Chapter 6 Ethical issues in health promotion
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:
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.
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).
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 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’.
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:
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.
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.
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.
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 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.
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).
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: