Empowerment in healthcare policy making: three domains of substantive controversy
Luca Chiapperino A B D and Per-Anders Tengland C
+ Author Affiliations
- Author Affiliations
A European Institute of Oncology, via Adamello 16, 20139 Milan, Italy.
B Italian Institute of Technology, via Adamello 16, 20139 Milan, Italy.
C Faculty of Health and Society, Jan Waldenströms gata 25, Malmö University, 205 06 Malmö, Sweden.
D Corresponding author. Email: luca.chiapperino@ieo.eu
Health Promotion Journal of Australia 26(3) 210-215 https://doi.org/10.1071/HE15035
Submitted: 8 May 2015 Accepted: 19 October 2015 Published: 10 December 2015
Abstract
This paper distinguishes between the uses of empowerment across different contexts in healthcare policy and health promotion, providing a model for the ethical and political scrutiny of those uses. We argue that the controversies currently engendered by empowerment are better understood by means of a historical distinction between two concepts of empowerment, namely, what we call the radical empowerment approach and the new wave of empowerment. Building on this distinction, we present a research agenda for ethicists and policy makers, highlighting three domains of controversy raised by the new wave of empowerment, namely: (1) the relationship between empowerment and paternalistic interferences on the part of professionals; (2) the evaluative commitment of empowerment strategies to the achievement of health-related goals; and (3) the problems arising from the emphasis on responsibility for health in recent uses of empowerment. Finally, we encourage the explicit theorisation of these moral controversies as a necessary step for the development and implementation of ethically legitimate empowerment processes.
References
[1] Segal L (1998) The importance of patient empowerment in health system reform. Health Policy 44, 31–44.| The importance of patient empowerment in health system reform.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1c3psFaqtw%3D%3D&md5=c763c77194b3a0c8169ac6322127a057CAS | 10180200PubMed |
[2] Laverack GU. Public health: power, empowerment and professional practice. London: Palgrave Macmillan; 2005.
[3] Veitch K (2010) The government of health care and the politics of patient empowerment: New Labour and the NHS reform agenda in England. Law Policy 32, 313–31.
| The government of health care and the politics of patient empowerment: New Labour and the NHS reform agenda in England.Crossref | GoogleScholarGoogle Scholar |
[4] Colombo C, Moja L, Gonzalez-Lorenzo M, Liberati A, Mosconi P (2012) Patient empowerment as a component of health system reforms: rights, benefits and vested interests. Intern Emerg Med 7, 183–7.
| Patient empowerment as a component of health system reforms: rights, benefits and vested interests.Crossref | GoogleScholarGoogle Scholar | 22278387PubMed |
[5] Woodall JR, Warwick-Booth L, Cross R (2012) Has empowerment lost its power? Health Educ Res 27, 742–5.
| Has empowerment lost its power?Crossref | GoogleScholarGoogle Scholar | 22717939PubMed |
[6] Freire P. Pedagogy of the oppressed. New York: Continuum; 2005.
[7] Rappaport J (1987) Terms of empowerment/exemplars of prevention: toward a theory for community psychology. Am J Community Psychol 15, 121–48.
| Terms of empowerment/exemplars of prevention: toward a theory for community psychology.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL2s3mslCgsQ%3D%3D&md5=35db0f2222297d8d55b56faff1e41dd2CAS | 3604997PubMed |
[8] Wallerstein N, Bernstein E (1988) Empowerment education: Freire’s ideas adapted to health education. Health Educ Q 15, 379–94.
| Empowerment education: Freire’s ideas adapted to health education.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL1M7lsFWjtw%3D%3D&md5=b270e59a09a5ebbc7876a3e03a3ade73CAS | 3230016PubMed |
[9] Rodwell CM (1996) An analysis of the concept of empowerment. J Adv Nurs 23, 305–13.
| An analysis of the concept of empowerment.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK283gvFSlug%3D%3D&md5=3367da57421c64e16ad50b65461aeb57CAS | 8708244PubMed |
[10] Laverack G, Labonte R (2000) A planning framework for community empowerment goals within health promotion. Health Policy Plan 15, 255–62.
| A planning framework for community empowerment goals within health promotion.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M%2FnslyhsA%3D%3D&md5=c30dbf86108a134e40bc42942ba62f74CAS | 11012399PubMed |
[11] Richards T, Coulter A, Wicks P (2015) Time to deliver patient centred care. BMJ 350, h530
| Time to deliver patient centred care.Crossref | GoogleScholarGoogle Scholar | 25670197PubMed |
[12] Callon M, Lascoumes P, Barthe Y. Acting in an uncertain world. An essay in technical democracy. Cambridge, MA: The MIT Press; 2001.
[13] Jasanoff S. Designs on nature. Science and democracy in Europe and the United States. Princeton, NJ: Princeton University Press; 2005.
[14] Wallerstein N. What is the evidence on effectiveness of empowerment to improve health? WHO Regional Office for Europe, Health Evidence Network report. Geneva: World Health Organization (WHO); 2006.
[15] Herbert RJ, Gagnon AJ, Rennick JE, O’Loughlin JL (2009) A systematic review of questionnaires measuring health-related empowerment. Res Theory Nurs Pract 23, 107–32.
| A systematic review of questionnaires measuring health-related empowerment.Crossref | GoogleScholarGoogle Scholar | 19558027PubMed |
[16] Mok E (2001) Empowerment of cancer patients: from a Chinese perspective. Nurs Ethics 8, 69–76.
| Empowerment of cancer patients: from a Chinese perspective.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2MzlsleqtA%3D%3D&md5=90df19cc2cb8679b38a1e971ab6fd963CAS | 16010910PubMed |
[17] Wilson PM (2008) The UK Expert Patients Program: lessons learned and implications for cancer survivors’ self-care support programs. J Cancer Surviv 2, 45–52.
| The UK Expert Patients Program: lessons learned and implications for cancer survivors’ self-care support programs.Crossref | GoogleScholarGoogle Scholar | 18648986PubMed |
[18] Stang I, Mittelmark MB (2010) Intervention to enhance empowerment in breast cancer self-help groups. Nurs Inq 17, 47–57.
| Intervention to enhance empowerment in breast cancer self-help groups.Crossref | GoogleScholarGoogle Scholar | 20137030PubMed |
[19] Ryhänen AM, Rankinen S, Siekkinen M, Saarinen M, Korvenranta H, Leino-Kilpi H (2012) The impact of an empowering Internet-based breast cancer patient pathway programme on breast cancer patients. Patient Educ Couns 22, 1016–25.
| The impact of an empowering Internet-based breast cancer patient pathway programme on breast cancer patients.Crossref | GoogleScholarGoogle Scholar |
[20] Martin GW (1998) Empowerment of dying patients: the strategies and barriers to patient autonomy. J Adv Nurs 28, 737–44.
| Empowerment of dying patients: the strategies and barriers to patient autonomy.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1M%2FksFWhtA%3D%3D&md5=62ef4a36112da2f1b218d9eeeee86eb4CAS | 9829661PubMed |
[21] Minkler M (1999) Personal responsibility for health? A review of the arguments and the evidence at century’s end. Health Educ Behav 26, 121–41.
| Personal responsibility for health? A review of the arguments and the evidence at century’s end.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1M7jsFGhtQ%3D%3D&md5=6dd63a13e26aeb4f3a250d7508a2e60dCAS | 9952056PubMed |
[22] Chamberlin J (1997) A working definition of empowerment. Psychiatr Rehabil J 20, 43–6.
[23] Anderson RM, Funnell MM (2005) Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm. Patient Educ Couns 57, 153–7.
| Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm.Crossref | GoogleScholarGoogle Scholar | 15911187PubMed |
[24] Asimakopoulou KG, Newton P, Scambler S (2010) ‘First do no harm’: the potential shortfalls of empowerment in diabetes. Int Diabetes Nurs 7, 79–81.
| ‘First do no harm’: the potential shortfalls of empowerment in diabetes.Crossref | GoogleScholarGoogle Scholar |
[25] Tuohimaa H (2014) In search of an empowering and motivating personal wellbeing pathway for Finnish heart patients. Springerplus 3, 475
| In search of an empowering and motivating personal wellbeing pathway for Finnish heart patients.Crossref | GoogleScholarGoogle Scholar | 25279284PubMed |
[26] Lodewijk B. Patient empowerment: a two-way road. In Wickramasinghe N, editor. Critical issues for the development of sustainable e-health solutions, Healthcare delivery in the information age (pp. 203–27). New York, NY: Springer; 2012.
[27] European Science Foundation. Forward look: personalised medicine for the European citizen. Strasbourg: Ireg; 2012.
[28] Prainsack B, Reardon J, Hindmarsh R, Gottweis H, Naue U, Lunshof JE (2008) Personal genomes: misdirected precaution. Nature 456, 34–5.
| Personal genomes: misdirected precaution.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD1cXhtlCjtrrP&md5=fafc4bbb037c924ac73eadcd60daed26CAS | 18987720PubMed |
[29] Juengst ET, Flatt MA, Settersten RA (2012) Personalized genomic medicine and the rhetoric of empowerment. Hastings Cent Rep 42, 34–40.
| Personalized genomic medicine and the rhetoric of empowerment.Crossref | GoogleScholarGoogle Scholar | 22976411PubMed |
[30] World Health Organization. Innovative care for chronic conditions: building blocks for action: global report. 2002. Available from: http://www.who.int/chp/knowledge/publications/icccglobalreport.pdf?ua=1 [Verified 26 October 2015].
[31] Salmon P, Hall GM (2004) Patient empowerment or the emperor’s new clothes. J R Soc Med 97, 53–6.
| Patient empowerment or the emperor’s new clothes.Crossref | GoogleScholarGoogle Scholar | 14749397PubMed |
[32] Sandroff R (2012) Are you feeling empowered yet? Hastings Cent Rep 42, 3
| Are you feeling empowered yet?Crossref | GoogleScholarGoogle Scholar | 22976401PubMed |
[33] Goldstein MM, Bowers D (2015) The patient as consumer: empowerment or commodification? J Law Med Ethics 43, 162–5.
| The patient as consumer: empowerment or commodification?Crossref | GoogleScholarGoogle Scholar | 25846046PubMed |
[34] Tengland PA (2007) Empowerment: a goal or a means for health promotion? Med Health Care Philos 10, 197–207.
| Empowerment: a goal or a means for health promotion?Crossref | GoogleScholarGoogle Scholar | 17089207PubMed |
[35] Tengland PA (2008) Empowerment: a conceptual discussion. Health Care Anal 16, 77–96.
| Empowerment: a conceptual discussion.Crossref | GoogleScholarGoogle Scholar | 17985247PubMed |
[36] Tengland PA (2012) Behavior change or empowerment: on the ethics of health-promotion strategies. Public Health Ethics 5, 140–53.
| Behavior change or empowerment: on the ethics of health-promotion strategies.Crossref | GoogleScholarGoogle Scholar |
[37] Tengland PA (2013) Behavior change or empowerment: on the ethics of health-promotion goals. Health Care Anal
| Behavior change or empowerment: on the ethics of health-promotion goals.Crossref | GoogleScholarGoogle Scholar | 24100936PubMed |
[38] Wallerstein N (1992) Powerlessness, empowerment and health: implications for health promotion programs. Am J Health Promot 6, 197–205.
[39] Wartenberg T. The forms of power. Philadelphia: Temple University Press; 1990.
[40] Perkins DD (1995) Speaking truth to power: empowerment ideology as social intervention and policy. Am J Community Psychol 23, 765–94.
| Speaking truth to power: empowerment ideology as social intervention and policy.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s%2FgsVSgug%3D%3D&md5=b463aa343efac9835c0bba8cc601bbd6CAS | 8851349PubMed |
[41] Taylor G, Hawley H (2006) Health promotion and the freedom of the individual. Health Care Anal 14, 15–24.
| Health promotion and the freedom of the individual.Crossref | GoogleScholarGoogle Scholar | 17137016PubMed |
[42] Christens BD (2013) In search of powerful empowerment. Health Educ Res 28, 371–4.
| In search of powerful empowerment.Crossref | GoogleScholarGoogle Scholar | 23487560PubMed |
[43] European Commission. Commission staff working document: use of ‘-omics’ technologies in the development of personalised medicine. Brussels: European Commission; 2013.
[44] Covolo L, Rubinelli S, Orizio G, Gelatti UO (2012) Misuse (and abuse?) of the concept of empowerment. The case of online offer of predictive direct-to-consumer genetic tests. J Public Health Res 1, 7–10.
| Misuse (and abuse?) of the concept of empowerment. The case of online offer of predictive direct-to-consumer genetic tests.Crossref | GoogleScholarGoogle Scholar | 25170440PubMed |
[45] Great Britain Department of Health. The NHS improvement plan: putting people at the heart of public services. London: The Stationery Office; 2004.
[46] Great Britain Department of Health. Choosing health: making healthy choices easier. London: The Stationery Office; 2004.
[47] Great Britain Department of Health. The NHS cancer plan and the new NHS: providing a patient-centred service. London: The Stationery Office; 2004.
[48] Great Britain Department of Health. Creating a patient-led NHS: delivering the NHS improvement plan. London: The Stationery Office; 2005.
[49] Great Britain Department of Health. High quality care for all. NHS next stage review final report. London: The Stationery Office; 2008.
[50] Thorpe C (2010) Participation as post-Fordist politics: Demos, New Labour, and science policy. Minerva 48, 389–411.
| Participation as post-Fordist politics: Demos, New Labour, and science policy.Crossref | GoogleScholarGoogle Scholar | 21258426PubMed |
[51] World Health Organization. Ottawa Charter for Health Promotion. Adopted at the international conference on health promotion, ‘The Move Towards A New Public Health’. 1986. Available from: http://www.phac-aspc.gc.ca/ph-sp/docs/charter-chartre/pdf/charter.pdf [Verified 26 October 2015].
[52] Great Britain Department of Health. Equity and excellence: liberating the NHS. London: The Stationery Office; 2010.
[53] Great Britain Department of Health. Liberating the NHS: local democratic legitimacy in health. London: The Stationery Office; 2010.
[54] Great Britain Department of Health. Liberating the NHS: commissioning for patients. London: The Stationery Office; 2010.
[55] Great Britain Department of Health. Liberating the NHS: transparency in outcomes – a framework for the NHS. London: The Stationery Office; 2010.
[56] Great Britain Department of Health. Healthy lives, healthy people. Our strategy for public health in England. London: The Stationery Office; 2010.
[57] Cribb A. Health and the good society: setting healthcare ethics in social context. Oxford: Oxford University Press; 2005.
[58] Swift C (1984) Empowerment: an antidote for folly. Prev Hum Serv 3, xi–xv.
| Empowerment: an antidote for folly.Crossref | GoogleScholarGoogle Scholar |
[59] Feste C, Anderson RM (1995) Empowerment: from philosophy to practice. Patient Educ Couns 26, 139–44.
| Empowerment: from philosophy to practice.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK28%2FjslCktw%3D%3D&md5=0234675bc27d54e304a7cc8c45dc19ddCAS | 7494713PubMed |
[60] Buchanan D. An ethic for health promotion: rethinking the sources of human well-being. New York: Oxford University Press; 2000.
[61] Fox NJ, Ward KJ, O’Rourke AJ (2005) The ‘expert patient’: empowerment or medical dominance? The case of weight loss, pharmaceutical drugs and the Internet. Soc Sci Med 60, 1299–309.
| The ‘expert patient’: empowerment or medical dominance? The case of weight loss, pharmaceutical drugs and the Internet.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2M%2FgtFGgsw%3D%3D&md5=cd4066c444ff3833952dcaafdf260d3aCAS | 15626525PubMed |
[62] Holland S. Public health ethics. Cambridge: Polity; 2007.
[63] Rose N. The politics of life itself. Biomedicine, power and subjectivity in the twenty-first century. Princeton: Princeton University Press; 2007.
[64] Greenhalgh T, Wessely S (2004) ‘Health for me’: a sociocultural analysis of healthism in the middle classes. Br Med Bull 69, 197–213.
| ‘Health for me’: a sociocultural analysis of healthism in the middle classes.Crossref | GoogleScholarGoogle Scholar | 15226207PubMed |
[65] Wilkinson S (1999) Smokers’ rights to health care: why the ‘restoration argument’ is a moralising wolf in a liberal sheep’s clothing. J Appl Philos 16, 255–69.
| Smokers’ rights to health care: why the ‘restoration argument’ is a moralising wolf in a liberal sheep’s clothing.Crossref | GoogleScholarGoogle Scholar | 15497230PubMed |
[66] Buyx A, Prainsack B (2012) Lifestyle-related diseases and individual responsibility through the prism of solidarity. Clin Ethics 7, 79–85.
| Lifestyle-related diseases and individual responsibility through the prism of solidarity.Crossref | GoogleScholarGoogle Scholar |
[67] Brown RCH (2013) Moral responsibility for (un)healthy behaviour. J Med Ethics 39, 695–8.
| Moral responsibility for (un)healthy behaviour.Crossref | GoogleScholarGoogle Scholar |
[68] Marmot M, Wilkinson R, editors. Social determinants of health. Oxford: Oxford University Press; 2005.
[69] World Health Organization (WHO). Review of social determinants and the health divide in the WHO European region: final report. Geneva: WHO Press; 2013.