Advertising Essay

There are enduring, almost perennial debates on the efficacy and ethics of fear campaigns in

public health that reemerge with whack-a-mole frequency, as eloquently chronicled by Fairchild

et al. (p. 1180). Supported by evidence-based reasoning about motivating behavior change and

deterrence,1 these campaigns intentionally present disturbing images and narratives designed to

arouse fear, regr et, and disgust.

Having health problems can be a profoundly negative experience unappreciated by those not

living with them. Pain, immobility, disfigurement, depression, isolation, and financial problems

are common sequelae of disease and injury. It is beyond argument that these outcomes are self-

evidently anticipated and experienced as adverse, undesirable, and so best avoided. Efforts to

prevent them are therefore, prima facie, ethically beneficent and virtuous.

FIVE CRITICISMS

Criticism of the ethics of fear messaging takes five broad directions. First, it is often asserted that

fear campaigns should be opposed because they are ineffective: they simply "don't work" very

well. Fairchild et al. note that this argument persists despite the weight of evidence. The

ineffectiveness argument can be valid independent of the content of failed campaigns: "positive"

ineffective campaigns should be subject to the same criticism. Yet sustained criticism of

ineffective positive campaigns is uncommon, suggesting this criticism is enlisted to support more

primary objections about fear campaigns.

Second, critics argue that such campaigns target victims, not causes ofhealth problems, and so

are soft options mounted in lieu of more politically challenging upstream policy reform of social

determinants of health, such as education, employment, and income distribution as well as

legislative, fiscal, and product safety law reforms.

It is difficult to recall any major prescription for prevention in the past 40 years not involving

advocacy of comprehensive strategies of both policy reforms and motivational interventions. For

example, tobacco control advocates target advertising bans, smoke-free policies, and tax hikes as

well as increased public awareness campaign financing. When governments fail to enact

comprehensive approaches to prevention, supporting only public awareness campaigns, it is

plainly concerning. The resultant concentration of public discourse on the importance of

individualistic change instead of systemic, legislative, or regulatory change in controlling health

problems may lead to public perceptions that solutions are mostly contingent on what individuals

do or do not do.2 This myopic definition of health problems and their solution promotes victim

blaming,3 in which notions of individual responsibility are held to explain all health problems

when any volitional component is involved.

This can be a serious criticism of governments' failure to commit to prevention, but is it a fair

and sensible criticism of public awareness campaigns in themselves? Those making this

argument draw the meritless implication that until governments are prepared to embrace the full

panoply of policy and program solutions to health problems, they should not implement any

individual element of such comprehensive approaches. If you cannot do everything, don't do

anything?

Furthermore, in any public health utopia where governments enacted every platform of

comprehensive programs and made radical political changes addressing the social determinants

of health, every health problem with a behavioral, volitional component would still require

individuals to make choices to act and to be sufficiently motivated to do so. Campaigns to inform

and motivate such changes will always be needed. The reductio ad absurdum of this objection is

that attention-getting warning signs and poison labels are unethical.

Third, those who live with the diseases or practice the behaviors that are the focus ofthese

campaigns can sometimes experience themselves as having what Irving Goffman called "spoiled

identities"4 and may feel criticized, devalued, rejected, and stigmatized by others. The argument

runs that these campaigns "ignore evidence that stigma makes life more miserable and stressful

and so is likely to have direct health effects"5(p14-15) and fail to recognize that the stigmatized

health states or behaviors "travel with disadvantage."5

Criticism of fear campaigns is mostly applied to health issues for which personal behavior, as

opposed to public health and safety, is the focus. Campaigns seeking to stigmatize and shame

alcohol- and drug-affected drivers, environmental polluters, domestic violence perpetrators,

sexual predators, owners of savage dogs, or restaurant owners with unhygienic premises are

rarely criticized. Some people deserve tobe stigmatized, apparently.

A fourth argument used against fear campaigns is that many personal changes in health-related

behavior are difficult, requiring physical discomfort, perseverance, sacrifice, and sometimes

major lifestyle change, which is often limited by structural impediments such as poor access to

safe environments, cost, and work and family constraints.

But unless one subscribes to an unyielding, hard determinist position that people have no agency

and are total prisoners of social and biological determinants, the idea that individuals even in the

direst of circumstances cannot make changes in their lives when motivated to do so is an extreme

position, difficult to sustain. It is instructive, for example, to reflect that today in many nations, it

is only a minority of the lowest socioeconomic group who still smokes.

IS IT UNETHICAL TO UPSET?

Perhaps the most common argument, though, is that we should always avoid messaging that

might upset people. This argument has two subtexts. First, an assumption is made that how

people feel about something ought to be inviolate and challenging it is disrespectful. But we all

have our views challenged often on many things, and some of those challenges motivate

reflection and change-and in the process sometimes make us feel uncomfortable. Why is the goal

of avoiding any communication that might make people feel uncomfortable or selfquestioning

self-evidently a noble, ethical criterion in the ethical assessment of public health

communication?

Feelings about desirable health-related practices often reflect powerfully promoted commercial

agendas to normalize practices, such as overconsumption, poor food choices, and addiction.

Those who hold the notion that such agendas should be not challenged out of some misguided

fear of offending those who are its victims would see the door held open even wider to those

commercial forces seeking to turbocharge the impacts of their health-damaging campaigns. If a

smoker gets comfort and self-assurance from inhabiting the commercially contrived meanings

ofsmoking promoted through tobacco advertising, should we suspend strident criticism

of tobacco marketing because it might be disrespectful of smokers?

It is a perverse ethics that sees it as virtuous to keep powerful, life-changing information away

from the community simply because it upsets some people.6 Should we really tiptoe around

vividly illustrating how deadly sunburn can be because we fear offending some who value

tanning? Although rendering vivid the carnage and misery caused by speed and intoxicated

driving may upset some who are quadriplegic, how do we balance the support for such

campaigns by others now living that way and evidence that fear of public shame and personal

remorse works to deter both? And if ghoulish pack warning illustrations of tobacco-caused

disease like gangrene and throat cancer render the damage of smoking far more meaningful than

more genteel explanations, whose interests are served by decrying such depictions as being

somehow unethically disturbing?

Some in the community do not like encountering confrontational information that challenges

their ignorance or complacency, but public health is not a popularity contest in which an

important criterion for assessing the merits of a campaign is the extent to which it is liked.

Fairchild et al. make a superb contribution to our field's confused thinking on fear appeals in

public health that deserves wide discussion.

Simon Chapman, AO, PhD

Sidebar

Correspondence should be sent to Simon Chapman, School of Public Health A27, University of

Sydney, NSW 2006, Australia (e-mail: [email protected]). Reprints can be

ordered at http://www.ajph.org by clicking the "Reprints" link.

This editorial was accepted June 15, 2018.

doi: 10.2105/AJPH.2018.304630

References

REFERENCES

Chapman, Simon,A.O., PhD. (2018). Is it unethical to use fear in public health

campaigns? American Journal of Public Health, 108(9), 1120-1122.

doi:http://dx.doi.org.libraryresources.columbiasouthern.edu/10.2105/AJPH.2018.3