Week 14: Ethics of Behavioral and Attitudinal Change

Objectives:

 Describe and explain the ethics related to behavioral and attitudinal

change

 Recognise ethical issues related to behavioural change

 Overview key concepts related to the ethics of behavior

modification in public health.
1
 Behavior Change
• Behavior change approach aim to influence people to change their health related behavior
(e.g. stop smoking, eat less, exercise more, drive safely, use bike helmets or stop using drugs).

• Efforts are often expressed as wanting people to change their ‘lifestyles’

According to Glanz (2008): goal of research programs has been

“ to identify and test the most effective methods to achieve health-behavior change”

According to Simmonds (1976): defined health education as the practice of

“ bringing about behavioral changes in individuals, groups and larger populations … to behaviors that
are conducive to present and future health”
 Thus efforts are driven to find effective methods and to develop techniques
that have powerful effects, in order to achieve behavior change, and reduce
resistance to change.

These strategies include:

1. Behaviorist conditioning (e.g. use of rewards and punishment).
2. Communicative persuasion (e.g. use of subliminal information or scare campaigns).
3. Group pressure (e.g. through meeting strategies, to influence people to abstain from certain behaviors).
4. Direct instrumental power (e.g. through prohibitions or authority).

A variety of different theories (or models) are used to underpin the various
kinds of strategies to change behavior or lifestyle
 Use of social psychological theories
• Many strategies use theories to achieve their goal.
o Health belief model
o Theory of planned behavior/reasoned action
o Social cognitive theory
o Transtheoretical model
• Theories/models are used as tools for targeting specific
behaviors in order to change them.

Thus, they are instrumental in influencing and changing

health-related behavior of groups of people
 How do theories work in behavior change
approaches
Rosenburg (2008) presented teleological scientific model of how individual behavior should be explained:
Why a person acts (does, or refrains from doing, something), the following requirements have to be met:

1. The individual X wants (in a strong sense) Y (e.g. to lose weight)

2. X believes that doing Z (swim regularly) is a means to bring about Y under the circumstances

3. There is no action believed by X to be a way of bringing about Y that under the circumstances is more preferred by X (e.g. cycling)

4. X has no wants (e.g. playing computer games) that override Y

5. X knows how to do Y (e.g.can swim).

6. X is able to do Y (e.g. is healthy enough to swim).

Opportunity was added as a final requirement of the model, and reserve ability for the relevant internal features needed to
perform the action.
 Health related behavior change is the instrumental aim.

Immediate targets are usually psychological and cognitive factors (e.g. beliefs, attitudes, and self-
efficacy).

• The teleological model is used to explain action, but also for predicting and influencing action.

• Interventions often target one or several requirements in order to achieve health related change.

Ex. Interventions:

- Interventions aim to influence attitudes to wants through advertising (making 1 or 4 more or less likely).

- Changing beliefs through information (2, 3 and 5)

- Strengthening self-efficacy through discussion groups (1 and perhaps 6).

 Ethical problems with the Behavior
Change Approach
Behavior change approach has been criticized because

1. Does not respect autonomy (freedom) and the dignity of the individual.
2. Risks harming the individual
3. Risks increasing health inequalities.
Issues with the right to Autonomy and Equality

• Informing
Behavior change interventions often use
• Persuading strategies to influence a target group to
• Coercing reach a goal of behavior change

• Manipulating

Strategies do not sufficiently respect the individual’s right to autonomy (self-determination)

and liberty.
i.e. the right to decide over one’s life, and over specific issues concerning that life
 Informing people about health threats/benefits does not involve any
major ethical issues.
If the strategy is successful – individual or group found the information useful/persuasive
and choose to act on it

The degree to which different groups are likely to understand or act on the
information they get raises some ethical issues.
Low socio-economic groups – less prone to act on health advice vs. less vulnerable
groups
Due to:
- Time and effort Even if people benefit from information
- Financial campaigns or programs, there is an
- Health literacy increased risk of health inequalities
- Low motivation
- Capacity to access, understand or use health related information.
 Issues related to an individuals right to privacy
(autonomy)
‘Opportunistic’ health information: professional may take the opportunity to bring up a topic that
they may feel is relevant to the individual (or group).

This may lead to:

- An infringement of an individual’s right to privacy (autonomy) to be informed about lifestyle matters

the individual did not ask for (i.e. implying a problem).

- Questions regarding an individuals habits or ‘lifestyle’, may also cause embarrassment, unease,
shame or guilt, thus comprises their dignity.

- Stigmatization (e.g. when addressing obesity or parents who smoke).

 Issues related to persuasion and the use of authority

Authoritative persuasion: an individual (e.g. doctor, community nurse or health promoter)

pressures someone to change a behavior.
EX: Discussing smoking cessation or weight loss, but do not address more pressing
health related issues (e.g. housing, lack of education, child care).

The situation becomes an ethical question when the issue is wholly determined by the
professional, without taking into account the individuals (personal wants) and pressurizing
them to comply with advice given.

Introduces
- a mixture of paternalism (i.e. ‘to impose limitations on someone or to require actions by
someone for his or her own good’)
- authority that puts the individual in a weak position. (i.e. does not respect their right to
autonomy, and risks making them feel offended, vulnerable and powerless).
 Issues related to coercion and manipulation
• Top-down strategies constitute more serious ethical problems (e.g. legislation and
social marketing).

• All governments act paternalistically (protective manner) for good reasons (e.g.
wear seat belts, don’t drink and drive, not use narcotics).
Yet , sugar use is not prohibited, or smoking (unless in public areas), though the health
consequences are known.
people’s right to do
the state’s interest in

Tension
what they
intervening in order to
themselves find
protect the population (from
best
itself)

The less important (or the more trivial) the infringement and the greater the health gain, the less problematic the project.
Particularly if it respects other important ethical principles (e.g. equality and social justice).
 Issues related to the endorsement of manipulative
strategies
• Present in social marketing and ‘scare’ campaigns.

• Social marketing uses commercial marketing tools for the benefit of both individual (group) or
society. (e.g. using gender and age stereotypes for ‘selling’ health behavior).
- Marketing tools are often manipulative (i.e. influence the individual’s wants, and beliefs).

• The major ethical problem with manipulative marketing strategies is that they try to make the
person do something that she/he has not herself (actively) chosen—for reasons she is not fully
aware of.

• Thus, it creates inauthentic wants (1 and 4), as well as installing false beliefs (2), and,
disregards the right to autonomy (self-determination).
 • 'Scare’ campaigns aim at influencing an individuals behavior, through pre-
reflective emotional reactions, such as associating health hazards with
something unpleasant, disgusting or (vaguely) dangerous.

• These campaigns try to manipulate wants (1 or 4), or exaggerate and

provide misinformation.

Ex: ‘Scare’ campaigns may exaggerate susceptibility and severity to make people
change their behavior (as in the HBM)
- Susceptibility, e.g. the likelihood of getting HIV if you have unprotected sex.
- Perceived severity of the consequences (2).

Thus, these campaigns disregard the right to autonomy through manipulating the person’s beliefs
system, as well as distorting their wants.
 Ethical consideration: define problem and goal of the
program/intervention.

• Target behaviors selected must be most important for the individual and/or society.

• Emphasis should be given to teaching functional, age-appropriate skills, including

those with disabilities

• Goals should be consistent with basic rights of the individual (dignity, privacy, and
humane care).

• Actively involve participant in the selection of goals and identification of target

behaviors.
 Ethical considerations: selection of
intervention/treatment method.
• Use the most effective, validated methods with least discomfort and
fewest side-effects.

• Use least intrusive and restrictive interventions.

• No agreement on a continuum of intrusiveness or restrictiveness

• Provide informed consent and attain ethical approval from committees.

 Ethical considerations: on-going evaluation
• Maintenance of accurate data throughout the program.

• Carry out behavioral assessment before the program, and on-going monitoring of
the target behavior.

• Note possible side-effects

• Carry out appropriate follow-up evaluation after the program.

• Frequent discussion with participants about their progress in the program