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Behavior Change or Empowerment: On the Ethics of Health-Promotion Goals

Article  in  Health Care Analysis · October 2013

DOI: 10.1007/s10728-013-0265-0 · Source: PubMed

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Behavior Change or Empowerment

1

Behavior Change or Empowerment: On the Ethics of Health-

Promotion Goals (Penultimate version)

Per-Anders Tengland

Health Care Analysis (2016) 24:24–46

First published electronically fall 2013: DOI : 10.1007/s10728-013-0265-0

Introduction

One important ethical issue for health promotion and public health work is to determine what

the goals for these practices should be [13]. This paper will, then, try to clarify some of the

issues concerning what these goals are thought to be, and what they ought to be. It will

specifically discuss two different approaches to health promotion, namely, behavior change

and empowerment. 1 Before we look closer at them we need to have a conceptual framework

in which we can place these two traditions.

Background and Framework

Let me first introduce some preliminary distinctions, one between kinds of goals, and the

other between kinds of health-promotive (or public-health) work.

General Public Health Goals

What should the ultimate goals of health promotion be, in a public health context? The health

and longevity of the population is the obvious answer. However, the answer has to be

qualified. We need to state what is meant by health, a question that will be dealt with in a

separate section. Furthermore, since health (as will be shown) to a large extent is an

instrumental goal (and, thus, primarily has instrumental value), we have to relate it to some

other intrinsic or final goal (or value). Some plausible ultimate goals for public health and

public policy are equality, happiness, and quality of life. I have earlier argued that health

should be a goal for health promotion only in so far as it is quality of life related [77]. The

reason is simply that if an increase in health or longevity does not contribute to an

1 A previous paper in a similar way discusses and ethically evaluates the different means used by these two

approaches [83].

Behavior Change or Empowerment

2

individual‟s, or population‟s, quality of life, it is not worth trying to achieve it. Thus, we

should only try to promote health if it is expected to lead (directly or indirectly) to increased

quality of life, that is, if the specific health increase either constitutes quality of life, or

causally contributes to it. 2 Most increases in health do, however, contribute to quality of life,

even if sometimes only minutely, and some health increases, mainly in (health-related) well-

being, constitute increases in quality of life [80]. 3

But quality-of-life-related health promotion is not all there is to the goals of public health.

First of all, most ill health is caused by disease and injury [52; 81-82]. Therefore preventing

such states will also be important goals for public health. 4 Second, as will be clear later, since

very little is directly done to individuals or populations, health-wise, we also have to consider

the „opportunities‟ to stay healthy, e.g., promoting those environmental and social factors that

contribute to increased or sustained health, especially since public-health work mainly targets

the healthy population [20; 23]. Furthermore, the average aggregated health status in a

population, and its increase (or decrease), is important, but it is not all that should concern us.

It is also of importance how health is distributed in a population [13, p. 41 ff.; 87]. Thus,

health inequalities between groups have to be taken into account when evaluating the health

status of a population [13, pp. 43-44; 21; 93].

Kinds of interventions and some contemporary health problems

Interventions can be initiated on various levels in society. There are „top-down‟ measures,

such as fiscal policy, macro environment changes, health campaigns, or legislation, and most

2 There is no room to develop a theory of quality of life here, but a few remarks need to be made. It seems to me

that what best explains what makes a life go well for a person (her quality of life) is that her (final) desires are

fulfilled. It follows that it is not sufficient that the desires are only believed to be fulfilled (an idea that would

permit also false beliefs to contribute to a person‟s quality of life), which is the case in some happiness theories

of quality of life. It also seems plausible that the desires that count most (in evaluating the good life) are the ones

that are authentic, i.e., that are autonomous and informed. Brülde, who has argued for the above position [12; see

also 72], adds a hedonistic dimension to his theory of quality of life. The best life is one where one‟s (authentic)

desires are fulfilled and one experiences well-being, and does not suffer. I will assume here that this dimension

is not necessary, since to experience well-being, and be free from suffering, are (in most cases) covered by a

person‟s (authentic) desires.

3 In a public health-context we differentiate between individuals and populations. What might constitute a

relevant and important health-promotive activity on the individual level, and a relevant goal, e.g., for a physical

therapist, might not constitute such an activity or such a goals on the population level, and vice versa.

4 For a discussion about the relation between health promotion and disease prevention, see [81-82].

Behavior Change or Empowerment

3

public health policy is realized in this macro fashion [3; 5, p. 173, ff.; 24]. There are,

furthermore, (what I prefer to call) „local‟ measures, where professionals meet and directly

interact with individuals, groups, or communities [83]. 5 These projects are often of the kind

that ad

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