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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
Behavior Change or Empowerment: On
the Ethics of Health-Promotion
Strategies
Per-Anders Tengland*
Abstract
There are several strategies to promote health in individuals and populations. Two general
approaches to health promotion are behavior change and empowerment. The aim of this article is to
present those two kinds of strategies, and show that the behavior-change approach has some moral
problems, problems that the empowerment approach (on the whole) is better at handling. Two
distinct ‘ideal types’ of these practices are presented and scrutinized. Behavior change interventions
use various kinds of theories to target people’s behavior, which they do through information,
persuasion, coercion and manipulation. Empowerment is a collaborative method where those
‘facilitated’ participate in the change process. Some ethical problems with the behavior-change
model are that it does not sufficiently respect the right to autonomy of the individuals involved and
risks reducing their ability for autonomy, and that it risks increasing health inequalities.
Empowerment, on the other hand, respects the participant’s right to autonomy, tends to increase
the ability for autonomy, as well as increasing other coping skills, and is likely to reduce inequalities.
A drawback with this approach is that it often takes longer to realize.
Introduction
There are three main ethical issues related to public health (including health promotion). i) What are
the (ultimate) goals for public health practice, i.e. what ‘good’ should be achieved? ii) How should
this good be distributed in the population? iii) What means are we allowed to use in trying to achieve
and distribute this good (Brülde, 2011b)? The last question is possibly the most important of the
Background
There are a great number of strategies to promote health in groups, communities and populations.
We can legislate (Downie et al., 1996: 136, 137), e.g. prohibit certain things; we can use fiscal means
to change people’s behavior patterns (Downie et al., 1996: 52, 53), e.g. increase or reduce tax on
certain items; we can use communication strategies (Finnegan and Viswanath, 2008), e.g. inform
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
people, or even manipulate them, e.g. through social marketing techniques (Cheng et al., 2011); we
can try to persuade, induce or ‘nudge’ people into certain kinds of behavior (Buchanan, 2000; Thaler
and Sunstein, 2008); we can cooperate with and ‘facilitate' people (Rogers, 1961; Freire, 1972;
Laverack, 2009) and we can change the environment (Baum, 2008: 389 ff.), e.g. install speed bumps
in order to reduce vehicle speed and thereby reduce the risk of accidents. These interventions, in
general, consist of top–down strategies, where a government, ministry, county council or
municipality decide to change some factors in order to reduce the risk of illness, disease or injury, or
augment the likelihood of increasing or sustaining population health (Verweij and Dawson, 2007).
However, not all strategies are top–down. Some are ‘local’, which means that they involve
professionals meeting people eye-to-eye. Mostly, these interventions are concerned with people,
groups or communities that are vulnerable in one way or another. Roughly, the individuals and
groups that might need support fall into two overlapping categories. Their problems might have to
do with their living conditions, such as poverty, marginalization, poor housing and unemployment,
which put them at a risk of developing illness or disease. Or they have a ‘risk behavior’ or a ‘lifestyle’
problem, such as smoking, drinking alcohol, using drugs, engaging in unsafe sex, or being overweight
or obese. Research shows that if one belongs to a vulnerable group, one is more likely to have
lifestyle problems (Marmot and Wilkinson, 1999; Marmot, 2004; Baum, 2008), and most lifestyle
problems, save for alcohol consumption, are more common in vulnerable and low socio-economic
groups (Pellmer and Wramner, 2009).
Few population strategies directly increase or sustain the health of the population (Nordenfelt, 1991;
Tengland, 2010).1 Most of them are indirect or instrumental, where improvements in (future) health
are achieved through some other change or activity, e.g. when an information campaign makes
people eat more fruit and vegetables, which leads to better overall health, or when the construction
of a new bike lane makes people bike to work, thereby increasing their general fitness. As the
examples show, some of these indirect strategies have to do with internal changes (within the
individual), and some with external (environmental) changes.
Among the general strategies that try to deal with these kinds of problems, we find two approaches,
namely behavior change and empowerment. Both these kinds of approaches purport to help people
achieve better health. A major difference is that the empowerment approach can only be used in
‘local’ interventions, since it requires collaboration with the individuals involved, whereas behavior-
change strategies can be used in both top–down and local interventions. Despite their common
general aim, i.e. sustained and increased health, both have their specific approach or ‘tools’. These
approaches and these tools might partly overlap, but they also seem to come into conflict.
Aims and Method
The aims of this study are to present the behavior-change approach and display some of its moral
disadvantages, to introduce the empowerment approach as an alternative strategy and show that it
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
can handle most of the problems of the first approach and, finally, to discuss some of the potential
problems with the empowerment approach and how they can be dealt with. Several ethical
arguments will be given, but primarily they will be rights-based and consequentialist and, to some
extent, egalitarian ones.
There are obviously many different versions of these two approaches, some of which might make
them seem more or less identical. In order to make behavior change and empowerment stand out as
real alternatives, I have created two distinct ‘ideal types’ of these practices (Ringer, 1997). As to
empowerment, I will use my own earlier analysis of the concept (Tengland, 2008). Concerning the
behavior-change approach, I will state what I believe to be some of its core characteristics, so that it
becomes a clear alternative to the empowerment approach. Scientific literature has, then, been
studied and analyzed in order to produce these two ‘ideal types’.
The Two Approaches to Health Promotion
In the following sections I will present the two approaches, and then turn to a discussion and
evaluation of them. Before that, in order to understand what the means used are aimed at, we need
to know more about the aims of the two approaches discussed. Their main general aim (in this
context2) is health.3 The instrumental aims of the two approaches, purporting to lead to better
health, are somewhat different. The instrumental aim in one case is changing health-related behavior
or lifestyle, and in the other, helping people acquire better control over the determinants of their
health (Tengland, 2011). As we shall see, there are also lower-level instrumental goals targeted, such
as beliefs, attitudes, skills or environment changes.
Means to Behavior Change
In brief, professionals working with the behavior-change approach want to influence (other) people
to change their health-related behavior, be it to stop smoking, eat less, eat better, exercise more,
drink less alcohol, use condoms, abstain from unsafe sex, drive more carefully, use bike helmets or
stop using drugs (Buchanan, 2000: 41; Earl and O’Donnell, 2007: 81; Holland, 2007: 112 ff.). This is
sometimes expressed as wanting to make people change their ‘lifestyles’ (Lalond, 1974; Earl and
O’Donnell, 2007: 81, ff.; Holland, 2007: 112 ff.).4 According to Glanz et al. (2008), an important goal
of research programs has been ‘to identify and test the most effective methods to achieve health-
behavior change’ (p. 16). This is not a new thought. In 1976, Simonds 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’ (in Glanz et al., 1997: 7). There is,
furthermore, a striving to find ‘effective methods’ (Glanz et al., 2008: 16) and to ‘develop techniques’
(Glanz et al., 1997: 26) that have ‘powerful effects’ (Glanz et al., 2008: 4), in order to achieve
behavior change, and ‘reduced resistance to change’ (Glanz et al., 1997: 26).
David Buchanan mentions four kinds of (more or less problematic) strategies that the behavior-
change approach uses to influence people to change their behavior: behaviorist conditioning, e.g.
through ‘rewards’ and ‘punishment’; communicative persuasion, e.g. through subliminal information
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
or ‘scare’ campaigns; group pressure, e.g. through ‘meeting strategies’ where people are influenced
to abstain from certain kinds of behavior; and direct instrumental power, e.g. through prohibitions or
authority (Buchanan, 2000: 35). Furthermore, a variety of different theories (or models) are used to
underpin the various kinds of strategies to change behavior or lifestyle (Buchanan, 2000).
What is common for many of these strategies is that they often use some kind of social psychological
theory, e.g. the health belief model, the theory of reasoned action, or the social cognitive theory
(Buchanan, 2000), in order to achieve their ends. Other theories used are the transtheoretical (stages
of change) model, the diffusion of innovation theory, and the communication–behavior change
model (Glanz et al., 2008; Nutbeam et al., 2010). These theories and models are used as tools for
targeting specific kinds of behaviors in order to change them. Thus, they are instrumental in
influencing and changing the health-related behavior of groups of people (Buchanan, 2000: 14, ff.;
Nutbeam et al., 2010: 9). Several authors and theoreticians emphasize their practical utility (Glanz et
al., 2008: chs. 2, 22). ‘[T]heories can help us to understand what methods we can use’, and clarify
‘the most effective means of achieving change’ (Nutbeam et al., 2010: 3), and according to Bandura,
the ultimate test of theories is ‘when they indicate methods that are “capable of effecting significant
changes in human affect, thought, and action”’ (in Maibach and Parrott, 1995: viii.).
Health-related behavior change is the primary instrumental aim, but the immediate targets are
typically psychological or cognitive factors, such as beliefs, attitudes and self-efficacy, and to a lesser
extent the environment (Bandura, 1982; Downie et al., 1996: 29–31; Tones and Green, 2004: 80 ff.;
Baum, 2008). The psychological or social environment is sometimes also targeted, as with social
cognitive theory (Nutbeam et al., 2010: 17), but traditionally, the physical, social and cultural
environments receive little attention (Baum, 2008: 457).5
Let us look closer at how the theories work. First, they accept a teleological scientific model of how
individual behavior should be explained. One elaborate version of this kind of ‘practical syllogism’ is
presented by Rosenberg (2008: 35). In order to explain why a (rational6) agent 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 (can swim); and 6: X is able to do Y (is
healthy enough to swim). Because ‘ability’ sometimes includes ‘opportunity’ and sometimes excludes
it, it is important to distinguish between them, especially since the distinction is crucial in discussing
health promotion. All the above-mentioned premises might be fulfilled, but there might not be a
possibility to act. For example, having decided to exercise through swimming in the public swimming
pool, the person might find that the pool is closed for maintenance. I will therefore add 7:
opportunity as a final requirement of the model, and reserve ability for the relevant internal features
needed to perform the action.
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
All of the above-mentioned social, psychological and other theories (or models) use this way of
reasoning, albeit in more rudimentary forms [steps 3 and 4 are usually not mentioned, but have to be
considered, since there are usually both alternative action strategies and overriding wants to take
into account. Real opportunity (7) is also often ignored in these models, even though ‘perceived’
opportunity might be mentioned]. The teleological model is used for explaining action, but also for
predicting and influencing action. The interventions target one or several of these requirements in
order to achieve health-related change, such as trying to influence attitudes to wants through
advertising (making 1 or 4 more, or less, likely), changing beliefs through information (2, 3 and 5), or
strengthening self-efficacy through discussion groups (1, and perhaps 6).
Empowerment as a Goal and as a Process
The term ‘empowerment’ has two distinct meanings, one referring to a state of the individual, group
or community (and a goal to be achieved in empowerment projects), and the other referring to the
process (or means) to attain the goals (empowerment in the first sense) sought (Tengland, 2008). The
first meaning will not concern us much here, but it still needs to be mentioned. Empowerment as a
state concerns the individual’s (or group’s) control over her (their) life. More precisely: to be
empowered is to have control over the determinants of (i.e. those factors that contribute to) one’s
quality of life. Because we are within a health promotion context, we are not interested in all kinds of
control, but mainly in health-related control (Tengland, 2007). The ability for autonomy (self-
determination) has a central place in this approach, because the higher it is, the better the individual
will be at determining her authentic goals (Tengland, 2007, 2008).7
The second definition of empowerment (as a process) is more important for us here, since it has to
do with the means of working toward health, empowerment and quality of life. Empowerment as a
process (a means) is directly related to professional practice on the ‘local’ level, i.e. working together
with the people involved. The concept is found in literature discussing civil rights movements in the
1960s and onwards (Rissel, 1994; Starrin, 1997; Craig et al., 2011), and the idea is inspired by, among
others, Paolo Freire (1972) and Carl Rogers (1961, 1977).
Empowerment as a process is about letting the client, group or community have as much control as
possible over the change processes they are involved in (Rogers, 1961; Freire, 1972; Tengland, 2008;
Laverack, 2009). They should therefore actively participate in the problem formulation, the solutions
to the problems and the actions performed to solve them. The professional should primarily be an
enabler or a facilitator.
As distinct from the behavior-change approach, which primarily relies on cognitive or behavioral
psychology, the empowerment approach is based on humanist–existentialist ideas about human
nature. One difference is that the empowerment approach emphasizes that individuals themselves
have the (internal) means to change and develop in a positive direction. Given psychological
conditions that include empathic listening, nonjudgmental attitudes, genuine participation on the
part of the professionals and enabling dialogical conditions, as well as (external) opportunities, the
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
individuals or groups involved will empower themselves (Rogers, 1961, 1977; Freire, 1972;
Wallerstein and Bernstein, 1988; Tones and Green, 2004; Laverack, 2009). No persuading, rewarding,
punishing, coercing or manipulating is needed.
As to the teleological model mentioned earlier, it is not always explicitly utilized in the empowerment
approach, although ‘folk psychology’ (i.e. Rosenberg’s model) is implicitly taken for granted, since the
approach has to take beliefs, wants, knowledge, etc. into account at some point. The crucial
difference is that the empowerment approach focuses less on (influencing) beliefs and wants (1–4),
and much more on (increasing) ability, e.g. on generic skills development (Freire, 1972; Laverack,
2009), and (creating) opportunity (5–7) (Laverack, 2009). No doubt, this will have effects on both
beliefs and wants.
Ethical Problems with the Behavior-Change Approach
In the following sections, we will look at some ways in which the behavior-change approach may be
criticized, namely in that it does not respect the autonomy and the dignity8 of the individual (or
group), in that it risks harming the individual, and that it risks increasing health inequalitites.
Problems with the Right to Autonomy and Equality
As we saw, most behavior-change projects have narrow lifestyle goals, such as smoking cessation or
increased physical activity, and they use various means to influence the target group, sometimes
informing, persuading, coercing, or manipulating the individuals or groups targeted, in order to reach
these goals. Some of these strategies do not sufficiently respect the indivdual’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. Others are less problematic and can be defended on other moral grounds.
Let us look at some strategies. Informing people about health threats or health benefits does not
appear to involve any major ethical problem, because if the strategy is successful, it seems to be
because the individuals or groups themselves found the information useful or persuasive and chose
to act on it. One problem, however, is that different groups are, to a varying degree, likely to
understand and act on the information they get. More vulnerable groups, e.g. low socio-economic
groups, seem to be less prone to act on health advice than less vulnerable groups (Baum, 2008: 475).
One reason for this might be that acting on the information requires some sacrifices, e.g. in terms of
time, effort or money. Another reason might be low ‘health literacy’, i.e. low motivation or capacity
to access, understand or use health-related information (Nutbeam et al., 2010: 37, 38). It is, then,
possible that the information will not benefit these vulnerable groups. Thus, even if some people will
benefit from information campaigns, and the average (aggregated) health might increase in the
population, there is also a risk of increasing health inequalities (Brülde, 2011b; Daniels, 2011; Wilson,
2011). This should, of course, not make us conclude that health information is not important. It
should rather make us aware of the fact that other complementary measures are necessary in order
to reduce health inequalities.
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
In some of the ‘local’ cases, the professional takes the opportunity to bring up a topic that she feels is
relevant for the individual (or group), so-called ‘opportunistic’ health information, as well as asking
questions about health-related behavior (Nikku, 1997; Fitzpatrick, 2001).9 One moral objection to
this practice is that it might be thought to be an infringement of the individual’s right to privacy
(autonomy) to be informed about lifestyle matters she did not ask for (implying a problem), and
furthermore, to be asked about her habits, or ‘lifestyle’. Such questions might cause embarrassment,
unease, worries, shame and feelings of guilt, and thus, compromise her dignity.10 This might,
furthermore, lead to feelings of stigmatization, a risk that also has to be taken into account in top–
down projects, such as addressing problems with obesity (French et al., 2009: 146; Loss and Nagel,
2010: 60), or parents who smoke (Grier and Bryant, 2005: 335).
Persuasion, and especially the use of authority, is another (similar) problem that might appear in
face-to-face encounters, especially when the agenda is set by the professional (Nikku, 1997).
Authoritative persuasion here means that a person with real or perceived high status (Wrong, 2004:
35 ff.), e.g. a doctor, a community nurse or a health promoter, tries to talk or pressure someone into
a change of behavior—i.e. basically influencing aspect 1 (wants) in Rosenberg’s scheme—where
there is some initial resistance on the part of the individual (or group). This might happen
opportunistically, but perhaps more often when a person or a group is invited to discuss a predefined
topic or problem, and has little influence on the agenda. For instance, a person might be given the
opportunity to discuss smoking cessation or weight loss, but not to discuss other, more pressing,
health-related issues, such as housing problems, lack of education or child care. It becomes an ethical
question when the issue or problem, and how it should be dealt with, is wholly determined by the
professional, without taking into account what the individual (or group) wants, and pressurizing her
(or them) into complying with the advice given (Nikku, 1997). In these situations, there is, thus, a
mixture of paternalism (i.e. ‘to impose limitations on someone or to require actions by someone for
his or her own good’; Bayer et al., 2007: 86.) and authority that puts the individual in a weak position.
Thus, it does not respect her right to autonomy, and it risks making her feel offended, vulnerable and
powerless (Nikku, 1997; Buchanan, 2000; Holland, 2007).
Coercion and manipulation may constitute more serious ethical problems, but such measures mostly
appear in top–down strategies, such as legislation and social marketing. Some kinds of coercion are,
however, morally unproblematic. All governments act paternalistically, often for good reasons. Much
of this is done by coercing people through legislation (legal force), e.g. to wear seat belts, not to drink
and drive, and not to use narcotics. In liberal welfare societies, there is, however, a suspicion about
too many restrictions (Mill, 1859; Holland, 2007). We do not, for example, prohibit the use of sugar,
or smoking (unless in public areas), even though we know they are bad for people’s health. There is a
tension between the state’s interest in intervening in order to protect the population (from itself)
and people’s right to do what they themselves find best (Holland, 2007: 37–40). Thus, using coercive
means to change health-related behavior is not always a problem. The less important (or the more
trivial) the infringement and the greater the health gain, the less problematic the project, especially if
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
it respects other important ethical principles, such as reciprocity, equality or social justice (Upshur,
2002; Holland, 2007).
The major ethical problem with the behavior-change approach is that it allows and endorses
manipulative strategies. We primarily find this problem in strategies like social marketing, and in
‘scare campaigns’ (Buchanan, 2000). Social marketing is a kind of intervention that uses commercial
marketing tools, for the benefit of both the individual (or group) and society (French et al., 2009;
Cheng et al., 2011), e.g. using gender and age stereotypes for ‘selling’ health behavior (Naidoo and
Wills, 2005: 164). Marketing tools are often manipulative, in that they influence the individual’s
wants (Rosenberg’s 1 and 4) and beliefs (2) (Pollay, 1986, 2000).11 Appealing to sex or sexiness is one
such manipulative strategy. A German advertisement aiming at getting women to visit their
gynecologist to check if they are at risk of developing breast cancer, show a ‘femme fatale’, focusing
on her barely covered breasts, with the accompanying text: ‘75% of all men first look at a woman’s
bosom. Your gynecologist should be one of them’ (in Loss and Nagel, 2010: 59; author’s translation).
Thus, the major ethical problem with manipulative marketing strategies is that they try to make the
person do something that she 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 thus, disregards
the right to autonomy (self-determination).
Scare campaigns are no better. Some aim at influencing people’s behavior, through pre-reflective
emotional reactions, such as associating health hazards with something unpleasant, disgusting or
(vaguely) dangerous (Witte and Allen, 2006: Loss and Nagel, 2010; Brülde, 2011a), i.e. they try to
manipulate wants (1 or 4). Others might involve exaggerations and misinformation, especially when
trying to meet marketing ‘rules’, e.g. ‘[k]eep it short and simple’ (Loss and Nagel, 2010: 59; Brülde,
2011a).12 In the latter cases the influence is often cognitive (2), rather than emotional (even if
perceived threats due to exaggeration or misinformation are also likely to increase emotional
arousal) (Witte and Allen, 2006: 592). A model sometimes used is the health belief model, which
(among other things) states that a perceived threat (2) makes the person more likely to act to avoid
the threat, and that the more severe the consequences are thought to be (2), the more likely it is
that the person takes action (Nutbeam et al., 2010). ‘Scare’ campaigns might use this model and
either exaggerate the susceptibility, e.g. the likelihood of getting HIV if you have unprotected sex, or
the perceived severity of the consequences (2), e.g. that smoking makes men impotent (2), in order
to make people change their behavior (Brülde, 2011a). Thus, this kind of campaign disregards the
right to autonomy through manipulating the person’s beliefs system, as well as distorting her wants.
Defenders of the above mentioned strategies might claim that people are not very autonomous in
the first place, since all kinds of forces in society influence us to want and do things (Foucault, 1986),
and in this case, we might as well ‘counter-manipulate’ individuals (Holland, 2007: 128, 129). No
doubt, the ability for autonomy (self-determination) differs in the population. However, assuming
that we are not fully determined by material or social structures, the answer to this problem should
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
not be more paternalistic manipulation, but, rather, to strenghen the autonomy of those with less
ability for it.
Coercion and manipulation are not very common on the local level, especially not in health
promotion. When they occur, we find that the individuals (or group) participating often accept being
manipulated or coerced.13 This might, for example, happen in certain kinds of psychotherapy, where
the therapist uses ‘manipulative’ techniques (autonomously) accepted by the individuals
participating. One example is to accept hypnotic treatment, e.g. for smoking cessation (Holroyd,
1980). Voluntarily accepted coercion, although rare, is found in cases where individuals ask to be
committed to treatment, for, say, alcoholism, drug abuse or a mental disorder (Carroll, 1991; Wild,
2006).
This seems to imply that coercion and manipulation, in these specific cases, are acceptable
strategies. No doubt they are, assuming that there are other strategies available to choose from. If
the person has few options, we cannot really conclude that the strategy fully respects the right to
autonomy.14
Some Measures Risk Causing Harm
Interventions that are persuasive, manipulative or coercive do not respect the individual’s right to
autonomy. Some such interventions, e.g. the obligation to wear seat-belts when driving, can be
defended, since they constitute minor rights infringements and the harms avoided are substantial.
But what if the individual is inadvertently harmed in some other way? Are there behavior-change
interventions that lead to situations that are worse than the ills they were designed to alleviate?
Improving a person’s future health through reducing her quality of life might be such an example.
Professionals might try to persuade, coerce or manipulate people into actions or behavior that they
on the whole dislike, such as exercising more, giving up smoking, or giving up some of their favorite
foods or drinks (Fitzpatrick, 2001: 35 ff.; Holland, 2007: 122).
But a more serious harm might be that of reducing the individual’s ability for self-determination (or
autonomy), or, similarly, that ‘coercive interference’ might ‘displace individual initiative’ (ascribed to
J.S. Mill by Powers et al., 2012: 10). Manipulation risks leading to such a result. Marketing strategies
are in general manipulative, because they try to induce people to do, or buy, things that they did not
originally want, and that they would not have bought or done, had they had more information or
sufficient time to deliberate. Employing manipulative techniques in social marketing appears to be
counter-productive, as the risk is that the more people are manipulated, the less autonomous they
will become. Some reasons for this are that manipulation reduces knowledge (a prerequisite for
autonomous choices), through false, skewed or partial information, and that it makes the individual
less inclined to critically reflect on the options available (Pollay, 1986, 2000). Note also that
marketing in general, appeals to ‘vices’ such as ‘[l]ust, sloth, greed and pride’ (Mayer, 1961 in Pollay,
1986: 908) and, adds David Buchanan, to ‘envy and gluttony’ (Buchanan, 2000: 77)—vices that are
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This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Public Health Ethics
following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
usually not rationally (i.e. autonomously) chosen (Buchanan, 2000). Alluding to vices, and indirectly
reinforcing them, thus appears to be a suspect way to lure people into health-related behavior.
Buchanan (2000: 77, 78) provides an example. In a planned campaign to get young men to drink less
alcohol, the message to be delivered was that young women find men that drink less more ‘sexually
attractive’. Thus, such an intervention might have negative health consequences, since the emphasis
on the value of sexual attractiveness might lead to more casual sex in these groups of young people,
this in turn leading to increases in sexually transmitted diseases and in teenage pregnancies. This is
debatable,15 but referring to sex (in this case, a form of ‘greed’ for more sex) as a motive for reduced
drinking may still be seen as questionable, especially since such an appeal to sexuality may also
reinforce gender stereotypes, thus compromising other important values and norms (Buchanan,
2000: 77, 78). Marketing companies do not need to use these kinds of stereotypes but they typically
do (Wolin, 2003), even if things might be changing for the better (Wolin, 2003). Note that in the USA,
the companies used for social marketing are sometimes the same ones as used for ordinary
marketing (Buchanan, 2000: 76).
Note, finally, another sort of harm that might be the result of certain behavior-change strategies.
Interventions such as social marketing and scare campaigns, and sometimes also ‘non-reciprocal’
coercion (Upshur, 2002), might erode the trust that people have in authorities (Brülde, 2011a: 224),
because some such interventions might appear to be cynical, as they use people as means, and do
not treat them as capable, thinking citizens (Buchanan, 2000: 78).
Positive Aspects of Working with Empowerment as a Process
The empowerment approach avoids the ethical problems found in the behavior-change approach. It
fully respects the participating individuals’ right to self-determination, since they are completely
involved in the problem formulation, the decision process, and the actions undertaken. Moreover,
the approach also develops or increases the ability for autonomy, as well as other forms of control,
since active participation requires taking or sharing responsibility for what is to be achieved, and for
how it is to be achieved. This in turn leads to the development of various kinds of knowledge, skills
and ‘well-being’ (Laverack, 2009; Powers et al., 2012: 9). Groups that participate develop their
‘collective autonomy’, in that they develop deliberating, reasoning and negotiating skills, and
therefore acquire tools for making democratic decisions (Laverack, 2009). Thus, the focus of the
approach is first and foremost on the last aspects in Rosenberg’s teleological schema, namely, ability
(6), and the know-how (5) required by 6. This may lead to changing beliefs (2) and perhaps also to
changing wants (1 or 4).16
How do we justify this emphasis on respecting (the right to) and furthering (the ability for) autonomy
(self-determination)? One way is to point to the fact that self-determination is considered a human
right (UNO, 1948). But what makes it a human right? Griffin (2008: 32, 33) reasons as follows:
Personhood is what makes us most distinctly human, and certain things are required for personhood,
namely autonomy (i.e. ‘choosing one’s own path in life’), some degree of welfare, or ‘minimum
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following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
provision’ (i.e. a minimum of ‘resources and capacities’) and liberty (i.e. not being forcibly stopped
from pursuing one’s life plans). Autonomy as discussed in this article includes both Griffin’s account
of autonomy (choosing) and opportunity (being able to act), i.e. freedom. Empowerment as a state
(having control over life and health), then, to a great extent overlaps with the requirements for
Griffin’s idea of personhood. Empowerment as a process respects people's right to self-
determination, and therefore also their personhood.
But how is autonomy (self-determination) linked to health? The central idea is that (in general) the
more autonomous a person is, the more likely it is that she stays healthy, and this is vindicated by the
research. Control over the determinants of health (including, as we have seen, ‘resources and
capacities’) is, in general, positive for health (Karasek and Theorell, 1992; Marmot and Wilkinson,
1999; Marmot, 2004; Wilkinson and Picket, 2010). This might involve behavior change, e.g. exercising
more, but behavior change (in itself) does not always lead to better control or increased autonomy.
Finally, do the empowerment strategies aimed at creating more control over health also reduce
inequalitities in health? When it comes to our primary concern, local interventions, they do decrease
inequalities, since they primarily target vulnerable groups, i.e. those that have poorer health and
worse living conditions than other groups (Freire, 1972; Laverack, 2009: 80 ff.). On the whole, then,
empowerment projects will decrease inequalitities.
Possible Problems of Working with Empowerment as a Process
There are a number of concerns that have been raised over the years about the feasibility of the
empowerment approach. Critics have claimed that professionals cannot, and should not, reduce
their power or control over projects, that the empowerment approach imposes its ‘method’ and
goals on the participants, and, therefore, does not live up to its own standards, and finally, that the
approach is more time consuming and therefore also risks costing more.
The Limits of Reduced Professional Control over the Process
Do we really want professionals to reduce their power over the process? Could that not even be
dangerous? What if the individual, or group, wants to initiate projects where the means used are
believed by the professional to be mistaken, counterproductive, or even harmful, or that might not
be expected to lead to better health for the individual or for the group (Braunack-Mayer and Louise,
2008: 6)?
There are limits to what professionals can and are legally and morally allowed to do. A professional
should only participate in projects that are considered possible, reasonably effective, legal (if there
are no strong moral reasons for illegal actions) and morally defensible (Tengland, 2011). The
professional is part of the project, and should therefore also have a say in the matters discussed and
decided on, and she always has the option to refrain from continuing a project (on the grounds
stated above). This should not, however, be taken as a professional’s way to, in fact, impose her will.
Good arguments have to be provided for refusing to accept a project not found feasible or morally
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Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
acceptable. Furthermore, many professionals will not work at all with the empowerment approach,
since it is not possible to do so in their field; this, for example, goes for (most) police officers, fire
fighters, judges and emergency ward staff.
The Professional Can Never Refrain from Exerting Power
An important question, which has been much discussed, concerns whether professionals can refrain
from using their power in empowerment projects (Buchanan, 2000: 80; Holland, 2007: 129). They
should, after all, be ‘experts’ on how to achieve an empowering process (Lietaer, 1998). Is it possible
then, to work in the envisioned way, without power (in a problematic sense) entering at some point?
The question hinges upon what we mean by ‘power’ and the ethical implications of different aspects
of power.
Clearly, a professional will have an influence on every project she participates in. However, that
cannot be seen as a problem in itself. It depends on the kind of influence involved, i.e. if it is morally
legitimate or illegitimate. Giving advice when asked, cannot be seen as a problem, not even giving
(matter-of-fact) arguments for certain choices. The professional is, after all, collaborating with the
people facilitated and is, thus, part of the process. What is morally problematic, as we have seen, is
persuasion, manipulation or (covert or overt) coercion, i.e. making participants do what they have
not consciously/deliberately and freely chosen. For the professional to have an agenda, other than
facilitating increased control over life and health, would contradict the definition (taken for granted
in this article) of empowerment as a process, i.e process and goals should harmonize (Tengland,
2008). In conclusion, it is hard to see that the professional necessarily has to exert power over the
other participants (in any problematic way). That some professionals fail to fully live up to the
demanding requirements of the empowerment approach can only be expected, especially since few
schools of public health or health promotion train students in it (Buchanan, 2000: 144 ff.).
Furthermore, on the whole, the professional is usually more empowered than the average
participating individual, group, or community member. For example, she has more knowledge about
relevant fields of professional practice. Again, this should not necessarily be a problem, as long as all
people involved are respected as equals, and where everyone’s ‘expertise’ is taken into account in
the project. The participating members have experiences and knowledge that the professional lacks,
e.g. about their own concrete problems and living conditions. In the same way, the professional’s
knowledge should count as an available asset. Thus, what we will end up with is ‘group power’ (Allen,
1998), where all members contribute and strengthen the collective power of the group.
Autonomy and Control as Predetermined Goals
It has, so far, been taken for granted that the right to (and increase in) autonomy and control is
something positive and that people should (be invited to) participate in decisions that affect their
lives. Using this strategy and furthering these aims might also be seen as paternalistic, since the
agenda is decided beforehand by the professionals (Braunack-Mayer and Louise, 2008: 6). Thus,
when using the empowerment strategy, the professionals can still be seen as having power over the
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following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
change process and its aims. True, but is this really a problem? Every intervention has to rely on
some ethical foundation, and all are not equally acceptable. As we have already seen, there is a very
strong Western liberal tradition that people should be permitted, and encouraged, to govern
themselves, and this is tied to the personhood and dignity of the individual (Mill, 1859; Nordenfelt,
2004; Griffin, 2008).17 Just as we refuse to count the abolition of democracy as a valid goal in a
democracy, even if it would lead to better health, or increased quality of life, we refuse to count
disregarding the right to autonomy or self-determination as a legitimate consequence of public
policy, with certain exceptions (already mentioned).18
It Takes Longer to Achieve the Goals
A final critical point has to do with the expected fact that empowerment interventions are more time
consuming (Nutbeam et al., 2010). The fact that people have to gather and deliberate on the goals
and means, before anything can get off the ground, is a strong indication that the assumption is
correct (Laverack, 2009). It is well known that psychotherapy, which is not ‘goal-directed’ or
‘problem-focused’ is expected to take longer (Mearns, 2004). Compare, for example, the very specific
attempt to get rid of an obsession (cognitive-behavioral therapy) with the exploration of a childhood
trauma where the child was abandoned by her mother (person-centered therapy). The same thing
goes for participatory research strategies (McIntyre, 2008), i.e. they take longer than many other
kinds of research strategies.
If projects take longer, this also means that they might be more costly. The professionals need to stay
longer in the field, meeting with the people involved. The time frame basically depends on two
things. First, it has to do with what goals are chosen by the individual or group involved, and with the
means needed for attaining these goals. The more ambitious the goals are, the more likely it is that
they will take time to achieve. Second, it also has to do with the level of awareness, knowledge, skills
and autonomy in the individual, group or community that is involved. The lower the initial
competence is, the more likely it is that the project will take time.19 There are other factors that
might also influence the time it takes. Conflicting interests within the group or community might
have to be dealt with, and the goals chosen might be in conflict with the interests of (powerful)
groups in society.
The principle of cost-effectiveness states that we should choose to maximize the outcome (health) in
relation to what we spend (Brülde, 2011b). In general, the behavior-change projects are more narrow
in scope, since they often focus on one kind of risk behavior and therefore seem more cost-effective.
The problem is, however, that it is difficult to compare outcomes if the targeted health goals are
different, which they most likely are, because, in empowerment projects, the specific health goals
will be chosen by the group in question, and we cannot know beforehand (exactly) what they will be.
It is then, more or less impossible to compare (in terms of cost-effectiveness) behavior-change
projects, such as a smoking cessation group (1, in Rosenberg’s model), with empowerment projects,
such as a community-intervention project where the communal decision is to try to get rid of drug
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following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
dealers in their neighbourhood (e.g. reducing the opportunity for kids to try drugs, 7 in Rosenberg’s
model). But even if we, on comparing typical intervention designs, grant that behavior-change
projects might be more cost-effective than empowerment interventions, it is only one of the several
criteria for success, and we can, as we have seen, defend empowerment interventions on other,
moral, grounds.
Behavior Change and Empowerment: Reaching Their Targets?
What about the success of behavior change and empowerment of interventions? Many projects
whose goal was to change people’s behavior and lifelstyle in a more health-enhancing way have been
tried over the years. Coercive, top–down, legislative interventions, such as the requirement to wear
seat-belts and crash-helmets, have often succeeded (Pellmer and Wramner, 2009), as have some
fiscal policies, such as taxing alcohol highly, which is the case in the Nordic countries (Babor et al.
2003). But the results of lifestyle projects are more mixed. Some have succeeded, or have partly
succeeded (Snyder and Hamilton, 2002; Glanz et al., 2008), while others have failed (SBU, 1997;
Beaglehole and Bonita, 2004: 263; Baum 2008: 474). A major review conducted by Swedish
researchers who studied eight large-scale (scientifically well-designed) top–down behavior-change
projects showed that the effects of these projects were moderate or nonexistent (SBU, 1997). The
authors of one of the original studies concluded that the ‘net improvements… that can be attributed
to the MHHP intervention were modest, generally of limited duration and usually within chance
levels” (in SBU, 1997: 122). Glanz et al. come to a similar conclusion (2008). The results of many
major behavior-change projects ‘cast doubt on the presumed effectiveness of population-based
intervention strategies over the long term’ (Glanz et al., 2008: 16; see also Syme, 1996: 21, 22; Baum,
2008: 460 ff.; Laverack, 2009: 117; Syme and Ritterman, 2009: 4, 5).
This is one reason why strategies have changed over the last years, focusing more on changing the
environment, such as in “healthy cities” projects, rather than focusing straight-forwardly on
behaviors and their immediate internal determinants (Baum, 2008: 531). This is partly the result of
the Ottawa Charter for Health Promotion, where focus was moved to the social determinants of
health (WHO, 1986). This change has been accompanied by an emphasis on individual and
community participation and empowerment strategies (WHO, 1986). Further emphasis on the
determinants of health within the WHO confirms this trend (WHO, 2008). These kinds of projects and
policies move us closer to the empowerment strategy, since they often involve creating
opportunities (WHO, 2008).
Concerning local projects, it is hard to give a general answer. Many behavior-change projects report
some success (Snyder and Hamilton, 2002; Glanz et al., 2008; Nutbeam et al., 2010), which means
that it might, for this reason, be premature to abandon them. And as mentioned, some projects of
this kind might succeed also on empowerment terms, e.g. increasing health-related knowledge,
which might increase control over health-related factors. An interesting development within health-
care, traditionally very behavior-change oriented, is the move towards more participatory strategies,
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Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
such as ‘motivational interviewing’ (Miller and Rollnick, 2002), used, for example, to achieve smoking
cessation (Schinitzky and Kub, 2001).
A number of local projects, likewise, show support for empowerment as a process. A major literature
review of research concerning various kinds of empowerment projects, made by Nina Wallerstein for
the WHO in 2006, showed that the approach was successful in a number of health-related areas,
such as maternal health, HIV reduction, mental illness reduction, building self-confidence in young
people, and child health, to mention just a few areas (Wallerstein, 2006).
Several other authors support Wallerstein’s (2006: 5) conclusion about the value of empowerment
and of ‘authentic participation’. Tones and Green (2004: 39), for example, advocate the
empowerment approach, not only for its ‘ideological soundness’, but also for its ‘practical
effectiveness’. Laverack suggests that public health programs ‘will only be successful if they can
maintain a high degree of participation’ (Laverack, 2009: 121), and that in order to achieve
sustainable change we have to combine top–down agendas, primarily those addressing socio-
economic inequalities and bottom–up (local) ones (Labonté and Laverack, 2008).
Involving people may have some advantages. One is that the aims of the project will be more
appropriate, because people in the communities are more aware of what their ‘wider’ problems are
(i.e. have knowledge about the causes of their health problems, such as unemployment or lack of
education), and they will therefore choose to try to change what they experience as the more
important aspects of their situation—aspects that professionals, civil servants and politicians often
know less about (Rogers 1961, 1977; Freire 1972; Laverack, 2009; Syme and Ritterman, 2009).
Second, some authors claim that projects that include ‘real’ participation of those involved, i.e. when
people are engaged in what is important to them, are more likely to succeed, and that the effects are
more likely to be sustained (Beaglehole and Bonita, 2004: 262, 263; Tones and Green, 2004; Baum,
2008; Laverack, 2009; Syme and Ritterman, 2009).
This does not prove, however, that on the whole empowerment projects succeed more than
behavior-change projects, but it indicates that there is a general trend toward more participation,
perhaps for other reasons than success, such as moral ones.
Conclusions
This article presents a comparison between two kinds of approaches in health promotion, namely
behavior change and empowerment. It tries to show why we should prefer empowerment methods,
rather than work with persuasive, manipulative or coercive tools to change specific behaviors.
Some behavior-change projects are relatively unproblematic, and might even empower people—
even if they risk increasing inequality in health. Furthermore, some interventions might be
legitimately coercive. But we have also seen that behavior-change projects can be morally
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following peer review. The definitive publisher-authenticated version Tengland, Per-Anders. (2012) Behavior
Change or Empowerment: On the Ethics of Health-Promotion Strategies, Public Health Ethics, 5, 140-153, is
available online at: http://dx.doi.org/10.1093/phe/phs022
problematic for several reasons, e.g. in that they do not sufficiently respect, nor further, the
autonomy (or freedom) of the individuals involved, or respect their dignity, and in that they risk
increasing health inequalities. However, we have to acknowledge that some people participate in
behavior-change projects that they have chosen, and where the goals and means are determined
beforehand. The major problem in these cases is rather that the kinds of interventions available may
be limited, and that they focus narrowly on behavior change and not on a change of life situation,
which might better address the ‘real’ health problem, i.e. the wider causes of the problem, and not
just its symptoms.
Local interventions are often more morally delicate than top–down ones, since they involve meeting
people ‘eye-to-eye’, and ususally target lifestyle changes, such as choice of foods and drinks,
smoking, sexual behavior or physical activity, i.e. issues more closely related to the identity of
individuals, and (usually) more important for their quality of life.
Empowerment, as I have tried to show, can handle most of the problems of the behavior-change
approach. It respects the right to autonomy, as well as furthering autonomy as ability, it respects the
person’s dignity, and it reduces inequalities. Empowerment strategies do, of course, fail at times and
they can be realized to a larger or lesser extent. The general point made, however, is that, on the
whole, the empowerment approach is preferable to the behavior-change approach.
Acknowledgements
I would like to thank Bengt Brülde, Glenn Laverack, Martin Berzell, Katarina Graah-Hagelbäck, my
colleagues at the department of Public Health, Health and Society, at Malmö University and the two
anonymous reviewers for valuable comments on earlier versions of this article.
Footnotes
↵1. One exception is vaccination programs that do something to people’s bodies, namely strengthen
their immune system. Another one is putting fluoride in the drinking water to strengthen the enamel
of people’s teeth, and thereby increasing dental health of the population.
↵2. Empowerment, at least, is a goal in many other professional contexts, e.g. social work and
education.
↵3. In an earlier article, I have argued that the goal should rather be quality-of-life-related health
(Tengland, 2007), because health is primarily an instrumental goal and, therefore, health gains that
do not lead to a better life do not appear worthwhile trying to achieve. The distinction is not,
however, important for this article and will not be used.
↵4. Note that the two categories ‘health-related behavior’ and ‘lifestyle’ do not seem to overlap fully.
‘Health-related behavior’ appears to be a somewhat broader notion than ‘lifestyle’. The latter notion
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usually covers choice of food and drinks, smoking and drug use, sex activities, sunbathing and
physical activities, whereas the former notion also includes issues such as wearing seat-belts and
crash-helmets, hand washing, using bed nets, taking vitamin pills, and mammography and
vaccinations. Lifestyle matters seem more important to people, and the debate about them more
‘heated’, perhaps because they lie closer to the identity of the individual or group, and/or perhaps
because they are more relevant for people’s quality of life. However, it is hard to make the
distinction precise, and it will not be used in this article.
↵5. This article does not discuss some of the contemporary changes in health promotion where more
and more attention is directed toward the environment (Baum, 2008: 465), primarily because this
risks blurring the distinction made in the article between behavior change and empowerment.
↵6. That is, given that the ‘premises’ are fulfilled, the agent is rationally obliged to act. The syllogism,
however, allows irrationality in one or several of its premises. A person might ‘act rationally’ on
irrational beliefs or on irrational wants. The explanation of the action is still valid.
↵7. Autonomy is always ‘contextual’, i.e. choices are made within a social and cultural structure that
limits the ones available (or possible to pursue), conceptually and empirically. However, in our
globalized world these choices can be quite numerous and diverse.
↵8. Dignity, here, more or less refers to what Nordenfelt (2004: 75) has called ‘dignity of identity’, i.e.
the dignity attached to our ‘integrity and identity as human beings’, which is closely related to self-
respect and feelings of worth.
↵9. The assumption here is that this information is not asked for, nor related to the problem that the
individual sought help for.
↵10. There is a difference between getting (opportunistic) information concerning e.g. a suspected
melanoma, or concerning the risks related to alcohol consumption. The more serious the potential
problem, the less controversial this kind of information. We can assume that most people want to be
informed about serious and immediate health risks, and in cases where they do not, the positive
consequences of the information clearly outweigh the negative ones.
↵11. If they are purely informative, or only change the environment, they will be ignored here.
↵12. Few campaigns use straightforward lies, as many countries, like the USA and Sweden, have laws
against using lies in advertising (Brülde, 2011a: 225).
↵13. The point was made by Bengt Brülde (personal communication, February 2012).
↵14. Coercion in the (stronger) sense of using force or compulsion, sometimes regarded as necessary
for some public health measures, is less common in the health-promotion context. Compulsive
measures, such as forcing people to leave their homes in emergencies (e.g. flooding, forest fires), or
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imposing quarantine or isolation on people or groups in cases of serious pandemics (Verweij, 2011),
do not specifically relate to behavior or behavior change.
↵15. Reduced alcohol intake might make the person less, rather than more, likely to engage in casual
sex. The point was made by Martin Berzell (personal communication, March 2012).
↵16. It should be added that the empowerment approach is compatible with the insight that some
people do not want to participate actively, or decide on certain issues. For certain kinds of projects
such a standpoint must be respected, especially if it rests on an autonomous choice. Any such refusal
to participate should be a strong incentive to try to find out why this is the case.
↵17. The relativist idea that these are Western ideals and not applicable to other cultures has been
refuted by a number of thinkers, e.g. by Martha Nussbaum (2011: 101 ff.).
↵18. The best reason for not respecting (the right to) autonomy is future ‘substantive autonomy’ (i.e.
autonomy as ability) (J. Raz, in Braunack-Mayer and Louise, 2008: 6). Also see Nikku (1997).
↵19. Personal communication with Glenn Laverack (25 August 2010).
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