Academic journal article Public Health Reviews; Rennes

How to Think about Health Promotion Ethics

Academic journal article Public Health Reviews; Rennes

How to Think about Health Promotion Ethics

Article excerpt

HOW TO THINK ABOUT HEALTH PROMOTION ETHICS

Ethics is the discipline devoted to moral reasoning about what we should do. It is traditionally divided into: meta-ethics, concerned with fundamental questions like "what is good?" and "what are convincing ethical arguments?"; normative ethics, focused on rules, frameworks or principles for evaluation; and practical ethics, concerned with the ethics of practices such as regulating, policing, teaching or medical care.1 Health promotion ethics is a form of practical ethics.

A substantial literature in bioethics-the practical ethics of medicine and biotechnology-has existed since the 1960s.2 The public health ethics literature grew rapidly from 2000,3-13 initially focused on crises such as pandemics and bioterrorism.14 A small formal and informal literature on health promotion ethics15-22 and values23-27 has existed for some time,i but has recently regained attention within public health ethics. Our purpose is to survey key issues in health promotion ethics, and suggest approaches needed for this field to flourish.

Defining health promotion is notoriously difficult.26,29-32 In some jurisdictions health promotion is an occupational category, so health promotion could be "what those practitioners do." But many others promote health, within and beyond public health and medical systems, and health promotion ethics should arguably also be relevant to them. Complicating matters further, conditions that do promote health may not be implemented to promote health.33 Public transportation, urban design and the structure of markets can promote or undermine health without that intention; a country's political culture and system can influence the determinants of health independent of a formal "health promotion" sector.34,35 This makes a discussion of health promotion ethics slippery: should we focus only on activities defined as health promotion, or should we include all activities that promote health?33 Finally, the boundaries between health promotion and the rest of public health are unclear, so health promotion ethics and public health ethics may not be meaningfully different. There is no absolute solution to these problems: we can only suggest a working conception of health promotion. To do this, we will distinguish between health promotion as a normative ideal, and health promotion as it is practiced. These can, but do not always, overlap.

The normative ideal of health promotion arises from a 30-year-old discourse, found in the Alma-Ata Declaration, the World Health Organization (WHO) "Global Strategy for Health for All by the Year 2000," and the Ottawa Charter for Health Promotion.23,36,37 Bauman and colleagues suggest that Alma-Ata and "Health for All" created health promotion out of health education,ii promoting a then-radical account of health as more a product of social conditions than of clinical services, and emphasising equity, empowerment and justice.26,29,38,39 The Ottawa Charter powerfully asserted this account, listing "fundamental conditions and resources for health" as "peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity."23 We think this ideal form of health promotion has two main distinguishing characteristics. The first is its vision of citizens: as active participants in and potential authors of their own health, people with whom health promotion practitioners should work directly and, to some extent, be guided by when forming goals and strategies. The second is its focus on increasing the equitable availability of the conditions and resources that improve health, including through structural change and advocacy.iii,34 Although this will at times overlap with risk reduction strategies, it emphasises primary prevention: promoting health for everyone, whether they are at low or high risk of developing disease.43 On this idealised account, health promotion becomes 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. …

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