February 23, 2024

Does fear change behaviour?

Bioethicists claim that fear-based public health campaigns are effective and not necessarily stigmatising

In 2010 the New York City Department of Health launched a grisly 30-second TV ad (above) aimed at reducing the incidence of HIV amongst men who have sex with men. It showed angst-ridden young men reacting to the words osteoporosis, dementia, anal cancer.

The campaign was extremely controversial in the gay community. Some hated it: “it’s sadistic and bullying,” said UK-based journalist Gus Cairns. But gay rights activist Larry Kramer loved it: “these nyc department of health public service announcements are in fact not strong enough!”

These comments represent the two extremes of debate over fear-based public health campaigns. Bioethicists, whose work is supported by the pillar of autonomy, criticise them as stigmatising; public health ethicists, who often take a more utilitarian approach, believe that fear saves lives by motivating people to change their behaviour. From the 1950s to the 1970s, the anti-stigma crowd had had the upper hand. The consensus was that fear did not work.

In the 1980s the question became urgent with the HIV/AIDS epidemic. At first there was bitter resistance to using fear-based advertising to encourage young gays to use condoms. However, deliberately stigmatising warnings have been responsible for declines in the incidence of smoking since the mid-1950s.

An on-line first article in the Journal of Medical Ethics this week asked whether it is time to change tack and recognise that fear does “work”. Campaigns to decrease consumption of cigarettes and soft drinks by using cringe-inducing images appear to have had an impact. Why not HIV?   

“[a meta-analysis in 2015] concluded that fear appeals were effective at positively influencing attitudes, intentions and behaviour; there were very few circumstances under which they were not effective and there were no identifiable circumstances under which they backfired and led to undesirable outcomes…

[T]he long and sometimes bitter debate about the efficacy of fear-based campaigns may be drawing to a close. In thinking about fear-based campaigns in the future, it will be increasingly necessary to ask: not can we, but should we?…

To acknowledge that fear-based campaigns have a role to play is not the equivalent of endorsing efforts that seek to shatter a sense of self. To tug at the gut is not the equivalent of endorsing efforts that seek ‘a total destruction of the individual’s status in organized society’.

What about the danger of stigma? The authors respond that fear-based campaigns do not necessarily stigmatise people. In fact they can increase their autonomy as long as they are not deceptive.

Unlike the now dominant perspective within bioethics, a central ethical claim for fear-based efforts was that despite virulent arguments to the contrary, they may in fact enhance autonomous choice… But the justification of appeals to fear and emotion should not be confused with the reliance on outright deception and exaggeration of the risks posed to public health.

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