There are enduring, almost perennial debates on the efficacy and ethics of fear campaigns in public health that reemerge with whack-a-mole frequency, as eloquently chronicled by Fairchild et al. (p. 1180). Supported by evidence-based reasoning about motivating behavior change and deterrence,1 these campaigns intentionally present disturbing images and narratives designed to arouse fear, regr et, and disgust. Having health problems can be a profoundly negative experience unappreciated by those not living with them. Pain, immobility, disfigurement, depression, isolation, and financial problems are common sequelae of disease and injury. It is beyond argument that these outcomes 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 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. 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 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. Second, critics argue that such campaigns target victims, not causes ofhealth 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, and income distribution as well as legislative, fiscal, and product safety law reforms. It is difficult to recall any major prescription for prevention in the past 40 years not involving advocacy of comprehensive strategies of both policy reforms and motivational interventions. For example, tobacco control advocates target advertising bans, smoke-free policies, and tax hikes as well as increased public awareness campaign financing. When governments fail to enact comprehensive approaches to prevention, supporting only public awareness campaigns, it is plainly concerning. The resultant concentration of public discourse on 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 do not do.2 This myopic definition of health problems and their solution promotes victim blaming,3 in which notions of individual responsibility are held to explain all health problems when any volitional component is involved. This can be a serious criticism of governments' failure to commit to prevention, but is it a fair and sens.

1. There are enduring, almost perennial debates on the efficacy
and ethics of fear campaigns in
public health that reemerge with whack-a-mole frequency, as
eloquently chronicled by Fairchild
et al. (p. 1180). Supported by evidence-based reasoning about
motivating behavior change and
deterrence,1 these campaigns intentionally present disturbing
images and narratives designed to
arouse fear, regr et, and disgust.
Having health problems can be a profoundly negative
experience unappreciated by those not
living with them. Pain, immobility, disfigurement, depression,
isolation, and financial problems
are common sequelae of disease and injury. It is beyond
argument that these outcomes 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 CRITICISMS
Criticism of the ethics of fear messaging takes five broad

2. 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. 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 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.
Second, critics argue that such campaigns target victims, not
causes ofhealth 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, and
income distribution as well as
legislative, fiscal, and product safety law reforms.
It is difficult to recall any major prescription for prevention in
the past 40 years not involving
advocacy of comprehensive strategies of both policy reforms
and motivational interventions. For

3. example, tobacco control advocates target advertising bans,
smoke-free policies, and tax hikes as
well as increased public awareness campaign financing. When
governments fail to enact
comprehensive approaches to prevention, supporting only public
awareness campaigns, it is
plainly concerning. The resultant concentration of public
discourse on 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 do not do.2 This myopic definition of health problems and
their solution promotes victim
blaming,3 in which notions of individual responsibility are held
to explain all health problems
when any volitional component is involved.
This can be a serious criticism of governments' failure to
commit 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

4. 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?
Furthermore, 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.
Third, those who live with the diseases or practice the behaviors
that are the focus ofthese
campaigns can sometimes experience themselves as having what
Irving Goffman called "spoiled
identities"4 and may feel criticized, devalued, rejected, and
stigmatized by others. The argument

5. runs that these campaigns "ignore evidence that stigma makes
life more miserable and stressful
and so is likely to have direct health effects"5(p14-15) and fail
to recognize that the stigmatized
health states or behaviors "travel with disadvantage."5
Criticism of fear campaigns is mostly applied to health issues
for which personal behavior, as
opposed to public health and safety, is the focus. Campaigns
seeking to stigmatize and shame
alcohol- and drug-affected drivers, environmental polluters,
domestic violence perpetrators,
sexual predators, owners of savage dogs, or restaurant owners
with unhygienic premises are
rarely criticized. Some people deserve tobe stigmatized,
apparently.
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, which is often limited by structural
impediments such as poor access to
safe environments, cost, and work and family constraints.
But unless one subscribes to an unyielding, hard determinist
position that people have no agency

6. 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
smokes.
IS IT UNETHICAL TO UPSET?
Perhaps the most common argument, though, is that we should
always avoid messaging that
might upset people. This argument has two subtexts. First, an
assumption is made that how
people feel about something ought to be inviolate and
challenging 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 sometimes make us
feel uncomfortable. Why is the goal
of avoiding any communication that might make people feel
uncomfortable or selfquestioning
self-evidently a noble, ethical criterion in the ethical assessment

7. of public health
communication?
Feelings about desirable health-related practices often reflect
powerfully promoted commercial
agendas to normalize practices, such as overconsumption, poor
food choices, and addiction.
Those who hold the notion that such agendas 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 turbocharge the impacts of their
health-damaging campaigns. If a
smoker gets comfort and self-assurance from inhabiting the
commercially contrived meanings
ofsmoking 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.6
Should we really tiptoe around
vividly illustrating how deadly sunburn can be because we fear
offending some who value

8. tanning? Although 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 confrontational
information that challenges
their ignorance or complacency, but public health is not a
popularity contest in which an
important criterion for assessing the merits of a campaign is the
extent to which it is liked.
Fairchild et al. make a superb contribution to our field's
confused thinking on fear appeals in
public health that deserves wide discussion.

9. Simon Chapman, AO, PhD
Sidebar
Correspondence should be sent to Simon Chapman, School of
Public Health A27, University of
Sydney, NSW 2006, Australia (e-mail: [email protected]).
Reprints can be
ordered at http://www.ajph.org by clicking the "Reprints" link.
This editorial was accepted June 15, 2018.
doi: 10.2105/AJPH.2018.304630
References
REFERENCES
Chapman, Simon,A.O., PhD. (2018). Is it unethical to use
fear in public health
campaigns? American Journal of Public Health, 108(9), 1120-
1122.
doi:http://dx.doi.org.libraryresources.columbiasouthern.edu/10.
2105/AJPH.2018.3