Health Promotion and Ethics

What ought we to be doing?

What actions are right or wrong?

A clear definition of health might be useful

NHS 's aim might be thought to do with
health care provision
Need a clear definition of health to assess
this
To distinguish health care from social care
Philosophical reasons for wanting an
account of health

Philosophers love clarity

How is health related to disease and
illness?
Is somebody healthy a factual
question?
Are you healthy or not depend on
your decision, feelings, desires?
Is it for society to decide as a whole
what constitutes health?
The issue of what health is, has vital
ethical implications
Question might not be, but the answer
very likely to be
“Health is a good thing, which ought
to be promoted”
Actions taken by health care workers
that promote health are morally good
actions
 Health definitions - WHO
"Health is a state of complete
physical, mental and social well-
being and not merely the absence
of disease;"

Confusion of health and welfare

Is anyone healthy?
Motivational reasons
Health definitions - Seedhouse
'A person's health is equivalent to the
state of the set of conditions which fulfil
or enable a person to work to fulfil his or
her realistic chosen and biological
potentials'.

Personal involvement to shape health

Different people talk about different
things as being healthy
Contributor factors which go towards a
person's well being
 Health definitions - Illich
'Health is a task, and as such is not
comparable to physiological balance of the
beasts…Success is in large part the result
of self-awareness, self-discipline and inner
resources'.

Focus on the individual

Health under personal control/responsibility
Health clearly more than absence of
disease
 Healthy or not?
– A 6 year old with measles

– A 42 year old business woman with

malaria

– A 28 year old who has been trying to

conceive for six years

– A 19 year old with a fractured hip

 Healthy or not?
– A 22 year old suffering from morning
sickness during pregnancy

– A 52 year old male, a diabetic since

childhood, who complains of erectile
dysfunction

– A 25 year old carrier of the sickle cell gene

– A 25 year old carrier of the Huntingdon's

gene
 The Ethical Grid
Seedhouse, David. (1998). Ethics: The Heart of Health
Care

Blue Layer:
Health care purposes

Red Layer:
Duties & motives

Green Layer:
Consequences & priorities
re. proposed outcomes

Black Layer:
External environment;
practical considerations
 The roles of v alues. ethics & ev idence in health promotion practice
(Using the Interactiv e Domain Model of Best Practices in Health Promotion)
(Barbara Kahan & Mic hael Goodstadt, 2001)

Internal & external environments

(social, political & economic structures & systems;
psychological and physical conditions)

HP Values

Which issues?
What methodology?
How used?
Un d erp in n in g s o f BP Who decides?
in HP

HP Evidence

HP Un d erstan d in g o f
En viro n men t

HP ETHICS
Values-based
decision-making

HP Best Practices

HP GOALS
 Individual Health Population Health

Bioethics = Public health =

human rights, utilitarian,
civil liberties paternalistic,
and individual social
autonomy responsibility,
approach communitarian
medicalized system orientation
Moral imperative of health promotion to
ensure and protect the health of the
population and the individual
Ethical foundations traditionally implicit
in health promotion
The right to health?
Renewed awareness of conflict between
individual rights and community rights
Effects of doing or not doing health
interventions or “best practices”
 When and when not to act
Judgment, experience, evidence, ethics
Experience of Good Public Health Practice
Threat of preventable mortality or risk
factor
When dangers/costs of not acting exceed
those of acting
Public right to know
Public right to protection
Individual rights
Balance
Accountability, transparency
Many issues of conflict between good
of the individual and good of society
Immunization, chlorination,
fluoridation
HIV/AIDs, MDRTB
Aging and chronic diseases
Human Genome Project
Genetically modified foods
Technology and resource allocation
Does society’s responsibilities =
paternalism?
Does freedom of individual = hostility to
the state in all it’s manifestations?
Do we need informed consent for all
interventions?
Do individual rights over-ride social
responsibility? E.g. AIDS contact tracing?
The “Precautionary principle” = must
prove zero risk of intervention?
Equity in health?
Adequate funding and its allocation
 Old-New Battles
UK Variolists oppose vaccination vs. smallpox
C19th
US Opposition to public health departments in
1920s
UK GPs oppose immunization with pertussis
(1980s) and MMR (2002)
AMA opposes to national health insurance
1920s to present
Civil rights vs HIV control, 1980s US
Anti-fluoridationism 1950s to present
Anti-food fortification in Europe
Anti-genetic engineering of food in Europe
Responsibility to protect society
Responsibility to the individual
Individual vs community rights
Government responsibility
Corporate responsibility
Right to health care
Personal responsibility - self care
Quality of care
Freedom of choice
Government obligation to protect health of
the population
Power of government to legislate, tax,
spend, regulate, punish
Restriction of personal liberties e.g. seat
belt laws or smoking restrictions vs. human
rights
Economic and social impact of intervention
vs. non-intervention
Laws enacted by legislative bodies and
court decisions
 Individual Community

Personal hygiene Sanitation

Immunization Herd immunity
Right to health care Universal access
Self care Education
Choice of provider Gatekeeper function
Right to know Mandatory reporting
Confidentiality Case follow-up
Privacy Resources for health
Informed consent Cost containment
Equity
Minority and special
groups
High risk groups
 Kahan & Goodstadt
(Best Practices in Health Promotion Workbook)
VALUES GOALS ETHICAL PRINCIPLES
1. social justice: to increase overall 1. aim to benefit rather
equity re. the fair levels of: than harm
distribution of 1. social justice 2. put principles above
resources; respect 2. power sharing self-interest
for diversity 3. ecological respect & 3. think of the
2. power sharing: sensitivity consequences of any
empowerment; 4. enriched individual action
participation and community life 4. have an explicit
3. health: optimal 5. health and well- decision-making
health for all, holistic being of strategy for conflict
health communities and resolution
4. the environment: individuals 5. recognize & deal with
ecological respect & 6. others competing ethical
sensitivity considerations
5. enrichment of 6. consider whether an
individual and action is the best one
community life: 7. others
authenticity;
creativity; critical
reflection; joy;
meaningfulness;
social connectedness
6. others