Ethics is at the heart of health communication. Ethical issues are embedded in a wide array of health communication activities that aim to influence people’s health-related beliefs or behaviors. These activities include disseminating information about particular health risks, persuading people to adopt healthy lifestyles or to persuade others to adopt healthy lifestyles, and modeling healthy behaviors. Invariably, such health communication activities raise a multitude of ethical concerns, in particular because they deal with deeply held personal preferences and social values, or aim to foster social norms opposed by certain groups.
Perhaps because the general intent of health communication interventions is to promote the health of individuals or populations, ethical issues embedded in these activities are often unacknowledged. However, all aspects of communication aimed to influence people’s health involve ethical issues, from the choices made regarding which populations should be the “target” of the intervention, to the strategic approaches used. Health communication also involves addressing issues such as responsibility, risk, and social and cultural values. Further, some critics maintain that because health communication interventions have such a strong presence in society, they compete – along with commercial advertising – in an appropriation of the political, social, and moral realms of the public discourse.
Prominent ethical theories and principles defining the moral duties and obligations of practitioners in the health-care context offer guidelines and principles for identifying and addressing ethical issues in health communication interventions. A particularly influential framework is presented by Beauchamp and Childress (2001), in the field of bioethics. These ethicists present a series of moral obligations for health-care practitioners: (1) to do the utmost to better people’s health; (2) to avoid doing them any harm (whether on a physiological, psychological, social, or cultural level); (3) to respect autonomy and privacy; (4) to ensure equity and fairness; (5) to provide for those who are particularly vulnerable or who have special needs; and (6) to maximize the greatest utility from the health promotion efforts, especially when resources are limited.
Harm may occur when messages create undue anxiety, label, or stigmatize. Respect for personal autonomy and privacy is another central ethical obligation, based on the premise that individuals have an intrinsic right to make decisions for themselves on any matter that affects them, at least insofar as such decisions do not bring harm to others. This precept is rooted in the liberal western tradition, which places strong emphasis on individual autonomy, and it has been the foundation for the development of important medical care codes such as patients’ rights and informed consent. Other ethicists note that the respect for individual rights is considered a fundamental principle of health-care, but that individual rights may be superseded when it is believed that the state should intervene in order to assist in the protection of these rights. Some criticisms of this framework are that it represents mainly a western approach to the conception of moral issues, that it draws too much on assumptions of individualism and universalism, that it may be removed from the socio-cultural milieu in which moral choices actually take place, and that it does not reflect diversity in moral reasoning.
Additional stipulations that can help identify ethical issues in health communication interventions can be found in ethical frameworks in the rhetorical and persuasive communication literature and more recently also in those presented by scholars and practitioners involved in social marketing. These include: (1) the obligation to be truthful and not base claims on hidden arguments; (2) acknowledging alternative ways of framing and prioritizing the health issues; (3) ensuring that issues are truly relevant to the intended populations and not made to seem relevant; (4) offering accurate, complete, and relevant information on the health issue; (5) providing reliable, correct, and accurate claims; (6) not exaggerating negative consequences or the magnitude of the problem, even if this would positively influence the intended populations; (7) not modeling inappropriate behavior; (8) not offending certain cultural norms and beliefs; (9) providing fairness and balance; (10) not stigmatizing certain behaviors or groups; and (11) avoiding stereotypes, even if doing so seems to serve the goals of the intervention.
Ethical Issues In Health Communication
Whereas consensus exists about the need to obtain patients’ or their guardians’ informed consent in medical practice, and in many health-care systems it is mandated by law, in health communication this is not the case. Practitioners and scholars do not have official guidelines for obtaining informed consent from populations for whom health messages are intended.
A significant challenge is identifying who represents an intended population, particularly when it is a large group or a community. Further, within one group, some may want the health messages to be disseminated, whereas others may find them offensive. One mechanism for obtaining the equivalence of an informed consent in community or population settings is the use of advisory boards, which are often mandated by governments or funding agencies. An ethical concern raised by this mechanism is that the board members may not represent marginal groups or that they may hinder the efficiency of the communication intervention.
Targeting Certain Populations
A major strategic approach in health communication, which draws also from the social marketing approach, is to identify groups of people with shared characteristics as “segments,” and narrow the focus of the health communication intervention by “targeting” these particular groups. This means that the issues, themes, messages, information, and other aspects of the process of communicating with this population are designed according to its particular needs, beliefs, values, and behaviors, or the communication channels it uses. The underling rationale for this approach may be utilitarian – to improve the chances that the communication intervention will be more effective and efficient in utilizing resources. A utilitarian approach may also serve as the rationale for decisions to focus on those most likely to adopt the health-related recommendations.
Alternatively, the decision of whom to “target” may be based on considerations of equity, and the intervention would try to reach disadvantaged groups, in particular those considered “hard to reach” and thus less likely to adopt the health recommendations. “Targeting” thus can serve ethical obligations of maximizing utility as well as equity, by attending to the particular needs of vulnerable populations. However, a common ethical concern associated with targeting is that, despite its utility, it can be unfair by excluding certain populations. This raises ethical concerns similar to those raised when making policy decision on rationing health-care resources.
The Use Of Persuasive Appeals
In order to help people adopt health-promoting beliefs and practices, health communication scholars and practitioners have developed theoretical and tactical approaches on how to make effective persuasive claims and appeals. Ethical issues are embedded in each approach because a persuasive tactic, by definition, is an attempt to influence a person, and this may infringe on people’s rights not to be manipulated. In support of using highly persuasive tactics, some health communicators argue that such tactics are the most efficient way to help motivate people to adopt recommended health practices.
Further, some communicators feel that because health communication often takes place in a media-saturated environment, they need to employ strategies that “break though the clutter” in order to gain people’s attention, and that this justifies the use of some form of exaggeration, misrepresentation of information, or strong emotional appeals. However, this strategic approach is likely to conflict with their obligation to be truthful and to respect people’s autonomy by not using manipulative techniques.
Messages On Personal Responsibility
Personal responsibility is a central theme in health communication. It can be viewed as epitomizing people’s sense of autonomy, but also raises ethical concerns characterized as victim blaming. The notion of responsibility may refer to, for example, an obligation to talk to your children about drugs or to ensure your spouse adopts a healthy lifestyle. Such messages may be associated with social roles and serve to reinforce moral commitments to others. Responsibility may refer to making prudent choices in your food consumption, leisure activities, and sexual relations. People may be warned that they will become a burden to their family, or to society as a whole, if they are not responsible in their lifestyle.
A major ethical concern is that such appeals may elicit feelings of shame and guilt among individuals, who find that they are not able to adopt the recommended practices for varying reasons. This is referred to as “victim blaming”; when health-related behaviors are often not fully within the volition of individuals but are influenced by factors such as work and housing conditions, access to health-care, or pollution. Responsibility messages thus raise concerns regarding violations of the precept of “doing no harm.” Further, they can have an impact on public opinion and health policies, with the consequence of requiring those viewed as “irresponsible” to pay more for the expenses of certain health conditions or to receive a lower priority for their health-care services. A different type of ethical concern is that, as pointed out by sociologists and anthropologists, a discourse on responsibility is ideologically and culturally based, and what is considered irresponsible depends on each society’s selection of what it considers risky and its definition of social roles, behavioral obligations, sanctions, and rewards.
Labeling, Stigmatizing, And Stereotyping
Communication activities aiming to promote health may have inadvertent negative outcomes. By warning against the risk of contracting a stigmatized medical condition or by a negative portrayal of those who do not adopt the health recommendation, the message can stigmatize individuals or groups. This may even contribute to the creation of new types of negative stereotypes. Even humorous uses of presumably harmless stereotypes in health messages may have ethical implications. Communication activities can also serve to label people as “sick” and can negatively influence their sense of identity. Some critics suggest that one possible way to meet the challenge of developing non-stigmatizing messages is to focus on social and environmental risk factors rather than on disability as the dreaded outcome.
Inequity And Social Gaps
Communication scholars note that, because of socio-economic differences, considerable gaps can be found between groups of people in the acquisition of pertinent information; this has been characterized as the knowledge gap. Occurrences of such gaps have been found regarding health information as well. Thus, the presumption that health communication activities invariably help to advance the health of disadvantaged groups may not be realized, and health communication activities may inadvertently serve to reinforce existing social disparities.
The perpetuation of social gaps can also occur when health communication recommendations call upon people to relinquish various practices they enjoy or that have cultural significance or emotional importance. Whereas those with economic means may find it easier to find substitutes for practices considered unhealthy, members of vulnerable groups may find that these “unhealthy” practices provide not only pleasure, but also they serve as an important coping mechanism that is not easily replaced.
Constructing Health As A Value
Scholars and health promotion ethicists have expressed concern that the growing profusion of health communication messages may result in people viewing health as a top priority, or turning the importance of health into an overriding value. This concern can draw on media studies that note that an important role played by the mass media is its “agendasetting” capacity, and thus the coverage particular issues receive in the media, as well as the way they are framed, can result in the prioritization of these issues on the public and personal agendas. Good health increasingly signifies virtue, and health communication interventions can appear to color the pursuit of health with moral overtones. Another concern is that such a prioritization can come at the expense of prioritizing other social issues, and may contribute to escalating expectations from medicine and health-care providers and industries. Ethicists suggest that this raises questions of equity, because the more powerful groups will demand that healthcare systems meet their escalating needs, whereas members of vulnerable groups will continue to receive relatively fewer services.
With the advancing professionalization of the practice of health communication interventions and the adjacent field of social marketing, interest in ethical issues is growing. Though an official code of ethics has not yet been proposed, discussions of ethical issues can be found in journal articles, book chapters, and a few books entirely devoted to the topic. However, conceptual approaches regarding ethical issues – in particular those that address health communication interventions that utilize games and new media channels, or entertainment-education approaches that increasingly include reality shows – must be explicated and developed. Ethical approaches in health communication may need to draw further on communication theory and address issues concerning diversity, ethical relativism, and the role of health communication in social change.
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