Ethical practice of health care professionals in health promotion

Health promotion as a process of empowering individuals to improve health in the social environment is based on ethical principles in medical practice and public health and on the responsibility of the social community. Whereas medical ethics dictates the observance of the principles of justice, equality, beneficence, and the respect for patient rights, freedom and personal choice in the process of achieving health care, the patient’s environment can cause ‘negative freedom’, stigmatization or restriction of choice, while the provision of an environment that promotes health is primarily considered to be the responsibility of health workers.

This review paper deals with the contemporary ethical issues and moral dilemmas that health workers face during health promotion initiatives, whose aim is to enable community residents to make a good personal choice regarding behavior that can help preserve and improve health (“healthy choice”), and to motivate them to achieve their full health potential even when their environment imposes or stimulates different choices. In the reviewed literature, special emphasis is given to the choices that the community regulates in terms of ensuring the realization of the rights and freedoms of patients and the timely dissemination of information, in the context of clinical practice.

INTRODUCTION

In the healthcare system, ethical issues in the broader context of the health of patients and citizens – the ethics in health policy and practice and public health, are intertwined with ethics in the narrower context – the ethics of the clinical practice of health workers [1],[2].

Key ethical issues for healthcare workers arise in the areas of management, organization, resource generation and health promotion financing, prevention and protection from health risks, prevention of infectious and non-infectious diseases, ensuring respect for the rights and freedoms of healthcare users, as well as in relation to information technologies, public health surveillance of diseases and health threats, health interventions and experimental research, etc. [3].

These issues are related to the observance of ethical principles, most commonly considered basic in healthcare systems around the world, such as the principle of justice, the principle of respect for human life, the principle of beneficence, and the principle of patient rights [4]. The principle of justice implies equality in terms of exercising the right to healthcare. The principle of beneficence is based on achieving the end benefit for the patient in the process of providing health care, with special emphasis on nonmaleficence (Lat. primum non nocere). Among the legitimately supported patient rights, the patient’s right to personal respect and autonomy in decision-making stand out, as well as confidentiality, informed consent and timely information about the state of health, health risks, prognosis and further diagnostic and therapeutic procedures which the patient is to undergo [5],[6]. In the European declarations/charters on the rights of patients of 1994 and 2002 [7],[8] and in some national laws (Law on Patients’ Rights, Republic of Serbia), the rights related to the free choice of a doctor, the right to a second opinion, the right to complete information when the patient is being informed about his/her state of health, as well as the patient’s right to access medical records, are defined. All information about health status, treatment conditions, diagnoses, prognosis and treatment must remain confidential even after the death of the patient [7],[8],[9]. Keeping the medical secret, as a professional duty, was described in the literature of ancient Greece, since the time of Hippocrates.

Confidential information may be disclosed only in specifically defined cases, with the consent of the patient or if stipulated by law. It is important to point out that health professionals are required to have the patient’s consent for every diagnostic and therapeutic procedure in medical practice, with a special emphasis on the end benefit of the intervention to the patient and on ensuring equality in the provision of health services.

This review article deals with contemporary ethical issues and moral dilemmas which healthcare workers are faced with during health promotion initiatives whose aim is to enable members of the community to make a good personal choice of behavior oriented towards preserving and improving health (‘healthy choice’), and to motivate them to achieve their full health potential, even when their environment imposes or encourages them to make different choices. In the reviewed literature, a description is given of the approach to solving ethical issues, primarily those related to the choices that the community regulates in terms of ensuring the realization of patient rights and freedoms and timely information, in the context of clinical practice.

For the purpose of this study, a review of the literature obtained by analyzing the collected publications that were published in the period including the last decade of the 20^th century and the first two decades of the 21^st century, was done, with the help of the following keywords: ethics, healthcare workers, medical practice, health promotion, public health.

After being analyzed, the most important results from the literature review were synthesized and categorized so as to describe ethical issues and approaches from the point of view of health workers engaged in activities of individual and community health promotion.

ETHICAL ISSUES IN HEALTH PROMOTION

Ethical issues in the process of health promotion are manifested in the problems that patients and citizens encounter in their community with regards to the respect for and provision of their freedom of choice, as well as with regards to their ability to exercise it. Namely, in a regulated society, an individual has a responsibility towards society, but the community should also create a context that allows the individual to achieve an adequate level of health [10]. From the perspective of freedom, each individual can make good or bad choices, and therefore has responsibility for attitudes and behaviors that affect health. The social structure, i.e., the social context, is the basis within which an individual can decide on good or bad choices [11]. It is a fact that a responsible society provides the individual with the conditions necessary for health (safe drinking water, food, access to health services, vaccination, and other public health benefits), and that a society with fewer socio-economic inequalities represents a healthier society

Ethical dilemmas in health promotion relate to the connection between personal health-related choices of individuals and the conditions in the community. The positive concept of freedom and health implies the interrelation between individuals and the environment in which individuals have different opportunities to reach an adequate level of health. An example of this relates to smoke-free law campaigns and their impact on the freedom of individuals to choose their own behavior. Namely, in countries where smoking bans are respected, a safe environment has been created in which it is possible to make a healthy choice. Consequently, the prevalence of smoking is lower and other health indicators are more favorable, which means that an adequate level of health in the population has been achieved. The ethical dilemma that arises is whether paternalism is what we need in health promotion, or is it manipulative, in the sense that others are perceived to know better than us as to what is good for us, i.e., others determine and impose on us the choices they consider healthy. Researchers Thaler and Sunstein point out that the paternalistic approach is democratic, if the common good, i.e., common benefit, is considered to be above everything, including individual interests [12],[13].

Public health campaigns are also an example of how to help individuals make good choices. However, if the individual does not have the opportunity, as well as the support of the environment, to make a good choice, then the ethics of marketing and communication interventions in the field of health promotion is called into question. Healthy choices require creating community architecture that is accessible to all, such as bicycle lanes.

If we look at health promotion in the broader context of health care provision, then a clinical environment that supports the ‘right choices’ can be ethically considered in terms of medical paternalism. Eriksson and Lindström emphasize the process of creating healthy choices or ‘healthy learning’ as a mode of communication in the health care worker – patient relationship, which is based on trust and guidance through learning about healthy choices [14],[15].

The ban on smoking, the obligation to wear seat belts while driving, meals with whole grain cereals, meals with fresh fruits and vegetables, these all represent the influence of certain components of society in health promotion, which, when working to strengthen health, lead to ‘negative freedom’, thus limiting the autonomy of patients and citizens by imposing attitudes or examples of practice and by aiming to persuade the public as to the suitability of certain choices that are socially desirable [10].

According to the theory of negative freedom, there is no interference between individuals and the state, and individuals are responsible for their own health and free to make choices regarding their own health. In contrast, when the community creates resources and equal opportunities for each individual to participate in the activities of the society according to his/her own needs, this is ‘positive freedom’, which emphasizes that moral dilemmas and ethical issues are related to the strength of the connection between individual needs and freedoms and the characteristics of the community.

Ethical dilemmas also exist regarding consent as to the way that communication interventions are implemented, i.e., regarding the admissibility of valid evidence, as well as in relation to whether invested public resources are being used in the most efficient way [16],[17].

Ethical issues also refer to the equal availability of promotional material for all segments of the population, through various media, which is reflected in the possibility of increasing the literacy of the population in the use of certain media (e.g., digital medina), thus enabling the effective use of health promotion material [18],[19].

Health promotion activities must be in line with the moral obligation of promoting the equality of implementation in all social groups, although there are scientific facts that testify to differences in the provision of services and increased availability of services to certain segments of the population [20].

APPROACHES TO RESOLVING ETHICAL ISSUES IN HEALTH PROMOTION

The concept of positive freedom in resolving ethical issues in the field of health promotion is significant because it calls for social communities to carry out activities and responsibly dispose of resources in the process of preserving and improving health needs and freedoms [11].

In the process of resolving ethical issues in healthcare systems, the most commonly applied approach is from the point of view of the existence of evidence of end benefit for patients [21], as well as of the autonomy or independence of the patient in making decisions when using healthcare [22]. In promoting health and ensuring universal, comprehensive, just, and affordable healthcare in the community, ethical principles that are supported by scientific evidence regarding the general public health benefit of medical procedures are also respected [23].

The basis of the concept of health promotion within the healthcare system is ‘patient empowerment’, which implies constant efforts of health workers to educate patients for making appropriate and healthy lifestyle choices and to empower patients to make lifestyle changes that improve health. It is considered that, in all situations when healthcare services are provided to patients, the patient should be educated on the right choices necessary for attaining the highest level of health and instructed to take responsibility for their own choices, in order to build mutual trust, raise motivation for ‘healthy choices’, and empower citizens [24].

A particular goal of health promotion is the improvement of health through mechanisms for improving the economic and social circumstances of persons with certain functional deficiencies or risk factors, which may reduce the end benefit for the patient [25]. In this regard, it is important to point out that, in communication interventions in the domain of addiction to tobacco, psychoactive substances and food, health workers should have the skills to recognize the psychological characteristics of the patient and motivational factors, in order to reduce the possibility of stigmatization during therapy, as well as increase the effect of the therapy itself [16].

Apart from individuals (citizens or patients) and the health system (health workers), as potential creators of an empowered society with the desired level of health and well-being, social conditions and resources for health are also necessary, which, according to the Ottawa Charter for Health Promotion (1986), should be equally accessible, should be used fairly, and there should be solidarity - the willingness to help others. This refers to environmental resources such as a stable ecological system, education, income, healthy food and water, and sustainable resources in the community.

Each citizen has a different potential to achieve the highest level of health. Therefore, in resolving ethical dilemmas in health promotion, the health worker primarily relies on the individual characteristics of the patient, taking into account both the values of the community and the impact of society on health [26]. Namely, according to Powers’ and Faden’s theory of social justice and well-being, health is one of the six dimensions of human well-being, inseparable from personal security, reasoning, respect, attachment, and self-determination [25]. In this sense, if there is an ethical dilemma, a solution is sought that supports the right of everyone (without exemption) to achieve a certain level in each of these dimensions, while society (public institutions in the sectors of health, education, administration, food production, trade and tourism, as well as other segments of the community that ensure health) should provide the necessary resources [25],[10].

From the aspect of ethics, in health promotion activities, it is important to ensure evidence-based practices, while respecting patient rights, their personal choices, habits, and the cultural characteristics of individuals and the environment, without the risk of stigmatization and without any discrimination in the provision of health promotion services. [27]. It is necessary to respect, strengthen, highly value, and improve the image of the work of health workers who carry out health promotion activities, because they have a moral obligation to improve health through the basic ethical principle of nonmaleficence [28], which, since Hippocrates, has been considered a postulate for all communication interventions in health promotion. In this way, communication interventions in health promotion should be aimed at the individual or the community at the physiological, psychological, social, and cultural levels, so as to prevent stigmatization and enable just and equitable provision of health services, with the aim of improving public health.

CONCLUSION

Ethical dilemmas and issues are present in all forms of medical practice, from informal forms of health education to formal, institutional forms of providing health services in the community, where health workers play a key role in empowering patients to make healthy choices. Health promotion activities should be carried out in keeping with the basic ethical principles of justice, equality, respect for individual rights, as well as sensitivity to all social issues and mutual relations of community members, in order to suppress the stigmatization of certain sections of the population, promote social good and improve the health of the community.