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Ethics in Health Promotion and Disease Prevention

Joseph Kuhn, Manfred Wildner

(last update 13 January 2015)

Ethics, Morals, Rights

Prevention and health promotion are fields of practice. Wherever people are active, we are dealing not only with descriptive matters - how things are - but also with normative matters: How they should be. On the legal side, the answers are provided by the system of law and jurisprudence; on the moral side of things by ethics. Ethics provide the rationale for moral norms. For example, the directive in obesity prevention of not making fun of overweight people is a moral norm. What that means and why this norm should be acknowledged is the subject of ethics (reconstruction, reflection, legitimization). Ethical problems in preventive action may be found in everyday life (“Should I drink alcohol during my pregnancy?” “Should I smoke in the presence of children?”) as well as in professional contexts - which is, in turn, the subject of the following.

Ethics in medicine have a long tradition. The basis for medical ethics (or morals) was established more than 2000 years ago in the Hippocratic Oath, which contains instructions on how to deal with medical knowledge as well as the obligations to help and not to harm, not to participate in euthanasia, not to perform abortions, not to abuse patients and to remain silent about anything learned in the course of medical care provision. Medical ethics are considered professional ethics and part of the medical profession. It does not suffice, however, when it comes to multidisciplinary prevention and health promotion, though it does contain some general norms that are relevant to public health ethics.

During the Nazi rule in Germany, professional ethical guidelines did not prevent doctors from perpetrating crimes against persons with impairments and concentration camp prisoners as well as being actively involved in the annihilation of Jews, Sinti and Roma. Among other things, an important role in their actions was played by preventive ethics toward preserving a “healthy racial corpus.” The presumed interest of the nation as a whole body supposedly yielded the right of some to decide about the lives of others. Traditional medical ethics were subordinated to nationalistic collective ethics. As a reaction to these events, the constitution of the Federal Republic of Germany contains a right to life and physical integrity (Article 2) as well in particular the inviolability of human dignity (Article 1) as the highest values in society. This confronts every form of collective ethics with limits. Thus, the German constitution establishes a legally binding rank order of values that is relevant to both the discussion of ethical questions in the health sciences as well as in prevention and health promotion in particular. The experiences in the past also affected the reforms of medical ethics laid down in the International Code of Medical Ethics, the Declaration of Geneva and the Declaration of Helsinki. The Declaration of Geneva is now used as a preamble for the German Medical Professional Code of Conduct.

The subject of ethics belongs to philosophy, which has a number of different ethical approaches. One widely used differentiation is between deontology, virtue ethics and consequentialism. Deontology presumes there are hard and fast behavioral norms, the highest of which Kant called the “categorical imperative”: Act as if your maxims should serve at the same time as a universal law. Virtue ethics proceed from the value of personal virtues which are worth striving for (e.g., bravery, truthfulness). Someone who behaves well is someone who acts based on such a virtue. Consequentialism, on the other hand, concentrates on the results of one’s actions: An action is ethically legitimized if the results are good or useful. The most influential course of consequentialism may be found in utilitarianism, which forms the basis for many types of health-economic evaluations and all in all plays an important role in public health. Utilitarianism sees an action as ethically justified when the resulting overall benefit is positive - even if some people had to suffer disadvantages. Clearly, the inviolability of human dignity puts certain limits on this type of logic. Klaus Dörner, an important representative of German social psychiatry, for example, using Kant’s categorical imperative, demands dropping utilitarianism in order to remain aware of the weakest in society: “Act such that in the scope of your responsibility you deploy  all your resources of listening, caring and loving, including manpower and time, beginning with the weakest - with those who are least worthy.” In prevention and health promotion this means attending to reducing social inequalities.

One could raise grave objections to every one of the above-mentioned ethical concepts, and in fact philosophy has not reached a consensus about the “right” form of ethics. For this reason, a number of authors have suggested using principles from the mid-level of abstraction since they are more easily understood and more easily substantiated using different philosophical approaches (principle ethics) or to discuss using examples (case-based approach).

Exemplary Fields of Conflict

The English-speaking world has experienced a very intensive discussion over the past few years concerning public health ethics, which also deals with population based strategies of prevention and health promotion. Well known, for example, is the principle ethics standpoint of Beauchamp and Childress, who formulated four basic ethical principles: autonomy, beneficence, non-maleficence, justice. In the German-speaking countries Peter Schröder-Bäck took up this idea and formulated five principles of independent public health ethics as opposed to individual-medical ethics: maximization of overall health utility and public protection, respect for human dignity, justice, efficiency and proportionality. Respect for human dignity is explicitly integrated into the collectivistic-ethical approach.
Based on such principles the ethical dimension of actions in prevention and health promotion strategies can at least be illustrated as follows:

  • How to set priorities in prevention and health promotion? Are the right problems being addressed? Can we ethically condone the orientation toward epidemiological evidence as opposed to an orientation toward processes of participation and consensus? Do cost-benefit analyses have more importance than advocacy for socially disadvantaged persons?
  • What imperatives for health promotion and prevention result from the existing socioepidemiological evidence on poverty and health?
  • Must professionals in the field of health promotion become socio-politically active?
  • How are we to ethically view matters of financing in the field of prevention? For example, is it ethical to demand that socially disadvantaged persons (co)pay for health courses? Is it ethical to put political pressure on the manufacturers and suppliers of vaccinations to lower their prices in order to avoid rationing?
  • Under what conditions is it ethical to curtail the autonomy of individuals? For example, is it acceptable to forbid smoking in public places or drinking while driving a car? Are seatbelt laws compatible with the autonomy principle? Is it legitimate to demand that everyone participate in cancer screening tests? What is the rationale behind taking measures which curtail freedom of action in order to prevent epidemics?
  • Is it allowed to preventively treat (healthy) persons despite a certain risk of side effects, e.g., by putting fluoride in the drinking water or instituting compulsory vaccination?
  • Should test results be passed on to insurance companies? Do patients have to be informed about all examination results? Is there such a thing as the right not to know and how can it be formulated appropriately?
  • How is responsibility applied in the discourse concerning individual responsibility? Are “blaming-the-victim” strategies suitable to preventive policies?
  • Is the identification and designation of specific target groups always harmless - or does that introduce labeling effects and stigmatizations, e.g., in obesity prevention or other prevention activities among the social disadvantaged?
  • Should what is preventatively possible become the norm for everyone? Do people have the obligation to remain healthy?
  • Where are the ethical limitations to improving health and physical performance, e.g., through pharmacological enhancement (= doping) or through eugenic measures?
  • What new ethical challenges will emerge from the linking of preventive and predictive medicine, in combination with the “omics sciences” - both on the individual and on the public health level?
  • What should be allowed in sponsoring and in third-party funded research, for example, with respect to grants provided by the tobacco industry?

In concrete cases the ethical aspects must be weighed against professional, economic and political aspects. In some spheres, inasmuch as the decision-making process is not legally regulated, support from ethical codes or ethically relevant guidelines may already be present, e.g., in occupational medicine, with genetic testing or screenings. Codices of ethics should not replace the individual conscience (individual ethics); rather, they provide compiled knowledge and the results of ethical discussions. The examples given above are also meant to show that professional ethics for health promotion and prevention may not limit itself to the individual relationship between healthcare professionals and patients as often systemic questions need to be dealt with, which demand ethics reflecting whole institutions or the social order.

Science and Ethics

In prevention and health promotion the need for action is often legitimized in epidemiologically relevant data, for example, “lost years” (PYLL, potential years of life lost) or “avoidable mortality.” This approach forces ethical considerations to take a back seat in the prioritization of themes and target groups. When determining the need for preventive action, epidemiology indeed plays a big role: Unlike the curative situation, interventions do not emerge directly from the demands made by those in need of treatment. Yet there is no simple line running from preventive goals to the findings of epidemiology. Deriving what “should” be from what is, according to David Hume, means committing a “naturalistic mistake” (there is no valid logical conclusion that leads from what is to what should be). Epidemiological constructs like those of PYLL or avoidable mortality (epidemiology) are no exceptions. Proper action cannot be calculated - something that is true as well for ethically proper actions: Such action can emerge only through communication with others, in particular with the participation of those affected and with the disclosure of all enlisted premises (ethical discourse). Especially in the field of prevention and health promotion one possible result of the deliberations may be that what is ethically right cannot always be determined without a doubt.

Bayer R/Gostin LO/Jennings B/Steinbock B, Public Health Ethics, New York 2007.
Beauchamp T/Childress J, Principles of Biomedical Ethics, New York 1994.
Hafen M, Ethik in Prävention und Gesundheitsförderung, in: Prävention und Gesundheitsförderung 2013, 8 (4), 284-288.
Kolb S/Seithe H/IPPNW (Eds.), Medizin und Gewissen. 50 Jahre nach dem Nürnberger Ärzteprozeß, Frankfurt 1998.
Naidoo J/Wills J, Lehrbuch der Gesundheitsförderung. Überarbeitete, aktualisierte und durch Beiträge zum Entwicklungsstand in Deutschland erweiterte Neuauflage, hrsg. von der Bundeszentrale für gesundheitliche Aufklärung (BZgA), Gamburg 2010.
Schröder P, Ethische Prinzipien für die Public-Health-Praxis: Grundlagen und Anwendungen, Frankfurt 2014.

Internet addresses:
www.drze.de (Deutsches Referenzzentrum für Ethik in den Biowissenschaften)
www.ethikrat.org (Deutscher Ethikrat)
www.nuffieldbioethics.org (Nuffield Council on Bioethics)

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