On Monday 1st July we are discussing this paper:
CARTER, Stacy M., Lucie Rychetnik, Beverley Lloyd, Ian H. Kerridge, Louise Baur, Adrian Bauman, Claire Hooker, and Avigdor Zask. (2011) Evidence, Ethics, and Values: A Framework for Health Promotion. American Journal of Public Health, Vol. 101, No. 3, pp. 465-472. doi: 10.2105/AJPH.2010.195545 http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2010.195545
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Introduction to the paper and questions for discussion
Ethical principles related to biomedicine are routinely referred to to guide clinical and research practice. While there are areas of debate and contention, ethics is well-established as an area of discussion in professions allied to medicine, and related research. However, until relatively recently, ethics in public health and specifically, health promotion, were addressed only implicitly. Frameworks from biomedical ethics, such as appeal to principles of autonomy, beneficence, non-maleficence and justice, are of limited benefit when considering the scope of health promotion actions:
“Under what circumstances, for example, would a health promotion perspective suggest that autonomy should be overridden in the interest of the greater good? What is health promotion’s response when considerations of social justice conflict with rights or the maximization of health gain?” (Sindall, 2002)
Evidence and ethics
In the article we are discussing, Carter et al propose that the evidence base and ethics base within health promotion practice /evaluation must be linked and underpinned by values. The role of evidence to inform health promotion is problematised.
While many interventions are applied with little underpinning evidence of effectiveness, growing awareness of the need for robust evidence has, they claim, led to a skewing of focus towards individual-level behaviour change interventions which are more amenable to evaluation using a trial design. Furthermore, they illustrate how there is little agreement within public health practice about the most desirable outcomes – for example, which is the more important- fitness, or body weight?
The authors identify two ethically-relevant concepts for consideration in body weight interventions.
Coercion may occur where choices and liberties are constrained (e.g. via structural interventions), or, the authors argue, where the public are manipulated or exposed to fear about risk, in order to initiate behaviour change.
Stigmatization occurs where individuals are linked to negative stereotypes; it can have serious, negative consequences for individuals’ sense of self. ( Weight stigma is a growing area of concern – see e.g. this recent conference on the issue).
They illustrate the discussion with the example of interventions regarding body weight. The specific case study used is an Australian social marketing campaign, Measure Up. The TV campaign adverts analysed can be viewed:
The second advertisement is available here: Ad 2.
Developing a framework
Carter et al propose a framework that links their thinking on ethics, evidence and values in health promotion. A key aspect is the necessity for transparency and reflection about the ethical and evidential values underpinning a situation or intervention.
They then apply their framework to the ‘Measure Up’ campaign using the concepts of stigma and coercion:
Their results indicate that the ethical and evidential underpinnings of the campaign are questionable:
“Might the campaign be unreasonably coercive, encouraging unjustifiable fear, self-surveillance, self-loathing, or sense of failure?”
Overall, the authors present their framework as a set of ‘thinking tools’ to guide practice in health promotion, with a particular focus on transparency regarding ethical priorities in specific practice situations. They suggest that further ‘ethically relevant concepts’ need have their dimensions specified in the same way that stigmatization and coercion were addressed in this paper.
Questions for journal club:
1) Are the aims clear?
2) Who will be affected by these results? What is the scope?
3) Was the development of their framework justified and clearly explained?
4) Was the application of the framework to the case study (‘How do you measure up?’) transparent and reasonable?
5) What are the implications for policy/practice?
If you are interested in further reading on public health ethics, try these books:
- Dawson, A. (ed.) (2011) Public Health Ethics: key concepts and issues in policy and practice. Cambridge: Cambridge University Press.. Cambridge: Cambridge University Press.
- Peckham, Stephen; Hann, Alison (eds) (2010) Public Health: ethics and practice. Bristol: Policy Press
The journal, Public Health Ethics also has many interesting articles. It is a subscription journal, but carries occasional open-access papers (including one of the choices in our Poll for this topic).