Ethics and health promotion: research, theory, policy and practice

This special issue of the HPJA deals with ethics and health promotion. The accompanying editorial focuses particularly on Human Research Ethics Committee (HREC) approval for health promotion research, evaluation and quality assurance (QA), based on the first three papers in this issue. In this brief editorial, we introduce the remaining papers, noting some common threads that are woven through the papers.

Ethics is concerned with two sorts of questions. First: What is the right or good thing to do in a given situation? Or, what would a good person do in this situation? Second: Why is that course of action right? Or, what is it about that person or practice that makes it good? As this special issue makes plain, discerning the right and good is often difficult; it is a sphere laden with tension and challenge.

Health promotion practitioners will be especially aware of the importance of ethical sensitivity when working with Aboriginal and Torres Strait Islander communities. Several papers in this issue address this health promotion challenge specifically. The first, coauthored by Karen McPhail-Bell, Chelsea Bond, Mark Brough and Bronwyn Fredericks, is entitled ‘We don’t tell people what to do’: ethical practice and Indigenous health promotion.¹ These authors highlight the ways in which health promotion’s empowerment aims are in conflict with Australia’s historical and contemporary colonialism. They challenge health promotion to find ways to move beyond this legacy to support self-determination for Indigenous communities and individuals. Elaine Kite and Carol Davy’s paper points to the value of using Indigenist and Indigenous methodologies to define what Aboriginal and Torres Strait Islander peoples experience as quality of life.² Lilon Bandler’s provocative paper, ‘Beyond Chapter 4.7’, asks whether we should extend the ethical requirements for research engagement with Aboriginal and Torres Strait Islander Australians to all research communities and participants.³ All three papers acknowledge the need to consider values, ethical systems and health promotion practice within a cultural context.

In his paper ‘Operating from different premises: the ethics of inter-disciplinarity in health promotion’, Alan Cribb also deals with a set of value tensions.⁴ He begins with ordinary situations, illustrating the kinds of ethical dilemmas we all face in everyday life. He then draws parallels to a tension that most health promotion practitioners will recognise: that between health promotion and biomedicine. He considers the compromises, politics and underlying assumptions that are a fundamental part of, and challenge to, attempting to practice ethically in health promotion. Underlying his paper is the centrality of reflective practice or, as Cribb puts it, ‘sustained – and, ideally, theoretically informed – reflexivity’. Recognition of the crucial role that reflexivity plays in ethical reflection and analysis is also central to the four papers that follow Cribb’s contribution. The first two are by Grace Spencer, and by Luca Chiapperino and Per-Anders Tengland.^5,6 They each engage with an ethically-relevant concept: empowerment. Although this word is commonplace in health promotion, these authors suggest that the concept is more complex than it seems. The next two papers consider the centrality of critical reflection for health promotion, in quite different ways. Drew Carter and Annabel Axford describe and reflect on the experience of building ethical competencies in health promotion practice,⁷ while Rebecca Tretheway evaluates critical reflection models with respect to their ethical acceptability for health promotion practice.⁸

The remaining papers in this special issue explore specific facets of health promotion research and practice. James Smith, Dagmar Schmitt, Lisa Fereday and Jason Bonson emphasise the difficulties faced by health promotion practitioners in isolated and remote settings, using the Northern Territory as an exemplar.⁹ Their challenges are similar to those identified by Greer Lamaro, Melissa Graham and Hayley McKenzie in their paper on cross-cultural health promotion research, particularly with respect to the key role that community and cultural values can play in ethics and consent practices.¹⁰ Both papers highlight the varied and imaginative ways in which health promotion practitioners contend with the ethical challenges they encounter, and the importance of trust, transparency and reciprocity for ethical practice. These are followed by Janina Hildebrand and colleagues’ contribution on research with young people;¹¹ Lily O’Hara, Jane Taylor and Margaret Barnes’ paper on health promotion messages in the ‘war on obesity’;¹² and Clare Delany, Caroline Fryer and Gisela van Kessel on health promotion in physiotherapy practice.¹³ In each paper there is an explicit attempt to identify the values that underpin health promotion practice and to evaluate their utility. Again, reflexivity, expressed through the capacity to consider how one’s background, experiences, and professional and private identity shape encounters with research participants, patients, clients and communities, is foregrounded and crucial to ethical analysis and reflection. The final paper, by David Buchanan, considers a conundrum in health promotion research: the tension between ‘natural science’ and constructionist models of evidence generation and evaluation.¹⁴ Buchanan’s challenge to positivist science is particularly apt for this issue of the HPJA; the problems he identifies are implicit in the ways in which many of the papers in this collection shift between practice-based evidence and evidence-based practice in their search for ethical insights.

Some of the papers in this issue seek to ground their analysis in a case study that applies recognised principles to practice. Other papers seek to build ethical principles out of a case study. Readers will notice that some of the authors in this issue make conflicting arguments; this is the nature of ethical deliberation. When asking what is right or good, and why, it is possible to reach multiple, conflicting conclusions, for different reasons. The best we can do is to work through those possibilities, attempting to be as clear and coherent as we can in justifying our thinking, and engaging respectfully with those who have different points of view. In all papers in this special issue, there is a recognition that research, theory, policy and practice in health promotion is ethically contentious and demanding, and – ultimately – challenging. We hope that this issue provides opportunities to explore those challenges.