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50 Moral responsibility narratives in health promotion: examining ethical concerns and the relationship with overdiagnosis
  1. George Gillett
  1. Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK


‘Nothing is more punitive than to give a disease meaning – that meaning being invariably a moralistic one’.1 If Susan Sontag’s observation was borne out of the HIV/AIDS pandemic, its lessons are still relevant today. Writing of contemporary narratives surrounding smoking, Nicholas Lezard notes ‘a habit which is bad for me appears equivalent with what is bad of me’2 This growing societal narrative – to associate so-called ‘health behaviours,’ and their associated medical diagnoses, with themes of personal responsibility - has been termed the ‘responsibilisation of health’ by academics.3 Importantly, this trend may harbour harms of its own. For example, shame and guilt are prevalently associated with ‘health behaviours’ such as mothers’ inability to breastfeed,4 while perceptions of lifestyle-related diseases such as lung cancer often lead patients to hide their illness from others due to the shame they experience.5 Such narratives may amplify the deleterious effects of Overdiagnosis, by compounding and contributing to the causes and harms of overdiagnosis in wider society.

This presentation will outline how contemporary health promotion campaigns often employ moral responsibility narratives to invoke feelings of shame, guilt, disgust and fear to engender population-level changes in health-related behaviours. I will then examine the ethical context of these narratives, to explore how the promotion of healthy behaviours using such approaches may sometimes conflict with a duty to respect autonomy. By introducing two observations relating to modern healthcare: i) epidemiological transition and ii) the changing understanding of the concept of health, I will argue that many contemporary health promotion strategies are predicated on dubious ethical grounds. This is supported by the claim that many traditional ethical justifications for such approaches, including overall benefit, collective efficiency, state duty, harm principle and justice arguments, may not be valid in the context of non-communicable disease prevention.

I will conclude that contemporary healthy promotion strategies may risk encroaching on patient autonomy in a manner which clinicians would ordinarily regard to be ethically unjustifiable. This approach will highlight a potential avenue to mitigate the harms which result from overdiagnosis, by reducing the prevalence and potency of such practices.


  1. Sontag S. AIDS and Its Metaphors, United States: Farrar, Straus and Giroux, 1989

  2. Lezard N. Iceland’s cigarettes-on-prescription plan needs to be stubbed out, The Guardian (2011)

  3. Schramme T. Disease and Dispositions as Objects of Individual Responsibility. Paper presented at Concepts of Disease: Dysfunction, Responsibility and Sin Conference, Oxford, UK. (January 2017)

  4. Guttman N, Zimmerman DR. Low-income mothers’ views on breastfeeding. Social Science & Medicine, 2000;50(10):1457-73

  5. Chapple A, Ziebland S, McPherson A. Stigma, shame and blame experienced by patients with lung cancer: qualitative study. The BMJ, 2004;328(7454):1470

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