Abstract
One important ethical issue for health promotion and public health work is to determine what the goals for these practices should be. This paper will try to clarify what some of these goals are thought to be, and what they ought to be. It will specifically discuss two different approaches to health promotion, such as, behavior change and empowerment. The general aim of this paper is, thus, to compare the behavior-change approach and the empowerment approach, concerning their immediate (instrumental) goals or aims, and to morally evaluate the strengths and weaknesses of these two goal models, in relation to the ultimate goal of health promotion. The investigation shows that the behavior-change approach has several moral problems. First of all, it is overly paternalistic and often disregards the individual’s or group’s own perception of what is important—something that also increases the risk of failed interventions. Furthermore, it risks leading to ‘victim blaming’ and stigmatization, and to increased inequalities in health, and it puts focus on the ‘wrong’ problems, i.e., behavior instead of the ‘causes of the causes’. It is thereafter shown that the empowerment approach does not have any of these problems. Finally, some specific problems for the empowerment approach are discussed and resolved, such as, the idea that empowering some groups might lead to power over others, the objection that the focus is not primarily on health (which it should be), and the fact that empowered people might choose to live lives that risk reducing their health.
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Notes
A previous paper in a similar way discusses and ethically evaluates the different means used by these two approaches [83].
There is no room to develop a theory of quality of life here, but a few remarks need to be made. It seems to me that what best explains what makes a life go well for a person (her quality of life) is that her (final) desires are fulfilled. It follows that it is not sufficient that the desires are only believed to be fulfilled (an idea that would permit also false beliefs to contribute to a person’s quality of life), which is the case in some happiness theories of quality of life. It also seems plausible that the desires that count most (in evaluating the good life) are the ones that are authentic, i.e., that are autonomous and informed. Brülde, who has argued for the above position [12]; see also 72], adds a hedonistic dimension to his theory of quality of life. The best life is one where one’s (authentic) desires are fulfilled and one experiences well-being, and does not suffer. I will assume here that this dimension is not necessary, since to experience well-being, and be free from suffering, are (in most cases) covered by a person’s (authentic) desires.
In a public-health context we differentiate between individuals and populations. What might constitute a relevant and important health-promotive activity on the individual level, and a relevant goal, e.g., for a physical therapist, might not constitute such an activity or such a goal on the population level, and vice versa.
It is probably better to reserve the notion ‘bottom-up’ for initiatives that are truly born in, and initiated by, the communities themselves (without the help of professionals). ‘Local’ projects will mostly be initiated by professionals, e.g., civil servants, or local politicians.
This primarily goes for the developed countries, even if there are similar tendencies in the developing world [5].
This does not mean that there could not have been an original external cause to the suffering. An accident might have caused a concussion, but the subsequent headache has an immediate internal cause (i.e., the damage caused to the brain), and therefore counts as health related.
Other kinds of well-being, e.g., emotions, have outer sustaining causes (usually mediated by beliefs), such as being happy because of a promotion, or sad because of a personal loss.
This level is more or less what Nordenfelt [52] calls the person’s “second order ability”.
Strictly, fundamental health also has to be related to the environment [52].
The definition needs much more elaboration than there is room for here. Some exceptions have to be made, e.g., for pregnancies (to the extent that they typically reduce health).
Medicine (broadly conceived) is the only kind of practice close enough to people’s bodies and minds to be able to change them directly. For example, most treatment of disease or illness, such as operating on a knee, or giving pain killers, does directly influence the individual’s manifest health, namely, through restoring the knee’s function (fundamental health) and the ability to walk (manifest health), and reducing pain (manifest health) [51, 81, 82].
“Behavior change” + “health” yields a great number of entries in Google scholar.
In a few cases the targets are the behaviors of politicians, civil servants or (other) professionals, e.g., in health advocacy [88].
For some people these kinds of behavior can also be part of a ‘lifestyle’, and, thus, of a person’s identity, for example, not using a crash helmet because of belonging to a ‘motorcycle culture’ [38].
Note that false beliefs also lead to (in)actions, and that health promoters sometimes use this insight, e.g., when they exaggerate the danger of certain practices, such as trying out narcotics, to scare young people from testing such practices [36].
This is not to deny that there are behaviours that there are good reasons to prohibit (solely for the sake of reducing harm in the individual herself), either because the infringement on the person’s liberty is slight, as with having to wear a seat-belt, and/or because the harm from the behavior is great, as with autonomy-reducing behaviours such as using heavy drugs.
This means that we also need other theories, other than those narrowly focused on behavior, to guide us—political, social, environmental, organizational, and economic theories—in order to understand social reality, and in order to achieve alternative goals, such as empowerment.
Note that a group’s quality of life is the aggregated (authentic) desire-fulfilment of the members of the group. The desires might differ, but in certain collective actions they are likely to merge, e.g., when a group fights for social recognition.
In certain kinds of (paternalist) top-down interventions it seems acceptable to impose restrictions on people, for their own sake, e.g., mandatory schooling, prohibiting drug use, or requiring (through taxation) that people deposit money in (their own) pension funds. The best argument for such interventions is that they promote future autonomy, or empowerment.
Note that we are dealing with two kinds of ‘groups’ or ‘communities’, one geographical, i.e., people living in the same area (e.g., block., village, town, county, or country), and one where the individuals involved share a certain ‘property’, i.e. share the same kind of ‘problem’ (e.g., being unemployed, illiterate, or obese). The two might, of course, go together, such as living in a village where everyone is poor, or illiterate.
This, obviously, is not the same as the right to autonomy, and increasing the ability for autonomy is compatible with some restrictions of individual liberty (exercise of autonomy). See footnote 18.
Not only individuals, but groups, and communities, need autonomy, opportunity, and liberty, even if this is not specifically for their “personhood”!
Note that all choices, also autonomous ones, are ‘contextual’, i.e. they (including their fulfillment) are limited by physical, mental, and social constraints. Within these constraints we can, however, be more or less autonomous, and the general claim is that the greater the ability for self-determination, the better.
It is, of course, conceivable that someone else knows better what belongs to our quality of life, but this is less likely than if the (relatively autonomous) person herself (or group itself) were to choose.
The means used in empowerment projects are also a testimony to that, e.g., that treating people as autonomous individuals or groups will induce them to become more engaged and take responsibility, and this is expected to lead to greater dignity (as identity) of the individuals involved [15, 53]. And the dialogical, collaborative quality of empowerment projects fosters other values, such as mutuality, respect, compassion, and morality [30, 62].
This is a simplification, since ‘power over’ ought also to cover, at least, such things as intentionally induced experiences, e.g., threats, and the intentional creation or limitation of opportunities, such as withholding someone's passport or money.
Unless this is a very specific tax-financed project, making people pay local tax for it. But this is ‘power over’ coming from the politicians, not from those involved in the concrete empowerment project.
The most problematic ethical aspect of the exercise of ‘power over’ is making people do what is not in their own interest [43]. But it is not obvious that having to pay taxes for empowerment projects is against (all) taxpayers’ interests, at least not if the projects are successful. Nor should we assume that people in general do not want to pay taxes.
In most other respects I find Buchanan’s book highly important and inspiring. Most of what he wants to achieve clearly falls under what I would call the empowerment approach.
But perhaps not for other kinds of social interventions, since (control over) quality of life (on the whole) is more important than (control over) health (even if they are causally interrelated).
I have the term from Luca Chiapperino (personal communication April 2013).
Note that in many cases people should also be allowed to pursue inauthentic goals. However, society should create social foundations for authenticity, as well as those for health, empowerment, and quality of life.
References
Abraham, C., & Sheeran, P. (2000). Understanding and changing health behavior: From health beliefs to self-regulation. In P. Norman, C. Abraham, & M. Conner (Eds.), Understanding and changing health behavior: From health beliefs to self-regulation (pp. 3–26). Amsterdam: Harwood Academic Publishers.
Barry, B. (2005). Why social justice matters. Cambridge: Polity.
Baum, F. (2008). The new public health (3rd ed.). Oxford: Oxford University Press.
Bayer, R., Gostin, L. O., Jennings, B., & Steinbock, B. (Eds.). (2007). Public health ethics. Theory, policy, and practice. Oxford: Oxford University Press.
Beaglehole, R., & Bonita, R. (2004). Public health at the crossroads. Cambridge: Cambridge University Press.
Berglund, S. (2008). Competing everyday discourses: The construction of heterosexual risk-taking behavior among adolescents in Nicaragua. Malmö: Malmö högskola, Hälsa och samhälle.
Braunack-Mayer, A., & Louise, J. (2008). The ethics of community empowerment: Tensions in health promotion theory and practice. IUHPE: Promotion and Education, 15(3), 5–8.
Brülde, B. (1998). Vad är hälsa? Några reflektioner kring hälsobegreppet [What is health? Some reflections about the concept of health]. Göteborg: Filosofiska institutionen.
Brülde, B. (2000). On how to define the concept of health: A loose comparative approach. Medicine Health Care and Philosophy, 3, 305–308.
Brülde, B. (2000). More on the looser comparative approach to defining ‘health’: A reply to Nordenfelt’s reply. Medicine Health Care and Philosophy, 3, 313–315.
Brülde, B. (2003). The concept of mental disorder. Philosophical Communications, Web Series, No. 29. Department of Philosophy, Gothenburg University.
Brülde, B. (2007). Happiness theories of the good life. Journal of Happiness Studies, 8(1), 15–49.
Brülde, B. (2011). Health, disease, and the goals of public health. In A. Dawson (Ed.), Public health ethics (pp. 20–47). Cambridge: Cambridge University Press.
Brülde, B., & Tengland, P.-A. (2003). Hälsa och Sjukdom: En begreppslig utredning [Health and illness: A conceptual investigation]. Lund: Studentlitteratur.
Buchanan, D. (2000). An ethic for health promotion. Oxford: Oxford University Press.
Buchanan, D. (2008). Autonomy, paternalism, and justice: Ethical priorities in public health. American Journal of Public Health, 98, 15–21.
Cheng, H., Kotler, P., & Lee, N. R. (Eds.). (2011). Social marketing for public health: Global trends and success stories. Sudbury, MA: Jones and Bartlett.
Culver, C. M., & Gert, B. (1982). Philosophy in medicine. Oxford: Oxford University Press.
Dahl, R. (1982). Power as the control of behavior. In S. Lukes (Ed.), Power. Oxford: Blackwell.
Daniels, N. (2008). Just health. Meeting healthy needs fairly. Cambridge: Cambridge University Press.
Daniels, N. (2011). Equity and population health: Toward a broader bioethics agenda. In A. Dawson (Ed.), Public health ethics (pp. 191–210). Cambridge: Cambridge University Press.
Davies, M., & Macdowall, W. (Eds.). (2006). Health promotion theory. Maidenhead: Open University Press.
Dawson, A. (2011). Resetting the parameters. In A. Dawson (Ed.), Public health ethics (pp. 1–19). Cambridge: Cambridge University Press.
Downie, R. S., Tannahill, C., & Tannahill, A. (1996). Health promotion: Models and values. Oxford: Oxford University Press.
Dworkin, R. (2010). Paternalism. http://plato.stanford.edu/entries/paternalism/. Accessed June 13, 2013.
Earle, S., Lloyd, C. E., Sidell, M., & Spurr, S. (Eds.). (2007). Theory and research in promoting public health. London: Sage.
Earle, S., & O’Donnell, T. (2007). The factors that influence health. In S. Earle, C. E. Lloyd, M. Sidell, & S. Spurr (Eds.), Theory and research in promoting public health (pp. 67–100). London: Sage.
Eklund, L. (1999) From citizen participation towards community empowerment. Academic Dissertation: University of Tampere, Tampere.
Fitzpatrick, M. (2001). The tyranny of health: Doctors and the regulation of lifestyle. London: Routledge.
Freire, P. (1972). Pedagogik för förtryckta [Pedagogy of the oppressed]. Stockholm: Gummessons.
French, J., Blair-Stevens, C., McVey, D., & Merritt, R. (2009). Social marketing and public health: Theory and practice. Oxford: Oxford University Press.
Fulcher, J. (2004). Capitalism: A very short introduction. Oxford: Oxford University Press.
Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: Theory, research, and practice (4th ed.). San Francisco: Jossey-Bass.
Griffin, J. (2008). On human rights. Oxford: Oxford University Press.
Guttman, N., & Salmon, C. T. (2004). Guilt, fear, stigma and knowledge gaps: Ethical issues in public health communication interventions. Bioethics, 18(6), 531–552.
Hastings, G., Stead, M., & Webb, J. (2004). Fear appeals in social marketing: Strategic and ethical reasons for concern. Psychology and Marketing., 21(11), 961–986.
Holland, S. (2007). Public health ethics. Cambridge: Polity.
Jones, M. M., & Bayer, R. (2007). Paternalism and its discontents: Motorcycle Helmet laws, libertarian values, and public health. American Journal of Public Health, 97(2), 208–217.
Karasek, R., & Theorell, T. (1990). Healthy work. London: Basic Books.
Kelly, M. (2006). Applications of models of behavior change. In M. Davies & W. Macdowall (Eds.), Health promotion theory. Maidenhead: Open University Press.
Lalond, M. (1974). A new perspective on the health of Canadians: A working document. Ottawa http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/1974-lalonde/index-eng.php. Accessed December 16, 2011.
Laverack, G. (2009). Public health, power and empowerment (2nd ed.). Basingstoke: Palgrave MacMillan.
Lukes, S. (2005). Power: A radical view (2nd revised ed.). Oxford: Oxford University Press.
Loss, J., & Nagel, E. (2010). Social marketing—Verführung zum gesundheitsbewussten Verhalten? [Social marketing—Seduction with the Aim of Healthy Behavior] Gesundheitswesen, 72, 54–62.
Maibach, E. W., & Cotton, D. (1995). Moving people to behavior change: A staged social cognitive approach to message design. In E. Maibach & R. L. Parrott (Eds.), Designing health messages: Approaches from community theory and public health practice (pp. 41–64). London: Sage.
Marmot, M., & Wilkinson, R. (1999). The social determinants of health. Oxford: Oxford University Press.
Marmot, M. (2004). The status syndrome. How your social standing directly affects your health. London: Bloomsbury Publishing.
Mayo, M., & Craig, G. (1995). Community participation and empowerment: The human face of structural adjustment or tools for democratic transformation? In G. Craig & M. Mayo (Eds.), Community empowerment: A reader in participation and development (experiences of grassroots development) (pp. 1–11). London: Zed books Ltd.
Mill, J. S. (1859). On liberty and utilitarianism (p. 1992). London: Everyman’s Library.
Morriss, P. (2002). Power: A philosophical analysis (2nd revised ed.). New York: St. Martin’s Press.
Nordenfelt, L. (1991). Towards a theory of health promotion: A logical analysis. Linköping university: Health service studies, 1100–6021, 5.
Nordenfelt, L. (1995). On the nature of health: An action-theoretic approach (2nd revised ed.). Dordrecht: Kluwer.
Nordenfelt, L. (2004). The varieties of dignity. Health Care Analysis, 12(2), 69–81.
Norman, P., Abraham, C., & Conner, M. (Eds.). (2000). Understanding and changing health behavior: From health beliefs to self-regulation. Amsterdam: Harwood Academic Publishers.
Nutbeam, D. (2006). Using theory to guide changing individual behavior. In M. Davies & W. Macdowall (Eds.), Health promotion theory. Maidenhead: Open University Press.
Nutbeam, D., Harris, E., & Wise, M. (2010). Theory in a Nutshell: A practical guide to health promotion theories (3rd ed.). North Ryde: McGraw-Hill.
Pellmer, K., & Wramner, B. (2009). Grundläggande folkhälsovetenskap [Basic public health]. Stockholm: Liber.
Perkins, D. D., & Zimmerman, M. C. (1995). Empowerment theory, research, and application. American Journal of Community Psychology, 23(5), 569–579.
Pestana, M. (1998). Moral virtue or mental health. New York: Peter Lang Press.
Powell, P., Spears, K., & Rebori, M. (2010). What is an obesogenic environment? Fact Sheet-10-11. Reno: University of Nevada Cooperative Extension.
Rawls, J. (1971). A theory of justice. Oxford: Oxford University Press.
Rogers, C. (1961). On becoming a person. Boston: Houghton Mifflin.
Rogers, C. (1977). Carl Rogers on personal power. New York: Delacorte.
Russell, B. (1986). The forms of power. In S. Lukes (Ed.), Power. Oxford: Blackwell.
Ryan, W. (1976). Blaming the victim. New York: Vintage books.
Sartre, J.-P. (1956). Being and nothingness. New York: Philosophical Library.
SBU. (1997). Att förebygga sjukdom i hjärta och kärl genom befolkningsinriktade program—en systematisk litteraturöversikt [To prevent cardiovascular disease through public programs—a systamatic literature review]. Stockholm: SBU (Statens beredning för utvärdering av medicinsk metodik [The government drafting committee for evaluations of methods in medicine]).
Shaw, A., Ritchie, D. Amos, A., Mills, L., O’Donnell, R., Semple, S., Turner, S., & Wilson, I. (2012). Smoking and stigma: A review of the literature. http://www.refreshproject.org.uk/wp-content/uploads/2012/02/REFRESH-Smoking-and-Stigma.April20124.pdf. Accessed February 21, 2013.
Starrin, B. (1997). Empowerment som tankemodell [Empowerment as a model for thought]. In E. Forsberg & B. Starrin (Eds.), Frigörande kraft – Empowerment som modell i skola, omsorg och arbetsliv. Stockholm: Gothia.
Storey, J. D., Saffitz, G. B., & Rimón, J. G. (2008). Social marketing. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (pp. 436–464). San Francisco: Jossey-Bass.
Stuber, J., Galea, S., & Link, B. G. (2009). Stigma and smoking. The consequences of our good intentions. Social Service Review, 83(4), 585–609.
Sumner, L. W. (1996). Welfare, happiness and ethics. Oxford: Clarendon press.
Swift, C., & Levin, G. (1987) Empowerment: An emerging mental health technology. Journal of Primary Prevention, 8(1&2), Fall/Winter.
Syme, S. L. (1996). To prevent disease. We need a new approach. In D. Blane, E. Brunner, & R. G. Wilkinson (Eds.), Health and social organisation. London: Routledge.
Syme, S. L. (2004). Social determinants of health: The community as an empowered partner. Preventing Chronic Disease, 1(1), 1–5.
Syme, S. L., & Ritterman, M. L. (2009). The importance of community development for health and well-Being. Community Development: Investment Review, 5(3), 1–13. Federal Reserve Bank of San Francisco. http://www.frbsf.org/publications/community/review/vol5_issue3/syme_ritterman.pdf. Accessed July 24, 2012.
Tengland, P.-A. (2006). The goals of health work: Quality of life. Health and Welfare, in Philosophy, Medicine and Health Care, 9, 155–167.
Tengland, P.-A. (2007). Empowerment: A goal or a means for health promotion? Medicine Health Care and Philosophy, 10(2), 197–207.
Tengland, P.-A. (2007). A two-dimensional theory of health. Theoretical Medicine and Bioethics, 28, 257–284.
Tengland, P.-A. (2008). Empowerment: A conceptual discussion. Health Care Analysis, 16, 77–96.
Tengland, P.-A. (2010). Health promotion and disease prevention: A real difference for public health practice? Health Care Analysis, 18(3), 203–221.
Tengland, P.-A. (2010). Health promotion and disease prevention: Logically different conceptions? Health Care Analysis, 18(4), 323–341.
Tengland, P.-A. (2012). Behavior change or empowerment: On the ethics of health-promotion strategies. Public Health Ethics, 5(2), 140–153.
Thompson, N. (2007). Power and empowerment. Lyme Regis: Russell House.
Tones, K., & Green, J. (2004). Health promotion. Planning and strategies. London: Sage.
Valdiserri, R. O. (2002). HIV/AIDS stigma: An impediment to public health. American Journal of Public Health, 92(3), 341–342.
Verweij, M., & Dawson, A. (2007). The meaning of ‘public’ in public health. In A. Dawson & M. Verweij (Eds.), Ethics, prevention and public health (pp. 13–29). Oxford: Oxford University Press.
Wallack, L., Dorfman, L., Jernigan, D. H., & Themba-Nixon, M. (1993). Media advocacy and public health: Power for prevention. London: Sage.
Wallerstein, N., & Bernstein, E. (1988). Empowerment education: Freire’s ideas adapted to health education. Health Education Quarterly, 15(4), 379–394.
Weber, M. (1978). Economy and society. Berkeley: California university press.
Weber, M. (1994). Definition of sociology. In W. Heydebrand (Ed.) Sociological writings. Continuum. http://www.marxists.org/reference/subject/philosophy/works/ge/weber.htm. Accessed July 13, 2013.
Wikler, D. (2007). Who should be blamed for being sick? In Bayer et al. (Eds.), Public health ethics. Cambridge: Cambridge University Press.
Wilson, J. (2011). Health inequities. In A. Dawson (Ed.), Public health ethics (pp. 211–230). Cambridge: Cambridge University Press.
Wrong, D. (2004). Power: Its forms, bases and uses. New Brunswick: Transaction.
Acknowledgments
I would like to thank Bengt Brülde, Martin Berzell, Luca Chiapperino, Katarina Graah-Hagelbäck, and Lennart Nordenfelt, for valuable comments on earlier versions of, or on specific aspects of, this paper.
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Tengland, PA. Behavior Change or Empowerment: On the Ethics of Health-Promotion Goals. Health Care Anal 24, 24–46 (2016). https://doi.org/10.1007/s10728-013-0265-0
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DOI: https://doi.org/10.1007/s10728-013-0265-0