Health Promotion International Advance Access published online on November 15, 2007
Health Promotion International, doi:10.1093/heapro/dam035
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Article |
Setting an ethical agenda for health promotion
Research Centre for Health Promotion, Faculty of Psychology, University of Bergen, Christies gate 13, 5015 Bergen, Norway
* Corresponding author. E-mail: maurice.mittelmark{at}uib.no
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SUMMARY |
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 TOP SUMMARY BACKGROUNDTHE CORNERSTONE OF A...THE OTTAWA CHARTER--CORNERSTONE...A PROFESSIONAL ETHICA RESEARCH ETHICREFERENCES |
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The Bangkok Charter for Health Promotion in a Globalized World has sparked lively dialogue. Welcomed by some as a Charter current to the times, there are others who see it as an unneeded and therefore unwelcome challenger to the Ottawa Charter for Health Promotion. Intended or not, the Bangkok Charter seems to signal a shift in discourse, from a social-ecological approach and an emphasis on individual and community capacity-building and empowerment, to an investment approach and an emphasis on globalization, macro-level factors and policy. Positively, the Bangkok Charter proclaims to build on Ottawa, and no one suggests it is meant to replace the Ottawa Charter outright. In concert with that, the dialogue today is not so much about the ascendancy of the one Charter over the other, but about the degree to which the Bangkok Charter remains true to the ethic of the Ottawa Charter. It is welcome that the Ottawa and Bangkok Charters are the subject of brisk dialogue about strategy and tactics in a rapidly changing world, and about the foundational values of health promotion. Regarding the latter, we have unfinished work in constructing an ethic for health promotion, and the present dialogue may inspire us to progress. Though we have the cornerstone of an ethic for health promotion, in the Ottawa Charter and in other principled documents that have followed, we have yet to build sufficiently on the cornerstone; an ethic for practice has yet to be codified, and the same is true for research. Health promotion journals, conferences and organizations can and should do more to facilitate dialogue on ethics in health promotion, and the Internet provides the means for all to participate actively.
Key words: health promotion; ethics; Ottawa Charter; Bangkok Charter
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BACKGROUND |
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TOPSUMMARYBACKGROUNDTHE CORNERSTONE OF A...THE OTTAWA CHARTER--CORNERSTONE...A PROFESSIONAL ETHICA RESEARCH ETHICREFERENCES |
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More than a decade ago, Yeo (1993)
characterized the ethical debate in health promotion as ‘tired’, and he advised us to ‘... resist the temptations of either a coercive, paternalistic ethic or an individualistic, laissez-faire ethic in favour of an ethic of enabling or empowerment’. He pointed to the heart of the Ottawa Charter for Health Promotion—the empowerment of communities—as a transcendence of the individual-versus-system debate. He advocated a health promotion ethic framed by the main ideas of the Ottawa Charter. Indeed, the Ottawa Charter for Health Promotion is considered by many in the field to be the most vital guide we have about how health promotion should be done. Today, 21 years after the first international health promotion conference, the Ottawa Charter for Health Promotion is inarguably the ethical cornerstone for health promoters round the world. However, to have the cornerstone is not enough, there is too little substance if it is not used as a foundation upon which to build a serviceable ethic for daily work. We have an ethical cornerstone, but do we have a serviceable ethic? The answer is ‘not yet’, and this article therefore aims to stimulate dialogue about addressing the unmet needs described below.
Almost a decade after Yeo described the ethical debate as tired, Sindall (2002) called into question health promotion's moral credibility, in the pages of this journal, pointing out that health promotion courses, books and articles, and conferences and gatherings pay scant attention to the subject of ethics. He called for remedial action; for example, that conferences on health promotion and ethics should be arranged, and that ethics courses be made mandatory in health promotion training, and he invited others to an energetic debate about health promotion's ethics and values.
The response has been less than overwhelming, based on the activity level in our journals. Since Sindall's editorial in 2002, Health Promotion International has published only seven papers in which ethics has been a main subject.
Callahan and Jennings (2002) echoed Sindall, using the editorial pages of the American Journal of Public Health, by calling for the field of public health to engage in an ethics debate. Since, one additional editorial and less than a handful of papers on the subject of professional ethics have been published in that journal.
Since 1992, the journal Health Education Research has published 10 pieces with ethics as a main subject, including six articles, two book reviews, one editorial and one news announcement, averaging less than one ethics publication a year.
The journal of which I recently became Editor-in-Chief, Promotion & Education, has since 1995 published 25 pieces in which ethics was a subject, only one of which dealt with the subject of professional ethics. Our average of about two ethics pieces a year is not particularly impressive. One can only conclude that dialogue about ethics, in our journals with global reach, is tepid at best.
Health promotion conferences are not doing much better, the most recent evidence shows that the activity level is miniscule. At the 2007 IUHPE World Conference on Health Promotion and Education in Vancouver, where several thousand papers were presented, just seven had ethics as a key part of their content.
Aside from journals and conferences, books are an important source of ideas and inspiration, and thank goodness, some of our colleagues are writing books on ethics, including David Buchanan, David Seedhouse, Deborah Lupton, Alan Cribb and Peter Duncan. However, the quite modest collection of books on health promotion ethics seems not to be awakening or informing a healthy dialogue, at least not in the journals, and not at the conferences.
Therefore, if one looks in the traditional places—journals, conferences, books—it would seem that Yeo's worry in the early 1990's is equally justified today. That should and does concern me, as a journal editor and as a professor of health promotion. If the dialogue on the ethics in health promotion is as muted as it seems to be, the intellectual forces in health promotion have to stand first in line to take the blame.
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THE CORNERSTONE OF A HEALTH PROMOTION ETHIC |
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TOPSUMMARYBACKGROUNDTHE CORNERSTONE OF A...THE OTTAWA CHARTER--CORNERSTONE...A PROFESSIONAL ETHICA RESEARCH ETHICREFERENCES |
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In the three parts that follow, I will make the case that the state of affairs is bleak, but not as bleak as my analysis up to this point portrays. My main points are these: first, the cornerstone of the ethic for health promotion, the Ottawa Charter for Health Promotion, is stirring lively dialogue and scholarly analysis, but this is happening on the Internet, not in our journals or at our conferences. Second, an ethic for health promotion practice, which could be built on the cornerstone, does not yet exist. The obstacle is that health promotion is not a recognized profession in most countries. I shall suggest a solution with international dimensions. Third, an ethic for health promotion research, which could be built on the cornerstone, does not yet exist, but I shall show that it is feasible to develop such an ethic, and apply it at the funding stage of research, to help ensure that what is labelled as health promotion research is indeed founded on the values of health promotion.
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THE OTTAWA CHARTER—CORNERSTONE IN THE ETHIC FOR HEALTH PROMOTION |
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TOPSUMMARYBACKGROUNDTHE CORNERSTONE OF A...THE OTTAWA CHARTER--CORNERSTONE...A PROFESSIONAL ETHICA RESEARCH ETHICREFERENCES |
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Almost since its delivery to the world in 1986, the Ottawa Charter has had a central and mostly safe place in health promotion ideology. Then, in 2004, we received some shocking news. The 6th Global Conference on Health Promotion, slated for Bangkok in the late summer of 2005, intended to issue a Charter—not a Statement, not a Declaration, not a Report, not a Summary—a Charter! The reaction was immediate, and important lines of dialogue that continue to this day began to emerge. The International Union for Health Promotion and Education (IUHPE) took up the issue. Its Board of Trustees immediately launched a listserv discussion debating the pros and cons of a Bangkok Charter, which continued for half a year, culminating in a decision by the Board to support the Bangkok Charter, but with great reservations about the use of the word ‘Charter’. One of the outcomes of those discussions was the decision by the IUHPE to examine explicitly the relevance of the Ottawa Charter 20 years after its issuance, in collaboration with the Canadian Consortium for Health Promotion Research. An important milepost in that project came in June of this year, at the IUHPE health promotion conference in Vancouver, when IUHPE President David McQueen launched the document, ‘Shaping the future of health promotion: Priorities for action’ (International Union for Health Promotion and Education, 2007
). The priorities are: put healthy public policy into practice; strengthen structures and processes in all sectors; engage in knowledge-based practice; build a competent health promotion work-force; empower communities.
The underlying ethic with which these priorities are to be addressed is spelled out clearly in the document, with these words: ‘The Ottawa Charter of 1986 laid a solid foundation for the theory and practice of health promotion, which has stood the test of time ... recommitment to the ideas of the Ottawa Charter and strengthening the conditions for effective health promotion are urgent matters.’ (International Union for Health Promotion and Education, 2007)
Parallel to the developments described above, Michel O'Neill, the Editor-in-Chief of the IUHPE's online journal Reviews of Health Promotion and Education Online, initiated a dialogue open to all comers, about the themes of the Bangkok conference and the future of health promotion. He initiated the dialogue with stimulating commentaries from some of the most respected figures in our field. Restrepo (2005) expressed appreciation that the circulating draft of the Bangkok Charter reinforced the principles spelled out in the Ottawa Charter, but called for much more powerful wording regarding the business sector's responsibility, writing ‘... we should demand greater change in their behaviours and practices that are killing the small industries and economies of the less developed nations. We should demand that they do not invade the health sector with big trusts of medical care regulated by the laws of the market which increase health inequities’.
In his commentary in the online journal, Saan (2005) remarked, ‘It is most interesting to see how we negotiate about the Bangkok Charter. The vigour shows how much many of us are fully engaged in health promotion and are ready to debate their principles and values. That in itself is a good sign of how health promotion is alive and kicking’.
Kickbusch (2005) took turn, writing ‘The fact that WHO together with the Thai organizers of the Bangkok Conference has signalled the intention to produce "a Bangkok Charter on health promotion" has sent storms, waves and ripples through the health promotion community. Suddenly, the uniqueness of the Ottawa Charter – a warm blanket that we had come to live with – was questioned’.
Among the host of contributors to the online dialogue were Kabwea Tiban, Larry Green, Don Nutbeam, Michel O'Neill, Valéry Ridde, Karine Aubin, Moncef Marzouki... and I contributed two commentaries. The contributions were in French, Spanish and English. The contributors referred frequently to one another's comments, and it was clear that a dialogue was underway, not just a posting of individuals' ideas. Other dialogues were going on in other online places, and efforts were made to link them up. In France, Arwidson (2005) coordinated an online discussion in the international Francophone community about the Bangkok Charter, which he synthesized in his online commentary for the rest of us. Ethical issues were very prominent in the Francophone dialogue, as in this passage: ‘Is the [Bangkok] Charter project a sign indicating a new orientation of WHO towards economic liberalism? Are references made to the market and the role of the companies a signal of that orientation?’ (Arwidson, 2005).
At the same time that dialogue was thriving in Reviews of Health Promotion and Education Online and in the Francophone online discussion, other more local online discussions were taking place in Canada, Australia and other countries. A search on the CLICK4HP website using the keywords ‘Ottawa Charter’ and ‘Bangkok Charter’ returns a great number of interesting contributions in a running dialogue that clearly has much to do with health promotion principles.
That a discussion about the ethical agenda for health promotion is to be found mostly online, and not much in Journals or at conferences, should not be surprising, after a little reflection. Journal and conference submissions require long-term planning, patience and no expectation that people will read and quickly react to what one writes. The threshold for online participation is, on the other hand, quite low, the investment of time and energy is affordable for most, immediate feedback is addictive, and real dialogue is fostered, as one must listen and no interrupting is possible.
The Bangkok Charter stimulated dialogue in the IUHPE, and it has also stimulated popular and scholarly critique that brings ethical issues into sharp focus. Noteworthy in this regard are the actions of The People's Health Movement, an international civil society network of health professionals, academics and non-government organizations, which was present and vocal at the conference that ended with the issuance of the Bangkok Charter. In a press release dated 18 August 2005, The People's Health Movement criticized the Bangkok Charter as ‘an inadequate and timid document that falls far short of what is required to tackle global health problems today.’ The press release went on to charge that ‘the failure to provide a robust critique of the causes of global poverty and failing health systems, results in the Charter omitting any reference to the negative social and health impacts of neo-liberal public policy, or the exploitation of natural and human resources by the corporate sector and the wealthy global minority or to the rapidly increasing concentration of wealth’ (People's Health Movement, 2005).
Made curious by these charges, Porter (2006) undertook a formal discourse analysis of both the Ottawa Charter and the Bangkok Charter to examine similarities and differences in the suggested agendas of the two Charters. To oversimplify a detailed analysis, Porter identified three main discourse changes from Ottawa to Bangkok that carry with them important ethical issues. The first discourse change is from new social movements to new capitalism, the second is from participatory democracy to global technocracy and the third discourse change is from socio-ecology to economy.
The first of the discourse changes is characterized as ‘dramatic’ by Porter, representing a shift from the issues of health and democracy, equity and diversity, to the economics of health. In embracing this shift, the Bangkok Charter merely follows the lead of others. The WHO in Europe has championed the development of the investment-for-health concept (Levin and Ziglio, 1997), and many health promotion meetings, journals and books promulgate the commercial metaphor. Consider these commercial terms, in common use today in health promotion conversations and writings: accountability, assets, benchmark, client, customer, diversification, gold standard, incentives, investment, joint venture, partnership, services and social capital.
The use of commercial metaphors in health promotion is partly just a matter of speech, but it is also partly a clear attempt to shift our agenda. The call for ‘investment for health’ implies serious promises, that such- and such specific investments in social and health services and community development will provide a return on investment—better health—that will enhance a society's quality of life and competitiveness in the rapidly globalizing world we live in.
If metaphors are merely harmless linguistic devices, that lend clarity to otherwise obscure matters, then no harm is done. But are they harmless? Rhodes and Garrick (2002) think not. They argue ‘the language of commerce increasingly appropriates "knowledge" by defining it in [economic] terms’ and that ‘... there are potential dangers of metaphors becoming reified, such that knowledge becomes describable only in economic terms ...’. This can happen when the metaphor overtakes an original meaning, as when ‘people are no longer seen as resources but are resources’ (Rhodes and Garrick, 2002). The way we understand our world, and play our roles, can be influenced by the metaphors we use. Froggatt (1998) writes about the significance of root metaphors, those that ‘reveal fundamental values and assumptions underpinning culture’. She illustrates her point by noting that the metaphors ‘body–as-container’ and ‘emotions-as-energy’ reflect a mechanistic conception of the world, which is derived from the root metaphor that the universe is a machine. Following from that, the body is a machine, separate from the mind and this downplays the importance of holistic approaches to care.
Does possible danger to health promotion follow from its growing infatuation with commercial metaphors? I think so. When ‘metaphoricity is suspended’ (Froggatt, 1998), the possibility may diminish for other metaphors to flourish. Buchanan (2000) takes aim at one of the most beloved metaphors in use in health promotion—that of power. He asks, ‘Why has empowerment assumed such prominence in [health promotion] these days? Of all the different candidates that could possibly be contemplated, why has the interest in power become so predominant? Why not caring, or compassion, or dignity, or love, morality, respect, harmony, responsibility, or some other significant human aspiration? Why has the pursuit of power captured so much attention?’
The second discourse shift revealed by Porter's (2006) analysis is that from participatory democracy to global technocracy, about which she writes ‘from Ottawa to Bangkok, the discourse shifts from health promotion being a democratic people project to technocratic law and policy work. The texts mark this in several ways, including shifts to functions rather than people, global over local, rights instead of needs, improved health opportunities instead of social justice and policy over education.’
The third discourse shift identified by Porter is that from socio-ecology to economy. It seems sufficient to jump right to her conclusion: ‘The Bangkok Charter claims that it "complements and builds upon" the Ottawa Charter. But rather than building on the Ottawa Charter's socio-ecological frame, it locates elsewhere, on the busy construction grounds of new capitalism.’ (Porter, 2006).
Porter's paper should stir lively dialogue, that could play out on the pages of journals, at conferences and on the Internet. It is a sure bet that a number of significant figures in the world of health promotion will disagree vigorously with Porter's analysis and conclusions. Will they take the time to compose and disseminate solid counter-positions? Will those positions then be challenged? One can only hope so, as a sign of health promotion's new/renewed interest in the core ethical issues of our common labour.
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A PROFESSIONAL ETHIC |
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TOPSUMMARYBACKGROUNDTHE CORNERSTONE OF A...THE OTTAWA CHARTER--CORNERSTONE...A PROFESSIONAL ETHICA RESEARCH ETHICREFERENCES |
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The professional ethic that might be built on the ethical cornerstone, the Ottawa Charter, does not yet have much substance. There seems little doubt that lack of professionalization of health promotion in many parts of the world is a key barrier. In many countries, health education is a well-developed profession, and anyone who calls herself a health promoter may be one in spirit, but by profession, she is quite likely to be a health educator, governed by the ethical standards and codes of health education. Health promotion may be developing as a profession in a few countries, but my guess is that will be the exception rather than the rule. And, as has happened in England, health promotion may become so intertwined with public health that it starts to lose its separate identify, even in places where it has become established.
Nevertheless, professionals who think of themselves as health promoters are clamouring for a professional identity as health promoters, something I encountered continuously during the 6 years I globe-trotted as IUHPE President. The IUHPE feels the need to start acting now on the need for professional standards (and later, I hope, on certification and a code of conduct), which could be approached at an international level rather than a national level. As the foremost global professional organization in the arena of health promotion, the IUHPE has the credibility to initiate and manage programmes and policies related to standards and ethical codes, and expressions of interest in this have been very strong, especially from health promoters in countries with weak public health infrastructure. It will take time to determine the most feasible ways to mount this international effort, but a big first step has been taken. The IUHPE has established the new post of Vice President for Capacity-building, Education and Training. Margaret Barry of Ireland, elected to the post in mid-2007, is mounting a global effort that should have far-reaching consequences, including, perhaps, the establishment of an IUHPE Code of Professional Ethics.
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A RESEARCH ETHIC |
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TOPSUMMARYBACKGROUNDTHE CORNERSTONE OF A...THE OTTAWA CHARTER--CORNERSTONE...A PROFESSIONAL ETHICA RESEARCH ETHICREFERENCES |
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The research ethic that might be built on the cornerstone of health promotion has yet to be realized. There exists, of course, standards for the protection of research participants, and also for judging the quality of research proposals and research reports, but these tend to be of a general nature and do not necessarily include criteria that emanate from a consideration of what is meant by the construct ‘health promotion research’. The ethical dimension in this is something I face often, as a reviewer of research proposals at universities and at national-level research funding organizations. The problem arises when a call for research proposals specifies that the theme is health promotion, but no criteria are provided for what constitutes health promotion research. Because there are no commonly accepted quality standards for health promotion research, reviewers use the standards of the various contributing disciplines. As very few reviewers have health promotion research as their primary research orientation, they fall back on the standards of their discipline, or some combination of disciplinary standards. On a review panel, the epidemiologist tends to be most impressed by the good epidemiology proposals, the psychologist by the good psychology proposals, the educator by the good education proposals, and so on. The reviewer with education, skills and experience in quantitative research may not even recognize qualitative proposals as research at all, and some qualitative purists may view quantitative research proposals as mere bean-counting and hardly scholarly endeavour.
In funding programmes within disciplines, where everyone is assumed to play by the same rules, there may be little or no problem. However, when the intention of a funding agency is to fund health promotion research, and good health promotion proposals are ranked behind good epidemiological proposals, the practical consequences of a lack of appropriate quality criteria are evident.
A few years ago, I participated in an international review group in Finland that was assembled by the National Academy to judge proposals submitted to a special funding programme for health promotion research. In the first years of the programme, we felt somewhat handicapped because no formal criteria for assessing the quality of health promotion research were available to guide us. Inevitably, because of our composition, we tended to place the greatest emphasis on classical quantitative study issues, judging the adequacy of the sampling plan and sample size, the quality of measurements, the internal and external validity and reliability, and so on. In the end, we funded some epidemiological studies that seemed rather remote from health promotion.
My Finnish colleagues did not only feel uncomfortable about the situation, they did something about it. I was invited to join a study which had these four aims: (1) define the special characteristics of health promotion research compared to research in contributing disciplines, (2) develop a set of specific evaluation criteria for health promotion research, (3) define the values and criteria that steer research in general, and (4) test the usefulness of such criteria. The health promotion research criteria were intended to provide a framework to help identify what was health promotion research, and what was not. The methodological details are available elsewhere (Lahtinen et al., 2005). To summarize, my Finnish colleagues conducted a systematic literature review, followed by consultations that were organized by the Finnish Centre for Health Promotion Research, involving Finnish and other European health promotion experts. The review was conducted with regard to the content of health promotion, its basic principles, as well as theories and models used to steer practical health promotion activities. The review and discussions were the foundation for the development of the criteria by the Delphi method, with health promotion experts as the participants. The resulting criteria were examined and discussed by the Scientific Advisory Committee of the Finnish Centre for Health Promotion Research, followed by discussions at the Netherlands Institute for Health Promotion and Disease Prevention, and an international seminar held in Helsinki. The revised criteria were tested in practice and further revised several times.
The seven published criteria are as follows:
The first criterion has to do with health promotion relevance. The research should address explicitly individual, social or societal level priorities for health promotion research as set forth by relevant policy documents, calls for proposals and calls for tenders, and so on. This calls for funders to be explicit about what they mean when they use the term ‘health promotion research’.
The second criterion has to do with health promotion values. The research methodology should address explicitly how health promotion values are incorporated in the research, including especially the values on citizen participation, partnership, fully authorized participation, open communication, sustainability and empowerment.
The third criterion has to do with health promotion innovation. The research should be innovative and distinctive, addressing explicitly its intentions to clarify and/or strengthen an important aspect of health promotion practice.
The fourth criterion has to do with health promotion discourse. The study questions should be framed in a manner consistent with, and flowing from, clearly stated theory/model/rationale with a high degree of relevance to health promotion discourse.
The fifth criterion has to do with health promotion practice. The research should have practical relevance for health promotion activities, and make explicit reference to the arena of practice to which it applies.
The sixth criterion has to do with health promotion action. The research should address explicitly action for health promotion, including action for change, and/or action to create opportunities for choice, and/or action for maintenance of change/choice already achieved, at any level or combination of levels from the individual to the societal.
The seventh criterion has to do with health promotion context. The research should demonstrate appreciation for the manner and degree to which it is embedded in a larger health promotion context, by reference to critical aspects of the problem that are not objects of study, for example systems, ecologies and/or processes of which the object of study is a part.
In addition to the seven criteria specific for health promotion research, seven general quality criteria were added, including scientific quality, defined scope, anticipated outcomes, operationalization, feasibility, process evaluation and documentation and dissemination.
It is too early to know if this work will spark a dialogue on an ethic for health promotion research, but the early experience is encouraging, and a Dutch research team has made good suggestions about how to optimize the health promotion research criteria (Kwak et al., 2005). What is clear is that we need to move towards agreement on an ethic for health promotion research. I am quite confident that the situation that stimulated the quality standards work in Finland is common in other countries, and that a lot of research is being funded as health promotion research that would fail to meet a reasonable test based on criteria such as those cited above.
Summarizing, with regard to an ethic for health promotion, we have yet to build sufficiently on the cornerstone; an ethic for practice has yet to be codified, and the same is true for research. Health promotion journals, conferences and especially national and international organizations should and must play their full part in stimulating dialogue and action. The Internet is an increasingly important forum for dialogue on ethics and values in health promotion. It seems every development on the Internet eases communication, lowers the threshold for participation and intensifies interaction. The Internet is an instance of globalization that serves us well.
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ACKNOWLEDGEMENTS |
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This manuscript is based on the opening plenary speech by the author, at the conference ‘Setting an Ethical Agenda for Health Promotion’, Ghent, Belgium, 18–20 September 2007.
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