sensitivity and serve as a way to encourage the adoption of the health recommendations in question. Interventions may aim to promote behaviors or attitudes that contradict certain cultural values or be viewed by members of this group as offensive (Cortese, 1990). Health promotors might need to find ways to raise issues or provide information on topics considered taboo or sensitive. For example, the issue of sexually transmitted diseases is socially sensitive in various cultures, and therefore, communication about it raises ethical dilemmas. On the one hand, health promoters have the obligation to provide people with information related to sexuality so that they can prevent or treat sexually transmitted diseases and to destigmatize these diseases; on the other hand, exposing people to such information might offend them.
Research in certain Asian communities indicates that advertisements that refer to the use of condoms can offend members of the community and cause embarrassment to them when shown in public. Similarly, other “unmentionables” are birth control products and contraceptives, and clinic services for sexually transmitted diseases (Waller & Fam, 2011). This poses challenges on how to provide people from marginalized social groups with relevant information on such topics. Further, it raises the question of whether the importance of providing this data might override cultural considerations that are highly important to a particular social group.
Health promotion interventions also might have to address the contentious issue concerning moral relativism: whether to respect particular cultural values that are cherished by members of a certain cultural group, but which conflict with moral precepts people outside it considered to be universal (Macklin, 1999). These might include gender equity and children’s health issues. There are situations in which health promoters may consider overriding the consideration of cultural sensitivity because they believe that it is essential to address the health topic, or even to abolish a certain practice if they conceive it as unhealthy and immoral.
Digital Media in Health Promotion: Issues of Privacy and Democracy
Developments in digital technology offer opportunities to tailor it to one’s own circumstance. They can also be used to help people manage their personal practices or receive support in order to promote their health or fitness. Using such personalized digital devices typically necessitates disclosing personalized information on one’s activities, preferences, weight, food and alcohol consumption, and even relationships. This raises issues regarding respect for privacy and infringement on people’s autonomy via the ability of organizations, corporations, and government agencies to obtain personal data, in particular since these platforms tend not to offer tight security of these data. Critics contend that these data can be used by corporations and government agencies for monitoring or commercial purposes. This poses an additional challenge associated with autonomy, to provide access to such data (on an aggregate level) for the purpose of advocacy and to enhance the capacity of autonomy to individuals and organizations to promote changes that are important to them. The emphasis on digitized personalized health promotion strategies raises an additional concern because it serves to focus on individual responsibility for health. This could serve to deemphasize social, cultural, and political determinants of health and also deemphasize inequities in the use of digital technology for health promotion due to social, cultural, and economic inequities among individuals and groups (Lupton, 2015a). Another issue concerns democracy and the ability of people to have access to information that is not controlled by commercial interests, given the commercial nature of mass media and the increasing commodification of internet and digital channels, whether in terms of search engines or social media. This also raises ethical issues regarding commercial companies’ use for public health promotion communication.
Denial of Gratification
Health promotion activities often call upon people to give up practices that they enjoy, which may serve as stress-coping practices or have become part of their identity or daily routine. These practices may have cultural significance or emotional importance, even when they may be viewed as risky or even immoral. Such practices might offer members of vulnerable groups not only pleasure, but also an important coping mechanism that is not easily replaced. This has been observed regarding smoking, food consumption, or engagement in practices that provide high sensations (MacAskill, Stead, MacKintosh, & Hastings, 2002; Hove, 2014). Those who are less economically or socially privileged may have fewer options for healthier substitutions. An ethical issue is whether health promoters are morally obligated to help find alternative practices when they aim to eliminate practices that serve social or emotional functions, particularly among members of diverse cultural or economically disadvantaged groups.
Turning Health into an Overriding Value and the Discourse About Health
Even ardent proponents of health promotion have noted with concern the moral impact of health promotion messages on culture and society, as people and governments conceptualize health as an overriding value (Becker, 1993). Critics maintain that industrialized societies have become obsessed with the promotion and protection of health and that the pursuit of health has turned into a crusade with moral overtones. When health becomes an overriding value, it can turn into something that people pursue relentlessly at the expense of other things in their lives, or in turn, they may feel inadequate when they do not do so. An emphasis on good health as a value can turn those who have no serious health problems into the “worried well” and may contribute to people’s escalating expectations from medicine and the healthcare system. This may raise concerns regarding equity because the more powerful groups will be able to demand that the healthcare system meet their needs at the expense of programs that meet the needs of underserved populations.
Another concern is that a cultural preoccupation with personal health practices may distract people and health promotors from other social issues, causes of ill health, and issues of justice (Carter et al., 2011). It is feared that an emphasis on personal health as a value may serve to promote self-interest at the expense of equity and concern for others. This raises the dilemma of how to promote health issues without them turning health into an overall value. Because health promotion communication interventions increasingly have a strong presence in society and are pervasive in the media on the national and local levels, in the workplace, at school, and in community settings, this raises a concern regarding their role in the appropriation of the political, social, and moral realms of the public consciousness and discourse.
Collaborations and Sponsorships
Health promotion interventions are often done in collaboration with organizations from the public and private sector, including work organizations, corporations, and commercial media companies. This is a growing phenomenon because of corporations aiming to be involved in activities that show their corporate social responsibility (also for economic reasons). Whereas these collaborations might be deemed beneficial and even necessary to reach various segments of the population, to obtain funds, or to make health promoting changes within these organizations, inevitably they raise ethical concerns as well. Organizations that market food products collaborate in health promotion interventions to promote healthier eating. One prominent example was the collaboration between a heart disease prevention organization and a large company that produces breakfast cereals (Glanz et al., 1995). Another prominent and contentious example is the partnerships of road safety organizations with alcohol companies in encouraging road safety. These companies support road safety initiatives such as promoting the use of designated drivers or providing rides for drivers who had consumed alcoholic beverages. These initiatives not only provide them with legitimacy, but they can also continue promoting their product and increase sales (Hastings, 2007). There are also collaborations that take place with organizations that could be considered in the “opposite camp” or the “competition”—for example, working on health promotion interventions with religious groups that oppose sex education (Truss & White, 2010). Some organizations or individuals might be against providing information and education to youth about the prevention of sexually transmitted diseases, although these youth might be at risk for these diseases. Each type of collaboration raises ethical issues that need to be identified and considered.
Another type of collaboration takes place when health promotion communication interventions are developed and implemented in collaboration with media professionals, which presents ethical challenges associated with this type of collaboration. For example, advertising media professionals might believe that it is their professional duty to be creative, which to them often means that they should develop appeals that are considered provocative. Advertising professionals might also aim to guard against using so-called preachy messages, which they believe would irritate the intended audiences, whereas health promotors might believe that it is their duty to emphasize the recommended health practices, which could come off as preaching (Bouman & Brown, 2010).
Health promotion communication interventions invariably raise different types of ethical issues that are important to consider from the outset. They pose dilemmas and ethical concerns on each level of the intervention, from its articulation of goals; decisions of who represents the intended population in order to gain trust, collaboration, and inclusion; the channels and content of the health-related information; and the assessment of the intervention outcomes. Ethical frameworks and stipulations can be used to identify and debate ethical issues and find ways to address them. It is important to identify ethical issues, especially in goals that appear to be most important or in strategies that are considered the most effective. It is important to be able to consider adverse unintended consequences on the individual, cultural, and social levels, as well as on democratic ideals. This requires a systematic ethical analysis to elucidate value considerations and requires scrutiny of the health promotion messages for ethical issues, which should become a routine part of health promotion activities.
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