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Application of nutritional ethics in nutrition education
VIEWPOINT Application of Nutritional Ethics in Nutrition Education JEFFERY SOBAL
Division of Nutritional Sciences, Cornell University, Ithaca, New York 14853 injections of large doses of vitamin A, the biomedical model is generally effective and relatively few dilemmas exist in applying related nutrition education. However, a biomedical model alone is not sufficient for most nutrition education practices because clients are human beings (not simply biological organisms) who eat foods (not simply ingest nutrients) and who have complex psychological, social, and cultural problems. Feeding people is not the same as feeding animals, and thus the simple biomedical model must be expanded into a biopsychosocial model (6, 7) that incorporates social science issues. The importance of considering social science issues has long been recognized by nutrition educators, who strive to understand food preferences, food habits, food ideologies, foodways and other social issues in order to make their educational activities more effective by being sensitive to the personal and cultural needs of their clients (8). Nutrition educators clearly need to ground their educational strategies in social science perspectives such as social learning theory (9) or the health belief model (10). Where social issues are the primary problem and biological information is fairly certain, a biopsychosocial approach can be effective, such as the use of reasoned action theory to encourage breastfeeding (ll). Just as with the biomedical model, however, a social science model, or even a biopsychosocial model, alone is not sufficient to deal with many of the dilemmas involved in nutrition education, because they ignore related ethical and philosophical issues. Questions about who, what, when, where, and how may be dealt with using biological and social science perspectives. However, questions about why, should, must, and ought receive insufficient guidance from theories on the biological and social levels of analysis. Addressing such dilemmas requires that concepts and theories on the moral level of analysis be used. Applying the moral level of analysis leads to a discussion of Nutritional Ethics.
Nutrition educators confront many ethical issues in their various activities, including ethical problems in relationships with clients, policy and program development, and public communication about nutrition (1-3). One method for considering the resolution of ethical problems is through the use of theories and concepts developed in the discipline of philosophy to frame and analyze ethical quandaries. This paper describes a framework of nutritional ethics for dealing with moral dilemmas.
LEVELS OF ANALYSIS: BIOLOGICAL, SOCIAL, AND MORAL Nutrition educators can draw upon concepts and data from three levels of analysis: biological, social, and moral. Biological knowledge is the foundation upon which nutrition education rests, and such knowledge is applied using a biomedical model. Much is not yet understood about many biological processes, such as the physiology of diabetes, and nutrition education on these topics can only be as good as the knowledge from biological science that forms its foundation. Uncertainty about the biological aspects of nutrition issues and the ongoing development and changes in such knowledge make it difficult for nutrition educators to have an unchallengeable biological base for their educational interventions. Fox (4, 5) delineates three types of uncertainty: uncertainty in the body of existing knowledge, uncertainty from incomplete mastery of existing knowledge, and uncertainty in distinguishing between limitations in the existence of knowledge and the mastery of that knowledge. The existence of these types of uncertainty for the biological sciences and for nutrition make it difficult to deal with many clients, and presents limitations in a reliance on a biomedical model. Where biological issues are the basic problem and uncertainty is low, such as in providing children severely deficient in vitamin A with Address for correspondence: Jeffery Sobal, Ph.D., M.P.H., Division of Nutritional Sciences, Cornell University, Room 303 MVR Hall, Ithaca, NY 14853; (607) 255-6015. 0022-3182/91/2304-0187$03.00/0 © 1991 SOCIETY FOR NUTRITION EDUCATION
A FRAMEWORK FOR NUTRITIONAL ETHICS
Nutritional ethics applies ethical theories and principles in an effort to deal with the moral dilemmas involved in 187
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nutrition, including nutrition education. Many concepts and theories for dealing with issues on the moral level of analysis exist, and are useful for resolving some of the ethical dilemmas nutrition educators face in practice. Nutrition educators can look to frameworks established in ethics for conceptual and theoretical tools with which to address ethical problems. Many presentations of ethical frameworks exist (1214), including short summaries (15, 16) and practical guides (17). One of the clearest and most widely used presentation of ethical theories, concepts and analytical processes for health professionals is the work of Beauchamp and Childress (12), and that work will serve here as a guiding framework. Beauchamp and Childress describe a hierarchy of moral reasoning derived from general ethical theories, with ethical principles operating within the frameworks set by theories, specific ethical rules developed from ethical principles, and the application of all these ethical considerations leading to individual ethical actions and judgments. An ethical action is based on justifications grounded in theories, principles and rules. Actions are justified by rules, which in turn must be justified by larger principles, and these are organized and interpreted using larger theories. Such justifications provide arguments and claims that one action is more morally sound than another. The amount of ethical justification and analysis required for the resolution of a particular dilemma will be proportional to the importance of the issue, the difficulty of resolving the problem, the time and resources available for ethical deliberation, and the motivation to act in an ethical manner. Ethical theories. Many ethical theories exist, and they are divided into two major types: Consequentialist and Nonconsequentialist. Consequentialist theories (also called teleological or utilitarian theories) hold that actions are morally right if the consequences have the greatest balance of benefits over burdens. Application of these theories often fits the saying that "the ends justifY the means." These theories use the outcome of a decision as the primary criterion for determining what is ethically right, although there are variant perspectives about which aspects of the consequences should be the primary consideration. A major consequentialist theory is utilitarianism, based upon John Stuart Mill's (18) principle of utility that states actions are right if they produce the greatest good for the greatest number of people. Nonconsequentialist theories (also known as deontological theories) assert that ethical actions are morally right or wrong irrespective of their consequences. There are many opinions about which actions or rules are morally correct in and of themselves. A duty-based nonconsequentialist theory is Kant's (19) principle of the categorical imperative, which states that an ethical duty exists to always treat people as ends in themselves and not as means to other ends. A rights-based nonconsequentialist
theory is the justice theory of Rawls (20), which states that everyone has a right to the greatest possible liberty and that any inequalities that do exist should benefit those who are least advantaged. Often consequentialist and nonconsequentialist theories will lead to the same decision. For example, providing information about the benefits of breastfeeding to all pregnant mothers could be justified as leading to the greatest long-term good for the most people, as a duty to offer essential knowledge about an important nutritional decision, and as a just action to give mothers the liberty to decide about infant feeding. At other times, consequentialist and nonconsequentialist theories may conflict. For example, in the debate about providing consumers with food labelling (21), a consequentialist might argue that the greatest good for all would be achieved by providing very simple nutrition information on food labels. By contrast, nonconsequentialists might argue that producers have a duty to provide any interested individuals, even if they are few in number, with data about fat content because all consumers have a right to detailed information about the percentage of kilocalories from fat in their foods. Ethical principles. Beauchamp and Childress (12) identify four primary moral principles used to justify ethical arguments: Beneficence (helping others), Autonomy (respecting others' self determination), Nonmaleficence (not harming people), and Justice (fairness). Debates about the ethics of particular actions use justifications based upon arguments that appeal to identified moral principles. For example, it is insufficient for a nutrition educator simply to assert that obese people should not he coerced into losing weight, without providing ethical justifications for the reasons behind that judgment. JustifIcations for such a position could be based on appeals to respect for the autonomy of obese people and the need to avoid harm from interventions and intrusions into peoples' lives. A beneficent intent to assist in weight loss may be an insufficient justification for the coercion of obese people. Reviewing the fundamental ethical principles provides information about their use as conceptual tools for justifying arguments about ethical dilemmas. Beneficence is the moral principle of aiding others. Beneficent actions provide benefit, remove harm, and prevent harm (12), which are primary goals for much of nutrition education. The principle of beneficence is used in moral claims to justify interventions into the foodways and food habits of clients and the general public. Many nutrition education activities have no ethical dilemmas resulting from interventions based on beneficence, but some clients challenge nutrition educators as being overly intrusive and seeking to involve people who do not need or want nutrition education. Charges of paternalism, coercion, and restriction of individual freedom or rights may emerge from people who oppose beneficent actions
J. of Nutr. Educ. Vol. 23, No.4 by nutrition educators. "Weak" paternalism is more ethically justifiable than "strong" paternalism (12). Thus, it is less difficult ethically to justify outpatient care for the treatment of anorexia nervosa than it is to require hospital admission against clients' wishes. Autonomy is the right to self-determination, where autonomous actions and choices are not constrained by others. Individual choice, the right to know about interventions, and decisions to refuse care are justified using claims based on the principle of autonomy. In relationships between a nutrition educator and client, autonomy is the ethical principle that usually conflicts with beneficence. The right of individuals to make autonomous decisions forms the basis for the concept of informed consent. Refusal of treatment is also justified using claims based on patient autonomy. For example, arguments based on the principle of autonomy may be used to justify nonparticipation in cholesterol education programs by claiming that a respect for autonomy permits a client to choose to avoid receiving information about cholesterol intake and to consume high cholesterol foods. N onmaleficence is the moral principle of avoiding harm or injury to others. It is closely related to the principle of beneficence, which extends beyond not harming to actions that help. Duties for non maleficence are grounded in such maxims as the Hippocratic oath's statement of primum non nocere (above all, do no harm). An important part of ethical arguments involving nonmaleficence is to consider many levels of harm. This becomes complex in such issues as weight loss educational interventions, which Parham (3) shows can benefit some individuals but harm society by reinforcing unnecessarily stringent norms and values about thinness. Justice is the principle of fairness. Justice considers the equity of the distribution of burdens and benefits among many individuals. Various ways exist for providing just distribution of costs and benefits, including equal distribution, distribution based on need, etc. Nutrition educators can apply justice arguments in decisions about the distribution of the benefits of their programs to various groups in society and the fairness of providing services to target populations. Nutrition educators may face justice issues in policy debates about the macro-allocation of resources between nutrition education and other health programs, such as between campaigns to encourage fiber consumption versus seat belt use. Micro-allocation justice dilemmas may occur when distributional issues are debated within nutrition education, such as debates about whether to use limited resources to encourage weight loss versus increasing calcium consumption. ETHICAL ANALYSIS Issues involving ethical dilemmas, such as whether to
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offer unsolicited nutrition interventions or how to divide limited nutrition education resources, are addressed by using the procedure of ethical analysis that delineates possible courses of action and uses arguments justified by ethical principles. Ethical analysis begins with the identification of the biological and social facts to determine whether or not an ethical dilemma exists (rather than simply an argument about problems located on the biological or social level of analysis). The biological and social facts provide evidence for describing the ethical problem. Next, the potential alternative solutions need to be presented. Finally, arguments for and against each solution are made using ethical theories, principles and rules to support and refute the various solutions. Several competing ethical arguments can often be used to justify one option over another in an ethical dilemma, with the weight of those arguments determining the outcome of the ethical decision. More than one ethical principle can be applicable to an action or judgment. Often several principles will support the same conclusion, such as the provision of food assistance programs being justified as beneficent, just, nonmaleficent and contributing to the autonomy of the hungry. In other cases, different ethical principles will lead to conflicting arguments, requiring techniques for dealing with conflicting ethical claims. There are several ways to proceed when ethical justifications conflict. Larger ethical theories may provide guidance, as in the utilitarian position that providing the greatest average benefit to the greatest number of people is the deciding criterion. Ethical principles will often conflict, and Ross (22) proposed that such principles are "prima facie," meaning that they should be followed whenever possible but can be conditional to being overridden by another principle. One ethical principle may often be justified as definitively taking precedence over another. Claims based on non maleficence may supersede those based on beneficence, using the principle of autonomy to make a stronger claim for the need for one person to avoid harm than for another to give unwanted benefits. For example, if there are negative consequences of weight loss counseling, then it may be more justifiable to avoid these consequences. Arguments based on a principle of justice may override claims based on autonomy. For example, the distribution of nutritional resources to those at greatest need may be justifiable, even if it risks the autonomy of some people in access to their usual and preferred amount and type of food. A major conflict for all the health professions is between paternalism justified primarily by beneficence, and client rights to refuse interventions justified by respect for autonomy (23). This is a primary ethical dilemma in nutrition education ethics (2) and in the models of helping behavior used in nutrition education (24). There has been a shift in values in health and medicine that tends to view conflicts between claims based on auton-
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omy versus beneficence to be more powerfully justified using autonomy. An example would be the competent, informed client refusing an intervention offered by a nutrition educator, with the autonomy claims of the patient taking precedence over the beneficence claims of the educator.
ETHICAL ISSUES IN THE PROVIDER-CLIENT RELATIONSHIP Many of the most trying ethical problems faced by nutrition educators involve relationships with clients. Codes of ethics often focus on provider-client relationships to provide anticipatory guidance for health professionals and to delineate the expectations of clients. Social science analysis may describe provider-client roles and their associated rights and duties, norms and values about the provider-client relationship, and social processes that influence providers and clients (25). However, social science perspectives do not provide sufficient guidance for dealing with ethical conflicts in this area. The ethical theories and principles outlined here are applicable to the moral dilemmas in provider-client relationships. Beauchamp and Childress (12) discuss four moral rules derived from fundamental ethical principles: Veracity, Confidentiality, Privacy, and Fidelity. These rules are closely related, but can lead to different duties and actions. In addition to these rules, the concept of desert is also an important ethical consideration in educator-client relationships. Veracity is the rule about telling the truth and not lying or deceiving. The professional role of nutrition educators carries an obligation to provide correct information to clients, not deceive them, and to not withhold information. This can become problematic in cases where withholding some information may enhance the adherence of a patient to a therapeutic diet, or where uncertainty about biological evidence exists and educators are uncertain about disclosing conflicting scientific information. Confidentiality is the rule about avoiding disclosure and dissemination of information about a client to protect autonomy. Duties of confidentiality apply to all health professionals, but are not absolute and can be superseded in cases where sufficient ethical justification is marshalled. Nutrition educators have a duty to avoid revealing information about clients obtained during counseling. In some situations, however, this duty can be overridden with strong justification from beneficence or nonmaleficence, such as the discovery of life-threatening practices among clients with anorexia nervosa, when sharing that data with others would improve the prognosis. Privacy is the rule safeguarding accessibility to a client, which includes access to the person and information about
him or her. Privacy is justified using the principle of autonomy. As with confidentiality, ethical rules about privacy create obligations that proscribe giving others access to a client. Obligations to respect privacy also apply to the nutrition educator, who should refrain from unwanted intrusions into the personal life of a client beyond those needed for nutrition education. Ethical dilemmas about privacy may emerge in the mounting of mass communication nutrition campaigns. Fidelity is the rule insuring faithfulness, promisekeeping, and trustful relationships, as justified from the principles of autonomy and justice. Health professionals, including nutrition educators, have moral duties of faithfulness to the clients with whom they have established relationships. Because of the social contract between the nutrition educator and the client, explicit and implicit obligations exist to avoid neglecting clients or inappropriately withdrawing from relationships without proper notice. Thus, a nutrition educator who has been counseling a client about weight loss should not capriciously avoid the patient or arbitrarily withdraw from a longstanding relationship. Desert is the concept of providing benefits to people based on judgments about their past actions, where people are provided with benefits and costs because of deservingness or merit (26). This is seen in the saying that "people should get their just desert." Desert involves the application of the principle of justice, which considers responsibility and fault. Positive deserts are deserved or earned, and negative deserts are underserved. Many moral claims exist independently from desert, with duties of health professionals to care for clients existing irrespective of desert because beneficence overrides deservingness. Some discussions of provider-client relationships consider who is responsible for the problem as well as who is responsible for the solution (2, 24). Most client problems involve complex biopsychosocial issues that include sufficient uncertainty about etiology and treatment to make determination of responsiblity difficult, which makes considerations based on desert in a provider-client model difficult to justify morally. Perceptions of desert should not interfere with the need for care by clients, which exists independently from their responsibility for the problem. If a person needs nutrition education, claims that moral duties exist for universalistic treatment of clients by health care professionals may be used to argue that a nutrition educator should fill a client's needs, even if the client is responsible for the existence of the nutritional problem.
CONCLUSION Nutrition educators must address many issues that cannot be resolved by using current biomedical and social
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science paradigms. Nutrition educators must consider moral issues, in addition to the biopsychosocial perspectives. Moral analysis involves the consideration of nutritional ethics, which can be drawn from existing ethical frameworks. The ethical analysis of problematic issues can provide unique insights into problems that might otherwise not be systematically addressed. Ethical issues are key aspects of relationships between educators and clients. Often the actions of a nutrition educator that are based on beneficence clash with the actions of clients that are based upon autonomy, leading to dilemmas that need to be resolved using ethical concepts and theories. Social duties involved in the role of the nutrition educator as a health care provider mean that the educator is obliged to provide care to his/her clients irrespective of perceptions of desert. The provision of the highest quality nutrition education services needs to include analysis and justification of actions using analysis based upon nutritional ethics. Ethical shifts that reflect trends in the larger moral orientation of society influence nutrition education. For example, the preferences of clients are being given an increased emphasis over the dictums of professionals. Recent interest among nutrition educators in empowerment reflects this change (27). Empowerment is morally based in the principle of autonomy, as opposed to the beneficence-based paternalism often used in nutrition education (28, 29). Conscious attention to the moral underpinnings of the entire scope of nutrition education activities at all levels is important for the development of a strong profession of nutrition education. Nutrition educators need to develop their capabilities for explicitly recognizing the moral positions underlying the actions they take and for understanding the philosophical justifications for their actions. Nutrition educators must demonstrate that they are capable of identifying and dealing with the moral issues they face. Otherwise, nutrition education will lag behind other health professions, such as medicine, nursing, social work and health education, that are actively developing an expertise in ethical analysis. Training in nutritional ethics is an essential part of strengthening nutrition education. Courses or lectures on the topic are important in undergraduate and graduate training. Nutrition educators can benefit from engaging in continuing education about ethics and learning to think critically about the moral dilemmas that they face in practice. For the successful future development of the profession of nutrition education, it is essential for nutrition educators to develop and demonstrate knowledge and skills in identifying, confronting, and dealing with ethical dilemmas. 0 ACKNOWLEDGMENT The author thanks Ardyth Gillespie, Cathy Campbell, and Cheryl Achterberg for helpful comments.
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REFERENCES 1 Larson, B.J. The new epidemic: Ethical implications for nutrition educators. Journal of Nutrition Education 21:101-103, 1989. 2 Achterberg, C. A., and L. L. Trenkner. Developing a working philosophy of Nutrition Education. Journal of Nutrition Education 22:189-93, 1990. 3 Parham, E. S. Applying a philosophy of nutrition education to weight control. Journal of Nutrition Education 22:194-7, 1990. 4 Fox, R. C. Training for uncertainty. In: The student-physician. R. K. Merton. G.c. Reader, and P.L. Kendall, eds. Cambridge, MA: Harvard University Press, 1957, pp. 207-41. 5 Fox. R.C. The evolution of medical uncertainty. Milbank Memorial Fund Quarterly 58:1-49, 1980. 6 Engel. C.L. The need for a new medical model: A challenge for biomedicine. Science 196:129-36, 1977. 7 Engel. C. L. The clinical application of the Biopsychosocial Model. American Journal of Psychiatry 137:535-44, 1980. 8 Sanjur, D. Social and cultural perspectives in nutrition. Englewood Clifli;, NJ: Prentice-Hall, 1982. 9 Houts, S.S. and R.H. Warland. Rotter's Social Learning Theory of personality and dietary behavior. Journal of Nutrition Education 21:172-79, 1989. 10 Becker, M.H. The Health Belief Model and personal health behavior. Thorofare, NJ: Slack Press, 1974. 11 Matheny. R.J., M.F. Picciano, and L. Birch. Attitudinal and social influences on infant-feeding preference. Journal of Nutrition Education 19:21-31. 1987. 12 Beauchamp, T. L. and J. F. Childress. Principles of biomedical ethics. 3rd edition. New York: Oxford University Press, 1989. 13 Veatch, R. M. A theory of medical ethics. New York: Basic Books, 1981. 14 Engelhardt, H.T. The foundations of bioethics. New York: Oxford Universitv Press, 1986. 15 Kimmel, A.J. Ethics and values in applied social research. Newbury Park: CA: Sage Publications, 1988, pp. 42--50. 16 Bunda, M.A. Alternative systems of ethics and their application to education and evaluation. Evaluation and Program Planning 8:2536, 1985. 17 Francoeur, R.T. Biomedical ethics: A guide to decision making. New York: Wilev, 1983. 18 Mill, J.S. Utilit;rianism. New York: Bobbs-Merrill, 1861, 1957. 19 Kant, 1. The metaphysical elements ofjustice . Indianapolis: BobbsMerrill, 1797, 1965. 20 Rawls, J. A theory ofjustice . Cambridge: Harvard University Press, 1971. 21 Levy, A.S., R.E. Schucker, J.E. Tenney, and O. Mathews. Consumer demand for detailed nutrition information: A case study. Journal of Nutrition Education 20:161-66, 1988. 22 Ross, W.D. The right and the good. Oxford: Clarendon, 1930. 23 Beauchamp, T.L. and L. McCullough. Medical ethics: The moral responsibilities of physicians. Englewood Cliffs, NJ: Prentice-Hall, 1984. 24 Brickman, P., V.c. Rabinowitz, J. Karuza, D. Coates, E. Cohn, and L. Kidder. Models of helping and coping. American Psychologist 37:368-84, 1982. 2.5 Gallagher, E.B. (ed.) The doctor-patient relationship in the changing health scene. DHEW Publication No. (NIH) 78-183. Washington. DC: U.S. Government Printing Office, 1978. 26 Sher, C. Desert. Princeton: Princeton University Press, 1987. 27 Rody, N. Empowerment as organizational poli~y in nutrition intervention programs: A case study from the Pacific Islands. Journal of Nutrition Education 20:133-41, 1988. 28 Riis. P. Etbics. health education and nutrition. In: Ethics in health education, S. Doxiadis, ed. New York: John Wiley and Sons, 1990, pp. 181-90. 29 Beauchamp, D. Life-style. Public Health and Paternalism. In: Ethical dilemmas in health promotion, S. Doxiadis, ed. New York: John Wiley and Sons, 1987, pp. 69-81.
Division of Nutritional Sciences, Cornell University, Ithaca, New York 14853 injections of large doses of vitamin A, the biomedical model is generally effective and relatively few dilemmas exist in applying related nutrition education. However, a biomedical model alone is not sufficient for most nutrition education practices because clients are human beings (not simply biological organisms) who eat foods (not simply ingest nutrients) and who have complex psychological, social, and cultural problems. Feeding people is not the same as feeding animals, and thus the simple biomedical model must be expanded into a biopsychosocial model (6, 7) that incorporates social science issues. The importance of considering social science issues has long been recognized by nutrition educators, who strive to understand food preferences, food habits, food ideologies, foodways and other social issues in order to make their educational activities more effective by being sensitive to the personal and cultural needs of their clients (8). Nutrition educators clearly need to ground their educational strategies in social science perspectives such as social learning theory (9) or the health belief model (10). Where social issues are the primary problem and biological information is fairly certain, a biopsychosocial approach can be effective, such as the use of reasoned action theory to encourage breastfeeding (ll). Just as with the biomedical model, however, a social science model, or even a biopsychosocial model, alone is not sufficient to deal with many of the dilemmas involved in nutrition education, because they ignore related ethical and philosophical issues. Questions about who, what, when, where, and how may be dealt with using biological and social science perspectives. However, questions about why, should, must, and ought receive insufficient guidance from theories on the biological and social levels of analysis. Addressing such dilemmas requires that concepts and theories on the moral level of analysis be used. Applying the moral level of analysis leads to a discussion of Nutritional Ethics.
Nutrition educators confront many ethical issues in their various activities, including ethical problems in relationships with clients, policy and program development, and public communication about nutrition (1-3). One method for considering the resolution of ethical problems is through the use of theories and concepts developed in the discipline of philosophy to frame and analyze ethical quandaries. This paper describes a framework of nutritional ethics for dealing with moral dilemmas.
LEVELS OF ANALYSIS: BIOLOGICAL, SOCIAL, AND MORAL Nutrition educators can draw upon concepts and data from three levels of analysis: biological, social, and moral. Biological knowledge is the foundation upon which nutrition education rests, and such knowledge is applied using a biomedical model. Much is not yet understood about many biological processes, such as the physiology of diabetes, and nutrition education on these topics can only be as good as the knowledge from biological science that forms its foundation. Uncertainty about the biological aspects of nutrition issues and the ongoing development and changes in such knowledge make it difficult for nutrition educators to have an unchallengeable biological base for their educational interventions. Fox (4, 5) delineates three types of uncertainty: uncertainty in the body of existing knowledge, uncertainty from incomplete mastery of existing knowledge, and uncertainty in distinguishing between limitations in the existence of knowledge and the mastery of that knowledge. The existence of these types of uncertainty for the biological sciences and for nutrition make it difficult to deal with many clients, and presents limitations in a reliance on a biomedical model. Where biological issues are the basic problem and uncertainty is low, such as in providing children severely deficient in vitamin A with Address for correspondence: Jeffery Sobal, Ph.D., M.P.H., Division of Nutritional Sciences, Cornell University, Room 303 MVR Hall, Ithaca, NY 14853; (607) 255-6015. 0022-3182/91/2304-0187$03.00/0 © 1991 SOCIETY FOR NUTRITION EDUCATION
A FRAMEWORK FOR NUTRITIONAL ETHICS
Nutritional ethics applies ethical theories and principles in an effort to deal with the moral dilemmas involved in 187
188
Sobal / NUTRITION ETHICS
nutrition, including nutrition education. Many concepts and theories for dealing with issues on the moral level of analysis exist, and are useful for resolving some of the ethical dilemmas nutrition educators face in practice. Nutrition educators can look to frameworks established in ethics for conceptual and theoretical tools with which to address ethical problems. Many presentations of ethical frameworks exist (1214), including short summaries (15, 16) and practical guides (17). One of the clearest and most widely used presentation of ethical theories, concepts and analytical processes for health professionals is the work of Beauchamp and Childress (12), and that work will serve here as a guiding framework. Beauchamp and Childress describe a hierarchy of moral reasoning derived from general ethical theories, with ethical principles operating within the frameworks set by theories, specific ethical rules developed from ethical principles, and the application of all these ethical considerations leading to individual ethical actions and judgments. An ethical action is based on justifications grounded in theories, principles and rules. Actions are justified by rules, which in turn must be justified by larger principles, and these are organized and interpreted using larger theories. Such justifications provide arguments and claims that one action is more morally sound than another. The amount of ethical justification and analysis required for the resolution of a particular dilemma will be proportional to the importance of the issue, the difficulty of resolving the problem, the time and resources available for ethical deliberation, and the motivation to act in an ethical manner. Ethical theories. Many ethical theories exist, and they are divided into two major types: Consequentialist and Nonconsequentialist. Consequentialist theories (also called teleological or utilitarian theories) hold that actions are morally right if the consequences have the greatest balance of benefits over burdens. Application of these theories often fits the saying that "the ends justifY the means." These theories use the outcome of a decision as the primary criterion for determining what is ethically right, although there are variant perspectives about which aspects of the consequences should be the primary consideration. A major consequentialist theory is utilitarianism, based upon John Stuart Mill's (18) principle of utility that states actions are right if they produce the greatest good for the greatest number of people. Nonconsequentialist theories (also known as deontological theories) assert that ethical actions are morally right or wrong irrespective of their consequences. There are many opinions about which actions or rules are morally correct in and of themselves. A duty-based nonconsequentialist theory is Kant's (19) principle of the categorical imperative, which states that an ethical duty exists to always treat people as ends in themselves and not as means to other ends. A rights-based nonconsequentialist
theory is the justice theory of Rawls (20), which states that everyone has a right to the greatest possible liberty and that any inequalities that do exist should benefit those who are least advantaged. Often consequentialist and nonconsequentialist theories will lead to the same decision. For example, providing information about the benefits of breastfeeding to all pregnant mothers could be justified as leading to the greatest long-term good for the most people, as a duty to offer essential knowledge about an important nutritional decision, and as a just action to give mothers the liberty to decide about infant feeding. At other times, consequentialist and nonconsequentialist theories may conflict. For example, in the debate about providing consumers with food labelling (21), a consequentialist might argue that the greatest good for all would be achieved by providing very simple nutrition information on food labels. By contrast, nonconsequentialists might argue that producers have a duty to provide any interested individuals, even if they are few in number, with data about fat content because all consumers have a right to detailed information about the percentage of kilocalories from fat in their foods. Ethical principles. Beauchamp and Childress (12) identify four primary moral principles used to justify ethical arguments: Beneficence (helping others), Autonomy (respecting others' self determination), Nonmaleficence (not harming people), and Justice (fairness). Debates about the ethics of particular actions use justifications based upon arguments that appeal to identified moral principles. For example, it is insufficient for a nutrition educator simply to assert that obese people should not he coerced into losing weight, without providing ethical justifications for the reasons behind that judgment. JustifIcations for such a position could be based on appeals to respect for the autonomy of obese people and the need to avoid harm from interventions and intrusions into peoples' lives. A beneficent intent to assist in weight loss may be an insufficient justification for the coercion of obese people. Reviewing the fundamental ethical principles provides information about their use as conceptual tools for justifying arguments about ethical dilemmas. Beneficence is the moral principle of aiding others. Beneficent actions provide benefit, remove harm, and prevent harm (12), which are primary goals for much of nutrition education. The principle of beneficence is used in moral claims to justify interventions into the foodways and food habits of clients and the general public. Many nutrition education activities have no ethical dilemmas resulting from interventions based on beneficence, but some clients challenge nutrition educators as being overly intrusive and seeking to involve people who do not need or want nutrition education. Charges of paternalism, coercion, and restriction of individual freedom or rights may emerge from people who oppose beneficent actions
J. of Nutr. Educ. Vol. 23, No.4 by nutrition educators. "Weak" paternalism is more ethically justifiable than "strong" paternalism (12). Thus, it is less difficult ethically to justify outpatient care for the treatment of anorexia nervosa than it is to require hospital admission against clients' wishes. Autonomy is the right to self-determination, where autonomous actions and choices are not constrained by others. Individual choice, the right to know about interventions, and decisions to refuse care are justified using claims based on the principle of autonomy. In relationships between a nutrition educator and client, autonomy is the ethical principle that usually conflicts with beneficence. The right of individuals to make autonomous decisions forms the basis for the concept of informed consent. Refusal of treatment is also justified using claims based on patient autonomy. For example, arguments based on the principle of autonomy may be used to justify nonparticipation in cholesterol education programs by claiming that a respect for autonomy permits a client to choose to avoid receiving information about cholesterol intake and to consume high cholesterol foods. N onmaleficence is the moral principle of avoiding harm or injury to others. It is closely related to the principle of beneficence, which extends beyond not harming to actions that help. Duties for non maleficence are grounded in such maxims as the Hippocratic oath's statement of primum non nocere (above all, do no harm). An important part of ethical arguments involving nonmaleficence is to consider many levels of harm. This becomes complex in such issues as weight loss educational interventions, which Parham (3) shows can benefit some individuals but harm society by reinforcing unnecessarily stringent norms and values about thinness. Justice is the principle of fairness. Justice considers the equity of the distribution of burdens and benefits among many individuals. Various ways exist for providing just distribution of costs and benefits, including equal distribution, distribution based on need, etc. Nutrition educators can apply justice arguments in decisions about the distribution of the benefits of their programs to various groups in society and the fairness of providing services to target populations. Nutrition educators may face justice issues in policy debates about the macro-allocation of resources between nutrition education and other health programs, such as between campaigns to encourage fiber consumption versus seat belt use. Micro-allocation justice dilemmas may occur when distributional issues are debated within nutrition education, such as debates about whether to use limited resources to encourage weight loss versus increasing calcium consumption. ETHICAL ANALYSIS Issues involving ethical dilemmas, such as whether to
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offer unsolicited nutrition interventions or how to divide limited nutrition education resources, are addressed by using the procedure of ethical analysis that delineates possible courses of action and uses arguments justified by ethical principles. Ethical analysis begins with the identification of the biological and social facts to determine whether or not an ethical dilemma exists (rather than simply an argument about problems located on the biological or social level of analysis). The biological and social facts provide evidence for describing the ethical problem. Next, the potential alternative solutions need to be presented. Finally, arguments for and against each solution are made using ethical theories, principles and rules to support and refute the various solutions. Several competing ethical arguments can often be used to justify one option over another in an ethical dilemma, with the weight of those arguments determining the outcome of the ethical decision. More than one ethical principle can be applicable to an action or judgment. Often several principles will support the same conclusion, such as the provision of food assistance programs being justified as beneficent, just, nonmaleficent and contributing to the autonomy of the hungry. In other cases, different ethical principles will lead to conflicting arguments, requiring techniques for dealing with conflicting ethical claims. There are several ways to proceed when ethical justifications conflict. Larger ethical theories may provide guidance, as in the utilitarian position that providing the greatest average benefit to the greatest number of people is the deciding criterion. Ethical principles will often conflict, and Ross (22) proposed that such principles are "prima facie," meaning that they should be followed whenever possible but can be conditional to being overridden by another principle. One ethical principle may often be justified as definitively taking precedence over another. Claims based on non maleficence may supersede those based on beneficence, using the principle of autonomy to make a stronger claim for the need for one person to avoid harm than for another to give unwanted benefits. For example, if there are negative consequences of weight loss counseling, then it may be more justifiable to avoid these consequences. Arguments based on a principle of justice may override claims based on autonomy. For example, the distribution of nutritional resources to those at greatest need may be justifiable, even if it risks the autonomy of some people in access to their usual and preferred amount and type of food. A major conflict for all the health professions is between paternalism justified primarily by beneficence, and client rights to refuse interventions justified by respect for autonomy (23). This is a primary ethical dilemma in nutrition education ethics (2) and in the models of helping behavior used in nutrition education (24). There has been a shift in values in health and medicine that tends to view conflicts between claims based on auton-
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omy versus beneficence to be more powerfully justified using autonomy. An example would be the competent, informed client refusing an intervention offered by a nutrition educator, with the autonomy claims of the patient taking precedence over the beneficence claims of the educator.
ETHICAL ISSUES IN THE PROVIDER-CLIENT RELATIONSHIP Many of the most trying ethical problems faced by nutrition educators involve relationships with clients. Codes of ethics often focus on provider-client relationships to provide anticipatory guidance for health professionals and to delineate the expectations of clients. Social science analysis may describe provider-client roles and their associated rights and duties, norms and values about the provider-client relationship, and social processes that influence providers and clients (25). However, social science perspectives do not provide sufficient guidance for dealing with ethical conflicts in this area. The ethical theories and principles outlined here are applicable to the moral dilemmas in provider-client relationships. Beauchamp and Childress (12) discuss four moral rules derived from fundamental ethical principles: Veracity, Confidentiality, Privacy, and Fidelity. These rules are closely related, but can lead to different duties and actions. In addition to these rules, the concept of desert is also an important ethical consideration in educator-client relationships. Veracity is the rule about telling the truth and not lying or deceiving. The professional role of nutrition educators carries an obligation to provide correct information to clients, not deceive them, and to not withhold information. This can become problematic in cases where withholding some information may enhance the adherence of a patient to a therapeutic diet, or where uncertainty about biological evidence exists and educators are uncertain about disclosing conflicting scientific information. Confidentiality is the rule about avoiding disclosure and dissemination of information about a client to protect autonomy. Duties of confidentiality apply to all health professionals, but are not absolute and can be superseded in cases where sufficient ethical justification is marshalled. Nutrition educators have a duty to avoid revealing information about clients obtained during counseling. In some situations, however, this duty can be overridden with strong justification from beneficence or nonmaleficence, such as the discovery of life-threatening practices among clients with anorexia nervosa, when sharing that data with others would improve the prognosis. Privacy is the rule safeguarding accessibility to a client, which includes access to the person and information about
him or her. Privacy is justified using the principle of autonomy. As with confidentiality, ethical rules about privacy create obligations that proscribe giving others access to a client. Obligations to respect privacy also apply to the nutrition educator, who should refrain from unwanted intrusions into the personal life of a client beyond those needed for nutrition education. Ethical dilemmas about privacy may emerge in the mounting of mass communication nutrition campaigns. Fidelity is the rule insuring faithfulness, promisekeeping, and trustful relationships, as justified from the principles of autonomy and justice. Health professionals, including nutrition educators, have moral duties of faithfulness to the clients with whom they have established relationships. Because of the social contract between the nutrition educator and the client, explicit and implicit obligations exist to avoid neglecting clients or inappropriately withdrawing from relationships without proper notice. Thus, a nutrition educator who has been counseling a client about weight loss should not capriciously avoid the patient or arbitrarily withdraw from a longstanding relationship. Desert is the concept of providing benefits to people based on judgments about their past actions, where people are provided with benefits and costs because of deservingness or merit (26). This is seen in the saying that "people should get their just desert." Desert involves the application of the principle of justice, which considers responsibility and fault. Positive deserts are deserved or earned, and negative deserts are underserved. Many moral claims exist independently from desert, with duties of health professionals to care for clients existing irrespective of desert because beneficence overrides deservingness. Some discussions of provider-client relationships consider who is responsible for the problem as well as who is responsible for the solution (2, 24). Most client problems involve complex biopsychosocial issues that include sufficient uncertainty about etiology and treatment to make determination of responsiblity difficult, which makes considerations based on desert in a provider-client model difficult to justify morally. Perceptions of desert should not interfere with the need for care by clients, which exists independently from their responsibility for the problem. If a person needs nutrition education, claims that moral duties exist for universalistic treatment of clients by health care professionals may be used to argue that a nutrition educator should fill a client's needs, even if the client is responsible for the existence of the nutritional problem.
CONCLUSION Nutrition educators must address many issues that cannot be resolved by using current biomedical and social
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science paradigms. Nutrition educators must consider moral issues, in addition to the biopsychosocial perspectives. Moral analysis involves the consideration of nutritional ethics, which can be drawn from existing ethical frameworks. The ethical analysis of problematic issues can provide unique insights into problems that might otherwise not be systematically addressed. Ethical issues are key aspects of relationships between educators and clients. Often the actions of a nutrition educator that are based on beneficence clash with the actions of clients that are based upon autonomy, leading to dilemmas that need to be resolved using ethical concepts and theories. Social duties involved in the role of the nutrition educator as a health care provider mean that the educator is obliged to provide care to his/her clients irrespective of perceptions of desert. The provision of the highest quality nutrition education services needs to include analysis and justification of actions using analysis based upon nutritional ethics. Ethical shifts that reflect trends in the larger moral orientation of society influence nutrition education. For example, the preferences of clients are being given an increased emphasis over the dictums of professionals. Recent interest among nutrition educators in empowerment reflects this change (27). Empowerment is morally based in the principle of autonomy, as opposed to the beneficence-based paternalism often used in nutrition education (28, 29). Conscious attention to the moral underpinnings of the entire scope of nutrition education activities at all levels is important for the development of a strong profession of nutrition education. Nutrition educators need to develop their capabilities for explicitly recognizing the moral positions underlying the actions they take and for understanding the philosophical justifications for their actions. Nutrition educators must demonstrate that they are capable of identifying and dealing with the moral issues they face. Otherwise, nutrition education will lag behind other health professions, such as medicine, nursing, social work and health education, that are actively developing an expertise in ethical analysis. Training in nutritional ethics is an essential part of strengthening nutrition education. Courses or lectures on the topic are important in undergraduate and graduate training. Nutrition educators can benefit from engaging in continuing education about ethics and learning to think critically about the moral dilemmas that they face in practice. For the successful future development of the profession of nutrition education, it is essential for nutrition educators to develop and demonstrate knowledge and skills in identifying, confronting, and dealing with ethical dilemmas. 0 ACKNOWLEDGMENT The author thanks Ardyth Gillespie, Cathy Campbell, and Cheryl Achterberg for helpful comments.
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