Skip to main content
Download PDF

How to Think about Health Promotion Ethics

Public Health Reviews volume 34, Article number: 9 (2012) Cite this article

Abstract

Health promotion ethics is moral deliberation about health promotion and its practice. Although academics and practitioners have been writing about ethics, and especially values, in health promotion for decades, health promotion ethics is now regaining attention within the broader literature on public health ethics. Health promotion is difficult to define, and this has implications for health promotion ethics. Health promotion can be approached in two complementary ways: as a normative ideal, and as a practice. We consider the normative ideal of health promotion to be that aspect of public health practice that is particularly concerned with the equity of social arrangements: it imagines that social arrangements can be altered to make things better for everyone, whatever their health risks, and seeks to achieve this in collaboration with citizens. This raises two main ethical questions. First: what is a good society? And then: what should health promotion contribute to a good society? The practice of health promotion varies widely. Discussion of its ethical implications has addressed four main issues: the potential for health promotion to limit or increase the freedom of individuals; health promotion as a source of collective benefit; the possibility that health promotion strategies might “blame the victim” or stigmatise those who are disabled, sick or at higher risk of disease; and the importance of distributing the benefits of health promotion fairly. Different people will make different moral evaluations on each of these issues in a way that is informed by, and informs, their vision of a good society and their understanding of the ends of health promotion. We conclude that future work in health promotion ethics will require thoughtfully connecting social and political philosophy with an applied, empirically informed ethics of practice.

References

  1. Kerridge I., Lowe M., Stewart C. Ethics and Law for the Health Professions. 3rd ed. Annandale, NSW: The Federation Press; 2009.

    Google Scholar 

  2. Kass NE. An ethics framework for public health. Am J Public Health. 2001;91: 1776–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Kass NE. Public health ethics: From foundations and frameworks to justice and global public health. J Law Med Ethics. 2004;32:232–42.

    Article  PubMed  Google Scholar 

  4. Bayer R, Fairchild AL. The genesis of public health ethics. Bioethics. 2004;18: 473–92.

    Article  PubMed  Google Scholar 

  5. Callahan D, Jennings B. Ethics and public health: Forging a strong relationship. Am J Public Health. 2002;92:169–76.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Dawson A, Verweij M. Public Health Ethics (Journal). Oxford: Oxford University Press; 2009 ff.

    Google Scholar 

  7. Holland S. Public Health Ethics. Cambridge: Polity; 2007.

    Google Scholar 

  8. Dawson A, Verweij M, (editors). Ethics, Prevention, and Public Health. New York, NY: Oxford University Press Inc.; 2007.

    Google Scholar 

  9. Peckham Sa, Hann A, (editors). Public Health Ethics and Practice. Bristol: The Policy Press; 2010.

    Google Scholar 

  10. Anand S, Peter F, Sen A, (editors). Public Health, Ethics, and Equity. Oxford: Oxford University Press; 2004.

    Google Scholar 

  11. Bayer R, Gostin LO, Jennings B, Steinbock B, (editors). Public Health Ethics: Theory, Policy and Practice. New York, NY: Oxford University Press; 2007.

    Google Scholar 

  12. Gostin LO, (editor). Public Health Law & Ethics. Berkeley, CA; New York, NY: University of California Press; The Milbank Memorial Fund; 2010.

    Google Scholar 

  13. Nuffield Council on Bioethics. Public health: ethical issues. London: Nuffield Council on Bioethics; 2007.

    Google Scholar 

  14. Viehbeck S, Melnychuk R, McDougall C, Greenwood H, Edwards N. Population and public health ethics in Canada: a snapshot of current national initiatives and future issues. Can J Public Health. 2011;102:410–3.

    PubMed  Google Scholar 

  15. Faden RR, Faden AI. Preface. Health Educ Behav. 1978;6:177–9.

    Article  CAS  Google Scholar 

  16. Allegrante JP, Sloan RP. Ethical dilemmas in workplace health promotion. Prev Med. 1986;15:313–20.

    Article  CAS  PubMed  Google Scholar 

  17. Seedhouse D. Health: The Foundations for Achievement. 1st ed. Chichester: John Wiley and Sons; 1986.

    Google Scholar 

  18. Bayer R, Moreno JD. Health promotion: ethical and social dilemmas of government policy. Health Aff (Millwood). 1986;5:72–85.

    Article  CAS  Google Scholar 

  19. Doxiadis S, Blaney R, (editors). Ethical Dilemmas in Health Promotion. Chichester: John Wiley & Sons Ltd.; 1987.

    Google Scholar 

  20. Burdine JN, McLeroy KB, Gottlieb NH. Ethical dilemmas in health promotion - an introduction. Health Educ Q. 1987;14:7–9.

    Article  CAS  PubMed  Google Scholar 

  21. Legal and Ethical Work Group - Conference on Medicine in the Twenty-First Century: challenges in personal and public health promotion. Ethical guidelines for health promotion. Am J Prev Med. 1994;10 (3 Suppl):47.

    Google Scholar 

  22. Sindall C. Does health promotion need a code of ethics? Health Promot Int. 2002;17:201–3.

    Article  PubMed  Google Scholar 

  23. First International Conference on Health Promotion. Ottawa Charter for Health Promotion, WHO/HPR/HEP/95.1. Ottawa: World Health Organization; 1986.

    Google Scholar 

  24. Downie RS, Fyfe C, Tannahill A. Health promotion: models and values. 1st ed. Oxford; New York: Oxford University Press; 1990.

    Google Scholar 

  25. Ritchie J. Values in health promotion. Health Promot J Austr. 2006;17:83.

    Google Scholar 

  26. Bauman A, O’Hara L, Signal L, Smith B, Ritchie J, et al. A perspective on changes in values in the profession of health promotion. Health Promot J Austr. 2007;18:3–6.

    CAS  PubMed  Google Scholar 

  27. Allegrante JP, Barry MM, Airhihenbuwa CO, Auld ME, Collins JL, et al. Domains of core competency, standards, and quality assurance for building global capacity in health promotion: the Galway Consensus Conference statement. Health Educ Behav. 2009;36:476–82.

    Article  PubMed  Google Scholar 

  28. Mittelmark MB. Setting an ethical agenda for health promotion. Health Promot Int. 2008;23:78–85.

    Article  PubMed  Google Scholar 

  29. Cribb A. Health and the good society. Oxford: Oxford University Press; 2005.

    Book  Google Scholar 

  30. Cribb A. The borders of health promotion—A response to nordenfelt. Health Care Anal. 1993;1:131–7.

    Article  CAS  PubMed  Google Scholar 

  31. Ridde V. Reducing social inequalities in health: public health, community health or health promotion? Promot Educ. 2007;14:63–7.

    Article  PubMed  Google Scholar 

  32. Tannahill A. Health promotion: the Tannahill model revisited. Public Health. 2009;122:1387–91.

    Article  Google Scholar 

  33. Cribb A, Duncan P. Health Promotion and Professional Ethics. Hoboken, NJ: Blackwell Publishing; 2002.

    Google Scholar 

  34. Raphael D. The political economy of health promotion: part 1, national commitments to provision of the prerequisites of health. Health Promot Int. 3 November 2011; epub ahead of print. doi: 10.1093/heapro/dar084

    Google Scholar 

  35. Raphael D. The political economy of health promotion: part 2, national provision of the prerequisites of health. Health Promot Int. 3 November 2011; epub ahead of print. doi: 10.1093/heapro/dar058

    Google Scholar 

  36. International Conference on Primary Health Care. Declaration of Alma-Ata. Alma-Ata, USSR: World Health Organisation; 6–12 September 1978.

    Google Scholar 

  37. World Health Organisation. Global strategy for health for all by the year 2000. Geneva: WHO; 1981.

    Google Scholar 

  38. Yeo M. Toward an ethic of empowerment for health promotion. Health Promot Int. 1993;8:225–35.

    Article  Google Scholar 

  39. Lalonde M. A new perspective on the health of Canadians: a working document. Ottawa: Minister of Supply and Services Canada, Government of Canada; 1974.

    Google Scholar 

  40. Lin V. Health promotion in Australia: twenty years on from the Ottawa Charter. Promot Educ. 2007;14:203–8.

    Article  PubMed  Google Scholar 

  41. Porter C. Ottawa to Bangkok: changing health promotion discourse. Health Promot Int. 2006;22:72–9.

    Article  PubMed  Google Scholar 

  42. Baum F. The Commission on the Social Determinants of Health: reinventing health promotion for the twenty-first century? Crit Public Health. 2008;18: 457–66.

    Article  Google Scholar 

  43. Carter SM, Klinner C, Kerridge I, Rychetnik L, Li V, Fry D. The ethical commitments of health promotion practitioners: an empirical study from New South Wales, Australia. Public Health Ethics. 2012;5:128–39.

    Article  Google Scholar 

  44. Goldberg DS. Social justice, health inequalities and methodological individualism in US health promotion. Public Health Ethics. 2012. doi: 10.1093/phe/phs013

    Google Scholar 

  45. Jennings B. Public health and liberty: beyond the Millian paradigm. Public Health Ethics. 2009;2:123–34.

    Article  Google Scholar 

  46. Rawls J. A Theory of Justice. Boston, MA: Harvard University Press; 1999, 1971.

    Google Scholar 

  47. Buchanan DR. An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being. New York, NY: Oxford University Press; 2000.

    Google Scholar 

  48. Dawson A, Verweij M. Solidarity: a moral concept in need of clarification. Public Health Ethics. 2012;5:1–5.

    Article  Google Scholar 

  49. Prainsack B, Buyx A. Understanding solidarity (with a little help from your friends). Public Health Ethics. 2012;5:206–10.

    Article  Google Scholar 

  50. Salomon JA. Quantifying individual levels of health: definitions, concepts, and measurement issues. In: Murray CJL, Evans DB, (editors). Health Systems Performance Assessment. Geneva: World Health Organization; 2003. p.301–18.

    Google Scholar 

  51. Boorse C. A rebuttal on health. In: Humber JM, Almeder RF, (editors). What is disease? Totowa, NJ: Humana Press; 1997. p.1–134.

    Chapter  Google Scholar 

  52. Venkatapuram S. Health Justice. Cambridge: Polity; 2011.

    Google Scholar 

  53. World Health Organisation. Constitution. New York, NY: WHO; 1946 July 22nd.

    Google Scholar 

  54. Bok S. Rethinking the WHO definition of health. In: Heggenhougen K, (editor). International Encyclopedia of Public Health. Elsevier Inc; 2008. p.590–7.

    Chapter  Google Scholar 

  55. Green LW, Allegrante JP. Healthy People 1980–2020: raising the ante decennially or just the name from public health education to health promotion to social determinants? Health Educ Behav. 2011;38:558–62.

    Article  PubMed  Google Scholar 

  56. Nordenfelt L. On the Nature of Health: an Action-Theoretic Approach. 2nd ed. Dordrecht: Kluwer Academic Publishers; 1987/1995.

    Book  Google Scholar 

  57. Nussbaum MC. Sex & Social Justice. New York, NY, Oxford: Oxford University Press; 1999.

    Google Scholar 

  58. Seedhouse D. Health: The Foundations for Achievement. 2nd ed. Chichester: John Wiley and Sons; 2001.

    Google Scholar 

  59. Seedhouse D. Health Promotion: Philosophy, Prejudice and Practice. 2nd ed. West Sussex, England: John Wiley & Sons Ltd; 2004.

    Google Scholar 

  60. Powers M, Faden R. Social Justice: the Moral Foundations of Public Health and Health Policy. Oxford: Oxford University Press; 2006.

    Google Scholar 

  61. Ruger JP. Ethics of the social determinants of health. Lancet. 2004;364:1092–7.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.

    Google Scholar 

  63. Carter SM, Entwistle VA, McCaffery K, Rychetnik L. Shared health governance: the potential danger of oppressive “healthism”. Am J Bioeth. 2011;11:57–9.

    Article  PubMed  Google Scholar 

  64. Carter SM, Rychetnik L, Lloyd B, Kerridge IH, Baur L, et al. Evidence, ethics, and values: a framework for health promotion. Am J Public Health. 2011;101: 465–72.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Tannahill A. Beyond evidence-to ethics: a decision-making framework for health promotion, public health and health improvement. Health Promot Int. 2008;23:380–90.

    Article  PubMed  Google Scholar 

  66. Potvin L. Should we worry about the enthusiasm toward evidence-based health promotion practices? Promot Educ. 2006;13:228–9.

    PubMed  Google Scholar 

  67. Center for Health Leadership & Practice, Public Health Institute, Public Health Leadership Society Ethics Work Group, Public Health Leadership Society standing committee on Public Health Ethics. Principles of the Ethical Practice of Public Health. New Orleans, LA: Public Health Leadership Society; 2002.

    Google Scholar 

  68. Code of ethics for the health education profession. Coalition of National Health Education Organizations; 8 February 2011. Available from URL: http://www.cnheo.org/ethics.htm (Accessed 20 December 2012).

    Google Scholar 

  69. Views on health promotion online. Health promotion code of ethics. Saint-Denis Cedex, France: International Union for Health Promotion and Education; 2008 (updated 27 October 2008; cited 2009 October 16).

    Google Scholar 

  70. Nchogu S, Bull T. Summary report for VHPO stream of discussion on ethics. Views on health promotion online website: International Union for Health Promotion and Education; No date. Available from URL: http://vhpo.net/download/file.php?id=8&sid=c9faf04e4d0149452dcb4eee0eef95d4 (Accessed 20 December 2012).

    Google Scholar 

  71. Wikler DI. Coercive measures in health promotion: can they be justified? Health Educ Behav. 1978;6:223–41.

    Article  CAS  Google Scholar 

  72. Wikler DI. Persuasion and coercion for health: ethical issues in government efforts to change life-styles. Milbank Mem Fund Q Health Soc. 1978;56:303–38.

    Article  CAS  PubMed  Google Scholar 

  73. Faden RR, Faden AI. Ethics of health education as public health policy. Health Educ Monogr. 1978;6:180–97.

    Article  CAS  PubMed  Google Scholar 

  74. Faden RR. Ethical issues in government sponsored public-health campaigns. Health Educ Q. 1987;14:27–37.

    Article  CAS  PubMed  Google Scholar 

  75. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Cary, NC: Oxford University Press USA; 2008.

    Google Scholar 

  76. Nys T. Public health paternalism: continuing the dialogue. Public Health Ethics. 2009;2:294.

    Article  Google Scholar 

  77. Jones MM, Bayer R. Paternalism its discontents - motorcycle helmet laws, libertarian values, and public health. Am J Public Health. 2007;97:208–17.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Carter SM, Kerridge I, Sainsbury P, Letts JK. Public health ethics: informing better public health practice. N S W Public Health Bull. 2012;23:101–6.

    Article  PubMed  Google Scholar 

  79. Campbell A. Education or indoctrination: the issue of autonomy in health education. In: Doxiades SA, (editor). Ethics in Health Education. Chichester: Wiley; 1990. p.15–28.

    Google Scholar 

  80. Upshur REG. Principles for the justification of public health intervention. Can J Public Health. 2002;93:101–3.

    Google Scholar 

  81. Dworkin G. Paternalism. In: Zalta EN, (editor). The Stanford Encyclopedia of Philosophy (Summer 2010). Available from URL: http://plato.stanford.edu/ archives/sum2010/entries/paternalism/ (Accessed 20 December 2012).

  82. Thaler RH, Sunstein CR. Nudge. New York, NY: Penguin Books; 2009.

    Google Scholar 

  83. Blumenthal-Barby JS, Burroughs H. Seeking better health care outcomes: the ethics of using the “nudge”. Am J Bioethics. 2012;12:1–10.

    Article  CAS  Google Scholar 

  84. Braunack-Mayer A, Louise J. The ethics of community empowerment: tensions in health promotion theory and practice. Promot Educ. 2008;15:5–8.

    Article  PubMed  Google Scholar 

  85. Robeyns I. The Capability Approach: a theoretical survey. J Human Dev. 2005;6:93–117.

    Article  Google Scholar 

  86. Sen A, Nussbaum MC, (editors). The Quality of Life. Oxford: Clarendon Press; 1993.

    Google Scholar 

  87. Sen A. Inequality Re-examined. Boston, MA: Harvard University Press; 1992.

    Google Scholar 

  88. Golden SD, Earp JA. Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions. Health Educ Behav. 2012;39:364–72.

    Article  PubMed  Google Scholar 

  89. Widdows H, Cordell S. Why communities and their goods matter: illustrated with the example of biobanks. Public Health Ethics. 2011;4:14–25.

    Article  Google Scholar 

  90. Beauchamp DE. Community - the neglected tradition of public health. Hastings Cent Rep. 1985;15:28–36.

    Article  CAS  PubMed  Google Scholar 

  91. Azetsop J, Rennie S. Principlism, medical individualism, and health promotion in resource-poor countries: can autonomy-based bioethics promote social justice and population health? Philos Ethics Humanit Med. 2010;5:1.

    Article  PubMed  PubMed Central  Google Scholar 

  92. Allegrante JP, Green LW. When health policy becomes victim blaming. N Engl J Med. 1981;305:1528–9.

    Article  CAS  PubMed  Google Scholar 

  93. Maclean U. Health promotion - the value and virtue of health. Med Educ. 1984;18:311–3.

    Article  Google Scholar 

  94. Thompson L, Kumar A. Responses to health promotion campaigns: resistance, denial and othering. Crit Public Health. 2011;21:105–17.

    Article  Google Scholar 

  95. Guttman N, Ressler WH. On being responsible: ethical issues in appeals to personal responsibility in health campaigns. J Health Commun. 2001;6:117–36.

    Article  CAS  PubMed  Google Scholar 

  96. Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev Med. 1999;29:563–70.

    Article  CAS  PubMed  Google Scholar 

  97. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity. 2009;17:941–64.

    Article  PubMed  Google Scholar 

  98. Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367:528–9.

    Article  PubMed  Google Scholar 

  99. Cribb A. Why ethics? What kind of ethics for public health? In: Peckham S, Hann A, (editors). Public Health Ethics and Practice. Bristol: The Policy Press; 2010. p.17–32.

    Google Scholar 

  100. Rose G, Khaw K-T, Marmot M. Rose’s Strategy of Preventive Medicine - Updated Edition. Oxford: Oxford University Press; 2008.

    Book  Google Scholar 

  101. Capewell S, Graham H. Will cardiovascular disease prevention widen health inequalities? PLoS Med. 2010;7:e1000320.

    Article  Google Scholar 

  102. Buck D, Frosini F. Clustering of unhealthy behaviours over time: implications for policy and practice. London: The King’s Fund; 2012. Available from URL: http://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-time (Accessed 20 December 2012).

    Google Scholar 

  103. Hawe P, Shiell A, Riley T. Complex interventions: how “out of control” can a randomised controlled trial be? BMJ. 2004;328:1561–3.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Centre for Values, Ethics and the Law in Medicine, School of Public Health, The University of Sydney, NSW, 2006, Australia

    Stacy M. Carter BAppSci, MPH(Hons), PhD (NHMRC Career Development Fellow)

  2. Centre for Public Policy Research, King’s College, London, UK

    Alan Cribb BA, PhD (Professor of Bioethics and Education)

  3. Teachers College, Columbia University, USA

    John P. Allegrante BS, MS, PhD (Professor of Health Education and Deputy Provost, Adjunct Professor of Sociomedical Sciences in Public Health)

  4. Mailman School of Public Health, Columbia University, USA

    John P. Allegrante BS, MS, PhD (Professor of Health Education and Deputy Provost, Adjunct Professor of Sociomedical Sciences in Public Health)

Authors
  1. Stacy M. Carter BAppSci, MPH(Hons), PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alan Cribb BA, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John P. Allegrante BS, MS, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stacy M. Carter BAppSci, MPH(Hons), PhD.

Rights and permissions

Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.

The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/.

The Creative Commons Public Domain Dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Carter, S.M., Cribb, A. & Allegrante, J.P. How to Think about Health Promotion Ethics. Public Health Rev 34, 9 (2012). https://doi.org/10.1007/BF03391661

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/BF03391661

Key Words

  • Ethics
  • health education
  • health promotion
  • moral philosophy
  • political philosophy
  • public health

Public Health Reviews

ISSN: 2107-6952

Contact us