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Written by Rebecca Brown
This post is based on two recently accepted articles: Brown and de Barra ‘A Taxonomy of Non-Honesty in Public Health Communication’, and de Barra and Brown ‘Public Health Communication Should be More Transparent’.
In a previous post, I discussed some of the requirements for public health institutions to count as ‘honest’. I now want to follow that up to discuss some of the ways in which public health communication seems to fall short of honesty.
I’ll follow Christian Miller’s definition of the term ‘honesty’ to refer to a character trait that involves being disposed, centrally and reliably, to not intentionally distort the facts as one sees them. As discussed previously, it is pretty hard to get at the intentions of agents. We can rarely – if ever – say with certainty that a particular agent intended some outcome, since that information is available only to the agent herself. Instead, we must rely on extrapolating from whatever evidence is available to us.
This can make it hard to prove a failure of honesty, since we must often rely upon a ‘best guess’ as to the agent’s motivation when they acted in a particular way. For the kinds of cases I’m interested in – communications from public health organisations – it is even trickier, as it is not clear what agent is responsible for the communicative act in question (it could be an individual within an organisation, the organisation itself, or some subset of the organisation/individuals within it). But assuming certainty isn’t required, we might still judge that an agent (group or individual) probably intended to mislead or otherwise distort facts if the way they presented information could reliably be expected to create false beliefs in the recipient, and if we would reasonably expect the communicator to have known this. With that in mind, we might speculate about the honesty or otherwise of public health communication.
Public health communication frequently engages in a number of practices that look like they might not meet the demands of honesty. Some examples are:
Magnitude neglect where public health communication doesn’t provide an indication of the expected effect size of the benefit / harm discussed. This could include, for instance, saying that screening reduces your chance of dying from cervical cancer, without telling you by how much your risk of death is reduced.
Harm neglect involves providing information about the benefits of recommended behaviour changes / interventions without mentioning any possible harms.
Relative over absolute risk presentation. Whilst communicators rarely provide quantified effect sizes of the benefits associated with a recommended behaviour, when they do provide such estimates they often use relative risks rather than absolute risks. This will tend to inflate people’s estimate of the size of the benefit they can expect. For example, an intervention that reduces your risk of developing diabetes from 0.001% to 0.0005% cuts your risk in half – that is, reduces it by 50%. The first way of presenting this (using absolute risks) makes the change seem quite small; the second way (in relative risks) makes it seem much bigger. Public health communicators will often use relative risks to describe health benefits, which tend to make them seem much more impressive.
Mismatched reporting takes the above tendency, and pairs it with a tendency to report the harms of recommended behaviours in terms of absolute risks. If relative risks inflate people’s expectations, absolute risks deflate them. Pairing benefits described in relative risks with harms describes in absolute risks seems geared to encourage people to overestimate benefits whilst underestimating harms.
Causation laundering occurs when the content of public health communication implies a causal link between phenomena when it is difficult to know to what extent the relationship is causal. For instance, the health benefits of exercise are widely proclaimed (the NHS describes it as a “miracle cure”. Yet it is very difficult to extrapolate what health benefits associated with exercise are a result of exercise making people healthier, and what results from healthier people doing more exercise. Public health communicators sometimes gloss over such ambiguity, and imply that the causal relationship acts only in one direction – that is, exercise causes good health, rather than the other way around.
These ways of communicating health information, amongst others, seem likely to encourage people to form overoptimistic beliefs about the benefits of various health behaviour changes. Moreover, this seems predictably likely and – we might speculate – intentional. If this is indeed the case – if public health communicators intentionally frame their messages so as to encourage people to form overly optimistic (and inaccurate) beliefs about the likely benefits of health behaviour change – then this is inconsistent with communicating honestly.
This leaves out the question of whether or not there is anything wrong with failing to communicate honestly. Whilst there will almost certainly be cases where honesty is not all-things-considered desirable (e.g. it is better to tell a lie to protect an innocent victim from a murderer than to tell the truth and condemn them to death, contra Kant) it is not clear that public health communication is typically one such case. Indeed, it seems unlikely, given the emphasis on honesty in clinical communication, and the importance of allowing people to make well-informed decisions about how to lead their lives and take care of their health.
Most of the behaviours considered here – relating to diet, exercise, cancer screening and other preventative behaviours – require people to forego pleasures in the pursuit of longer term health. Whilst public health professionals might emphasise that there is “no safe” drinking level, individuals might reasonable decide that the benefits of alcohol consumption outweigh the risks. But people can only make these decisions sensibly if they are accurately informed about the harms and the benefits of these behaviours. And this requires public health communication to give a non-distorted, honest, picture of the available evidence.
References
Brown and de Barra (in press) ‘A Taxonomy of Non-Honesty in Public Health Communication’ Public Health Ethics
de Barra and Brown (in press) ‘Public Health Communication Should be More Transparent’ Nature Human Behaviour
Miller (2021) Honesty: The Philosophy and Psychology of a Neglected Virtue, Oxford University Press
By Abeezar I. Sarela.
In its recent guidance on consent, the General Medical Council (GMC) advises doctors to not provide treatment that ‘you (the doctor) don’t think would be in their (the patient’s) clinical interests’. It follows that doctors should only provide treatments that are in the patient’s clinical interests. But, what exactly is meant by ‘clinical interests’?
The GMC does not explain the term. In practice, it is sometimes confused with ‘best interests’. However, best interests is a legal term that applies specifically to making decisions for people who lack the capacity to do so for themselves. For example, oncologists might consider that either chemotherapy A or chemotherapy B could be in the clinical interests of a patient without capacity. Best interest decision-making would then involve choosing between A and B, or avoiding any chemotherapy and giving supportive care only. Whereas, patients with capacity would make these choices for themselves and do not need others to decide their best interests.
The difference between clinical interests and best interests is similar to that between setting a menu and then choosing from that menu. Clinical interests set the menu of treatment options that is available to a patient. Patients can then choose any option from this menu or decline all options, regardless of the consequences, because we all have a right of self-determination. But, do patients have a right to participate in setting the menu, too? Some might say yes. They would argue that treatment availability comes down to a matter of informed consent, through a process of shared decision-making (SDM) between the doctor and the patient.
However, senior judges have been clear that consent is valid only if the proposed treatment is, in the first place, ‘proper’. If the treatment is not proper, then the patient’s consent is meaningless, regardless of the sharing of information. In other words, setting the menu is not a matter for SDM. Rather, informed consent has two distinct stages. In the first stage, the doctor has to identify treatments that are proper (reasonable or available) for that patient. Then, the doctor has to involve the patient in the choosing between available treatments (or not having any treatment). It is this second stage that requires SDM: a dialogue about the menu of available treatments from the first stage.
What is it that makes a treatment available in the first place? Judges have explained that for a treatment to be available it has to be in the ‘public interest’. This turn to public interest can be justified in various ways. In a civilised society, we all (the ‘public’) have an interest in each other’s welfare. And, in some cases, the public interest can override an individual’s own wishes. Furthermore, in a publicly-funded health service it is inescapable that making treatment available to one person reduces resources for others. Consequently, it is in the public interest to set limits on availability of treatment.
The GMC would seem to have re-phrased ‘public interest’ as ‘clinical interests’. The endpoint of both is the same: the identification of available treatments. Thus, in advising doctors to think about a patient’s clinical interests, the GMC is actually asking doctors to consider the public interest. The GMC leaves this task to the professional judgment of doctors; and judges have done similarly. This approach is consistent with a well-established sociological argument that the public grants the medical profession with the authority to make certain decisions on its behalf. As doctors, let’s celebrate this sociological mandate and strive to serve the public. Or let’s challenge it, and find an alternative way. But, in the meanwhile, let’s not hide behind smokescreens of SDM and consent to decide about the availability of treatment.
Author: Abeezar I. Sarela
Affiliation: Department of Surgery, The Leeds Teaching Hospitals NHS Trust.
Competing interests: None declared
The post Re-thinking consent for treatment: clinical interests and the public interest appeared first on Journal of Medical Ethics blog.
By Charles Foster
Image: The Great Sphinx and Pyramids of Gizeh (Giza), 17 July 1839, by David Roberts: Public Domain, via Wikimedia Commons
Words are powerful. When a word is outlawed, the prohibition tends to chill or shut down debate in a wide area surrounding that word. That tendency is much discussed, but it’s not my concern here. It’s one thing declaring a no-go area: it’s another when the mere use or non-use of a word is so potent that it makes it impossible to see something that’s utterly obvious.
There has recently been an excellent and troubling example. Some museums have started to change their labels. They consider that the use of the word ‘mummy’ demeans the dead, and are using instead the adjective ‘mummified’: thus, for instance ‘mummified person’ or ‘mummified remains’. Fair enough. I approve. Too little consideration is given to the enormous constituency of the dead. But using an adjective instead of a noun doesn’t do much moral work.
Consider this: The Great North Museum: Hancock, has on display a mummified Egyptian woman, known as Irtyru. Visitor research showed that many visitors did not recognise her as a real person. The museum was rightly troubled by that. It sought to display her ‘more sensitively’. It’s not clear from the report what that means, but it seems to include a change in the labelling. She will no longer be a ‘mummy’, but will be ‘mummified’. She is a ‘mummified person‘: She’ll still remain in a case, gawped at by mawkish visitors.
The museum manager told CNN that he hoped that ‘our visitors will see her remains for what they really are — not an object of curiosity, but a real human who was once alive and had a very specific belief about how her body should be treated after death.‘
Let that sink in.
Whoever Irtyru was, she did indeed have a ‘very specific belief about how her body should be treated after death’. It did not involve lying in Newcastle, causing school children to scream. To describe her as ‘mummified’ rather than ‘a mummy’ does nothing whatever to address the offence of displaying her in a way wholly inconsistent with that ‘very specific belief’. That the museum apparently thinks it does is a symptom of moral blindness. There is a real issue about the display of Irtyru: it is not addressed by tweaking a word. More worrying is that that tweak seems to render invisible the very moral issue it purports to address. I’m not saying that Irtyru shouldn’t be displayed: I am suggesting that changing a word is no substitute for proper deliberation – let alone real change.
This is an example of a more general and sinister malaise. Virtue signalling has taken the place of serious, difficult ethical discourse.
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