Bringing Health Services to the Poor Through Social Marketing: Ethical Issues

280 Brief communication BRINGING HEALTH SERVICES TO THE POOR THROUGH SOCIAL MARKETING: ETHICAL ISSUES The well-documented relationship between health and economic status and the rapid growth of low-income and minority populations in the United States pose an enormous challenge to health educators. The poor suffer more disease and injury and are more prone to premature death than other groups for a variety of reasons, including limited access to health care resources and information, illiteracy, behavioral patterns, and attitudes toward health care professionals.1 "4 There have been numerous attempts to address the health needs of nonmainstream Americans and a proliferation of programs intended to be culturally relevant. These efforts have met with varying rates of success.5 Their effectiveness is limited by the vast cultural diversity within America's low-income population, which makes wide-ranging communication of health information difficult. Public health officials have come to realize that innovative approaches are needed to change health-related attitudes and behaviors of nonmainstream population segments. Social marketing, a systematic method of persuasion and behavior modification, has recently been embraced as the answer to the enormous challenge of bringing modern health care to nonprivileged Americans .6,7 Despite or perhaps because of the growing enthusiasm about social marketing , its potential role in public health has not been fully examined from an ethical perspective. This is not surprising since, historically, public health itself has lacked an explicit set of ethics and since its connection with human rights has not been explored fully.8 This paper explores ethical issues associated with social marketing. It is organized around six interrelated, underlying assumptions and arguments put forth in support of social marketing and is intended to stimulate discussion about the need for a clearly defined ethics regarding the use of this approach in public health programs. A definition of social marketing The term social marketing was coined in the early 1970s to describe the application of marketing concepts to social change programs.9 Philip Kotier describes social marketing as a "social change management technology involving the Journal of Health Care for the Poor and Underserved · Vol. 13, No. 3 · 2002 Musham, Trettin 281 design, implementation and control of programs aimed at increasing the acceptability of a social idea or practice in one or more groups of target adopters ."7 Simply put, social marketing is a strategy for changing behavior that blends modern marketing techniques with traditional social change methods. Implicit in social marketing are several underlying assumptions about effectiveness, appropriateness, and ethical correctness. The six assumptions elucidated here were distilled from our review of the literature, participation in national public health conferences, and experiences as risk communication and health education researchers. Some of them may be best characterized as generalizations; they are intended more as a stimulus for discussion than as a reflection of the perspectives and values of all social marketers. Assumption 1: Social marketing is ethically superior to commercial marketing because it is aimed toward the common good. Use of the qualifier social distinguishes social marketing from commercialbased marketing by underscoring its benefits for individuals and society; in itself, the qualifier suggests an ethical position. It hints at an ends-justifies-themeans rationale for this practice and suggests that good intentions motivate social marketers. This assumption is problematic because social marketing may not be subjected to rigorous ethical scrutiny if public health initiatives purporting to support the common good are deemed ethical without further investigation. Social marketers (typically working in public health and health promotion fields) make it a point to distinguish their efforts from business-based marketing , perhaps because profit-driven marketing is widely viewed as ethically suspect. The implication is that no one is making money off social marketing efforts, at least in a direct sense. However, lest social marketing practitioners be canonized (or condemned) as do-gooders, it is important to note that most social marketing programs are financially supported by government, foundations , and other organizations. The funded institution, the principal investigator , and other employees benefit both professionally and financially from this type of support. In fact, the lifeblood of many academic institutions (including teaching hospitals) is grants. For academicians engaged in research, "obtain funding or perish" is perhaps...