Ethical issues in health promotion

Chapter 6 Ethical issues in health promotion




Key points



• The philosophy of health promotion

• Duties in health promotion

• The individual and the common good

• Ethical principles:
– Beneficence (doing good)

– Non-maleficence (doing no harm)

– Autonomy

– Justice and equity

– Telling the truth


Overview


Health promotion involves working to improve people’s health. This requires a series of value judgements: about what better health means for the individual and society; and about whether, when and how to make a health promotion intervention. This book has used the perspectives of social science to help you explore your role and aims in health promotion. In this chapter we consider some of the prevailing problems for a health promoter from a philosophical perspective:


• The extent to which individuals can be held responsible for their own health

• Whether it is justified to institute health promotion interventions which have not been sufficiently evaluated

• The extent to which health promotion should influence the public to choose what is deemed to be the healthy (and by implication correct and good) choice

• The legitimacy of the state to influence the environment to encourage healthy behaviour.

In particular, the chapter focuses on the limits to individual freedoms and how these are balanced against the health of the community. The chapter outlines the key ethical principles of beneficence (doing good), non-maleficence (doing no harm), justice, telling the truth and respect for people and their autonomy.



The need for a philosophy of health promotion


Debate in health promotion has centred on discussion of practice and some attempts to deve­lop a theoretical base. However, according to Seedhouse (1988), there has been little discussion concerning the philosophy of health and yet it is an essential part of the way in which we understand the world.


Health promotion involves decisions and choices that affect other people which require judgements to be made about whether particular courses of action are right or wrong. There are no definite ways to behave. Health promotion is, according to Seedhouse (1988), ‘a moral endeavour’. Philosophical debate helps to clarify what it is that one believes in most and how one wants to run one’s life. It can and does help practitioners to reflect on the principles of practice, and thus to make practical judgements about whether to intervene and which strategies to adopt.


Philosophy has three main branches:


1. Logic – the development of reasoned argument

2. Epistemology – enquiry into the nature and grounds of knowledge and meanings

3. Ethics – the enquiry into how we ought to act and conduct ourselves.

Morals refer to those beliefs about how people ‘ought’ to behave. These debates about right and wrong, good and bad, and duty are part of everyday discourse. Is it wrong to tell a lie? Is it justified to kill another? Is it our duty to look after ageing parents? Judgement about the morality of these actions may derive from our personal values and moral beliefs which derive from: religion, culture, ideology, professional codes of practice or social etiquette, the law or our life experience. The function of ethical theory is not to provide answers but to inform these judgements and help people work out whether certain courses of action are right or wrong, and whether one ought to take a certain action.


Western philosophy has been shaped by two theories of ethics – deontology and consequentialism. Deontology comes from the Greek word deonto meaning duty. Deontologists hold that we have a duty to act in accordance with certain universal moral rules. Consequential ethics are based on the premise that whether an action is right or wrong depends on its end result.



Duty and codes of practice


Deontologists hold that there are universal moral rules that it is our duty to follow. Many of the philosophical discussions about the nature of duty are based on the theories of Immanuel Kant. The essence of Kant’s thinking is encapsulated in the categorical imperative which can help us to discover, through reason, if a rule or moral principle exists (Kant 1909).


The major features of Kant’s theory are:


1. Act as if your action in each circumstance is to become law for everyone, yourself included, in the future. In other words, if everyone always behaved this way, would the overall effect be good? If it would, then this is the rule to apply in all similar situations. The biblical ‘Do unto others as you would they do unto you’ becomes a universal moral imperative.

2. Always treat human beings as ‘ends in themselves’ and never merely as ‘means’. A moral rule then is one that respects all people.

Deontological theories make decision-making apparently easy because, as long as we obey the rules, then we must be doing the right thing, regardless of the consequences.



imageBOX 6.1



Screening for antenatal disorders


This screening programme is in place to reduce the birth prevalence of a chromosomal disorder. The assumption underlying screening for conditions such as Down’s syndrome is that parents with a positive result will decide to terminate the pregnancy. Some positive-testing parents who do not choose termination may indirectly benefit from the test because they will be better able to adjust to the condition of their baby.


The Kantian objection is that the screened population becomes a mere means to achieve the public health goal of reducing chromosomal disorders in the population.


The ethical dilemma is pointed up, as Holland (2007, p. 182) puts it: ‘how feasible it is to use antenatal and screening and termination to combat a disability on the one hand, whilst maintaining a positive societal attitude towards extant disabled people on the other’.



imageBOX 6.2


This example centres on the duty to respect life and highlights some of the difficulties that canarise from carrying out this duty.


There is in medical care a commonly accepted doctrine of ‘acts and omissions’ which states that if a person fails to perform an action that would prevent negative consequences he or she is morally less blameworthy than if he or she performed an action that resulted in the same consequence.


In 2005 Dr Michael Irwin accompanied a terminally ill widow, Mrs May Murphy to Switzerland. She took a lethal dose of barbiturates while he was in the room. Assisted suicide, defined as doctors giving patients the means to kill themselves, is legal in Switzerland.


In 1992 medical staff stopped feeding Tony Bland, a young man crushed into a permanent vegetative state by the Hillsborough football disaster. This action was regarded as withholding life-saving treatment and morally acceptable.


Both acts had brought about the same consequence – the death of a patient. Is there a moral distinction, in your view, between killing and letting die? Must human life be preserved regardless of its quality?


Many health care workers have codes of practice which set out guidelines for the fulfilment of duties. For example, doctors take the Hippocratic oath which requires them as a first principle to avoid doing harm. The Nursing and Midwifery Council (2004) states the duty to respect life, the duty to care, and the duty to do no harm. Kant would have added ‘the duty to be truthful in all declarations is a sacred, unconditional command of reason, and not to be limited by any expediency’ (Kant 1909). The Society of Health Education and Promotion Specialists (SHEPS) includes these principles in its code of conduct:


Practitioners have a:


• Duty to care

• Duty to be fair

• Duty to respect personal and group rights

• Duty to avoid harm

• Duty to respect confidentiality

• Duty to report (SHEPS 1997).

But, as Sindall (2002) has argued, health promotion has not engaged in the kind of debate necessary to agree the principles, duties and obligations to which health promoters would need to agree to work in the field. Codes of conduct are simply devices offering a framework in which to practise. They do not help practitioners involved in the messy and complex everyday world of health care (Duncan 2008). For example, Article 3 of the nursing code (Nursing and Midwifery Council 2004) declares that the registered nurse, midwife or specialist community public health nurse must obtain consent before any treatment or care but the concept of informed consent is complex.



imageBOX 6.3


What do you understand by the concept of informed consent? What difficulties might there be in complying with this aspect of the code of practice?


Patients have different capacities to understand the nature of treatment or interven­tion. Patients may feel they will be judged or withheld from other interventions if they refuse. Consent is so obviously presumed in many cases, e.g. in the ‘invitation’ to screen or test, that refusal can seem impossible. Practitioners may also not communicate risk clearly such that patients are not fully informed when they consent.



Consequentialism and utilitarianism: the individual and the common good


The other classical school of ethics is known as consequentialism, of which utilitarianism is its best-known branch. Consequentialism differs from deontological theories because it is concerned with ends and not only means. The utilitarian principle is that a person should always act in such a way that will produce more good or benefits than disadvantages. Utilitarians such as John Stuart Mill and Jeremy Bentham aimed for the greatest good or pleasure for the greatest number of people. Utilitarians can thus respond to all moral dilemmas by reviewing the facts and weighing up the consequences of alternative courses of action. This can, of course, prove difficult. What exactly is a good end? How does one predict whether an outcome will be favourable? One of the main problems with utilitarianism is that, if the aim of all actions is to achieve the greatest good, does this justify harm or injustice to a few if society benefits? Smoking restrictions offer an example, where the health of society takes precedence over the right of the individual to smoke.


Health promotion raises many questions over its ends and means:


• Good health is a relative concept, so whose definition should take precedence? Is it ethical for a practitioner to persuade someone to adopt his or her perception of a healthier lifestyle?

• What means are justifiable to promote population good health? Should the interests of the majority always prevail?

• Since most ill health is avoidable, should those who adopt unhealthy behaviours be refused treatment?

In Chapter 4 we saw that some writers have expressed concern over ‘social engineering’ in health promotion and think that government intervention has risked becoming government intrusion. Many interventions are justified as being in the interests of a ‘healthy society’, yet they may not have been requested or desired.



imageBOX 6.4


Consider these examples of healthy public policies and whether, in your view, they are ethical.


• Fluoridation of tap water

• Subsidy of lead-free petrol

• Ban on smoking in public places

• Complete ban on drinking and driving

• Compulsory testing of all visitors to the UK for human immunodeficiency virus (HIV) infection

• Ban on the use of mobile phones in cars

• Government subsidy of child-minding places

• Reintroduction of nutritional standards for all school meals

• Compulsory immunization for all children entering education.


Some of these actions are intended to protect the population from possible harm. Others are promoting evidence-based health interventions, although their universal application can restrict the actions of others. For example, the use of public funds to support child care is not relevant for those without children.



Ethical principles


Ethical principles can help to clarify the decisions that have to be taken at work. Sometimes decisions may be guided by trying to do the best for the most number of people; at other times they may be guided by an overriding concern for people’s right to determine their own lives; and sometimes decisions may be guided by other ethical principles or a professional code of conduct.


There are four widely accepted ethical principles (Beauchamp & Childress 1995):


1. Respect for autonomy (a respect for the rights of individuals and their right to determine their lives)

2. Beneficence (the commitment to do actions that are of benefit)

3. Non-maleficence (the obligation not to harm patients or clients. If there is doubt, precaution should prevail)

4. Justice (the obligation to act fairly when dealing with competing claims for resources or rights).

These principles provide a framework for consis­tent moral decision-making. However, situations rarely involve a single option, but can encapsulate increasingly complex and sometimes conflicting choices between these principles. Seedhouse (1988) has developed these principles into an ethical grid which helps provide health promoters with an easy-to-follow guide on which to ground their work on moral principles (Figure 6.1).


image

Figure 6.1 The ethical grid. The limit to the use of the grid is that it should be used honestly to seek to enable the enhancing potentials of people. From Seedhouse (1988).



The ethical grid


This provides a tool for practitioners, helping them to question basic principles and values, and be clear about what they mean and intend to do. The grid suggests ways in which practitioners can work through proposed actions. In any situation we should be asking ourselves:


1. Central conditions in working for health
• Am I creating autonomy in my clients, enabling them to direct their own lives?

• Am I respecting the autonomy of my clients whether or not I approve of their chosen direction?

• Am I respecting all people as equal?

• Do I work with people on the basis of needs first?

2. Key principles in working for health
• Am I doing good and avoiding harm?

• Am I telling the truth and keeping promises?

Related posts:

  1. Developing healthy public policy
  2. Models and approaches to health promotion
  3. Measuring health
  4. Influences on health

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Mar 21, 2017 | Posted by in MEDICAL ASSISSTANT | Comments Off on Ethical issues in health promotion

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