You win some, you lose more

Ratings consistently show Australians love reality television. In 2013 our favourite thing on TV was to watch one another singing, dancing, cooking and renovating. Every year producers dish up more contrived scenarios, bitter conflicts, shameful embarrassments and heart-warming triumphs under familiar reality brands. We are entertained; they make money. Not surprising, then, that a new season of The Biggest Loser starts this weekend. More surprising is that recent years have seen the show's ratings fall. It's hard to know why: perhaps we're just bored. Perhaps we're more interested in watching someone sauté a quail in butter. Or maybe - and I'm being optimistic here - we're starting to listen to our intuition that this show is a bit wrong. That it is exploitative, even by reality TV standards. That it is ethically questionable. In the past 50 years, we have built a society in which it's easier to be fat than thin. I am not the first to criticise The Biggest Loser: Google can introduce you to my fellow travellers. Personal trainers, dieticians, weight-loss doctors, contestants and former employees of the show have critiqued its methods, its motives and its outcomes. And their criticisms suggest deep ethical problems. The simplest is this: the show is likely to harm contestants and unlikely to benefit them. They are rewarded not for improving their health, but for decreasing their weight

Overdiagnosis: an important issue that demands rigour and precision: Comment on Medicalisation and overdiagnosis: what society does to medicine.

Van Dijk and colleagues present three cases to illustrate and discuss the relationship between medicalisation and overdiagnosis. In this commentary, I consider each of the case studies in turn, and in doing so emphasise two main points. The first is that it is not possible to assess whether overdiagnosis is occurring based solely on incidence rates: it is necessary also to have data about the benefits and harms that are produced by diagnosis. The second is that much is at stake in discussions of overdiagnosis in particular, and that it is critical that work in this area is conceptually rigorous, well-reasoned, and empirically sound. van Dijk and colleagues remind us that overdiagnosis and medicalisation are not just matters for individual patients and their clinicians: they also concern health systems, and society and citizens more broadly. Keywords Overdiagnosis; Medicalisation; OvertreatmentNHMRC grants, 1023197 & 110413

Health promotion: an ethical analysis

Thinking and practising ethically requires reasoning systematically about the right thing to do. Health promotion ethics – a form of applied ethics – includes analysis of health promotion practice and how this can be ethically justified. Existing frameworks can assist in such evaluation. These acknowledge the moral value of delivering benefits. But benefits need to be weighed against burdens, harms or wrongs, and these should be minimised: they include invading privacy, breaking confidentiality, restraining liberty, undermining self-determination or people’s own values, or perpetuating injustice. Thinking about the ethics of health promotion also means recognising health promotion as a normative ideal: a vision of the good society. This ideal society values health, sees citizens as active and includes them in decisions that affect them, and makes the state responsible for providing all of its citizens, no matter how advantaged or disadvantaged, with the conditions and resources they need to be healthy. Ethicists writing about health promotion have focused on this relationship between the citizen and the state. Comparing existing frameworks, theories and the expressed values of practitioners themselves, we can see common patterns. All oppose pursuing an instrumental, individualistic, health-at-all-costs vision of health promotion. And all defend the moral significance of just processes: those that engage with citizens in a transparent, inclusive and open way. In recent years, some Australian governments have sought to delegitimise health promotion, defining it as extraneous to the role of the state. Good evidence is not enough to counter this trend, because it is founded in competing visions of a good society. For this reason, the most pressing agenda for health promotion ethics is to engage with communities, in a procedurally just way, about the role and responsibilities of the citizen and the state in promoting and maintaining good health.NHMR

The ethics of over-diagnosis: risk and responsibility in medicine

Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, including its inventor, say it should never be used to screen for cancer. My friend’s dad’s PSA test started him on a path to prostate cancer diagnosis and surgery. The surgery made him incontinent. Humiliated by accidents, he couldn’t be far from a toilet so could no longer coach soccer or go on his daily long walk with friends. He became socially isolated and sedentary. He put on weight. And he developed diabetes. Now his health is worse, but it’s not only his health that has been affected. Other aspects of his well-being – attachment to his friends and the ability to live the life he wants – have been undermined. His story is, sadly, not unusual, except for one thing. The hospital where he was treated called him in to apologise for operating unnecessarily and harming him. Both he and his clinicians concede he was over-diagnosed (the disease would not have produced symptoms or shortened his life) and over-treated (he received treatment he didn’t need.) Over-diagnosis and over-treatment happen for many reasons – commercial interests, technological developments, medico-legal threats and deliberate profiteering. But as consumers, we also contribute

The ethics of over-diagnosis: risk and responsibility in medicine

Recently a friend told me a story about her dad. Fit and well, he had a PSA test during a general medical check-up. The PSA test is controversial: many, including its inventor, say it should never be used to screen for cancer. My friend’s dad’s PSA test started him on a path to prostate cancer diagnosis and surgery. The surgery made him incontinent. Humiliated by accidents, he couldn’t be far from a toilet so could no longer coach soccer or go on his daily long walk with friends. He became socially isolated and sedentary. He put on weight. And he developed diabetes. Now his health is worse, but it’s not only his health that has been affected. Other aspects of his well-being – attachment to his friends and the ability to live the life he wants – have been undermined. His story is, sadly, not unusual, except for one thing. The hospital where he was treated called him in to apologise for operating unnecessarily and harming him. Both he and his clinicians concede he was over-diagnosed (the disease would not have produced symptoms or shortened his life) and over-treated (he received treatment he didn’t need.) Over-diagnosis and over-treatment happen for many reasons – commercial interests, technological developments, medico-legal threats and deliberate profiteering. But as consumers, we also contribute

LONGITUDINAL QUALITATIVE RESEARCH DESIGN: EXPERIENCE OVER TIME

In this paper I examine time in qualitative researchdesign. I focus on a study design that is almost absent from the literature, inwhich qualitative data are collected repeatedly and prospectively from a cohort of individuals over a long period. I will refer to this design as longitudinal qualitative research, and argue that it carries risks and benefits. It heightens the need for ethical clarity, particularly in respect to repeated participation. Unless the aim is to examine a trajectory of experience, longitudinal design may diminish a study’s explanatory power by making the sampling less purposive: commitments to long engagement must be honoured, and the participants selected may, over time, become less informative than expected about the issue under study. Conversely, longitudinal design benefits from the development of a history between the researchers and participants, offers unique access to the actions of, and interactions with, time in the experience under study, and helps to guard against epistemological naiveté on the part of the researcher. Qualitative research isoften blind to time, and I conclude that the greatest contribution of longitudinal qualitative research may be its sensitisation of researchers to the importance of time in social life

The Ethics of Menu Labelling

In this commentary, I explore the ethically relevant dimensions of menu labelling. The evidence that menu labelling changes purchasing or consumption behaviour is contentious and inconclusive; there is some suggestion that menu labelling may preferentially influence the behaviour of healthier and wealthier citizens. Some suggest that menu labelling is unjust, as it fails to direct resources towards those who most need them. An alternative is to see menu labels as just one of a set of strategies that can increase people’s real opportunities to be healthy. Complementing strategies will be necessary to ensure that all citizens can consider and value food choices, which may include becoming a more critical consumer in the food marketplace. Menu labels may also have the potential to (i) shift our attention from people to food, (ii) reallocate (some) responsibility in the food environment and (iii) facilitate structural change. It would be a mistake to expect too much of menu labels alone: rather, they should be integrated into a broader programme that supports health opportunities, especially for the least well off.This work was supported by an Australian National Health and Medical Research Council (NHMRC) Project Grant 632679, and a NHMRC Career Development Fellowship 1032963

LONGITUDINAL QUALITATIVE RESEARCH DESIGN: EXPERIENCE OVER TIME

In this paper I examine time in qualitative researchdesign. I focus on a study design that is almost absent from the literature, inwhich qualitative data are collected repeatedly and prospectively from a cohort of individuals over a long period. I will refer to this design as longitudinal qualitative research, and argue that it carries risks and benefits. It heightens the need for ethical clarity, particularly in respect to repeated participation. Unless the aim is to examine a trajectory of experience, longitudinal design may diminish a study’s explanatory power by making the sampling less purposive: commitments to long engagement must be honoured, and the participants selected may, over time, become less informative than expected about the issue under study. Conversely, longitudinal design benefits from the development of a history between the researchers and participants, offers unique access to the actions of, and interactions with, time in the experience under study, and helps to guard against epistemological naiveté on the part of the researcher. Qualitative research isoften blind to time, and I conclude that the greatest contribution of longitudinal qualitative research may be its sensitisation of researchers to the importance of time in social life

What is health promotion ethics?

What does it mean to think about the ethics of health promotion? When most of us think ‘ethics’ we think of the Human Research Ethics Committee applications required for research projects. But I’m thinking of something quite different here: the ethics of health promotion practice. Health promotion ethics is an attempt to answer questions such as: Can we provide a moral justification for what we are doing in health promotion? or What is the right thing to do in health promotion, and how can we tell? As other authors have argued, sometimes these questions are ignored in health promotion in favour of scientific and technical questions about effectiveness. But there is increasing recognition that health promotion is a moral project, that health promotion can be practised in ways that are more or less ethical, and thus that considering ethics in health promotion is just as important as – and related to – considering the evidence about whether or not health promotion works. 1-5 The number of publications about health promotion ethics has been slowly increasing since the 1980s, including in this journal, where authors have particularly argued the importance of being explicit about values in health promotion. If something has value, it has worth or importance. 6 Authors in the HPJA have suggested that health promotion practitioners value: health and wellbeing as opposed to the mere absence of disease, justice, environmental sustainability, empowerment, respect for culture, and truth telling. 3, 7, 8 But concern has been expressed that although these things are valued in health promotion, this may not always influence the way that health promotion is implemented and evaluated.NHMR