The efficacy and ethics of fear campaigns are enduring, almost perennial debates in public health which re-emerge with whack-a-mole frequency, eloquently chronicled by Fairchild et al [1].  Supported by evidence-based reasoning about motivating behavior change and deterrence [2],  these campaigns intentionally present disturbing images and narratives designed to arouse fear, regret and disgust.

Health problems can be profoundly negative experiences unappreciated by those not living with them. Pain, immobility, disfigurement, depression, isolation and financial problems are common sequalae of disease and injury. It is beyond argument that these are outcomes which 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 main 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 [1] 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 also 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.

Victim-blaming?

Second, critics argue that such campaigns target victims, not causes of health 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 or income distribution, or legislative, fiscal and product safety law reforms.

It is difficult to recall any major prescription for prevention in the last 40 years not involving advocacy for comprehensive strategies of both policy reforms and motivational interventions. For example, tobacco control advocates target advertising bans, smokefree policies, and tax rises as well as increased public awareness campaign financing. When governments fail to enact comprehensive approaches to prevention, supporting only public awareness campaigns, this is plainly concerning. The resultant concentration of public discourse around 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 don’t do(3). This myopic definition of health problems and their solution promotes victim blaming(4), where notions of individual responsibility are held to explain all health problems when any volitional component is involved.

This can be a serious criticism failed government commitment 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?

Further, 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.

Stigmatisation

Third, those who live with the diseases or practice the behaviors that are the focus of these campaigns can sometimes experience themselves as having what Irving Goffman called “spoiled identities”(5) 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.”[6] and fail to recognize that the stigmatized health states or behaviors “travel with disadvantage”. [6]

Criticism of fear campaigns is mostly applied to health issues where personal behavior as opposed to public health and safety is the focus. Campaigns seeking to stigmatize and shame alcohol and drug-affected driving, environmental polluters, domestic violence perpetrators, sexual predators, owners of savage dogs, or restaurant owners with unhygienic premises are rarely criticized. Some people deserve to be stigmatized, apparently.

Prisoners of structural constraints?

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, often limited by structural impediments like poor access to safe environments, cost, 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 smoke.

Is it always wrong to upset people?

Perhaps the most common argument though, is that we should always avoid messaging which might upset people. This argument has two sub-texts. First, an assumption is made that how people feel about something ought to be inviolate and to challenge 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 make us sometimes feel uncomfortable. Why is the goal of avoiding any communication which might make people feel uncomfortable or self-questioning, self-evidently a noble, ethical criterion in the ethical assessment of public health communication?

Here, feelings about desirable health-related practices often reflect powerfully promoted commercial agendas to normalize practices like over-consumption, poor food choices, and addiction.  The notion that such agenda 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 turbo-charge the impacts of their health damaging campaigns. If a smoker gets comfort and self-assurance from inhabiting the commercially contrived meanings of smoking 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.[7] Should we really tip-toe around vividly illustrating how deadly sun-burn can be through fear of offending some of those who value tanning? While 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 confronting information that challenges their ignorance or complacency, but public health is not a popularity contest where an important criterion for assessing the merits of a campaign is the extent to which it is liked.

Fairchild et al’s paper [1] is a superb contribution to our field’s confused thinking on fear appeals in public health and deserves wide discussion.

References

1. Fairchild A, Bayer R, Green SH, Colgrove J, Kilgore E, Sweeney M, Varma JK. The two faces of fear: a history of hard-hitting public health campaigns against tobacco and AIDS. Am J Public Health 2018;108(9): 1180-1186.
2. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261-71.
3. Bonfiglioli CM, Smith BJ, King LA, Chapman SF, Holding SJ. Choice and voice: obesity debates in television news. Med J Aust 2007;187(8):442-5.
4. Crawford R. You are dangerous to your health: the ideology and politics of victim blaming. Int J Health Services 1977;7(4):663-80.
5. Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs, N.J.:Prentice Hall, 1963.
6. Carter SM, Cribb A, Allegrante JP. How to think about public health ethics. Pub Health Rev 2012;3(1):1-24.
7. Chapman S. For debate: the means/ends problem in health promotion. Med J Aust 1988;149(5):256-60.

This is a pre-print of an editorial published in American Journal of Public Health 2018:1120-1122.