(Traditional)
The risk orientation and problem focus in preventive care have been criticized for being negative and related to health threat instead of resource oriented (1-3) or concerned with emotional wellbeing (4). Others maintain that preventive efforts in clinical work might be unethical due to "victim-blaming" and affirmation of social inequalities (2, 3, 5).
In opposition to this view, Tudor Hart (6) claims that the social inequalities and the undue social selectiveness of the fitness-movement and well-manclinics is rather a strong argument for proactive care and case-finding strategy in clinical practice. Empirical data do not support the assumption that health promotion fosters socially determined blaming of victims: independent of social status a sizable proportion of patients in general practice demand receiving advice on a healthier lifestyle (7).
The standards of healthy life and "normality" emphasized by preventive medicine may, however, contribute to unrealistic socio-cultural expectations set and thereby loss of control in vulnerable persons (8, 9). Self consciousness and introspection are associated with a tendency to amplify bodily symptoms and to sap subjective well-being (9). It seems an odd phenomenon that social and medical progress and safety is accompanied by a "risk epidemic" and continuous information about the menace of daily life (10). Benjamin Franklins observation that "Nothing is more fatal to health than an over care of it" seems relevant.
Also, strong emphasis on individual attributes of health imply a message of individualism and dependency on experts and technology. Health aspects as belonging, competence, mastering and well-being may accordingly be disregarded (11, 12), and the social and ecological emphasis regarding health determinants (5, 13-16) may vanish. It is an interesting observation that working class people to a greater extent than others emphasize socioeconomic and environmental determinants of health (7). We may therefore claim that individually based health promotion have a socially determined list.
Screening on healthy individuals is ethically different from everyday medical practice (17). To become ethically defensible health promotion and life style advice should alter the natural history of diseases, and should be mandated by the patients. According to some critics these conditions are often unmet in health promotion (5, 17-19), and possible health gain is seldomly weighed against unwanted side effects in healthy populations (17, 20-23).
Although a difference between patient-initiated and doctor-initiated encounters certainly exist, we may acknowledge that ethical challenges change over a wide spectrum from ailments linked to existantial and interpersonal problems via symptomatic and asymptomatic disease to presence of risk factors or risk behaviours. A common ethical obligation in clinical practice seems, however, obvious; i.e. to attend to the people with an impaired prognosis in such a way that prognosis is improved or accepted if inevitable.
Certainly, there is a possibility that health promotion may lead to neuroticism and hypochondriasis on a socio-cultural level. On a group level, however, emotional labelling effects have proved doubtful when appropriate care is offered (24-27). The majority of patients in general practice regards health checks as helpful (28-32). Some reports even suggest a beneficial effect on individual well-being and mastering not different from other caring situations (33), although other qualitative studies report important reservations (32).
From a socio-economic point of view health behavior councelling generally seems cost-effective. Smoking cessation advice by a general practitioner is in particular cost effective and competes by far with different kinds of treatment for existing disease (34).
As mentioned, screening and high risk intervention is often performed without any qualified opinion of what is an acceptable cost for the presupposed health gain (17, 20-22). Besides, health professionals and health authorities may lack interpretations of what is a relevant health gain. It is important to emphasize that these decisions belong as much to the moral and political ground as to the health professional sphere. In general, the expected health gain increases with increasing absolute risk provided an effective intervention. The high risk strategy should therefore be reserved to a limited fraction of the population with a relevant absolute risk (35).
The possibility that the high risk strategy may interfere with the population mass strategy should, however, be considered. The number of high risk individuals in any population is determined by the population averages of risk factors (36). High risk intervention may counteract efforts of changing health behaviour in the "low risk population" (37). The cardiovascular disease prevention programme of the Norwegian Health Screening Service (38) accounts specificly with this problem, offering a combined strategy.
There is a connection between moral conduct and health (39), and health belongs obviously to the context of human values (40). Realizing such a connection should, however, not lead to stigmatization or victim-blaming (39). In health education and therapy it is important to distinguish between responsibility for a problem and responisibility for a solution (41). The traditional medical model often is inappropriate by disburdening the responsibility for solutions and behaviour change in addition to the more appropriate relief from guilt. An alternative compensatory model has been proposed; where patients are responsible for solutions but not for causing the problems. Such a model seems more attractive as it fosters the sense of competence and self-esteem (41).
Additionally, preventive efforts should emphasize individuality instead of unsatisfactory stereotyping (42). Even harmful behaviours are often well motivated in the individual's context, and abstaining from such behaviours might evoke responses similar to human loss (42). According to Becker (5) a more humble position is needed, and the health promotion movement should "adopt a philosophy of well defined and constrained focus, reasonable scientific consensus, realistic goals and claims, and willingness to acknowledge and confront the macrocontext of (and influences on) health and wellbeing".
Comments & questions are welcome: Eivind.Meland@isf.uib.no
References
1. Wiesner PJ. Four diseases of disarray in public
health. Ann Epidemiol 1993;3:196-8.
2. Pedersen TB. Hva slags menneske henvender
helseopplysningen seg til? En sosialpsykologs observasjoner og refleksjoner - I. Utposten 1991;20:208-12.
3. Pedersen TB. Hva slags menneske henvender
helseopplysningen seg til? En sosialpsykologs observasjoner og refleksjoner - del II. Utposten 1991;20:292-6.
4. Eadie DR. Relationships between health and
fitness and the implications for health
education. Health Education Research 1987;2(2):81-91.
5. Becker MH. The tyranny of health promotion.
Public Health Rev 1986;14:15-25.
6. Hart JT. Coronary heart disease prevention in
primary care: Seven lessons from three decades.
Fam Pract 1990;7:288-94.
7. Coulter A. Lifestyles and social class:
implicaitons for primary care. J R Coll Gen
Pract 1987;37:533-6.
8. Frank SH. Expectations disease: A model for
understanding stress, control and dependent behavior. Fam Pract 1993;10:23-33.
9. Barsky AJ. The paradox of health. N Engl J Med
1988;318:414-8.
10. Skolbekken JA. The risk epidemic in medical
journals. Soc Sci Med 1995;40(3):291-305.
11. Sachs L. Hälsokontroll leder til större
konsumtion av obefogad vård? Läkartidningen 1991;88:4450-2.
12. Christensen V. Det sundhedspolitiske paradoks.
Månedsskr Prakt Lægegern 1994;(11):1517-24.
13. Hancock T. Health, human development and the
community ecosystem: three ecological models.
Health Promot Int 1993;8:41-7.
14. Evans RG, Stoddart GL. Producing health,
consuming health care. In: Evans RG, Barer ML, Marmor TR, ed. Why are some people healthy and others not? The determinants of health in populations. Berlin, New York: de Gruyter,
1994: 27-64.
15. Organization WH. Ottawa Charter for health
promotion. Helsedirektoratet 1986;.
16. Lidegaard Ø, Olsen O, Søndergård Kristensen T.
Sygdomsætiologi og -profylakse - teori og
praksis. Nordisk Medicin 1990;105:87-0.
17. Skrabanek P. The physician's responsibility to
the patient. Lancet 1988;:1155-7.
18. McCormick J. Health promotion: the ethical
dimension. Lancet 1994;344:390-1.
19. Solbakk JH. Helsemoralisme og teknologifanatisme
i moderne medisin. Utposten 1991;20:354-7.
20. Lunde IM, Højrup A. Screeninger - og de raske.
Månedsskr Prakt Lægegern 1995;73.
21. Lunde IM, Hafting M, Malterud K. Can
health-promotion/disease-prevention provide ill health? Nord Med 1990;105:275-6.
22. Lunde I, Lauritzen T. Risikoparadokset. Ugeskr
Læger 1993;151(51):4203-6.
23. Dehlholm G, Hansen D. Etiske og psykologiske
aspekter ved screeningsundersøgelse af børn.
Nord Med 1993;108:297-9.
24. Irvine MJ, Logan AG. Is knowing your cholesterol
number harmful? J Clin Epidemiol
1993;47(2):131-45.
25. Næss S, Holmen J, Moum T, Sørensen T. Awareness
of hypertension and psychosocial function.
Review of the literature. Tidsskr Nor Lægeforen 1992;112:24-6.
26. Moum T. Screening for disease detection and
prevention: some comments and future perspectives. In: Croyle RT, ed. Psychosocial effects of screening for disease prevention and detection. New York: Oxford University Press, 1995:
27. Dehlholm B, Færgeman O. Psykologiske og sociale
konsekvenser ved positivt test-resultat ved screeningundersøgelser for kardiovaskulære
sygdomme. Månedsskr Prakt Lægegern
1988;(11):759-64.
28. Norman P, Fitter M. Patients' views on health
screening in general practice. Fam Pract 1991;8:129-32.
29. Qvist P, Lybæk B, Kibsgård K. Patientreaktioner
på kolesterol måling. Månedsskr Prakt Lægegern
1991;.
30. Ochera J, Hilton S, Bland JM, Jones DR, Dowell
AC. Patients' experiences of health checks in
general practice: a sample survey. Fam Pract 1994;11:26-34.
31. Sullivan D. Opportunistic health promotion: do
patients like it? J R Coll Gen Pract
1988;38:24-5.
32. Stott NCH, Pill RM. 'Advise yes, dictate no'.
Patients' views on health promotion in the consultation. Fam Pract 1990;7:125-31.
33. Rose G, Segesten K. Someone who cares. Patients'
experiences concerning health examinations.
Scand J Caring Sci 1995;9:105-12.
34. Isacsson SO. Ischaemic heart disease: disability
and costs. Quality of Life Research
1994;3(1):S93-S96.
35. Jacobsen BK. Prevention of myocardial infarction
by reducing serum cholesterol. Tidsskr Nor
Lægeforen 1991;111:2159-61.
36. Rose G. The strategy of preventive
medicine.Oxford, New York, Tokyo: Oxford
University Press, 1992:29-52.
37. Kinlay S, Heller RF. Effectiveness and hazards
of case finding for a high cholesterol concentration. Br Med J 1990;300:1545-7.
38. Bjartveit K. Handbook for the cardiovascular
disease survey.Oslo: National Health Screening Service, 1987:160.
39. Steinholt O. The health educator - a prophet in
our time? Tidsskr Nor Lægeforen 1990;30:3935-8.
40. Baelz PR. Philosophy of health education. In:
Sutherland I, ed. Health Education/Perspectives
& Choices. Cambridge: National Extension
College, 1979: 20-38.
41. Brickman P, Rabinowitz VC, Karuza Jr. J, Coates
D, Cohn E, Kidder L. Models of helping and
coping. Am Psychol 1982;37:368-84.
42. Stott NCH, Pill RM. Health promotion and the
human response to loss: Clinical implications of
a decade of primary health care research. Fam Pract 1987;4:278-86.
Home Page Department
Home Page
University
Department of Public Health and Primary Health Care, last updated 19.02.96
Hogne.Sandvik@isf.uib.no