Ethical Dilemmas in Health Campaigns

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  • This article was downloaded by: [University of California, SanFrancisco]On: 19 December 2014, At: 19:00Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

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    Ethical Dilemmas in HealthCampaignsNurit GuttmanPublished online: 10 Dec 2009.

    To cite this article: Nurit Guttman (1997) Ethical Dilemmas in HealthCampaigns, Health Communication, 9:2, 155-190, DOI: 10.1207/s15327027hc0902_3

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  • IIEALTH COMMUNICATION, 9(2), 155-190 Copyright O 1997, Lawrence Erlbaum Associates, Inc.

    Ethical Dilemmas in Health Campaigns

    Nurit Guttman Department of Communication, Tel Aviv University and UMDNJ-Robert Wood Johnson Medical School

    The design, implementation and evaluation of health campaigns involve inherent ethical concerns and dilemmas. Many of these concerns, however, are often invisible. This article presents 13 dilemmas related to 4 specific areas: (a) strategies and content of health communication campaign messages, (b) inadvertent adverse outcomes from campaign activities, (c) power and control, and (d) social values. Examples to illustrate these ethical dilemmas draw from the literature and from a study of 2 national and 3 community-based health communication interventions. The 13 ethical dilem- mas are summarized as a series of practice-oriented questions to help scholars, practitioners and the those who are targeted by the campaign to identify and articulate ethical concerns embedded in health campaigns.

    The design and implementation of public health campaigns invariably raise ethical dilemmas. These ethical dilemmas, however, are often invisible. Certain health-re- lated topics such as abortion or euthanasia stir heated public debates abounding with ethical concerns, some of which are also conspicuous in HIV-related cam- paigns (e.g., Fortin, 1991; Kleining, 1990; Manuel et al, 1991; Mariner, 1995). These topics are characterized as relatively more glamorous (Barry, 1982). In contrast, in other intervention areas such as the prevention of cancer or heart disease, ethical issues, although inextricably linked to intervention goals and strategies (Doxiadis, 1987; McLeroy, Gottlieb, & Burdine, 1987; Ratzan, 1994; Rogers, 1994; Salmon, 1989; Witte, 1994), are less visible, tend to be discussed in limited contexts, and lack conceptual frameworks (Salmon, 1992).' Because such cam- paigns typically employ persuasive strategies aimed at influencing people to adopt

    Requests for reprints should be sent to Nurit Guttman, Department of Communication, Faculty of Social Sciences, Tel Aviv University, Ramat Aviv, Tel Aviv 69978 Israel.

    '~nterest in ethical issues in the healthcare context is increasing, which is evident in the inclusion of ethics in health professionals training, in the growth of the number of books on bioethics, the creation of ethics committees in hospitals, and in recent editions of health communication books (e.g., Kreps & Thornton, 1992; Northouse & Northouse, 1992; Thornton and Kreps, 1993).

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  • 156 GUTT'MAN

    or avoid certain practices, the argument can be made that they are also inundated with ethical concerns (Burdine, McLeroy, & Gottlieb, 1987; Eisenberg, 1987; Faden, 1982,1987; Gruning, 1989; Salmon, 1989; Winett, King, & Altman, 1989; Witte, 1994), many of which are similar to concerns typically raised in biomedical contexts (Gillon, 1990). Furthermore, although health campaigns are presumably for the good of the target populations (Rogers, 1994), benefits from their outcomes might not be distributed equally across target populations. In fact, critics argue that well-meaning messages might cause particular members of the population inadver- tent harm (Barsky, 1987; Becker, 1993; Wang, 1992). In addition, because health campaigns increasingly adopt sophisticated social marketing techniques, this en- hanced ability to persuade and enable practitioners to design and implement more effective interventions raises concerns regarding the extent to which campaigns might engage in unethical manipulation (Faden, 1987). We need to be reminded, say ethicists, that "[a] preventive health campaign is a marketing effort, subject to all the risks of motivational marketing hyperbole, demagoguery, or praying upon fears and prejudices" (Goodman & Goodman, 1986, p. 29). Making ethical con- cerns more explicit and examining them more systematically in health campaigns is an important but often neglected process in research and practice, though it can be seen as crucial to their analysis, design, and evaluati~n.~

    This article provides a conceptual approach for identifying ethical issues in health campaigns by presenting 13 dilemmas associated with four major areas: (1) intervention strategies, (2) inadvertent harm, (3) power and control, and (4) social values. Each area is addressed further through practice-oriented questions (see Tables 1-4). The framework presented in this article draws on Brown and Singhal's (1990) discussion of ethical dilemmas in the use of television programs to promote social issues that they refer to as prosocial television. Brown and Singhal under- scored the importance of considering four types of dilemmas: dilemmas regarding the content of messages and the promotion of equality among viewers-included here in the area of strategies; dilemmas related to unintended effects, expanded here to include the area of social values; and dilemmas related to the use of the media for development-included here in the area of strategies.3

    The framework also draws on Forester's (1989,1993) adaptation of Habermas' (1979) work to the context of planning. Forester (1993) suggested that planners, or in this context the designers of health campaigns, make normative claims that relate

    or example, which goals should be pursued, how to achieve these goals, what are indicators of desired outcomes, and how to assess the extent to which these outcomes serve to enhance the health of the opulatiob (see Salmon, 1989). P

    Stuart Nagel (1983) presented ethical dilemmas in policy evaluation. Some of the dilemmas he outlined share the same concerns raised in this article. The nine dilemmas he discussed concern policy optimization, sensitivity analysis, partisanship, unforeseen consequences, equity, efficient research, research sharing, research validity, and handling official wrongdoing.

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  • ETHICAL DILEMMAS 157

    to Habermas' three processes of social reproduction: cultural, in which views are elaborated and shaped; social integration, in which norms, rules, and obligations are shaped or reinforced; and socialization in which social identities and expressions olf self are influenced. Planned social interventions, in which we can include health campaigns, are communicative processes. Their potential impact, following For- ester's framework, raises concerns regarding possible distortions in (a) the truth of the messages, which can affect people's beliefs about the issue and can be related to ethical concerns about strategies and values or cultural reproduction; (b) the legitimacy of the norms invoked, which might affect people's consent and can be related to ethical concerns about power and control, or the reproduction process of social integration; (c) expressiveness, which might affect perceptions of relation- ships or identity and can be related to ethical concerns about inadvertent outcomes such as privileging, labeling and culpability, or the reproductive process of sociali- zation; and (d) framing, through the selection or prioritization of issues, which can be related to ethical concerns regarding social values and ideologies.

    The ethical concerns discussed in this article also draw from the bioethics literature, specifically ethical principles such as respect for autonomy and justice or fairness, and from a feminist emphasis on the ethic of care.

    DILEMMAS CONCERNING CAMPAIGN STRATEGIES

    Choosing to use specific campaign strategies elicits implicit moral judgments. The first two dilemmas (Persuasion and Coercion) raise concerns regarding manipulation and infringement of people's personal autonomy for the sake of doing good (benefi- cence), or for the sake of ensuring the effectiveness of the campaign. The first dilemma focuses on the use of persuasive appeals and the second on restrictive strategies. Both raise ethical concerns regarding rights of the individual. The third dilemma (Targeting), which addresses mainly (risk) group or societal level issues, raises ethical concerns related to targeting. These concerns tend to be discussed in the context of ethical principles of justice or fairness, or from a feminist perspective of caring. The fourth dilemma (Harm Reduction) is whether it is justified to use strategies that support behaviors seen as socially deviant, immoral, or harmful, because they might prevent further harm to target populations. The ethical issues it raises are related both to pragmatic societal-level concerns such as preventing the spread of infection and individual-level concerns such as doing good.

    Persuasion Dilemma

    To what extent is it justified to use persuasive strategies to reach the intended health-promoting effects of the campaign, even if the use of such strategies might infringe on individuals' rights?

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  • This dilemma is often shared, though less often acknowledged, by many, if not all, public communication campaigns (Witte, 1994). Because public health cam- paign goals typically aim to influence target populations' beliefs or behaviors, usually persuasive and social marketing strategies are employed (Elder, Hovell, Lasater, Wells, & Carleton, 1985; Evans, 1988; Fine, 1981; Lefebvre & Flora, 1988; Jaccard, Turrisi, & Wan, 1990; Manoff, 1985; Rogers & Storey, 1987; Scherer & Juanillo, 1992).~ The ultimate goal of these intervention strategies, Witte (1994) pointed out, is to get people to practice what the campaign sponsors believe are health-promoting behaviors. Health promoters, in their efforts to do good and to convince the public of the benefits of adopting particular behaviors or of avoiding others, might use persuasive strategies to arouse anxieties or fears and facilitate persuasion. Faden and Faden (1982) stated that although campaigners might argue that their efforts are restricted to information and skill building, we might ask whether it is "possible to distinguish apurely informational or educative effort from a persuasive appeal in the context of a communicative program?'(p. 10). This raises concerns regarding the use of manipulative or persuasive tactics, which by defini- tion, infringe on individuals' rights for autonomy or self-determination. Faden and Faden added that campaigns have tended to be designed to promote predetermined behavioral changes through specially constructed persuasive appeals. This raises concerns regarding paternalism or the notion that certain experts or professionals know what is best for particular members of society or the public as a whole.

    Although these concerns traditionally are raised in the practitioner-patient context (e.g., Bok, 1978; Childress, 1982; Veatch, 1980), they are also highly relevant in the campaign context because campaigns are a purposeful effort to get people to adopt health-related practices that are perceived as beneficial to them or help them avoid potential harm (Beauchamp, 1988; Campbell, 1990; Doxiadis, 1987; Faden, 1987; Pinet, 1987). According to the principle of respect for auton- omy, health promoters should honor the self-respect and dignity of each individual as an autonomous, free actor. The underlying assumption is that all competent individuals have an intrinsic right to make decisions for themselves on any matter affecting them, at least so far as such decisions do not bring harm to another party (Hiller, 1987), and that only the individual knows and is interested in his or her own well-being (Mill, 1978).

    The use of persuasive appeals also raises concerns regarding the extent to which they distort or manipulate information to persuade target populations (as elaborated by Forester, 1993) or the extent to which such manipulative strategies can under-

    4 ~ o r example, the National Cholesterol Education Program's (NCEP) 1992 Communication Strategy document stated that it "is not enough to create messages based on scientific consensus-it is critical to provide messages that the audience will understand, that they will care about, and that they can act upon. To accomplish this, the NHLBI's public education efforts have successfully employed the principles of social marketing" (p.8).

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  • ETHICAL DILEMMAS 159

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