Ethical Issues and Considerations in Health and Risk Message Design
Summary and Keywords
The design and dissemination of health and risk messages invariably involves moral and ethical issues. The choice of the topics, the focus on particular recommended practices, the choice of particular groups to be the intended recipients of the messages and their inclusion in or exclusion from the message development process, all raise ethical issues. Further, the persuasive tactics used to influence people to change their attitudes and beliefs and to adopt recommended changes in their lives also raise ethical concerns. For example, persuasive tactics may infringe on people’s privacy when people view images they may find intrusive, offensive, or cause them distress. Tactics that “tug” at people’s emotions may infringe on their unhindered ability to make a conscientious decision. Employing digital media and sophisticated advertising and marketing tactics also elicits ethical challenges both related to their manipulative potential and their differential reach: all of which may contribute to social and health disparities. In addition, the practices recommended in health and risk messages may conflict with values people cherish. For example, people could be urged to change the way they communicate with their spouses on intimate issues, relinquish the consumption of favorite traditional foods—or messages may raise issues that recipients find taboo according to their culture or religious beliefs. Health and risk messages may have unforeseen and unintended adverse effects that could affect people’s emotional and physical aspects by inadvertently contributing to people’s sense of guilt through shaming or stigmatization. Also, on the cultural and social level, such messages may contribute to an idealization of a certain lifestyle or commercialization of products and celebrities associated with the messages.
Philosophical and ethical frameworks typically used in communication ethics, bioethics, communication campaigns, and social marketing literature emphasize the central guiding principles of personal autonomy and privacy with the aim to ensure equity and fairness. The obligation to avoid “doing harm” includes concerns regarding labeling, stigmatizing, and depriving; the obligation to help; the obligation to respect people’s autonomy to make free choices, particularly concerns regarding persuasion tactics and manipulations and the use of threat tactics, provocative appeals, distressing images, framing tactics, cultural sensitivity, and moral relativism; the obligation to obtain consent; the obligation to truthfulness; the obligation to sincerity; the obligation to correctness, certitude, and reliability; the issue of personal responsibility; equity obligations including concerns regarding segmentation and “targeting”; the obligation to comprehensibility; the obligation of inclusion; utility and efficiency considerations; the “harm reduction” approach; and concerns regarding social value priorities and “distortions,” which includes prosocial values as moral appeals.
The Challenge in Identifying Ethical Issues
Since health and risk messages inherently aim to influence issues associated with people’s lifestyles, relationships, and personal preferences, their design involves moral and ethical issues. Health and risk messages deal with diverse issues such as food consumption habits, drinking alcohol, taking medication, driving, breastfeeding, early detection of diseases, and sexual practices. Practices associated with these issues involve deeply held social, cultural, and personal values and are influenced by cultural conceptions of what is right or wrong (Carter et al., 2011). As such, they raise moral judgments on whether certain health-related practices are considered “good” or “bad.” Health and risk messages also aim to influence social norms and practices (at the community, organizational, or national level), as well as public policy. Despite the significant role of ethical and moral issues in the development of health and risk messages, practitioners or organizations involved in their development may not be cognizant of the moral issues associated with them.
A major challenge in identifying ethical issues in health and risk messages is that this type of communication is lauded as serving a benevolent or a noble cause (Rogers, 1994). Consequently, it may be taken for granted that its objectives and means to achieve them are not morally problematic and that it is not required to be concerned with ethical issues. This could explain why it is rare to find reports regarding the development and testing of health promotion and risk messages that discuss ethical concerns. Studies typically focus on effectiveness in terms of how appeals used in messages affect people’s attitudes, intentions, or behaviors, or how to make messages as persuasive as possible. Further, ethical issues associated with health and risk messages may be implicit and health and risk communicators or researchers may not be trained in identifying them. This is illustrated in the findings of a study of practitioners who developed antismoking messages. The researchers found that most interviewees did not use or were not supportive of codes of ethics for the design and execution of antismoking ads. Instead, they mainly relied on what the researchers identified as a teleological or a utilitarian perspective that justified employing tactics such as exaggeration, omission, fear, and other emotional appeals (Cheng & Lee, 2012). Even when ethical concerns are identified, practitioners may not know how to analyze and address the ethical dilemmas that emerge. Some may argue that they cannot create effective messages if they have to adhere to various moral principles. Indeed, some may believe that identifying ethical issues in health and risk message design will result in investing more time and effort and in choosing a less persuasive approach. However, according to the literature in ethics in social marketing, these arguments can be countered by both moral and practical suppositions (Smith, 2001; Donovan & Henley, 2010). A moral argument is directed toward achieving a moral goal, and one needs to employ moral means and by implication a high ethical standard in communication interventions aiming to promote individual and societal well-being (Eagle et al., 2009; Holden & Cox, 2013; Kirby & Andreasen, 2001). A practical argument is that messages viewed as morally appropriate are more likely to have a long-term impact and less likely to be rejected by the people whose welfare they are supposed to promote. Specifically, messages scrutinized by an ethical analysis are less likely to be offensive and more likely to resonate with people’s values (ten Have et al., 2011).
Additional challenges relate to the fact that risk and health communication messages are disseminated in multicultural societies and communities. Thus, their development needs to take into consideration not only cultural differences in terms of preferences and customs but also differences in terms of deeply held value-laden traditions. Members of different cultural or religious groups may hold different conceptions of health, risk, gender roles, parenting responsibilities, and community obligations. They may find certain health recommendations offensive or even counter to their norms and beliefs. The conception of risk is also related to culture and raises ethical concerns. Risk is taken for granted in most societies as a given, but as scholars point out, moral judgments about risk are socially constructed. The essence of risk communication, by definition, is to warn people of particular risks and to recommend practices that can help avoid or mitigate these risks. Yet, conceptions of risk are value-laden and largely determined by the cultural, social, and political context. Anthropologists and sociologists (e.g., Douglas, 1994; Lupton, 2013) explain that individuals’ and societies’ definitions of risk and their moral judgements about what should be considered socially approved or socially disapproved risk taking depends on the social norms and cultural beliefs. Social norms and beliefs influence what individuals or groups consider as an acceptable risk, and in what circumstance and for whom (e.g., firefighters, professional or “extreme” sports, “at risk” pregnancies), and which risk-taking activities should be discouraged, reproved, or even punished (e.g., driving after consuming alcohol). Therefore, putting an emphasis on certain risks and not on others—or considering certain groups as “being at risk” and blaming people for taking certain risks—raise ethical concerns associated with ethical principles of autonomy, equity, and fairness.
Ethical issues in health and message design emerge when employing digital media as well as various persuasive tactics used in advertising and marketing. Such use presents a host of ethical challenges associated with sophisticated means to attract people’s attention and influence their choices, including children and youth. These include tactics that involve people as disseminators and as creators of messages, which raises ethical concerns such as when people may be encouraged to disclose personal stories that may reach unintended audiences or that people may regret. The section that follows presents broad ethical theoretical frameworks. Then there is a series of ethical obligations and issues presented that have particular relevance in articulating and identifying ethical concerns associated with health and risk message design.
The literature on ethics in health and risk message design and health communication campaigns draws on philosophical ethical frameworks in communication as well as on the field of bioethics—and more recently on the literature on ethics in marketing and advertising. Some of these ethical theories or frameworks are based on theological canon or are attributed to ancient Western philosophers, which serve as the basis to articulate guiding rules and ethical principles that define moral duties and obligations and criteria for judging the moral worth of people’s actions (or inaction). Scholars explain that these principles may be limited in serving as practical guides: first, because they may be subject to alternative interpretations, and second, because often adopting a certain approach in order to adhere to one principle conflicts with upholding another, thus creating an ethical dilemma. Those focusing on persuasive messages in the health context also draw on ethical principles from the bioethics literature. These frameworks typically emphasize central guiding principles to respect people’s autonomy and privacy and to aim to ensure equity and fairness. These principles are also referred to in the communication ethics literature (e.g., Bouman & Brown, 2010; Johannesen, 1996) and in the literature on ethics in advertising (e.g., Lee & Cheng, 2010) and ethics social marketing (e.g., Andreasen, 2001).
The precepts and principles cited in various codes of ethics mainly draw on philosophical approaches. One major philosophical approach that emphasizes the requirement to respecting people’s autonomy is referred to as the deontological approach (the Greek word deon means duty) mainly associated with the moral philosophy of the 18th-century German philosopher Immanuel Kant, who emphasized moral obligations as “categorical imperatives.” According to this approach the ethicality of people’s actions is intrinsic (rather than outcomes), and people should not be treated as a means to an end, regardless of the importance of the end. This provides the justification to uphold the principle of respect for autonomy and not interfering with the ability of people to make an unhindered choice. In contrast, some emphasize a utilitarian perspective guided by the principle of maximizing the greatest benefit to the largest number of people, especially when resources are limited. This broadly corresponds to the philosophical teleological (the Greek word telos means “end” or “purpose”) perspective that focuses on consequences as the main criteria for determining moral worth. It should be noted that some refer to teleological and utilitarianism—often associated with the philosopher John Stuart Mill and broadly defined as doing the greatest good for the greatest number—as separate approaches. Some make distinctions within utilitarianism, such as act or rule utilitarianism, and these approaches differ in their consideration of types of consequences. Thus they do not merely adopt a simple rule of “the end justifies the means.”
The utilitarian perspective may also emphasize efficiency and effectiveness according to the principle of maximizing the greatest good to the greatest number of people within society’s limited resources.
The adoption of particular goals and strategies, whether intentional or not, reflects the adoption of a particular moral approach. For example, the choice to present certain statistics on risk in a manner that may be misleading (but likely to capture the attention of large populations) reflects a teleological moral approach; whereas, choosing not to proceed with a potentially effective strategy because some people may be offended reflects a moral commitment to the precept of not compromising individual dignity.
Ethical Obligations and Precepts
Since ancient times, philosophers have been concerned with ethics in communication (Johannesen et al., 2008), and a central precept is reflected in what has been referred to as the “golden rule.” This rule can be found across religions and faiths and requires individuals to treat others as one would expect to be treated. Mutual sincerity and veracity is the bottom line here. There are also national and international documents that define basic human rights. Social marketing scholars have proposed that the United Nations Universal Declaration of Human Rights can provide the basis to help define the social good that pro-health interventions aim to promote (Donovan & Henley, 2010; Gordon, Russell-Bennett, & Lefebre, 2016). These rights concern freedom of choice, nondiscrimination, privacy, democratic processes, access to adequate health, living, and educational services. In the communication ethics literature scholars offer standards that specifically refer to ethical communication. These standards represent a basic assumption that one should uphold ethical behavior toward others that reflect ethical principles such as respect for people’s autonomy dignity and privacy as well as considerations of equity. There are numerous versions of ethical standards in communication, and they are applied in various communication contexts, including journalism and interpersonal communication. Some of these standards refer specifically to persuasive messages and thus could be used as guidelines in the development of health and risk message design.
Stipulations that have particular relevance to health and risk message design, drawing on their articulation in Johannesen (1996) are: the obligation for truthfulness, correctness, certitude and reliability, sincerity, comprehensibility, and inclusion (further elaborated in the sections that follow). The American Marketing Association presents a statement of ethics (American Marketing Association, 2016) with similar precepts, but its first precept is similar to the precept stated in a prominent framework in bioethics literature developed by Beauchamp and Childress (1994): accordingly, marketers must do no harm. Other precepts in the American Marketing Association refer to the obligation of marketers to foster trust and not to mislead but to embrace ethical values that include honesty, responsibility, fairness, respect, openness, and citizenship. In the advertising literature a framework called TARES based on five guiding principles: truthfulness of the message, authenticity of the persuader, respect for the people whom one intends to persuade, equity of the persuasive appeal, and social responsibility for the common good (Baker & Martinson, 2001). This framework has been applied by communication scholars also to analyze the ethicality of antismoking messages and people’s responses to these messages (Lee & Cheng, 2010).
Another perspective that is influential in communication scholarship that also refers to standards has been defined as the ideal speech situation by the German philosopher and sociologist Jürgen Habermas, whose work concerns communicative processes and democracy (Habermas, 1987). It outlines several prerequisites that can serve as conditions to create a noncoercive communicative situation in which people can attempt to convince each other in an ethical manner. These standards call for truth, correctness, sincerity, and comprehensibility. The assumption is that if they are not fulfilled, the communicative process is likely to produce distortions that contribute to misconceptions regarding what is true and legitimate, who has the authority or expertise, what are the causes and solutions for certain health-related problems and can adversely affect how people view themselves and others. This framework underscores the issue of power, because distortions can privilege certain ideologies, conceptions of what should be on the agenda, or power relations. It points to the potential impact of health and risk messages on the cultural and social level.
The literature on ethics in the health and risk message design context draws on a dominant ethical framework from bioethics, in particular the framework originally presented in the 1990s by Beauchamp and Childress (1994) that emphasizes the principles of doing no harm, doing good, autonomy and justice, also influenced by the philosophical frameworks noted above. Childress and colleagues (Childress et al., 2002) add to these moral obligations the obligations of least infringement on people’s rights, keeping promises, disclosing information and speaking truthfully, and building and maintaining trust. Smith (Smith, 2001), in the context of social marketing, presents several questions that draw on moral principles that social marketers should ask when developing programs and messages. These include and are paraphrased as: are we being entirely truthful, or do we employ some exaggerations or inaccuracy or omission? Are we invading the privacy of people or groups? Are we revealing private information about people? Are we inadvertently modeling antisocial or undesirable behaviors? Are we demonstrating or encouraging behaviors that society finds offensive? Are we being fair to all groups? Are we inadvertently perpetuating inappropriate or harmful stereotypes? Are we protecting children for possible negative impact of our messages? For the purpose of this article fourteen central obligations and considerations that are particularly relevant to ethical concerns in the design and dissemination of health and risk messages that draw on the bioethics and communication ethics literature are presented below and summarized in Table 1.
The Obligation to Avoid “Doing Harm”
According to the Beauchamp and Childress (1994) framework, a major obligation in the health context is to avoid doing harm (nonmaleficence). This obligation has been proclaimed as a major ethical maxim for health-care practitioners since ancient times and attributed to Hippocrates, and the notion of “harm” has been extended from the situation of providing medical treatment to patients to causing harm to individuals or groups—whether, physical, social, and psychological—as a result of communication to promote health or risk messages. The literature points to several types of inadvertent “harm” that may affect the individual group of sociocultural level. These are described as labeling, self-blame, helplessness, stigmatization, and depriving from gratifications in the sections that follow. Ethical issues in the use of threats and graphic and distressing images are discussed as they relate to the obligation to autonomy but also include concerns about potential harm.
Concerns Regarding Labeling and Stigmatizing
On the personal level, health and risk messages may label people as part of a group that “has a problem” and may cause people in this group to feel inadequate if they are not able to adopt recommended practices. One criticism refers specifically to labeling. The argument supported by empirical studies is that health and risk messages that “label” people as being in a “risk group” can result in people finding themselves in a continuous state of anxiety when viewing themselves as being “at risk.” This has been characterized as the phenomenon of the “worried well” (Barsky, 1988). Perhaps stronger criticisms are raised regarding stigmatization. For example, critics note that communication campaigns regarding obesity may have a negative effect on people’s self-image and identity by exacerbating the feelings of self-blame, helplessness, and low self-image of those unable to lose weight and in extreme cases may even contribute to anorexia (Carter et al., 2011). This can be explained by the way messages position fat bodies as ugly and diseased for the purpose of evoking feelings of disgust, shame, guilt, and fear (Lupton, 2013). A related negative effect is stigmatization that can occur on the personal and group level because people may attach moral assessments and social stereotypes to people with particular illnesses (Douglas, 1994; Sontag, 1989) or who engage in practices considered risky and socially or morally unacceptable. This has been found even in campaign messages that depict a youth in a wheelchair as a result of a car crash attributed to driving after drinking alcoholic beverages (Guttman, 2014; Janger, 2012; Wang, 1998). An example of the internalizing stigmatization is presented in a study of men who are smokers and new fathers who feel negatively viewed by society (Greaves et al., 2010).
Some campaigns intentionally aim to stigmatize (or as some refer to it, aim to “de-normalize”) those engaging in the unhealthy or risky practice. This can be found in campaigns that employ derogatory depictions of smokers, reckless drivers, or drivers who drive after consuming alcohol. Some proponents argue this approach is justified because they believe it is potentially effective and a dispute about this was published in a 2013 Hastings Center Report issue (Bayer & Fairchild, 2016). Bayer (2008) cites arguments in favor of employing stigma as an effective and morally justified approach when conceiving smoking as “deviant behavior” or eliciting disgust and shaming regarding drunk driving or hate crimes. Other scholars also argue that from a utilitarian perspective this approach is ineffective and may serve to distance those whose behavior is criticized (Bayer & Fairchild, 2016; Burris, 2008; Thompson & Kumar, 2011). It also is conceived as ineffective from the behavior-change goal because it does not address the social conditions that contribute to the health/risk problem (e.g., in the context of obesity Goldberg & Puhl, 2013). The potential negative impact of stigmatization calls for serious scrutiny of the possibility of stigmatization occurring in health and risk message design. Empirical studies found that people do not favor stigmatizing messages in campaigns that aim to motivate people to adopt health-promoting practices. A study of public perceptions of obesity-related public health media campaigns from the United States, the United Kingdom, and Australia found that messages that were publicly criticized for their stigmatizing content also received the most negative ratings and lowest intentions to adopt their recommendations by the study participants (Puhl, Peterson, & Luedicke, 2013).
Concerns Regarding Depriving
A common recommendation in health and risk messages is to avoid the consumption of foods with low nutritional value that can contribute to illness or to relinquish practices that are highly pleasurable or have a strong cultural significance. Critics propose that such campaigns can have an inadvertent negative impact particularly on members of disadvantaged groups because these practices provide them with emotional satisfaction, social cohesion, or serve as a means for stress-coping. Often these practices are part of their daily routine and social relations, and people with limited economic means cannot easily find ways to replace them (Hove, 2014; MacAskill, et al., 2002). This poses a moral challenge in the design of health and risk messages: how to provide alternatives to the practices that people are asked to give up.
The Obligation to Help
Another central obligation in the Beauchamp and Childress (1994) framework refers to the obligation of the practitioners to do good (beneficence) and is considered a basic tenet of the helping professions. This obligation refers to the mandate to act in order to help people to pursue better health and avoid risk. The requirement to adhere to this obligation raises the dilemma what to do in situations when the helping process inevitably involves doing some harm. In medical care a common dilemma arises when the treatment can also cause physiological harmful “side effects.” In the health and risk message design context certain messages regarding illness or injury may cause people to feel anxiety or shame. Scholars explain that this potential contradiction between the different obligations calls for weighing and balancing benefits against harms. One example of having to weigh and balance benefits against harms is the challenge faced by communicators working with health-promotion organizations who feel they are obligated to reach populations who do not want to hear about particular risks to themselves to their community members. Thus, in order to overcome resistance from members of the intended population they may choose to employ provocative tactics, entertainment formats, or celebrities. Each of these tactics raises ethical concerns such as whether these tactics infringe on their privacy or autonomy as discussed in the next section.
The Obligation to Respect People’s Autonomy to Make Free Choices
Another major principle in the Beauchamp and Childress (1994) framework is the obligation to respect people’s autonomy, privacy, and dignity. Turoldo (2009) explains that the emphasis on respect for autonomy counterbalances the emphasis in ancient medical ethics that was mainly based on the principle of beneficence and a tendency to paternalism, according to which the physicians know what is best for the patients. The challenge to the authority of medicine became prominent in the 1960s and 1970s, reflected in the emphasis on the principle of personal autonomy in the bioethics literature. It could also be seen as associated with the emphasis on a market economy and consumer choice. The principle of autonomy is rooted in liberal Western tradition that places high importance on individual choice regarding political life and personal development. It is based on the premise that every person who is competent has the inherent right to make decisions for themselves on all matters that affect them when such decisions do not bring harm to another party. This right is also extended to communities and societies and serves as the basis of democratic systems and as the basis for charters of patients’ rights, the obligation to obtain informed consent, and the obligation to strictly adhere to confidentiality rules in medical care. Health and risk communicators are by implication obligated to honor the right of individuals as well as families and communities to make their free choice regarding their lifestyle, privacy, and dignity (Hiller, 1987). This respect for autonomy is also relevant to considerations of entitlement: who defines what should be the health goals, what is the “social good,” and who defines desirable behaviors (Eagle et al., 2009).
Concerns Regarding Persuasion Tactics and Manipulations
Using persuasive communication tactics that are considered manipulative clearly violates the principle of respect for autonomy because they serve to bypass people’s capacity to reason effectively, thus infringing on their autonomy (Rossi & Yudell, 2012). Some communicators may suppose that employing manipulative tactics is justified because the sponsors of the messages know what is good for their intended recipients. This approach could be characterized as paternalistic. According to O’Keefe (2007) paternalism is inherent in persuasion because those who advocate the practice think they know what other people “should believe, decide and do” (p. 161). However, it could be argued that communication ethics standards as well as the “ideal speech” conditions (described above) present guidelines to help avoid paternalism and manipulation.
Faden (1987) distinguished between persuasion and manipulation according to whether it is a deliberate attempt to influence according to reason (persuasion) or taking advantage of appeals that elicit emotional states of mind that can compromise people’s capacities to critically process the information. The latter would be considered a manipulation that infringes on people’s right to autonomy. In contrast, Bayer and Fairchild (2016) maintain that even in such situations the ethicality of using such appeals would depend on the context. Thus, there is a contention among scholars regarding what would be considered manipulative (e.g., does the tactic reduce people’s ability to make cognizant decisions), as well as a contention regarding the ethicality of using communicative tactics considered manipulative in order to promote people’s health (are the means justified by the ends?). In the communication ethics literature scholars propose that manipulation on the whole is not justified and that nonmanipulative argumentative strategies could be employed (Johannesen, 1996).
In a book on social marketing Donovan and Henley (Donovan & Henley, 2010) explain that health promoters justify using marketing tactics that may be viewed as “strong” by arguing that many of the behaviors they aim to influence are not entirely voluntary because they are influenced by external powerful forces such as commercial marketing. Thus social marketing efforts are intended to “level the playing field” (p. 207) and by doing so help restore personal autonomy. Along the same argument but from a different perspective, Bayer and Fairchild (2016) raise the question whether manipulation is always morally problematic. They note that these questions were raised two decades earlier by bioethics scholars who struggled with moral dilemmas associated with health communication campaigns. They present Dworkin’s assertion that the dissemination of health information by authorities should be “graspable” in “an emotionally genuine manner” and by implication that it could be assumed that using emotional appeals is morally justified. They also propose that ethical concerns arise not only as they relate to how to make risk information cognitively accessible but also what to do when it is known that people may resist or deny it. Therefore they ask whether employing emotional appeals to help people overcome their resistance indeed denies them personal control or in fact serves to enhance their autonomy (to choose what is best for them). Similarly Rossi and Yudell (Rossi & Yudell, 2012) raise the question whether emotional appeals that aim to “help a person to imagine what a particular condition is like in a more vivid way than words alone can” (p. 22)—for example, showing a graphic picture of cancerous lungs—are manipulative. They propose that this could correspond to what philosophers refer favorably as “imaginative acquaintance” to help determine what we ought to value. However, it could be argued that there are alternative illustrative means to present risk, including using simulations and metaphors, and that the use of distressing graphic vividness may be gratuitous (Guttman, 2014; Hastings et al., 2004). Ethical concerns regarding employing what are referred to as “fear” of “threat” appeals are further discussed in the next section.
The Use of Threat Tactics and Distressing Images
Communicators in the health and risk context have frequently been found to deliberately employ tactics that will evoke strong negative emotional responses such as anxiety, fear, distress, disgust, guilt, and shame by using graphic, violent, or “visceral” types of appeals. They justify this choice mainly with the argument that eliciting strong emotions is an effective way to influence members of the intended population to adopt the health/risk recommendations (Crawshaw, 2012; Gagnon, Jacob & Holmes, 2010), especially with younger populations (Donovan et al., 2009). Further, members of the population themselves, particularly youth, often suggest employing such tactics (“Scare us!”). Whereas the use of such tactics often succeeds in gaining attention and memorability, there are conflicting conclusions regarding their effectiveness in terms of influencing members of the intended population to actually adopt the recommended practices. Several reviews of “fear appeal” research conclude that the empirical evidence does not support claims of their effectiveness and that although they attract people’s attention, people attend to them defensively (Ruiter et al., 2014). Other scholars argue that their use is effective if it adheres to conceptual frameworks that include elements of coping with the threat. However, aside from the strong disagreements about the effectiveness or the utility of these tactics, there are also disagreements regarding what is considered as effectiveness, and also there appears to be confusion regarding what “fear appeals” actually are. Thus, some refer only to “strong” appeals, whereas others may include messages on risk and threats that may not raise emotional responses but rather may elicit cognitions. Therefore, justifications based on utility arguments may need to be more exact regarding the type of appeal they intend to employ, the effectiveness they propose to achieve, and why they could not use less distressing alternatives. Critics report from personal experience as practitioners that the use of “strong” appeals could be also a result of organizational and political factors, when the sponsors want to show the public that they use a “strong” approach as a demonstration that they are doing something “powerful” to address the problem (e.g., in road safety; see Guttman, 2014).
From an ethics perspective, employing strong emotional appeals that may distress people raises several types of issues. Bayer and Fairchild (2016) present a series of questions that present some of the major dilemmas regarding the use of these tactics, adapted for the purpose of the design of health and risk messages: Do these tactics work? If they do work, what is the “ethical” normative price they exact regarding public policy? Does their use tread on autonomy, thus threatening the capacity to choose, or do they enhance the ability to choose in the face of barriers people face in adopting health practices? What is their impact on dignity? Do they impose unfair burdens on the intended recipients—in particular disadvantaged populations—or do they represent the value of protecting by forcefully warning those who are particularly vulnerable? Some of the main objections to the use of “fear” or threat tactics can help formulate these kinds of questions. These include arguments regarding strong emotional appeals that raise concern that they may deny people from engaging in autonomous decision making. Another type of ethical concern refers to the harmful effects on people exposed to these tactics such as anxiety and distress triggered by the images that may be even unrelated to the actual message. In addition, there are ethical concerns regarding equity, for example, where tactics may generate among vulnerable populations a sense of ineptness or even of fatalism (Hastings, Stead & Webb, 2004). One example of the effect of helplessness are findings from a study on climate change, in which participants reported that the most distressing images made them feel incapable of doing anything about climate change and made them feel disempowered and helpless at a personal level (O’Neill & Nicholson-Cole, 2009).
The use of provocative or “shocking” visual images (e.g., violent or disgusting images, self-mutilation) or of offensive words or expressions is also a tactic that aims to elicit strong emotional reactions but is distinguished from the more “general” tactic of eliciting strong emotional appeals by aiming to “shock.” This tactic is justified by proponents as a means to gain the attention of individuals and the media in a “cluttered” and “saturated” media environment (Donovan et al., 2009; Huhmann & Mott-Stenerson, 2008; Vezina & Paul, 1997). As in the case of the use of threatening graphic images, researchers note that this tactic may have the impact of being memorable but may not achieve long-term behavior change goals (Brown, Bhadury & Pope, 2010). Ethical concerns are inherent in the use of provocative messages, because by definition provocation is based on presenting images or words that aim to shock or even outrage people by challenges to social norms and taboos or their moral sense. Provocative messages may include graphic images of violence or things that are considered disgusting. They may use language considered obscene, vulgar or offensive, or things considered to be morally offensive, such as the exploitation of children or harming animals and depicting death or illness in a non-respectful way (Dahl, Frankenberger, & Manchanda, 2003). There are numerous examples of how provocative ads aimed to “scare” people to adopt healthier practices were found as harmful by those it portrayed negatively. For example, a US HIV prevention campaign was criticized for showing images of men wearing diapers. Its purpose was to encourage gay men “to stay [HIV] negative” by showing graphic and evocative photographs of physical ailment associated with HIV or the medications (Lefebvre, 2006). However, it also raised criticisms that it essentially serves to reinforce the stigma of people living with AIDS (Richey, 2013). Another critique of provocative ads is that the strong emotional impression they create could overshadow other types of discourse and social values. Further, studies find that the responses of people from vulnerable populations to public health campaigns using negative emotional appeals were anger, retreat, guilt, passive helplessness and despondency, rather than empowered decisions to act (Lupton, 2015).
Scholars point out that various other persuasive tactics also raise ethical concerns regarding manipulation. For example, Rossi and Yudell (Rossi & Yudell, 2012) contend that critics may worry that priming could be manipulative, but they propose that priming can be considered as ethical when it functions to make something more cognitively available to the message recipients as a resource to help them deliberate the health/risk issue. Even in the choice of “framing” a persuasive appeal there are inherent ethical issues. For example, as O’Keefe (2007) notes, the decision whether to use persuasive appeals that are either “gain-framed” (emphasis on advantages) or “loss framed” (emphasis on disadvantages) can have ethical implications as well, in additional to considerations of their effectiveness as persuasive appeals. O’Keefe explains that since each type of framing may influence people in a way they are unaware of, their choices may not be the same if the issue had been framed in another way. O’Keefe also notes that there are presentation devices that could (potentially) exploit human psychological weaknesses. For example, presenting 90% survival is perceived differently than “10% mortality.” O’Keefe concludes that such findings “point to a potential conflict between the practical interest of the advocate (who wants to persuade) and what we may think of as normatively-appropriate argumentative conduct” (p. 158).
Criticisms of the Emphasis on Autonomy
The emphasis in ethical frameworks on autonomy as a central and guiding moral precept has been criticized both in terms of its moral basis and practicality. One of the main criticisms is that it is removed from cultural and social contexts and does not reflect diversity in moral reasoning (e.g., Blackhall et al., 1995; Carrese & Rhodes, 1995). Critics explain that an emphasis on autonomy represents a Western conception of moral issues and mainly draws on assumptions of individualism and universalism but does not represent alternative conceptions of morality found in other cultures (Makau & Arnett, 1997; O’Brien-Hallstein, 1999). For example, scholars advocating adopting an African philosophy argue that there is too much emphasis on autonomous decision making and that the principle of respect for autonomy, which is highly emphasized in Western ethical frameworks, is too individualistic. They explain that in the African philosophy of Ubuntu a person obtains personhood through other persons, people are interdependent, and the individual’s well-being is tied up with that of others (e.g., their family and community). Thus, there is a strong emphasis on harmonious relationships and not necessarily on justice. This ethical approach according to its advocates offers a richer, broader, and more inclusive conception of justice and communitarianism (Biller-Andorno, 2011; Metz, 2010). These conceptions are similar to discussions on diversity in ethics of different cultures and religions (Cortese, 1990) and the emphasis on community or relationships is also found in communitarian (e.g., Bouman, & Brown, 2010) and feminist scholarship (Tong, 1998). A related criticism is that viewing persuasion and manipulation as tactics that do not respect people’s autonomy presents a narrow conception of autonomy because they may be part of social context of people’s social relations (Bouman, & Brown, 2010; Owens & Cribb, 2013). Similarly, in the medical context, critics argue that the preoccupation with individual autonomy, which may mandate practitioners to provide detailed information about one’s condition and prognosis is based on a cultural bias on the part of the Western medical and bioethics communities and may contradict the values and ethics of patients and their families. Thus, the argument is that the precept of respect for autonomy should be considered in light of people’s values, and these may emphasize family relations, loyalty, compassion, and solidarity (Blackhall et al., 1995). Another critique is that public health interventions often restrict autonomy through regulation and mandatory behaviors (Turoldo, 2009). By implication, it could be argued that communication or messages employed to support these mandated behaviors (e.g., sanitary measures, immunizations, or safety regulations) also serve to restrict people’s autonomy.
Cultural Sensitivity and Moral Relativism
An important debate on moral relativism has implications to the health and risk message design context. The issue of moral relativism raises the question whether there are certain moral principles that are considered to be universal or whether, regardless of one’s moral conviction, one must respect certain cultural values that conflict with one’s own moral principles but are highly valued by other cultures (Macklin, 1999). Such values may include personal autonomy, privacy, and gender equity. In general, drawing on the precept of autonomy, as well as on the moral and practical precepts to be “culturally sensitive,” the obligation in health and risk message design is to adhere to the cultural values and preferences of the people for whom the communication program or messages are intended. The assumption is that it is important to avoid contradicting their values and beliefs. However, there are circumstances that create a conflict between this obligation and the obligations inherent in one’s own values and moral principles that the organization sponsoring the intervention believes override those values of the population. In some cases this may be when the issues raised are associated with topics considered to be offensive or taboo (i.e., regarding contraceptives to prevent the spread of sexually transmitted diseases), and this requires finding ways to present the information that will be culturally sensitive as well as effective. For example, a study in China found that women preferred implicit messages regarding sexually transmitted diseases that would also be more sensitive to their cultural values of gentleness, supportiveness, and dependence, as well as keeping harmony in the family (Waller & Fam, 2011).
The Obligation to Obtain Consent
The principle of respect for autonomy serves as the basis for the requirement in health-care systems to inform people about possible adverse side effects of a medical treatment and to obtain their consent before perform it. In many countries it is required legally and can be found in patient rights documents. Obtaining consent in the context of health and risk message design presents several challenges and dilemmas. One must know whether it is possible to obtain consent from those for whom the messages are intended; if not, what are the alternatives when the intended populations are not individually known or addressed by the communication programs or its messages? Clearly, the regulations and procedures typically employed in obtaining consent on the individual level would be difficult to apply in a community or nationwide communication program, which often use mass media or digital channels to disseminate them. In community settings the message development can be scrutinized by members of the community to identify any possible ethical concerns, and the messages could be viewed according to community standards and mores. But this solution is also limited because it cannot elicit the diverse views within the community. Further, there would be dilemmas as to how to deal with disagreement or objections of community members to messages that may be important from a public health perspective. Thus, an important challenge is to devise ways to involve representatives from the intended population that can advise on ethical issues that arise, both in community level contexts as well as when people are reached though mass media of digital channels. Such participatory processes can benefit from the diverse methods available (e.g., Abelson et al., 2003).
Obligation to Truthfulness
A major standard in ethical communication is truthfulness. The ethicality of misrepresenting the truth, even for a good cause, is highly contested, and people are often extremely upset when they find out they have not been told the truth. Not being told the truth is associated with lack of respect for one’s autonomy. But as noted in the discussion on disagreements regarding the emphasis on autonomy, some may justify not adhering to the precept of truthfulness when it is important to help people and it is believed that truthfulness may hinder it. This may be particularly relevant in certain cultures or communities that feel it is sometimes necessary to protect people by not telling them the truth (Cortese, 1990). Another contentious issue concerns exaggerations. Some scholars maintain that an exaggeration may be ethically justified because it is needed to make a point and reach the intended populations (Brown & Whiting, 2014; Lee & Cheng, 2010). However, exaggeration not only raises ethical concerns because of the inherent untruthfulness involved (this violates the precept of being truthful), but it may also risk being ineffective because people learn the actual facts and eventually may not believe exaggerated health claims. An example of people’s objections to exaggerations is reported by Messaris (2012), who described findings from an analysis of comments on public-health videos posted on YouTube. It found that a frequent topic of these comments refers to the untruthfulness of the images and the implied exaggerated claims contained in these videos. He referred to Australian and Singaporean antismoking videos on oral cancer that depicted a woman whose lips have been deformed by cancer. Much of the discussion was on the visual manipulation in the video. A related study that examined viewers’ responses to comments on such videos found that negative comments, such as those regarding the exaggeration in the video, decreased viewers’ perceived effectiveness (Shi, Messaris & Cappella, 2014). Bayer and Fairchild (2016) provide an example from an obesity prevention campaign when the health department staff became concerned about using the message that sugary sodas “make you 10 pounds fatter a year,” which was misleading because other factors contribute to becoming fat. The wording was changed by inserting “can” but nonetheless the nutrition experts who were consulted were not satisfied with the truthfulness of the claim.
The Obligation to Sincerity
Health and risk messages are disseminated from diverse sources, including public authorities, health-care organizations, advocacy organizations and commercial bodies, including pharmaceutical companies and food product manufacturers. Each of these sources has its own interests, goals, and agenda. The precept that calls for sincerity in communication (Johannesen, 1996) has particular importance in the case of health and risk messages because these aim to influence people’s practices that may significantly affect their well-being. Therefore the stipulation for sincerity calls for transparency regarding the motives and agenda of the sponsoring organization/communicators. Thus, messages that recommend drinking milk for nutritional purposes that are supported directly or indirectly by dairy organizations or messages that recommend having a “designated driver” funded by alcohol beverage companies (Dejong, Atkin, & Wallack, 1992), or messages regarding the benefits of certain medications sponsored by the pharmaceutical companies raise concerns regarding their sincerity (McCartney, 2010).
Obligation to Correctness, Certitude, and Reliability
In persuasive communication an important ethical standard is that the information presented to support the claims should be correct, accurate, and reliable. This implies that the claim should not be exaggerated nor presented as certain when it is not (Johannesen, 1996). Risk and health information may be based on scientific information limited within the scientific expertise, and available techniques may be incomplete or subject to different interpretations. Even within one or two decades risk and health recommendations could change and sometimes may even contradict previous recommendations. However, at the time they are presented to the public they may be presented as reliable. This raises the question of what extent should communicators present limitations of the health and risk claims—in particular when they are concerned that recommendations presented as more tentative are less likely to be accepted as persuasive. Regarding certitude, typically claims regarding risks are presented in a certain way rather than a tentative way, and claims regarding risks are not presented as probabilities, which may be lower than the public estimates. This presents a dilemma for communicators because they may feel it is best not to provide accurate information about risks because they fear it may reduce the potential impact of the persuasive message. For example, O’Keefe (2007) raises the question whether people should be told the actual risk when they overestimate it. He presents a conflict between the goal to persuade people in order to prevent them from being at risk and the obligation to provide accurate, complete, and sincere information. He explains that in the context of smoking, people may already be aware of this risk and may in fact overestimate its probabilities. The question then is this: should communicators provide correct information to those who are vulnerable to the risk when there is evidence that those who overestimate it are more likely to avoid it?
But there is a different kind of concern regarding accuracy and certitude. Scholars warn that one of the concerns regarding the design of health and risk messages relating to the reliability of the health/risk information is that “modernity” is characterized by the tendency to equate knowledge with certitude (Craddock Lee, 2010; Giddens, 1990). One example of a controversy regarding health advice is a UK report by the National Obesity Forum and the Public Health Collaboration cited in the British Medical Journal (Torjesen, 2016). It calls for a “complete overhaul” of dietary advice and argues that the current public health recommendations have been influenced by the food industry and contribute to obesity and associated medical problems such as diabetes. It states that the messages of “low fat” and “lower cholesterol” in public health messages are based on flawed science and have been exploited by the commercial interests of the food companies to promote the wide consumption of obesity-promoting processed food products. Further, the report argues that the focus of current guidelines regarding consumption of fats and calories is misleading and as a result people are less likely to consume nourishing and wholesome food. Although this critique has been challenged by researchers who support the recommendations, it illustrates the precariousness of health recommendations and the controversies regarding their reliability, whether regarding nutrition, exercise, or early detection medical tests. For example, the widespread use of screening tests for various medical conditions and the phenomenon referred to as “overdiagnosis,” including prostate and breast cancer have been contested as having detrimental outcomes on the personal level and as costly to the healthcare system, as well as contributing to medicalization (Gonzales & Cattamanchi, 2015; Hoffman, 2016; Morgan & Coleman, 2014).
The Issue of Personal Responsibility
Much has been written on personal responsibility in health promotion, and it is used as a common persuasive approach in health and risk messages to appeal to personal responsibility (see Guttman & Ressler, 2001; Turoldo, 2009; Voigt, 2013). Turoldo (2010) notes that its origin is relatively recent compared to the ancient roots of ethical philosophy. Personal responsibility can be considered a positive motivator and can contribute to promoting people’s sense of accomplishment and autonomy; these are people who have the ability to choose to engage in or to avoid practices that can promote their health or reduce their exposure to risk. This ability could also represent the potential sociologists refer to as having “agency,” or the ability to make choices that have an impact on their lives or those of significant others. It also corresponds to enhancing people’s conceptions of self-efficacy (Bandura, 2004) to make positive changes in their lives. Appeals to personal responsibility could be thus viewed as resonating with the ethical precepts associated with empowerment and self-fulfillment. The appeals to personal responsibility in health and risk messages on the one hand is viewed as promoting autonomy by emphasizing people’s ability to adopt practices that would improve their lives. On the other hand, it raises ethical concerns from the perspective that it in fact places the blame on them when they do not adopt the recommended practice, often because they did not have the resources to do so. On a macro level, scholars propose that an emphasis on personal responsibility can serve governments and even workplaces as a means to sanction or control people’s behavior and sense of obligation (Crawshaw, 2012). For example, by emphasizing that one should choose certain health-promoting/risk-mitigating practices a presumably “logical” implication is that those who do not choose these practices are in fact irresponsible. Thus, in various contexts those who do not adopt health-promoting practices may be blamed for their medical problems and they may be viewed in a negative way, as people who have “vices” or a “weak character,” and by doing this equating health practices with morality. This could lead to stigmatization and shaming of people—for example those considered overweight or those who find it difficult to quit smoking.
Critics warn against the phenomenon of “blaming the victim” when people are held accountable for detrimental outcomes when they were unable to prevent them because of external circumstances they have little control over. Often, those who cannot adopt the healthier practices are from disadvantaged or particularly vulnerable groups (Wikler, 1987). These may be members of minority or low-income populations who have limited access to health-promotion resources, those who need to address difficult economic circumstances, or youth who are targeted by commercial companies to consume unhealthy products. An emphasis on personal responsibility could also cause individuals and members of vulnerable populations harm by making them feel guilty or inadequate. Studies found that people from disadvantaged populations felt a more pronounced self-blame for their illness (Chapple, Ziebland & McPherson, 2004; Richards, Reid, & Watt, 2003). Yet, for example, when it comes to food choices, these are influenced by access to healthier food and structural, cultural and social factors (Mayes & Thompson, 2014). These vulnerabilities also relate to the issues of equity and justice discussed in the sections that follow. Gordon, Russell-Bennett and Lefebre (2016) point to political and ideological factors associated with the emphasis on personal responsibility. They explain that the change in government in the UK illustrates influences on social marketing resources and approaches. The result of the Conservative Party coming to power in 2010 resulted not only in cutting the budget for social marketing programs but also emphasized individual responsibility and the approach of “nudging” people to make healthier choices.
A related concern regarding an emphasis on personal responsibility in risk and health messages is that when the discourse emphasizes responsibility, it makes it appear that individuals indeed have control over their health outcomes. Further, it can serve to shift the focus away from structural, environmental, and social conditions that have a major impact on peoples’ behavior and their health. Holding people morally accountable for their health condition could also influence support for policies that do not offer insurance coverage for those who do not adopt certain health practices (Voigt, 2013). In order for individuals and communities to be held responsible, ethicists maintain that they need to be provided with fair opportunities to pursue healthier practices as well as capacities to make informed choices. This corresponds to the emphasis in social marketing on addressing environmental and social barriers that people need to face when they are encouraged to adopt healthier practices (Lefebvre, 2013).
Turoldo (2010) proposes an “ethic of responsibility” that draws on the ideal of caring for one another, in particular for those who are more vulnerable. It is based on the assumption that people need each other to survive and therefore it is important to maintain good relations with one another. In this framework, responsibility is mainly conceived as a commitment toward promoting the well-being of others as well as the capacity to assess and morally evaluate the consequences of one’s actions on specific individuals or society. Although Turoldo focuses on the medical care context, this approach can contribute to conceptions of responsibility in the health and risk message design context: as the author proposes, this approach underscores the question “to whom is one responsible” and the obligation to consider different cultural values and conceptions. This perspective can be found in health-promotion messages that call for people to help promote or protect the health of their close family members (e.g., spouses helping each other) or friends (e.g., “buddies” when they go out to drink). Appealing to this type of obligation represents social values of caring or solidarity. The positive effect of appeals to social rather than individual responsibility were found in a study in which messages on social responsibility as a collective effort were found to be more likely to be associated with more nutritional practices (Williams-Piehota et al., 2004). Yet, this type of appeal also raises ethical concerns because it may get people to feel they have an obligation that they cannot fulfill. They may not be able to coerce the other person to adopt the protective practice and may feel guilty if they “fail.” Further, it may reinforce gender role or cultural stereotypes, for example, when women are urged to cook healthier foods or to be “angels” on the road and keep male drivers from taking risks (Ulleberg & Must, 2005).
Equity, justice, and fairness are central values in ethical and legal frameworks. These serve as the basis for legislation against discrimination, which reinforces the obligation to provide equitable access to health-care services and to provide culturally appropriate communication programs to members of diverse populations. In public health, scholars refer to the issue of distributive justice in health care (Daniels, 1985) that is of particular importance because of the necessity to equitably allocate scarce resources. This distribution could be guided by a conception of the obligation to ensure an equitable opportunity to those with the greatest needs. For communicators this could mean that people should be provided with information in the language they understand and in a culturally appropriate manner. This obligation poses important challenges in risk and health message design and their distribution. In particular, because health is associated with socioeconomic factors, communication to promote health has been found to benefit especially those who have more means and opportunities, whether in the areas of smoking, cancer prevention and treatment, or physical activity (Viswanath & Ackerson, 2011). This phenomenon is related to the “knowledge gap” phenomenon studied by communication scholars. A gap that increases when those who have the ability and resources to both access and act upon relevant health information that can benefit their health and the health of their communities. Such disparities can be also found in crisis situations and pandemics (Lee, Rogers & Braunack-Mayer, 2008). Therefore, as discussed in the section on personal responsibility and as noted by scholars who are critical of social marketing (Brenkert, 2002), an important challenge is to avoid a situation in which communication initiatives contribute, rather than reduce social disparities. Thus for people to respond to risk and health messages and to meet the ethical principle of equity, they need appropriate socioeconomic and environmental conditions. By implication, communication that aims to persuade people to adopt practices to promote their health would raise ethical concerns if it does not address solutions to barriers that may prevent them from doing so. For example, messages may need to include not only nutritional information on which foods are healthier but also on how to obtain these foods on a budget. Similarly, communication to promote smoking cessation among disadvantaged populations needs to take into consideration economic and social barriers that smokers may face to even consider joining a smoking cessation program (Chapman & Mackenzie, 2012).
The use of digital media as a means to disseminate health and risk messages also raises ethical concerns and challenges to address them. Whereas digital media can enable reaching populations that may have been “hard to reach” such as youth and young adults it can also contribute to the health knowledge gap referred to above. The disparities in the use of digital media have been called the “digital divide” (Hargittai, 2002) and have implications to health disparities as well because health information has become widely available to those with Internet skills (Viswanath & Kreuter, 2007). Therefore, equity considerations present the challenge of utilizing various media channels, including digital media, to ensure equitable access to health and risk information for people with various types of literacy and from diverse cultural and social backgrounds—in particular, those who have limited literacy skills (Ginossar & Nelson, 2010; Kreps, 2005).
Concerns Regarding Segmentation and “Targeting”
Segmentation is a key feature in social marketing and guides message design, and it has implications concerning equity. It offers a pragmatic strategy to more effectively reach members of groups with particular characteristics and interests, and it can help address disparities by designing messages and means of dissemination to reach populations with special needs or particular cultural backgrounds (Hornik & Ramirez, 2006). Segmentation is considered an efficient strategy, despite the effort needed to develop information content and messages that are specifically appropriate to the intended population, based on their values and norms and utilizing symbols and metaphors from their culture. However, it raises several ethical concerns. A major concern is that by focusing on certain groups it may serve to stereotype and stigmatize its members. In addition, it raises concerns about equity and fairness, when particular “segments” are chosen and resources are allocated to develop messages for these particular segments.
The assumption that underlies the segmentation strategy in message design and dissemination is that development of strategies to influence people would be more effective within a larger population if they appeal to groups with certain characteristics. Sometimes particular groups are singled out because they are considered particularly at risk to themselves or to others’ health or safety or have the greatest need: for example, young novice drivers, smokers, or people at risk for sexually transmitted diseases. Sometimes certain populations will be prioritized because they are more likely to be the first to adopt the health/risk prevention practice (Lee & Kotler, 2015), and this would be justified by considerations of utility. Having to choose who will be more likely to benefit from the intervention through the use of segmentation raises ethical concerns because some people will be excluded because the messages will be less relevant to them or the messages may not even reach them. Segmentation thus can raise the dilemma of prioritizing and having to weigh consideration of cost effectiveness versus the needs of members of particular social groups. Newton, Newton, Turk, and Ewing (2013) differentiate between those who argue that it is important to be egalitarian and ensure that certain groups are not favored at the expense of others and those that justify singling out the most vulnerable people. A utilitarian approach would favor directing limited resources to focusing on population segments that are likely to adopt the recommendations. Thus, according to this approach the choice of target groups would be guided by those who can be most effectively and efficiently affected or according to the motto of marketers to target “low hanging fruit” as most cost-effective (see Brenkert, 2002).
Newton et al. (2013) propose that the background of the communicators’ discipline in social marketing influences their views when it concerns the ethics of segmentation. Those from a commercial marketing background would be less likely to be concerned with the moral issue of not reaching all those in need, compared to those from a public health background who would be concerned with a fair distribution of resources and with the population as a whole. They suggest that in the commercial context ethical concerns regarding segmentation are typically those that arise when vulnerable populations are the target of marketing efforts to get them to consume products that could be harmful. One possible solution to the segmentation dilemma is proposed by Kotler and Lee (2008), who maintain that there should at least be a long-range plan to reach groups that are not included in the first stages of the communication/social marketing plan.
Newton et al. (2013) propose that the Integrative Social Contract Theory, developed to evaluate ethical issues in the business context, could be helpful. It assumes that the ethicality of behavior is determined by macrosocial and microsocial contracts and could help address the ethics of segmentation. According to this theory macrosocial contracts consist of principles that draw on philosophical and religious precepts and relevant national and international professional bodies that specify what people ought to do. Microsocial ones depend on informal agreements about ethical practices developed within communities. The relationship between them takes place according to authenticity (when most people support them) and legitimacy (when consistent with broader contracts). They propose that segmentation that aims to address health gaps is justified according to international human rights charters (e.g., the United Nations Universal Declaration of Human Rights; the World Health Organization preamble; the World Health Organization Ottawa Charter for Health Promotion) and the constitutions of numerous countries. These international and national documents present macrosocial principles according to which all people have the right to health equity: therefore, segmentation is a justifiable response to health disparities. They also propose that segmentation ethics could draw on the theory of justice as fairness developed by the philosopher Rawls (1971) that includes the principle of the right to fair opportunity and the difference principle, according to which existing inequalities need to be addressed by maximizing benefits to those who are the worst off in society. This theory guided the development of several ethical frameworks in marketing and in the development of the Theory of Just Health Care by Daniels (1985) and can serve to justify health-related interventions for at-risk groups and the prioritization of limited resources according to an equitable distribution of resources. This framework also poses the condition that decisions need to be transparent and enable public scrutiny and that agreements about the decision process (not necessarily the outcomes) should use a deliberative approach to also serve to educate the public about the need to balance competing interests. The segmentation process, according to this framework, can be dynamic when situations change or new evidence is introduced according to various needs in the community. This perspective on decisions on ethical issues points to the important role of participatory and deliberative processes in the various stages of health and risk message development, and it also corresponds to Brenkert’s (2002) suggestion that transparency is a basic directive in social marketing and that communities should participate in the design and implementation.
The Obligation to Comprehensibility
The stipulation for comprehensibility points to the obligation in the persuasion context to provide information that can be fully understood by those it is intended for (Johannesen, 1996). If the health or risk messages carry important information for the welfare of those they are intended to reach but this information cannot be understood, this raises an important ethical concern. Those who cannot understand it—whether because of literacy skills, language proficiency, or because the message does not explain the issue in a way they can understand it—simply cannot benefit. This raises issues of autonomy, equity, as well as utilitarian concern for efficiency. By implication, messages need to be developed to ensure that they can be understood by members of diverse groups, including those with low literacy skills, so that they can make informed (autonomous) decisions. Oversimplification of an explanation may result in being less efficient because people are less likely to be fully convinced and consider different aspects of the issue. Studies show that people who are exposed to different arguments are more likely adopt a stronger stand regarding the recommended practice (Ivanov, 2012). Scholars explain that risk information can have potentially confusing and misleading effects related to its scientific basis and that laypeople may be confused about the meaning of health risk information: this is because it is often disseminated as if it were on the individual level when it is inferred from retrospective population-level data. They add that such risk information may obscure the complexity of the multiple causes of health risks such as cancer (Craddock Lee, 2010). A related challenge is how to present information on complex health- and risk-related issues. Various message design manuals recommend using clear and simple information, but this may be more applicable to providing practical recommendations and may not meet the stipulation of providing people with information that enables them to understand the complexity of the issue.
The Obligation of Inclusion
In communication ethics the precept of inclusion calls upon the obligation to respect others’ points of view (Johannesen, 1996). This corresponds both to the obligation to respect people’s autonomy and the obligation to equity. It poses several challenges and ethical concerns because often health and risk message design initiatives represent the agenda of government agencies or health organizations—or even commercial companies. Thus, the question is at what stage of the process are members of the intended population included and in what capacities (Brenkert, 2002). From a utilitarian perspective, involving members of the intended population could serve effectiveness goals. It can help identify pertinent needs and recommendations from the intended population’s perspective, as recommended in the social marketing literature. It can also elicit a trust and a sense of ownership among the populations for whom the intervention is intended. Thus, involving members of the population in the development of the content and format of informational materials and persuasive messages can result in more effective communication programs (e.g., in the development of a photovoice project, Castleden et al., 2008). This raises the question on how to distinguish between inclusion that can be viewed as “instrumental” and only for the purpose of developing more effective messages, and inclusion that is truly participatory and in which members of the intended populations are equal partners in the decision-making process. Further, the inclusion could be based on a deliberative approach that raises issues pertaining to social values and priorities. Scholars provide various examples of methodologies to develop and implement participative and deliberative strategies that can be adapted to different types of settings (e.g., Papa & Singhal, 2006), but they require a commitment to the overall idea of inclusion, and new approaches can be developed for digital media as well.
Utility and Efficiency Considerations
Because developing and disseminating health and risk messages requires economic and human resources as well as time, the precept of utility and efficiency is likely to become an important consideration. A utilitarian perspective would emphasize the obligation of the communicators to maximize the greatest utility from communication efforts and to use tactics that are considered the most effective. Thus, tactics considered more efficient may be preferred, even if they raise certain ethical concerns over other alternatives. For example, it may be recommended to use images that can be considered sexist, in order to attract the attention of young males. Or it may be considered effective to use provocative images that could offend members of certain groups. Ethical communication precepts may serve to guide discussions regarding the “boundaries” of utilitarian considerations. Further, some may argue that if ethical issues are not considered in message design and dissemination, the effectiveness of the communication initiative may be compromised and may raise anger and objections among the intended or non-intended populations (e.g., Janger, 2012; ten Have et al., 2011).
An ethical dilemma associated with utility concerns the use of commercial channels to reach populations, including associating the prosocial messages with content that is attractive. One example is from the context of environmental wild life protection. Myrick and Evans (2014) describe a case in which environmental advocates raise the dilemma whether to take advantage of popular entertainment events such as the Discovery Channel’s “Shark Week” that attracts many viewers. On the one hand, this type of event has been criticized by scientists and by environmental advocates as presenting inaccurate and potentially harmful portraits of sharks as killers. On the other hand, it offers a unique opportunity to reach and influence a large audience to support shark and marine conservation. This dilemma is compounded by study findings that show that participants asked to view video clips from Shark Week overstated their risk from shark attacks. Thus, the tactic may increase misconceptions. Nonetheless, the researchers proposed that this event could be potentially helpful in promoting the cause of shark conservation.
The “Harm Reduction” Approach
Communication programs that aim to influence people’s health- and risk-related practices may focus on changing certain practices that can help people avoid serious hazards; however, they can, at the same time, condone practices that may also put people at risk or are considered immoral by society’s standards. This is referred to the “harm reduction” approach, and its underlying ethical rationale is that it adheres to the obligation to protect people from a grave harm. It is also non-judgmental and may serve in certain circumstances as the principle of respect for autonomy. In some cases, the ethical dilemmas are typically explicit, and advocates may refer to this approach as “compassionate pragmatism.” For example, messages may focus on how people who use illicit drugs can reduce the risk of infection by sterilizing needles or participating in needle-exchange public health programs. The harm reduction prospection may also apply situations in which messages aimed to reduce an immediate risk but at the same time serve to sanction other practices that also could be unhealthy. For example, promoting the practice of “designate driver” can help prevent the risk of drinking and driving but could serve to encourage non-drivers to drink large amounts of alcohol (Ditter et al., 2005). In the case of alcohol consumption and drinking, an additional critique is that there are strong corporate interests in promoting designated driver messages because these essentially both protect the alcohol industry and promote heavy drinking practices (Dejong, Atkin & Wallack, 1992; Ditter et al., 2005). A related critique can be noted regarding workplace health promotion messages. Workplaces may provide exercise facilities and nutritional food options. Such programs can help motivate workers to adopt healthier practices in the workplace and reduce the harm of long hours spent sitting by the computer or in the consumption of unhealthy food products. However, they do not address the basic issue of long work hours that often prevent people from adopting an overall healthier lifestyle. Further, they can serve the interest of the corporation to justify long working hours and can help people adapt to the work constraints rather than change them. Workers may feel they are taking good care of their health while being at work instead of spending more time with their families or friends or engaging in prosocial activities outside the workplace. Thus, ethical issues could be found also in programs that aim to promote health and can have positive health effects on individuals but from a critical perspective may also have negative effects on their well-being.
Concerns Regarding Social Value Priorities and “Distortions”
Ethical concerns in health and risk message design can be raised also on the social and cultural level. One concern is that health messages that aim to promote various medical treatments can contribute to negative aspects of medicalization, when nonmedical aspects of human life begin to be considered medical problems, people tend to adjust their lifestyles according to medical information and a biomedical perspective is privileged in important areas of life and may depoliticize politically difficult social problems (Hoffman, 2016). Drawing on a critical perspective, health and risk messages can have an impact on the cultural level of people’s view of social priorities and social institutions. Craddock Lee stated this concern: “Prevention and public health are not just rules and regulations about right choices or right behaviours. Like clinical guidelines, they are value concepts that reflect what kind of society, what kind of health system, even individual health professional, we want to be.” (Craddock Lee, 2010, p. 114). Further, scholars propose that the multitude of health promotion messages can contribute to health becoming an overriding social value. Consequently people may find themselves prioritizing the pursuit of health at the expense of other things in their lives or could feel inadequate if they do not (Carter et al., 2011). From a critical studies perspective the emphasis on health as a value can be viewed as contributing to “distortions” of the priorities in social values.
Another possible “distortion” can result from what critics have referred to as power imbalance between the organizations doing the campaigns/social marketing and vulnerable populations (Brenkert, 2002). Researchers note that organizations increasingly choose to sponsor health and social causes, and this gives them more control of how their charitable money is spent and creates a positive association between them and the cause and ultimately a more positive image. This can result in more funding for causes that are viewed as more attractive. Further, sometimes these corporations create unhealthy products or harm to the environment (Donovan & Henley, 2010).
Prosocial Values as Moral Appeals
Appeals to people’s values and morality are also used in messages to influence their risk- and health-related practices. Such appeals are often related to people’s sense of obligation and responsibility, an issue elaborated on in the section on the principle of autonomy. People may also be encouraged to act according to prosocial values associated with altruism, solidarity, or caring for others. For example, appeals to solidarity and caring for others can be found in messages used to encourage organ donation both in media campaigns that appeal to members of the public to register as organ donors and in the interpersonal context, when appealing to family members to agree to donate the organ of the deceased (LaVail et al., 2010; Siminoff et al., 2011). Further, researchers in the organ donation context found that using gain-frame messages that emphasize helping others elicited more favorable reactions than loss-frame ones (Quick et al., 2015). Such appeals also raise ethical concerns, for example because some consider them as less effective than self-benefit appeals. Yet others maintain that the use of prosocial appeals is important because they reflect the kind of society they strive to live in, and they feel that people are in fact highly motivated by wanting to help others (Guttman et al., 2016). Also communication to the public to reduce the risk of climate change in their everyday practices often appeals to people’s values and refers to the task of protecting the environment as a shared moral challenge. Thus, prosocial values, altruism, or caring for the environment are employed to advance environmental goals (Corbett, 2005; Nisbet, 2009).
The Entertainment-Education Approach
Some of the ethical issues raised in the context of entertainment education correspond to and have particular relevance to health and risk message design in general. Some concern more “macro” issues regarding the overall ethicality of using communication and marketing strategies to systematically influence societal beliefs and behaviors. Similarly, one could raise questions regarding and dissemination of health and risk messages in entertainment media regarding who has the authority to make the decision about prosocial and antisocial messages in the popular media as well as whether it is ethical to prioritize particular audience groups and that some people may benefit more than others. There are also ethical concerns regarding the role of and impact of organizations from outside the country that sponsor entertainment-education programs in countries with lower income. Additional concerns are more specific to entertainment education; however, these concerns could also be relevant to health and risk message design in general, including whether entertainment programs can serve to reduce people’s defenses against issues they would have objected to (Slater, Rouner & Long, 2006), thus possibly being manipulative. A different type of concern is that there may be unintended consequences because viewers of entertainment programs that have health and risk messages may identify with characters that do not adopt the health or prosocial practices. Another concern is that the health or risk information may be presented inaccurately because of the way it is dramatized, thus misrepresenting the risk or providing unreliable information. Another type of ethical concern pertains to the collaboration of not-for-profit or public organizations with commercial media channels and having products associated with programs that have commercial and merchandizing value (Asbeek, Fransen & Smit, 2015; Brown & Singhal, 1990).
Example of Application
Donovan and Henley (2010) present a case study that illustrates how they used a series of questions as a means to help consider ethical concerns in the design of a domestic violence prevention campaign. The campaign’s intended population included perpetrators of the violence as well as the victims. They begin with the question that relates to the obligation to avoid doing harm and asked how one can ensure that the campaign will not cause physical or psychological harm; Donovan and Henley then explain that the strategy to address this was to use extensive formative research with relevant stakeholders from diverse groups that may be affected by the campaign messages. Another question that relates to equity obligations was whether the campaign gives help where it is needed, and they respond that its design aimed to ensure that it did not use messages at the expense of victims and that resources were offered for all. They also asked a question related to autonomy, which asks whether the campaign allows those who need help to have the freedom to exercise their entitlement. The authors responded that its goals were defined to help the intended population live without fear and counseling and that any materials received would be free of charge. They also responded to the concern about whether all parties are treated equally and stated that it would be unethical to raise anyone’s hopes through one’s practices unless sufficient resources are made available and are accessible over time. Thus, Donovan and Henley explain that the campaign was planned to be carried out over a 10-year period with multiple resources, including counseling staff and a helpline in many locations and availability after work hours. In terms of utility consideration, they asked whether the program produces the greatest good for the greatest number of people. The response was that a large number of people entered the counseling program (8,200 men who identified themselves as perpetrators of domestic violence) and reported substantial monetary savings when comparing the cost of providing counseling to the cost of treating victims and of domestic violence. Finally, Donovan and Henley ask whether the autonomy of intended populations was recognized, and they explained that the campaign held that the individuals are autonomous and have a right to be treated with dignity, including perpetrators of domestic violence. This case study illustrates the way using a framework of questions that draw on ethical obligations can serve planning and implementation of health and risk messages and has both moral and practical implications.
The literature on ethical issues in health and risk message design is diverse and points to different types of ethical issues and dilemmas that emerge in their design and implementation. It reminds us that health and risk message design and implementation is a moral and cultural endeavor. One of the challenges for researchers and practitioners is that much of this literature mainly discussed ethical issues from the perspective of a critical analysis; however, discussions of specific ethical issues that can serve as “case studies” and analyses of ethics—in particular tactics and persuasive approaches—are relatively rare. The obligations presented in this article can thus be used to develop questions that could help identify specific ethical concerns and possible ways to balance between conflicting values and obligations. One example is an article that concerns campaigns related to obesity. The ethical issues associated with messages in obesity prevention campaigns relate to the ethical obligations and considerations described in this article. The researchers raise a host of ethical concerns regarding the negative effects of obesity campaigns on physical health (e.g., contributing to dieting and eating disorders) and psychological well-being (e.g., by creating excessive and unwarranted fear and weight concerns), blame, infringement on people’s privacy and autonomy, including lifestyle choices and child rearing, stigmatization, discrimination and inadequate information, and disregard for the social and cultural value of eating (ten Have et al., 2011). Thus, the issue of identifying ethical issues in health and risk messages is not only a theoretical concern but can also be found in a plethora of actual programs and messages. These researchers propose that these issues can be viewed as belonging to one of the following three categories: The first encompasses issues that concern unforeseen and negative effects, such as a narrow focus on goals that does not include important relevant issues or uses unintentionally stigmatizing images of children or adults. The second employs appeals that can create anxiety among those who find it difficult to lose weight. The third concerns contrasting views; when some people think that the government should employ regulation to promote people’s health, while others view this as intrusive and overriding the principle of autonomy. This distinction underscores some of the major ethical concerns that emerge when the campaign messages or activities do not address core issues and consequently can cause psychological or social harm. The researchers propose that the challenge is to pay attention to possible ethical issues rather than rush to implement campaigns that may be well intentioned but may elicit serious ethical concerns. This conclusion is shared by scholars who are also engaged in actual campaign and messages design and who emphasize the central role of collaboration with members of the intended population and implementing appropriate formative evaluation of all proposed messages (e.g., Donovan & Henley, 2010; Lefebvre, 2013).
Table 1. Ethical Obligations and Consideration in Health and Risk Message Design
Obligations and considerations
Examples of ethical concerns
To avoid “doing harm”
The obligation to help
To respect people’s autonomy
To obtain consent
Correctness, certitude and reliability
Utility and efficiency
“Harm reduction” approach
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