Ethical Dilemmas in Health Promotion Practice

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1 CHAPTER 15 Ethical Dilemmas in Health Promotion Practice Raymonil Massd anil Bryn Williams-Jones lntroduction Hardly anyone will question the positive contributions of public health policies and health promotion programs to the improvement of a population's health. At first glance, goals such as the promotion of healthy lifestyles and public awareness of "at-risk" behaviours may appear sufficient to justify the ethical acceptability of health promotion interventions. But a moment's reflection makes it clear that there are many challenging questions that arise throughout the development and application of health promotion programs and policies. 15.1: Ghallenglng Questlons for Health Promotlon 1. What if the goal of promoting or protecting the common good infringes on individual civil liberties or shared values of minority cultural communities? 2. How far should we go in presenting positive (even moralizing) health information campaigns in the name of protecting public health without unduly stigmatizing people or making them feel guilty for their non-compliance? 3. Are there tensions or conflicts between the goals (and practices) of health promotion and fundamental social valuesuch as autonomy, responsibility, social justice, or beneficence? i4. What are the consequences of the social construction of health as an ultimate social good? Health promotion is an inherently value-laden enterprise and one that can lead to major ethical dilemmas. Ethical reflection on the part of health promotion professionals is thus essential in order to understand and negotiate the potentially conflicting fundamental values and interests of the diverse stakeholders (e.g., professionals, policy-makers, and citizens) involved in health promotion. Health Promotion as a Normative and Acculturative Enterprise Health promotion is, by its very nature, a normative and an acculturative enterprise. It is normative because it proposes or recommends norms about what is considered good health, what is acceptable or unacceptable risk, and what is a healthy physical and social environment. 24L

2 242 Part lll: Additional Topics to Consider in Reflecting on Health Promotion Practice But since lifestyles and health-related behaviours and environments are grounded in cultural values and social norms, health promotion is also an acculturative enterprise-that is, it is culture transforming. Put together, the normative and acculturative aspects of health promotion make it a deeply value-laden endeavour. Health promotion is a socially embodied "value 6eld"; its mission is to promote a sanitary culture, one that locates health at the top ofa hierarchy ofcultural values and social goals. Some commentators suggest that health promotion (and public health more generally) is a new morality, or even an alternative strategy of religious control of deviance in modern societies. For Petersen and Lupton (1996), health promotion is a form of "secular religion" in the context of which the new priests (health promotion professionals) define impenetrable avenues (for the citizen uninitiated in the epidemiology of risk) of health protection via the identification ofsecular sins (voluntary exposure to risk factors, refusal to modify at-risk behaviour). In this view, health promotion professionals behave more like proselytizing missionaries preaching an ideology than neutral and impartial scientists who are the legitimate experts and protectors ofpublic health. But ethical issues do not arise only rvith the use of coercive measures and paternalistic interventions. Many people are convinced that diseases are often self:inflicted, the product of one's own bad lifestyles or imprudent behaviours. This popular understanding can contribute to a moralizing public discourse that places the burden of responsibility on individuals for their illness, despite the overwhelming evidence that risk factors external to an individual's control can have an enormous impact on his or her health. Health promotion often takes a more subtle approach; citizens are encouraged to internalize health norms and to conform voluntarily to sanitary recommendations in order to construct a "civilized self." In such a context, health promotion can be seen as a pedagogic enterprise used for legitimizing the practices of control over individuals' lifestyles choices. One of the important ethical challenges in health promotion, then, is to examine and evaluate the legitimacy of socio-cultural constructions ofblame and moral judgments that may be attributed to "at-risk" groups. Thus, regardless of the laudable nature and ethical objectives of health promotion (i.e., protecting the public health and the public good), the nature and the ranp;e of means used for attaining these objectives may create important ethical challenges. Health promotion cannot simply take its own moral worth for granted. Much work needs to be done in order for this profession and field ofpractice to establish its moral credibility (Sindal, 2002), a credibility, we suggest, that must be founded on well-reasoned and argued principles. The existence and recognition of ethical questions or challengeshould not, however, become an excuse for inaction. The normative and acculturating; characteristics of health promotion activities are inherent in the mission of public health; they should be accepted, but also analyzed critically. Ethics, then, lies in the reflection and evaluation of the best balance between the means and the goals ofhealth promotion. But ethical issues do not arise only with the use of coercive measures and paternalistic interventions. Many people are convinced that diseases are often self-inflicted, the product of one's own bad lifestyles or imprudent behaviours. This popular perception can contribute to a moralizing public discourse that places the burden of responsibility on individuals

3 Chapter t5: Ethical Dilemmas in Health Promotion Practice 243 for their illness, despite the overwhelming evidence that risk factors external to an individual's control can have an enormous impact on his or her health (Leichter, 2003). This chapter will identify some of these ethical issues or challenges and suggest key components of an analytical framework for determining the ethical acceptability of health promotion interventions. What ls an "Ethics" of Health Promotion? Ethics in health promotion is not simply individual opinion or the blind following of normative rules or professional codes of ethics. Nor should ethics be seen as simply an empirical description of what people (the majority) think or believe, e.g., derived from opinion surveys: simply because something "is" does not mean that it is "good." Ethics in health promotion necessarily involves applying a critical, analytic gaze to a particular program or policy. This may mean deconstructing complex situations to show the various interests and values that are present, but that may not be obvious; or it may mean complicating apparently simple situations and challenging "obvious" solutions. Ethical questions often arise when socially recognized fundamental cultural values are infringed. Examples include the infringement on smokers' individual autonomy and right to smoke so as to respect non-smokers' right to a smoke-free public space; cyclists' right not to wear helmets versus regulations requiring helmets in order to protect cyclists' safety; the promotion of breastfeeding and the moralizing of mothers who do not seem to prioritize the health of their babies; or the protection of women's rights in a campaign against domestic violence that targets a particular ethnic population, despite the risk of stigmatization. Virtually any health promotion program will impinge upon or entail some degree ofinfringement ofat least one of the fundamental values recognized by Canadian society. In such a situation, ethics is about performing a context-sensitive and realistic analysis of the best approach. The terms "ethics" and "morality" are sometimes treated as synonymous in public and professional discourse. We take "morality" to be the set of shared social values, judgments, or beliefs about right and wrong behaviour. There are as many moralities as there are social, ethnic, or religious subgroups and communities. In order to be culture- and context-sensitive, a health promotion ethics has to show some fexibility. But for reasons of equity and social justice, health promotion ethics should also be founded on principles that could be applied to all Canadians. Ethics must go beyond local moralities; it is a critical discourse on particular moralities (popular, institutional, or professional), the goal of which is to ask if norms or rules are relevant or appropriate to a particular context. But what are health promotion professionals to do when values, norms, or interests conflict? Are there underlying principles or guides to action that people can agree on to resolve a particular conflict or dilemma? These are the questions at the heart ofethics; they necessarily go beyond a discussion ofwhat "is" in order to ask what "should be." For our purposes, then, ethics is an applied and analytic endeavour. It is very often about asking the right questions in challenging situations and less so about giving the right answers. In some cases, there may be no right answer or solution-the task may be to pick the best of various imperfect or even "bad" options.

4 2M Pafi lll: AdditionalTopics to Consider in Reflecting on Health Promotion Practice But ethics should not be seen as solely within the domain of experts who know the answers. Health promotion professionals have responsibilities that necessarily involve ethical reflection. It would be unethical for these professionals to simply transfer the task of ethical analysis to external experts and so absolve their own responsibility to evaluate and weigh the impact of their interventions. It is critical for professionals to develop the requisite knowledge and skills in ethical reflection so that ethics becomes integral to their practice and the performance of their professional responsibilities. Health Promotion as Value Laden The values underlying health promotion programs need to be made explicit if professionals want to be conscious of the ethical issues raised by their practice (Mass6, 2003; Ritchie, 2006). The job of thinking ethically begins with identifying problems and describing a situation with an "ethical language"; that is, it is useful to name the values and principles at stake (held by various actors or stakeholders), and identify the conflicts (ofvalues, interests) or dilemmas involved. Both Seedhouse (1997) and Guttman (2000) remind us that in spite of the preoccupation ofprofessionals for grounding their interventions on scientifically validated epidemiological, administrative, or evaluative data, the process is still one that is profoundly influenced by fundamental values, even if these values are rarely made explicit. Implicit values such as respect for autonomy, social justice, responsibility, non-maleficence, the common good, liberty, anti-paternalism, and many others profoundly orient the choice of criteria that define the priority accorded to specific public health problems, the nature of intervention strategies, the content of prevention messages, the modalities of putting health promotion interventions into action, and even the choice of the criteria to evaluate the efficacy of intervention programs. For example, in programs promoting teenagers'safe sexuality, choosing intermediate objectives such as the promotion of self-esteem or empowerment presuppose the valorization of individualism, autonomy, and personal responsibility. The choice ofobjectives is not only based on evidence regarding risk factors or the efficacy of programs as demonstrated by rigorous evaluative research. The values conveyed by professionals constitute only one ofthe determinants of the choice of strategies of intervention. The problem is not that such values are integral to or part of an intervention; the ethical issues arise when professionals and policy-makers ignore this fact and act as if the intervention is objective and value-neutral. Ethical Dilemmas of Health Promotion Interventlons In the past decade, many authors have sought to address the numerous ethical issues raised by health promotion interventions (e.g., Seedhouse, 2001; Buchanan, 2000; Mass6, 2003; Holland, 2007). We will identify, as examples, some domains in which the ethical acceptability of health promotion interventions is questioned because it may interfere with fundamental cultural values or ethical principles.

5 Chapter 15: Ethical Dilemmas in Health promotion practice 245 Autonomy and Information Communication Respect for autonomy, individual liberty, and private life is very important to most North American and European societies. An ethical framework should then recognize that these values are at the foundations of modern'western societies. In so doing, this reminds us to be careful about how persuasive or coercive measures are used in advancing laudable goals of promoting public health. The weighing and arbitration of individual rights and collective interests has always been a major ethical challenge for health promotion (Holland, 2007). One of the fundamental principles of 'Western clinical or medical ethics is respect for individual autonomy, most often translated as a requirement for individual informed consent. But the application of this requirement becomes problematic when it is the consent ofpopulations or communities that is at stake. Some of the ethical challenges that arise include: ' The communication of environmental risks in the case of pollution. Professionals agree that fansparency of information is primordial. However, a press communiqu6, a study into the impact of the risks, or a simple evaluation of the perception of risks might generate a great deal of uneasiness. The ethical dilemma results from the confrontation of two values: the right of citizens to make autonomous choices based on appropriate information, and the responsibility of professionals to not needlessly generate harmfui anxiety (non-maleficence). There is a conflict between a "right to know" and a "duty to inform." ' Knowing that a public understanding of "risk" (mostly a binary notion of presence vs. absence) differs substantially from a public health understanding (statistical notion of relative risk), the challenge is then to determine how far health promotion should go in explaining the intricacies and nuances of health risks so that the information can be well understood by the population before taking action. Is there a limit to the quantity and quality of information that can be transmitted effectively and ultimately understood by a target population? And at what point can health promotion feel morally authorized to exert pressure in favour ofthe adoption ofa particular healthy lifestyle? ' In a context where groups or communities stand to benefit from health promotion interventions-or, alternatively, suffer the consequences-should respect for autonomy be considered only with regard to individuals? For example, would it be more ethical to obtain, prior to embarking on health promotion interventions, the authorization of representatives of hemophiliac groups, the gay community, and the managers of local unions or leaders of ethnic communities? And, if so, on what basis should we recognize certain communities and not others (i.e., how do we define "community"?), or identify the credible spokespeople who are entitled to speak for these heterogeneous groups? Self-Determination, Paternalism, and Empowerment Health promotion has long been seen as fundamentally paternalistic in nature. In the name of protecting the public good, public health institutions have deployed coercive methods such as prohibitions of certain behaviours (e.g., smoking indoors), mandatory participation (e.g., in vaccination, fluoridation), or aggressive health promotion campaigns. While effective in many contexts, such paternalistic interventions also, to various degrees, impinge upon or limit

6 246 Part lli Additional Topics to Consider in Reflecting on Health Promotion Practice individual liberties. So another ethical issue for health promotion is the appropriate use of soft and hard paternalist methods. If health promotion usually considers hard paternalism (coercive interventions to counter voluntarily and consciously assumed behaviours) as an infringement on ethical principles (e.g., respect for autonomy, privacy), soft paternalism (where individuals are strongly encouraged to adopt behaviours that they believe are good for them) can be seen as inherent, unavoidable, and easily justifiable components of health promotion programs (even if sometimes they are less effective in their application). The empowerrnent approach appears to some professionals as a solution to this issue. By focusing on empowering individuals and communities instead ofsimply telling them what to do, health promotion campaigns would be more respectful ofindividuals. Once empowered, people would be more likely to listen to health advice and make autonomous decisions that are objectively good for their health. Nonetheless, while empowering people and communities may be laudable as an effective means of respecting autonomy, it may be simply impractical or ineflective in some circumstances. If an intervention is empoweringbut oflimited effectiveness at a population level, are nlore paternalistic (e.g., directive, moralizing) interventions then ethically justified? Beyond the issue of efficiency, can empowerment be seen as another mode of paternalism? If the goal of an empowerment-based intervention is to transform the at-risk individual into a "responsible" actor through voluntary health education and information campaigns, is it still possible to talk about voluntary participation? Or is empowerment simply an "ethical cleansing agent" of health promotion interventions, a means of making soft paternalist approaches more palatable (Duncan& Cribb, 1996)? Some authors would argue that it is always public health institutions that promote health as a supreme social good (Holland, 2007) and that define the acceptable limits of risk exposure. Empowerment may raise other ethical issues if it is seen as an end (i.e., that of making people responsible for their health) instead of as a means to reach ends defined by others (i.e., promoting public health). And if empowerment of communities is mostly a bottom-up approach that is respectful of communities' own priorities, it should nonetheless be harmonized with top-down policies in order to protect the interests of minority groups in the socio-culturally heterogeneous "bottom population" (Braunack-Mayer & Louise, 2008). BOX 15.2: Questlonlng Patemallsm 1. What are the limits on or justifications for the use of emotive marketing? 2. How, when, and to what extent can health promotion campaigns play on people's beliefs, emotions, or ignorance in order to promote a particular healthy behaviour or discourage an unhealthy behaviour? 3. What happens when the intervention goes against strongly held spiritual, religious, moral, or political beliefs, or when the 'scientific facts" simply do not convince? 4. When does legitimate health promotion become health marketing or even manipulative propaganda?

7 Chapter 15i Ethical Dilemmas in Health Promotion Practice 247 Social Labelling, Stigmatization, and the Challenges to Social Justice Health promotion should respect the principle ofjustice when it comes to interventions among individuals and target populations. Equity in access to health promotion interventions is a cenral concern. But the reality is that some people, often those who are already the most vulnerable, will remain on the margins and not benefit from even the most well-intentioned health promotion campaigns (Frohlich & Potvin, 2008). Ethical issues may also be raised if some social subgroups or some communities do not have access to a given health promotion program. It is generally agreed that health promotion services should not be oflered based on a person's effort (e.g., the degree of participation, implication, or collaboration of the individual with the programs) or merit (e.g., the person's "social value" or contribution to society). As well, infringement on the value of social justice may occur if some groups benefit from health promotion while others bear the burden of risks and costs associated with particular interventions. That burden is often in terms of social labelling, discrimination, and stigmatization of the groups targeted (e.g., those who refuse vaccination, smokers, mothers who refuse breastfeeding, and the overweight population). Uncertainty Epidemiology, Program Evaluation, and the Limits of lnstrumental Reason Principles ofjustice, beneficence, or autonomy are not absolute; they must be balanced with, among others, considerations of the consequences of particular interventions for individuals and populations. It is thus important to both maximize the possible benefits for a population while also limiting the harms or negative consequences for certain individuals or subgroups. The utilitarian approach, which prioritizes the maximization of goods or benefits (i.e., "the greatest good for the greatest number"), is central to health promotion interventions. In taking the health of the population as its key focus, it would be arguably unethical for health promotion interventions to not seek to promote the greatest health benefit for the greatest number of people with the least negative impact. However, an ethics of health promotion must be aware that a focus on (positive) consequences ofan intervention cannot be the only or even the main ethical principle. Specifically, health promotion should never be reduced to cost-effectiveness analyses for two main reasons grounded in two illusions related to instrumental reason.. The "scientific certainty illusion" suggests that scientific methods (e.g., epidemiology, quantitative evaluation design) are infallible in risk factor monitoring or the measurement ofprogram efficacy. Health promotion professionals must recognize that the modern citizen-consumer is exposed to a wealth of contradictory epidemiological research results and often divergent preventive messages. Thus, health promotion interventions that lack critical reflexivity toward the fragility of scientific knowledge will raise both important technical and ethical issues.. The "rationality illusion" rests on the postulate that all human beings are rational and self-interested, and so naturally dedicated to the maximization of their positive heaith state through the management of individual lifestyles and behaviours. This illusion

8 248 Part lll: AdditionalTopics to Consider in Reflecting on Health Promotion Practice ignores the role of alternative forms of rationality (Mass6,1997), or the fact that even the most rational people will at times behave emotionally or irrationally. This illusion also presupposes that a particular (i.e., dominant, scientific) definition of "health" is the only one that is legitinrate, something that ignores the possible diversity of views that may arise in the context of Canada's increasingly multicultural society. Yet a strong rejection of this illusion could lead to a dangerous ethical relativism whereby all values. in all contexts, are considered equal, thus undermining the possibility of applying broad ethical principles across the population (Kline & Huff, 2007). In developing an intervention to promote or prevent a certain behaviour or policy, we need to ask why, how, and for whom the intervention is designed. First and foremost, this involves considering the risks and benefits for the various stakeholders involved, and analyzing whose interests (and what type) are at stake. Second, it means recognizing the limits of the "natural" instrumental reason of individuals and communities, and thus requires a critical gaze on the naive utilitarian vierv of health pronlotion (Holland, 2007). Third, it is essential to recognize that some alternatives mav be suboptimal in terms of outcomes. but mav nonetheless be nrore ethically justifiable. An Ethical Framewoil for Health Promotion Due to the complexity and diversity of issues/challenges at stake in health promotion as illustrated above, it is essential that health promotion professionals have relevant and practical ethical guidehnes and methodologies. In this section, rve describe some key elements of a "tool box" for ethical reflection that are complementary to a broader "professional ethics" for those working in health promotion. Since the 1970s, the ethical analysis of health promotion programs has been strongly influenced by what has been called the "principlist approach," initially developed for clinical or medical ethics. According to this ethical framework, a health promotion intervention can be considered ethically acceptable if it respects a list of fundamental principles that are derived from the main ethical theories (liberalisnr, utilitarianism, Kantian deontology, virtue theory, etc.), are embedded in a "common morality," and respect universal values such as those expressed in the Universal Declaration of Hunran Rights. The most popular version of principlisnr is that developed by Tom Beauchamp andjanres Childress in their Prindples o-f Biomedical Etlrics (Beauchamp & Childress, 2009). According to this theory and methodology, an ethical analysis should balance the respect of four primajacie principles (autonomy, justice, beneficence, and non-maleficence). none of which are absolute or predominant. In this approach, ethical analysis involves a three-step process. First, theoretical principles nlust be specified; that is, follorving an in-depth analysis of the nature, context, and facts related to the program or intervention under study, the respective potential contributions of the four principles should be defined. Second, the relative importance of each of these principles must be weighed in light of the case analyzed. Third, the ethical analysis must arbitrate

9 Chapter 15: Ethical Dilemmas in Health Promotion Practice 249 between these principles considering that any health promotion (or biomedical) intervention cannot fully respect each of these principles. The best stance involves not a black or white posture, but difficult choices over which principles will have to be limited in their scope or application in the specific case. The major contribution of principlism is arguably its pragmatic methodological approach, which relies on relatively intuitive rules of thumb. In recognizing the limits of these four principles (and the principlist approach more generally), as well as the need for specific principles adapted to the population orientation of health promotion, many researchers (Holland,2007; Buchanan, 2000; Upsur,2002; Guttman, 2000; Mass6, 2003) have suggested other ethical frameworks and lists of principles that are specifically adapted to health promotion programs and policies. Other principles andlor fundamental values suggested include: utility, public good, fairness, proportionality, solidarity, shared responsibility, and precaution. Some have criticized principlism for its lack of theoretical foundation, its rationalistic abstraction, the relativism of these principles, and the risk of mechanical and automatic application in a checklist approach (Clouser& Gert, 1990), This last critique is partially true since many health professionals are prone to taking shortcuts through the complex and contextsensitive analytic method suggested by Beauchamp and Childress. However, if effort is made to identify fundamental principles adapted to the population approach of health promotion, then principlism provides three important assets to a health promotion ethics: (1) principlism rejects absolutist approaches that would give one specific principle (e.g., autonomy) an absolute or priority value over others; (2) the principles are secular and allow one to transcend religious specificity in targeting fundamental universal values; and (3) this approach recognizes that ethics is not a science oftruth or ofmorality, but a reflexive and evaluative process that often involves weighing or arbitration between a list of equally fundamental values or principles. Professional Ethlcs in Health Promotion Finally, health promotion professionals also have ethical obligations and responsibilities related to their position of authority as agents of the state, and their power-in some circumstancesto force or restrict certain behaviours or policies. In general, health promotion professionals are called upon to exercise their abilities in a competent, professional manner; to develop policies, programs, and interventions that are based on the best available evidence; to be respectful of the rights, interests, and values ofindividuals in the community; and to advocate for disenfranchised or vulnerable individuals or communities. Such principles are laudable and, taken at face value, unproblematic. However, it may be difficult to apply such principles in practice; in some cases, equally important principles may be in tension or even conflict. Alongside their duty to protect the public and behave in a trustworthy manner, health promotion professionals also have a responsibility to their employer (and ultimately to the state) to follow the orders oftheir superiors and to execute the tasks that they are given. In some contexts, health promotion professionals may be uncomfortable performing, or even disagree completely with, a particular intervention, yet be obligated to participate, e.g., the

10 250 Part lll: Additional Topics to Consider in Reflecting on Health Promotion Practice ,0 vaccination campaign for H1Nl "swine flu" influenza. To what extent can these professionals opt out on moral (or scientific) grounds? Should they have the right to be "conscientious objectors" or would the failure to follow orders be grounds for sanction or dismissal? To deal with these questions, health promotion professionals draw upon diverse sources of ethical guidance that include, for example, professional codes of ethics, institutional or national ethics policies, as well as personal moral or spiritual convictions. A number of ethical frameworks or codes have been advanced, such as the 2002 American Public Health Association's Code oj Ethics for Public Health Prcctice.!7hile the Ottawa Charter may be seen as a cornerstone in the ethics of health promotion (Mittlemark, 2007), it is not in and of itself a code of ethics. The International Union for Health Promotion and Education (IUHPE) is (in 2010) engaged in exploring the need for an international code ofethics for health promotion (see Debate on the pertinence of such a professional code of ethics is certainly important in order to define the duties and limits of health promotion research and practice. However, a codification of ethical professional practices should not mask the need for an in-depth analysis of the mission and underlying fundamental values, language. and even relevance of health promotion. Professional ethics is not about simply following the rules and guidelines; and, while necessary, an ethical health promotion cannot be contained in a professional code ofethics or standards ofgood practice. The diversity of health issues, actors, disciplines, methodologies, or political orientation militate for a common platform to define acceptable practices in health promotion. But it is not at all clear whether that platform should be a formal code of ethics (Sindal, 2002) or a global ethical framework based on guiding values or principles that leave institutions and professionals with the responsibility to develop a self-reflective ethical posture. '!Ve suggest that a professional ethics for health promotion should include, but not be restricted to, a set of practical tools to guide professionals and help them identify and manage the challenging issues or questions that arise in their daily practice. Beyond these practical tools, however, a professional ethics for health promotion should include conceptual tools designed to help professionals analyze the global impacts of health promotion on society and culture. That is, this ethics should combine: (1) an analytic applied ethics, e.g., based on the evaluation and arbitration of alist of key principles, with (2) a"critical ethics" (Cribb,2005) that is based on a critical consciousness about the social context ofhealth and an ethical reflexivity that incorporates a critical gaze regarding the intended and unintended effects on society ofthe values in which health promotion interventions are grounded. Gonclusion Health promotion may work for health as an ultimate common good and base its actions on the best available science and evidence base, yet it will still involve many challenging ethical issues and dilemmas. One of the main issues of concern is to determine when and how fundamental values of health promotion necessitate giving priority to the needs ofthe population over those of the individual (Parker, Gould & Fleming, 2007). lt has been suggested above

11 Chapter 15: Ethical Dilemmas in Health Promotion Practice 251 that neither an ethics framework for health promotion nor a professional code of ethics can give black or white answers to the challenging questions at stake. Ethics in health promotion necessarily involves the evaluation and weighing of principles and fundamental values in order to design programs and interventions that can promote health while minimizing infringements on individual and collective common goods other than health. A central question that must continually be asked is: How far should the society go in the promotion of healthy behaviours and habits, and what should be the proper level ofreflexivity on the part ofthe health promotion professionals? Since health promotion evolves in the context of a very broad set of social changes, we shall follow Alan Cribb's call for a new "social reflexivity" that involves "a pervasive and growing self-consciousness about the social construction ofour health experiences and practices" (Cribb, 2005, p. xi). However, if the associated challenging ethical issues are to be properly addressed, then health promotion professionals have to become actively engaged in the process of ethical reflection. Of particular importance is an in-depth and critical analysis of the goals of health promotion. Health promotion professionals must reflect on their imperative and desire to act in the name of the public good, balancing this with a precautionary attitude that recognizes the indeterminacy of much scientific evidence. In our view, an ethics for health promotion professionalshould thus include an ethical reflexivity that provides nuance to formal professional responsibilities and obligations, and a healthy skepticism about the social and cultural legitimacy of health promotion interventions. References Beauchamp, T.L. & Childress,J.F. (2009). Principles o.f biomedical ethks (6th ed.). NewYork: Oxford University Press. Braunack-Mayer, A. & Louise,J. (2008). The ethics of community empowerment: Tensions in health promotion theory and practice. Promotion and Education, XV(3),5-8. Buchanan, D.R. (2000). An ethics -for health promotion: Rethinking the sources of human wellbeing. New York: Oxford University Press. Clouser, K.G. & Gert, B. (1990). A critique ofprinciplism.journal ojmedidne and Philosophy, 15(2), Cribb, A. (2005). Settingheahhcarc ethics in social context. Oxford: Clarendon Press. Cribb, A. & Duncan, P. (2002). Heakh prontotion and professional ethics. Oxford: Blackwell Science. Duncan, P. & Cribb, A. (i996). Helping people change. An ethical approach? Heahh Education Research, 11(3),33e-348. Frohlich, K. & Potvin, L. (2008). The inequality paradox: The population approach and vulnerable populations. American J ournal of Publrc Health, 98 (2), Guttman, N. (2000). Publichealth communication interuentions: Values and ethicdl dilemmas. Thousand Oaks: Sage Publications. Holiand, S. (2007). Publit heakh edrics. Cambridge: Polity Press. Kline, MV. & Huff, R.M. (Eds.).(2007). Health promotion in multicultural populations: A handbook.for pnctitioners and students (2nd ed.). Thousand Oaks: Sage Publications. Leichter, H.M. (2003)."Evii habits" and "personal choices": Assigning responsibility for health in the 20th century. The Milbank Quarterly, 81(4),

12 252 Part lll: Additional Topics to Consider in Reflecting on Health Promotion Practice Mass6, R. (1997). Les mirages de la rationalit6 des savoirs ethnom6dicaux. Antlnopologie et Socitti:. 21(1), s312. Mass6, R. (2003). Ethique et sdnt6 publique: Enjeux, ualeurs, et normdtiuitt. Quebec: Les Presses de 1'Universit6 Lava1. Mittelmark, M.B. (2007). Setting an ethical agenda for health promotion. Health Promotion International, 23(1),78-8s. Parker, E.A., Gouid, T. & Fleming, M.-L. (2007). Ethics in health promotion-reflections in practice. Health Promotion Journal of Au*ralia, 18(1),69J2. Peterson, A. & Lupton, D. (1996). The new public heahh: Henkh antl self in the age of risk. Thousand Oaks: Sage Publications. Ritchie,J. (2006). Values in health promotion. Heahh PrornotionJournal ojaustralia, 17(2),83. Seedhouse, D. (1997). Henhh promotion: Philosophy, prejudice, and practice. New York: Wiley. Seedhouse, D. (2001). Health promotion's ethical challenge. Heakh PromotionJournal of Australia, 1(2), Sindal, C. (2002). Does healthpromotion need a code of ethics? Health Promotion InternationalJournal, 17(3), Upsur, R.E.F. (2002). Principles for the justification of public health intervention. Canadinn Journnl o.f Public Heahh, 93(2), Critical Thinking Questions 1. What are the limits of paternalistic health promotion interventions? Specifically, how far can one legitimately go in using marketing tactics to name a particular behaviour as 'good" or "bad" and so influence or even manipulate people to respond to the health promotion advice "for their own good"? 2. What is the acceptable level of risk associated with targeting social subgroups or communities in health promotion interventions? 3. lf the ethical acceptability of a given program or intervention is based on a list of ethics principles grounded in a 'common morality," how can we take into consideration the divergent understanding of these principles and values by local minorities, such as ethnic or religious groups? 4. How should health promotion professionals deal with voluntary health risk-takers (e.9., smokers, heavy drinkers), and with corresponding policies that aim to fairly allocate scarce resources (e.9., access to health interventions)? 5. Would it be ethical to ban health promotion campaigns because they infringe key principles or fundamental values? lf so, in which cases, and for which principles or values? Resources Further Readings Buchanan, D.R. (2000). An ethics Jor health promotion: Rethinking the sources qf human wellbeing. New' York: Oxford University Press. The author explains why health promotion is inescapably a moral and political endeavour. He suggests that its realization will be best achieved by promoting autonomy and responsibility by putting into practice the use ofpractical reason.

13 Chapter 15: Ethical Dilemmas in Health Promotion Practice 253 Coleman, C., Bou0sseau, M. & Reis, A. (2008). The contribution of ethics to public heakh. Bullerin of the World Heakh Orgnization, 86(8), The authors situate the origins of public health ethics in bioethics, and then map our six major areas or issues in public health that are in pressing need ofethical reflection. Public Health Leadership Society. (2002). Principles of the ethical practice of public health, uersion 2.2. Retrieved from: Version pdf This is an example ofa code ofethics for public health professionals, developed for the IJS context. Relevant Websites Population Health Ethics: Annotated Bibliography htm l#1 Population Heakh Ethics, a comprehensive annotated bibliography of key texts in population health ethics by H.L. Greenwood and N. Edwards, covers theoretical foundations and principles, ethical frameworks. and selected cases. Public Health Ethics h e, oxf o rdj o u rna ls. orgl Publit Heahh Ethics is a key international journal on ethics of public health and health promotion.

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