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Counter-Manipulation and Health Promotion

Counter-Manipulation and Health Promotion Abstract It is generally wrong to manipulate. One leading reason is because manipulation interferes with autonomy, in particular the component of autonomy called ‘independence’, that is, freedom from intentional control by others. Manipulative health promotion would therefore seem wrong. However, manipulative techniques could be used to counter-manipulation, for example, playing on male fears of impotence to counter ‘smoking is sexy’ advertisements. What difference does it make to the ethics of manipulation when it is counter-manipulation? This article distinguishes two powerful defences of counter-manipulative health promotion: that the counter-manipulation would prevent manipulation occurring, leaving people unmanipulated; and that the counter-manipulation would make people healthier without being any more manipulated than they would otherwise be. The article explains how counter-manipulation might work and the limits to its scope. The upshot is that counter-manipulative health promotion could respect the independence people are owed in virtue of their autonomy. However, autonomy is not the only consideration, and the article discusses further potential problems. Counter-manipulative health promotion might be misapplied, it might undermine trust, it might infringe on some norms for role behaviour and it might encourage a regrettable social practice. These objections are likely to be decisive against the counter-manipulation in some but not all cases. Introduction For years, tobacco firms have insinuated that smoking is sexy and manly through advertisements, sponsorship and product placement. One might well object not only to their aim, which is to sell a dangerous product, but also that their method is manipulative, and manipulation is wrong. Consider now anti-smoking advertisements such as this one, paid for by the California Department of Health Services: a glamorous-looking youngish man at a black-tie event lights up a cigarette as a beautiful woman walks towards him; alas, his cigarette wilts; her face shows a flash of horror, then resignation and she walks away. Then the same thing happens again, to three men in a row! The voiceover says: ‘Now that medical researchers believe that cigarettes are a leading cause of…impotence, you’re going to be looking at smoking a little differently. Cigarettes. Still think they’re sexy?’1 The advertisement is funny, to a non-smoker anyway, but a purist might think that using humour can be manipulative (Shabbir and Thwaites, 2007), and even a non-purist might find the advertisement manipulative in playing on widespread male fears, in glossing over the distinction between being a ‘leading cause of impotence’ and impotence being likely to happen and in showing remarkably young men being victims.2 Some instances of health promotion are clearly not manipulative and some are not clearly manipulative or non-manipulative. If some example of health promotion is accused of being manipulative, a sufficient defence would be to show that it is not. But I am interested in a second defence, that manipulative health promotion is really counter-manipulation. Health promoters frequently point out that people are subject to all sorts of manipulative ‘illness promoting’ influences by tobacco, alcohol or food firms (e.g. Holland, 2007; Marmot, 2015: 75). Why not use the tactics of the ‘illness promoters’ to counter their manipulative messages and thereby make people healthier? The answer depends on what counter-manipulation does. Manipulation is generally wrong, especially if it infringes on autonomy. But counter-manipulation might prevent manipulation or at least leave people no more manipulated than they would otherwise be. In either event, this article will argue, counter-manipulative health promotion need not interfere with autonomy. There are other objections to using manipulative methods besides autonomy, but this article will argue that they are not invariably decisive. Here are a few preliminaries. First, this article is concerned with health promotion taken broadly as ranging from population measures, such as social marketing for health, to individual measures, such as a doctor’s giving health advice to a patient. Secondly, and for the sake of argument, let us bracket a couple of possible problems with copying the techniques of commercial firms: that the techniques might be ineffective, or less effective, than enforced price rises for the unhealthy products or a regulated reduction in their availability (Toomath, 2016), and that the techniques might be stigmatizing, which would be bad in itself and likely to fail to promote health (Goldberg and Puhl, 2013). Thirdly, not all counter-manipulation attempts to manipulate. It would not be manipulative to unmask the methods of the manipulator by truthfully telling people what they are. This article, however, focuses on manipulative counter-manipulation. Finally, health promotion aims to make people healthier. However, we should not assume that we are therefore discussing only paternalism, understood as supplanting people’s choices for their own good. One could aim to make people healthier not for their benefit but for the sake of their families, their employers or taxpayers. Ethical questions about manipulative health promotion are not entirely questions about paternalism. As a first step in understanding the ethics of counter-manipulation, we need a sense of what manipulation is and what makes it ethically questionable. Manipulation and Counter-Manipulation Manipulation and the associated ideas of manipulating, being manipulated and someone’s being manipulative, are familiar to most people. It has been claimed that manipulation has its place in most languages and that people often agree on whether given cases do or do not involve manipulation (Kligman and Culver, 1992: 175). On the other hand, analysing manipulation has been tricky. Writers have tried to spell out what makes manipulation different from rational persuasion, giving incentives, threatening and using force. In my view, a fair amount concerning the concept of manipulation remains to be resolved. The account in this section is in no sense complete, given the complexity of manipulation, but it should be recognizable, given the familiarity of manipulation. The section begins with the concept of manipulation and moves to the ethics. The conditions for manipulation can be developed in different competing ways; this paragraph just sets out the rough essentials. To begin, it is widely accepted that the manipulation of a person has an agency condition. Thus manipulation must be done by agents as opposed to non-agents such as natural forces. It is also widely agreed that manipulation presupposes some intention condition: the agents must in some sense intend to influence their targets. However, truthful warnings can meet both conditions without being manipulative so it looks as if we also need some methods condition: the agent tries to shape the target’s decisions, beliefs, emotions, values or desires using some method that is manipulative. Many writers agree that a manipulator has many methods to choose from, and certainly more than just lying (Cialdini, 2007 is a classic presentation). But determining what makes a method manipulative is hard. For instance, it seems unlikely that we can say of any method that it is essentially manipulative because we can always find contexts in which the method seems not manipulative (Wilkinson, 2013). Take framing information: it can be a way to enhance as well as reduce understanding, so one cannot say that framing is essentially manipulative. Writers have proposed various general explanations of when a method is manipulative, such as ‘non-rationally influencing’ or ‘shaping people in ways they would not endorse’, but these have their problems too (Wilkinson, 2013; Coons and Webber (eds) 2014). Finally, manipulation also has a success condition: for manipulation to occur, the target must have been manipulated. Put another way, A can act manipulatively towards B, and yet B would not be manipulated by A if A’s attempt failed. By way of example of these conditions, consider Iago, as he appears in Shakespeare’s Othello. Iago is (1) an agent who (2) intentionally influences Othello, Cassio, Desdemona and Roderigo. Iago (3) uses manipulative methods, such as suggestion and outright deception, that generally work through Iago’s analyses of the characters’ vulnerabilities. Finally, (4) he succeeds; the characters act as he wishes because of his manipulation. Iago even obligingly tells us he is manipulating them, for instance in Act One, Scene Three, where he says ‘Thus do I ever make my fool my purse’. Iago’s soliloquies avoid the problem of determining whether someone has a manipulative intention. In real life, people tend not to admit or agree that they are manipulating. In the case of the anti-smoking advertisement, California’s Department of Health Services may have said it was merely informing, not manipulating, but then the tobacco firms have claimed the same of their advertisements. In sum, we can take manipulation this way: A manipulates B when A intentionally succeeds in influencing B using a manipulative method. I am only too well aware that this definition is loose and certainly does not give a complete operational test for when manipulation has occurred. I also think that no one has a tight accurate complete operationally usable definition of manipulation. Never mind: for the purposes of this article, which is about manipulation as counter-manipulation, the loose definition will do.3 Manipulation is a pejorative term and those who use it generally imply that manipulation is at least prima facie wrong. Manipulation may be wrongly against the target’s interests, betray trust, conflict with authenticity or express a vicious attitude on the part of the manipulator. But the leading explanation of its wrongness is that manipulation infringes on autonomy. Autonomy requires self-rule, in turn broken down into ruling oneself and being free from the rule of others. One can fail to rule oneself because of lacking capacity or being wildly misinformed and possibly—it is controversial—because of addictions and compulsions. One can fail to be free from the rule of others because of coercion and manipulation. It is important to see that the problem with both coercion and manipulation does not lie just in the difficult choices coercion might produce or the mistaken thinking manipulation might produce. One can face difficult choices or make mistakes for all sorts of reasons and remain autonomous. The point is that coercion and manipulation are especially damaging to autonomy because they are forms of intentional control by other agents. As Daniel Hausman and Brynn Welch put it in the case of manipulation, ‘Even when unshaped choices would have been just as strongly influenced by deliberative flaws, calculated shaping of choices still imposes the will of one agent on another’ (Hausman and Welch, 2010: 133). In Joseph Raz’s terms, coercion and manipulation violate independence from the will of others, a dimension of autonomy (Raz, 1986: 377–378). The distinct requirement of independence for autonomy explains the distinct importance of counter-manipulation, as we can see if we consider some possible arguments for manipulative health promotion. One possible argument would say that the gain in health outweighs the loss in autonomy, and this argument must defend sacrificing autonomy. Another possible argument would claim that people are often unhealthy for reasons such as a failure of self-control and manipulating them into being healthy would give them what they really want and so make them more autonomous. This argument sacrifices the independence component of autonomy for the sake of gains in the self-rule component. A third argument says that people are already subject to manipulative influences.4 This is the counter-manipulation argument. Unlike the previous argument, it claims that manipulative health promotion comes at no further cost to the targets’ independence. The counter-manipulation argument neither sacrifices autonomy to health nor one part of autonomy to another. It is thus a distinctive and distinctively powerful argument.5 Let us now turn to the question of why counter-manipulation might not harm its targets’ autonomy. As I said, counter-manipulation is sometimes described in writings on health promotion, but they generally leave vague how it is supposed to work. Take an influential description (but not quite endorsement) of counter-manipulation: [P]eople are already being manipulated in a plethora of ways…This helps justify health promotion because the alternative is not complete freedom to choose one’s health behaviours…health promotion is counter-manipulation, as opposed to manipulation proper; it is one of the myriad forces motivating our health behaviours, but one intended to counteract those forces that motivate unhealthy choices…The social marketer [for health promotion] is merely levelling the playing field by combating `illness promotion’ with health promotion (Holland, 2007: 128–129). I can see two importantly distinct interpretations of counter-manipulation in this quotation. The first is that manipulative health promotion does manipulate people, but it is justified because they would be manipulated anyway and better that they are healthy and manipulated than unhealthy and manipulated. The second, suggested by such phrases as ‘levelling the playing field’6 and ‘as opposed to manipulation proper’, is that manipulative health promotion cancels out the manipulative promotion of unhealthy products and leaves people unmanipulated. Because it would be better to prevent manipulation, I explore the second interpretation first.7 Preventing Manipulation How might counter-manipulation prevent manipulation? Here are some ways, partly adapted from writings on free speech and commercial advertising: Competing messages might jolt people into realizing that there is a second side to the story. As a result, they no longer mindlessly accept the initial manipulation or endorse the counter-manipulation message. Instead, they deliberate for themselves. On an optimistic Millian story, the one-sidedness of advocacy joined to competition is a good way to make people think for themselves (Mill, 1982: ch. 2). Less optimistically, people might dismiss as lies or distortion what everyone said on a topic and move to a state of disbelief. Either way, they are no longer manipulated. Competition may put people on their guard. The idea here is that that their general attitude changes, whereas the preceding point was about attitudes to specific messages. People might become sceptical voters or cynical consumers. It is harder to manipulate the wary. (1) and (2) prevent manipulation by putting people in a position where they deliberate for themselves. They do not take messages at face value. They evaluate with critical distance what they are told. They may in the end do what one side wants, but they have not been manipulated into it because they have not been under the control of that side. The independence component of their autonomy would be preserved. (3) Messages may cancel each other out (Hausman and Welch, 2010: 131). One reason could be psychological. Perhaps so many messages are given that they become white noise. Consider the idea that adverts must manipulate people into excessive consumerism because they are exposed to so many of them (Miller, 2009: 76). The idea seems plausible in the light of estimates that ‘[b]y the time we reach the age of sixty-six, most of us will have seen approximately two million television commercials’ (Lindstrom, 2009: 37). But the idea may be wrong if our minds simply screen them out, a proposition for which there is some evidence. For instance, a 2007 ACNielsen phone poll of 1000 people found that on average they recalled only 2.21 TV advertisements.8 (3) prevents manipulation in a different way from (1) and (2). Whereas (1) and (2) involved receiving the message and then evaluating it, (3) involves not receiving the message. Manipulation requires success. No matter how clever your manipulatory telephone manner, I would not be manipulated if you try it on me when the line is dead. (4) Cancelling could also occur because competing messages give opposing reasons, as when competing firms denigrate each other’s products. Counter-manipulation may then cause people to do what they would have done in the absence of any manipulative attempts, which might count as preventing manipulation. Consider a possible health example. Suppose someone would drink 21 units of alcohol per week if he were exposed to no marketing at all. However, the alcohol industry convinces him that drinking will bring good cheer which, in the absence of further influence, would cause him to drink 28 units per week. Enter anti-alcohol marketing, which convinces him that drinking more than 14 units per week risks his health. Suppose both sides exaggerate. The drinker weighs the good cheer against the health and drinks 21 units per week. The anti-alcohol manipulation cancels out the pro-alcohol manipulation. This final cancelling out case differs in one important respect from the others in being focused on the outcome, what the drinker did, and not the process, how the drinker came to do it. Manipulation is essentially about the process by which one comes to believe, decide or value and not about what one believes, decides or values. The final cancelling out case is thus less clearly one where manipulation is removed. The man who drinks 21 units as a compromise between two manipulative influences still decides as the result of a manipulated process, even though he does what neither the pro-alcohol nor pro-health promoters would like and even though he does what he would have done if he were not manipulated at all. I would be inclined to say that the counter-manipulation still manipulates the man. However, one might also say that the counter-manipulation enhances his autonomy in one respect, by preventing his actions being controlled by either pro- or anti-alcohol marketers, even as it damages his autonomy in another respect, by adding manipulated beliefs about the dangers of alcohol to his manipulated beliefs about its benefits. We have seen that counter-manipulation could block manipulation by preventing its success. The focus has thus been on what happens to the potential targets not on what the manipulative agents are doing. If instead we evaluate the behaviour of those doing the counter-manipulating, it would be a mistake to think they are off the hook whenever their attempts do not cause people to be manipulated. One can be blameworthy for failed attempts to do wrong. But it would make a difference what counter-manipulators thought they were doing. On the one hand, some would realize that they are in a competition which would result in no manipulation; some indeed could welcome that result. It does not seem generally wrong or even manipulative to use manipulative methods when one has both the intention of preventing the target being manipulated and a reasonable belief that the method would prevent manipulation. On the other hand, health promoters who do try to manipulate would be doing something prima facie wrong even if, as it happened, their efforts did prevent manipulation. The main aim in this section was to show how counter-manipulative health promotion may respect the independence component of autonomy by preventing manipulation. Whether health promotion actually does prevent manipulation is in part an empirical question that turns on such matters as whether advertisements stick in our minds. Manipulation for a Better Result The previous section pointed out that counter-manipulation might not manipulate. But it could, and what if it did? Consider this argument: counter-manipulation that indeed manipulates leaves people no more manipulated than they would otherwise be. However bad manipulation is, manipulation is a constant across the two cases of initial manipulation and counter-manipulation. Thus in determining the badness of counter-manipulation, we have to go to the next consideration, which we can suppose is the quality of the results. If the results of the counter-manipulation are better, then the counter-manipulation is all-things-considered justified. By way of example, remember the anti-smoking advertisement described at the start. Suppose people would be manipulated by tobacco firms unless they were manipulated by the anti-smoking advertisement. Either way, they would be manipulated. But it is better if people do not smoke, let us suppose. So the anti-smoking advertisement is justified counter-manipulation. California’s Department of Health Services could say to tobacco firms: ‘our manipulation is better than yours’. Call this the `better result’ argument. What needs to be the case for the better result argument to work? The manipulation really must have a better result. The ‘better result’ could be that the counter-manipulated people are all-things-considered better off for being healthier or that society is all-things-considered better off for their being healthier. However, being healthier need not be all-things-considered better because, for instance, health is not the only good. Nonetheless, being healthier is plausibly all-things-considered better in many cases. There is no alternative. The tacit assumption is that the only two options are manipulation by one side or another. In other words, there is no third way where targets are de-manipulated. When it comes to applying the argument in practice, one would have to check that no third way exists. The argument implies that manipulation is a constant across the two options in the sense that either the degree of manipulation is the same and\or that the manipulation is equally bad. However, not all manipulation is on a par (Sunstein, 2015). If A smokes because a wordless cowboy appeared in an advertisement and B smokes because a tobacco firm lied about the health effects, we should likely say that B is more manipulated or manipulated in a worse way than A. Thus for the better result to go through, the manipulative method used in health promotion must either be similar to the manipulation it counters, as when both manipulator and counter-manipulator are lying, or less bad than the manipulation it counters, as when health promoters exaggerate to counter a lie. Supposing the conditions are met, what could be the objection to counter-manipulating for a better result? Here are two that argue from within the value of autonomy. The first is unmotivated and the second is inconclusive. The first argument is about the frequency of manipulation. When someone is manipulated by A, that is bad; when that person is then counter-manipulated by B, that looks worse. Now the target is manipulated twice, not once. So counter-manipulation does not really hold manipulation constant, contrary to what the better result argument says. As against this argument, it is unclear why the frequency of manipulation matters. Frequency should not be confused with duration, which plausibly does matter. It is worse other things equal to manipulate for a longer time than a shorter. But duration is distinct from frequency. Suppose either that someone is manipulated by A for a year or that person is manipulated by A for 6 months and then counter-manipulated by B for 6 months. The duration of manipulation is the same. Leaving aside contingencies, such as one form of manipulation being worse than another, why would it be any worse to be manipulated twice rather than once? Could then counter-manipulation be objectionable because of its longer-run effects? Jennifer Blumenthal-Barby considers the case of a doctor whose patient has been manipulated into smoking; the doctor decides to manipulate the patient into not smoking instead. Blumenthal-Barby considers the argument that the patient’s autonomy, being already at zero, cannot be further impaired by the counter-manipulation, and writes: ‘my intuition is that one way in which it could is that this further manipulation…makes it harder for [the patient] to recover and govern himself, and in that sense does pose a further threat to autonomy’ (Blumenthal-Barby, 2014: 127). Blumenthal-Barby does not explain her intuition in more detail than this, so let me try to find out what she has in mind. She sees autonomy as being recoverable via some process that would be interfered with by counter-manipulation. What could such a process be? The most plausible explanation I can think of is some feedback mechanism, such as learning from one’s mistakes or finding out the truth. However, it is an open question whether counter-manipulation delays recovery. It could have no effect, for instance if the target never would learn from mistakes. Counter-manipulation could even speed up recovery, for instance by starting the target on the process of critical enquiry. Where recovery is no slower for the counter-manipulation, again the argument goes through.9 When it meets all the conditions set out in this section, the better result argument seems to have great power. How many cases would actually meet these conditions is another matter. But one could have powerful versions of the argument even when some of the conditions are not met. For instance, suppose that the effect of counter-manipulation was that the target was slightly more manipulated overall. An extra bit of manipulation might be justified if it prevented, say emphysema or lung cancer from smoking. Or suppose the interference of counter-manipulation did delay the recovery of autonomy but did not prevent it. One might then say that counter-manipulation could be wrong despite a good result if it prevented autonomy but not if it merely delayed autonomy for a time. These revisions to the better result argument would not succeed if the independence component of autonomy had lexical priority over other considerations. But if some independence may be traded off for good results, the revisions may work by showing that counter-manipulation could be justified if it did not reduce independence by much. The better result argument has been put in consequentialist form: counter-manipulation has better consequences because it leads to more of one good thing, health, and no less (or not much less) of another, autonomy. Put another way, counter-manipulation is the lesser of two evils. The argument thus faces the deontological problem of whether one should commit evils oneself to prevent worse evils being committed by others. Of course the problem is too complicated to resolve fully here, but I can make a few remarks. The deontological ideas that underlie the problem can be formulated in many different ways. The better result argument might be able to avoid some versions of the problem and may be able to overcome other versions. Consider patient-centred versions of deontology: these might stress the right not to be manipulated based on the especial badness of being manipulated.10 Such versions may well rule out manipulating people even when doing so would produce large benefits. But it is hard to see how they would rule out manipulating people who are already manipulated since the badness for them would not be changed. Patient-centred deontological objections can be avoided. Other deontological arguments might stress the duties of agents, in this case agents who might manipulate. Yet further arguments might have some hybrid agent–patient relation in mind. These arguments stress the wrongness of manipulating rather than the wrongness in being manipulated. They might say that it is worse to manipulate than to let manipulation happen, or that it is worse to intend to manipulate than to fail to prevent foreseeable manipulation. The better result argument may be unable to avoid these deontological objections—it would depend in part on how the objections were developed. But perhaps the better result argument could overcome the objections. Many writers agree that the duty not to manipulate may be justifiably overridden; it is not absolute (Goodin, 1980; Baron, 2014). They often have in mind manipulating someone for the sake of benefits to others. Still more is the duty likely to be overridden when the benefits come to the target at no further cost in being manipulated. The Scope of Counter-Manipulation To this point, we have focused on the relation between autonomy and counter-manipulation and considered arguments that counter-manipulative health promotion could make people healthier without sacrificing the independence component of their autonomy. These are powerful arguments, but they have an important limit on their scope. Their scope depends on what should be regarded as manipulative attempts to counter. Some writers bundle up too many ideas under the heading of manipulation and so give counter-manipulation too wide a scope. For instance, Holland appears to assume that peer pressure is a form of manipulation that health promoters might counter (Holland, 2007: 128). But peer pressure need not be manipulative in all its forms. If teenagers smoke so as to fit in with their peer group, we cannot infer that they are being manipulated. They may simply see smoking as the price of acceptance and one is not manipulated simply by having a price to pay. This is one example where one should be careful in using counter-manipulation arguments. Their distinctive force is in showing that it is possible to use manipulative methods without failing to respect the independence component of autonomy, but it is essential that the manipulative methods counter influences that do disrespect independence. Not all influences that cause people to act unhealthily, even irrationally, are manipulative. When the influences are not manipulative, using manipulation to counter them would disrespect independence. Further Considerations besides Autonomy The main aim of the article has been to show that counter-manipulative health promotion can respect autonomy, in particular its independence component. Unsurprisingly, there are numerous factors besides autonomy a full account would have to consider. I cannot hope to do justice to them here, but I hope to show that they are unlikely to be decisive against all counter-manipulation. One factor is the danger of misapplication; that using manipulative methods turns out not to be counter-manipulation. Another is that counter-manipulation could conflict with the value of trust. A third is that counter-manipulative health promotion violates some norm for roles. The final factor is that counter-manipulation may contribute to a bad social practice. When using manipulative methods to counter what one sees as manipulation, one could be wrong about whether the targets were manipulated. The mistake could lie in being wrong about what constitutes manipulation, as in the above example of peer pressure, or wrong in the facts, for instance about whether the targets really were fooled. Or one could be over-broad in one’s targeting, hitting some people who are manipulated but also some who are not. The risk of error is compounded by the dangers of wishful thinking. It is tempting, if one thinks that people are acting mistakenly, to see some form of manipulation as the explanation. Finally, the counter-manipulator risks moving from manipulation to manipulativeness. While some manipulation is probably justified, ‘manipulativeness’ is a vice—an unconditionally bad vice, according to Marcia Baron (Baron, 2003: 49). As a vice, it involves an arrogance that leads to taking decisions out of the hands of the people to whom they belong and being too quick to resort to manipulative methods, whether because the manipulative person sees reasoning with the targets as tiresome or, wrongly, as futile. The risk is that after acting manipulatively, the moral barriers are lower, and if the manipulation works, it would be tempting to manipulate again and again. These are serious points. They apply not only to individual health promoters but also to the behaviour and culture of organizations. On the other hand, it is hard to know what to conclude from these points in any given case. They raise a problem of decision: on a given occasion, there may be good reason to use manipulative methods, but a repetition of such good occasions will increase the risk of error and manipulativeness, so what should one do? Regrettably the decision problem has no quick solution, and space precludes attempting a slow one. Now consider the loss of trust.11 If we attempt to manipulate people, we may forfeit their trust and that could be a price too high to pay. As a general practitioner put it in discussing this article, if he attempted to manipulate his patients even in a good cause, it would destroy their relationship. The general practitioner’s point applies to any health promoters or organizations with a reputation to take care of. While I think the general practitioner exaggerated, I agree that in some cases, the risk to trust probably should rule out counter-manipulation. However, if we think through trust, we may see the cases where it should not. Suppose we interpret the trust objection this way: enough of the value of trust would be lost to outweigh the gains from the health promotion.12 Here are a few remarks about the factors that might affect how much trust would be lost. First, the trust involved need not be only between counter-manipulator and target. Third parties may observe the manipulation and trust the health promoters less. Other things equal, the more people whose trust would be lost, the greater is the reason against counter-manipulation. Secondly, how much trust would be lost would depend in part on how much trust already exists. A highly trustworthy institution or person should probably be especially careful to avoid the temptation of ‘reputation mining’ (Akerlof and Shiller, 2015), taking advantage of its reputation to manipulate. The highly trustworthy have more to lose ethically and prudentially than the less trustworthy. Thirdly, the extent of a loss of trust may depend on the means used to counter-manipulate. One could certainly see how a deliberate lie could both be discovered and cause great damage to a relationship. But not all possible manipulation is a deliberate lie; putting on a serious face and lowering the tone of one’s voice are not lies, although they are potential methods of manipulation (Dennett, 2003: 270). Even if a target becomes wise to the trick, when being lectured by a doctor about blood pressure or obesity, a target could still trust the doctor, and be rational to trust the doctor, not to tell an outright lie. Finally, the extent to which trust might be damaged plausibly depends on how targets and observers understand what has been done. They might be more likely to appreciate the point of counter-manipulation than of simple manipulation, since the counter-manipulation does not threaten independence. Health promotion has so many methods and sites that these factors would surely vary in importance. We may conclude that the loss of trust is likely to be a compelling objection to counter-manipulation in some cases but not all cases. Roles may matter or, in other words, who manipulates may matter as well as how and why they do it. For example, some writers object much more strongly to manipulative attempts by the government than by the private sector (White, 2013: ch. 6).13 Some of the arguments are about power. As against government manipulation, one could say that the government should be more restrained than firms because it has greater power than any firm. In reply it could be said that we can at least have some collective control via democratic government of influences on our behaviour, whereas we cannot have such control in the case of private sector influences. The dispute in turn depends in part on whether government power really can be controlled through transparency or other methods (Thaler and Sunstein, 2008; Rebonato, 2012; Barton, 2013). Roles may matter in healthcare too. We might feel entitled to expect more from doctors than private firms too given the power imbalance between doctor and patient, and given the codes of medical ethics supposed to govern medical behaviour (Blumenthal-Barby, 2012: 357). An objection based on roles may or may not be a good one; again I can offer only some brief comments. First, some of the reasons why roles matter may reduce to ones we have already considered, such as the loss of trust. For instance, one reason why some writers are relatively unperturbed by commercial attempts to manipulate is because they think most people do not trust advertising, which is partly a point about how firms do not forfeit trust since they were not trusted anyway. Secondly, the objection has a limit to its scope; it would not apply to counter-manipulation by those other than the government or health professionals. It would not apply, for instance, to those NGOs that had neither the power of government nor the duties of health professionals. Thirdly, one must acknowledge, however, that the boundaries between governments and NGOs are often blurred, since NGOs often receive money from governments. Someone who insisted that governments not counter-manipulate might include government-sponsored NGOs in the restriction. But then one should also acknowledge the role of government in assisting firms that promote unhealthy products through tax relief or subsidies for their marketing activities. At any rate, counter-manipulation will not be entirely ruled out by role norms, either because it does not infringe on those norms or because the norms are not weighty enough. Finally, counter-manipulation may support a regrettable social practice, for instance by sustaining a culture of exaggeration and distortion or undermining the prospects of simple clear reliable communication. Think how tiresome it would be to live in a society where every communication had to be decoded. If someone died, we would have to ask, as Metternich supposedly did of Talleyrand’s death, ‘What did he mean by that?’ On the other hand, recall the Millian-type advocacy mentioned earlier. Advocates may distort, appeal to emotion and so on in various ways that could be manipulative, but given that advocates of all sides are doing so, manipulation would not occur and, moreover, such advocacy is the best way to produce considered opinions in people’s minds. If this good result actually occurred, counter-manipulation would be an element in a game worth playing. Notice that the value of a practice is not reducible to the ethics of behaviour within the practice. By analogy, the prosecutors and defence within an adversarial system should act out their roles, not behave as they might in an inquisitorial system and yet we might judge the inquisitorial method to be better than the adversarial in criminal justice. Even if manipulative health promotion did support a regrettable social practice—which it might not—it might not be wrong to do, given that others would manipulate anyway. Still, the effects on a social practice should not be ignored, and they may be enough, in some cases, to tip the balance away from manipulative health promotion. Conclusion This article has brought together the ideas that manipulation is generally wrong, that at least some health promotion may be considered manipulative and that it often occurs in a context of manipulative ‘illness promotion’. The context matters because manipulative health promotion may then be counter-manipulation. It may enhance or at least not damage further its targets’ independence, the key relevant component of their autonomy. If and when counter-manipulative health promotion cannot be criticized on grounds of autonomy, the leading objection to it is removed. That leaves further objections, such as the loss of trust. Without claiming completeness, this article tried to show that these further objections are unlikely to be decisive. Even someone who takes manipulation to be seriously wrong need not then object to all counter-manipulative health promotion. Footnotes " 1. The advertisement can be seen here: https://www.youtube.com/watch?v=fYu8crlRe9g. " 2. Tengs and Osgood (2001) show that the state of evidence at the time did not support the categorical claims made in the advertisement, although the authors concluded that the risk of impotence was a reason to avoid smoking. Tengland (2012: 145) mentions impotence and smoking as a potential example of manipulation. " 3. Some writers, e.g. Goodin (1980), make it part of the definition of manipulation that the target is unaware of being manipulated. I disagree: there is nothing conceptually incoherent in being aware of being manipulated. For a superb example, see the picture in Cialdini (2007: 23) of the businessman paying for a flower at an airport; he is being manipulated and he knows it. " 4. Barton (2013) would be willing to sacrifice independence for self-rule but also thinks that cigarette warnings counter-manipulate too. " 5. A further argument might be that manipulative or counter-manipulative health promotion people would not infringe on independence when its targets consent. Although I set it aside here, consensual manipulation is both possible and would respect autonomy. See e.g. Wilkinson, 2013. " 6. Womack (2012: 224) also uses the phrase ‘level the consumer playing field’, in the context of counteracting food industry influences. " 7. A referee asked: if it is better to prevent manipulation than counter it, why not restrict all sources of manipulation rather than add counter-manipulation? In some cases it is desirable to prevent manipulation, e.g. through truth-in-advertising rules. But it is impossible to prevent all manipulation and undesirable to give the state the power to try (Sunstein, 2015). " 8. The study and suspiciously low figure is cited in Lindstrom, 2009: 37–38. " 9. The open question point also applies to Tengland’s (2012: 145) criticism that manipulative health promotion reduces the ability for self-determination. Maybe or maybe not. " 10. For the contrast between agent-centred and patient (or victim)-centred deontology, see Scheffler (1988). " 11. See also the discussion in Blumenthal-Barby, 2012: 358–359. " 12. To breach trust might also be betrayal, which may not lend itself to the analysis here, and which I have to leave aside. " 13. The arguments about private sector and government manipulation are adapted from discussion of nudging, although I do not think all nudging is manipulative. Put crudely, nudging is supposed to change behaviour without using penalties or rewards. The classic presentation is in Thaler and Sunstein 2008. Acknowledgments Geoff Kemp, Kathy Smits, Steve Wilkinson, Steve Winter and an audience at the Otago Bioethics Centre. References Akerlof G. , Shiller R. ( 2015 ). Phishing for Phools: The Economics of Manipulation and Deception . Princeton : Princeton University Press . Google Scholar Crossref Search ADS Google Scholar Google Preview WorldCat COPAC Baron M. ( 2003 ). Manipulativeness . Proceedings and Addresses of the American Philosophical Association , 77 , 37 – 54 . Google Scholar Crossref Search ADS WorldCat Baron M. ( 2014 ). The Mens Rea and Moral Status of Manipulation. In Coons C., Webber M. (eds), Manipulation: Theory and Practice . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Barton A. ( 2013 ). How Tobacco Health Warnings Can Foster Autonomy . Public Health Ethics , 6 , 207 – 219 . Google Scholar Crossref Search ADS WorldCat Blumenthal-Barby J. ( 2012 ). Between Reason and Coercion: Ethically Permissible Influence in Health Care and Health Policy Contexts . Kennedy Institute of Ethics Journal , 22 , 345 – 366 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Blumenthal-Barby J. ( 2014 ). Assessing the Moral Status of Manipulation. In Coons C., Webber M. (eds), Manipulation: Theory and Practice . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Cialdini R. ( 2007 ). Influence . New York, NY : Collins . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Coons C. , Webber M. (eds) ( 2014 ). Manipulation: Theory and Practice . Oxford : Oxford University Press . Google Scholar Crossref Search ADS Google Scholar Google Preview WorldCat COPAC Dennett D. C. ( 2003 ). Freedom Evolves . New York, NY : Viking Penguin . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Goldberg D. S. , Puhl R. M. ( 2013 ). Obesity Stigma: A Failed and Ethically Dubious Strategy . Hasting Center Report , 43 , 5 – 6 . Google Scholar Crossref Search ADS WorldCat Goodin R. E. ( 1980 ). Manipulatory Politics . New Haven : Yale University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Hausman D. , Welch B. ( 2010 ). To Nudge or Not to Nudge . Journal of Political Philosophy , 18 , 123 – 316 . Google Scholar Crossref Search ADS WorldCat Holland S. ( 2007 ). Public Health Ethics . Cambridge : Polity Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Kligman M. , Culver C. M. ( 1992 ). An Analysis of Interpersonal Manipulation . The Journal of Medicine and Philosophy , 17 , 173 – 197 . Google Scholar Crossref Search ADS PubMed WorldCat Lindstrom M. ( 2009 ). Buyology: How Everything we Believe about why we Buy is Wrong . London : Random House Business Books . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Marmot M. ( 2015 ). The Health Gap: The Challenge of an Unequal World . London : Bloomsbury . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Mill J. S. ( 1982 ). On Liberty . Harmondsworth : Penguin English Library . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Miller G. ( 2009 ). Spent: Sex, Evolution, and Consumer Behavior . New York, NY : Viking Penguin . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Raz J. ( 1986 ). The Morality of Freedom . Oxford : Clarendon Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Rebonato R. ( 2012 ). Taking Liberties: A Critical Examination of Libertarian Paternalism . Basingstoke : Palgrave . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Scheffler S. (ed.) ( 1988 ). Introduction. In Scheffler S. Consequentialism and its Critics . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Shabbir H. , Thwaites D. ( 2007 ). The Use of Humor to Mask Deceptive Advertising: It's no Laughing Matter . Journal of Advertising , 36 , 75 – 85 . Google Scholar Crossref Search ADS WorldCat Sunstein C. R. ( 2015 ). Fifty Shades of Manipulation . Journal of Marketing Behavior , 1 , 213 – 244 . OpenURL Placeholder Text WorldCat Tengland P. -A. ( 2012 ). Behavior Change or Empowerment: On the Ethics of Health-Promotion Strategies . Public Health Ethics , 5 , 140 – 153 . Google Scholar Crossref Search ADS WorldCat Tengs T. O. , Osgood N. D. ( 2001 ). The Link Between Smoking and Impotence: Two Decades of Evidence . Preventive Medicine , 32 , 447 – 452 . Google Scholar Crossref Search ADS PubMed WorldCat Thaler R. H. , Sunstein C. R. ( 2008 ). Nudge: Improving Decisions about Health, Wealth, and Happiness . New Haven : Yale University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Toomath R. ( 2016 ). Fat Science: Why Diets and Exercise Don’t Work—and What Does . Auckland : Auckland University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC White M. D. ( 2013 ). The Manipulation of Choice: Ethics and Libertarian Paternalism . New York, NY : Palgrave . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Wilkinson T. M. ( 2013 ). Nudging and Manipulation . Political Studies , 61 , 341 – 355 . Google Scholar Crossref Search ADS WorldCat Womack C. A. ( 2012 ). Public Health and Obesity: When a Pound of Prevention Really is Worth an Ounce of Cure . Public Health Ethics , 5 , 222 – 228 . Google Scholar Crossref Search ADS WorldCat © The Author 2016. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Counter-Manipulation and Health Promotion

Wilkinson, T, M
Public Health Ethics , Volume 10 (3) – Nov 1, 2017
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Oxford University Press
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© The Author 2016. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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1754-9973
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1754-9981
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10.1093/phe/phw044
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Abstract

Abstract It is generally wrong to manipulate. One leading reason is because manipulation interferes with autonomy, in particular the component of autonomy called ‘independence’, that is, freedom from intentional control by others. Manipulative health promotion would therefore seem wrong. However, manipulative techniques could be used to counter-manipulation, for example, playing on male fears of impotence to counter ‘smoking is sexy’ advertisements. What difference does it make to the ethics of manipulation when it is counter-manipulation? This article distinguishes two powerful defences of counter-manipulative health promotion: that the counter-manipulation would prevent manipulation occurring, leaving people unmanipulated; and that the counter-manipulation would make people healthier without being any more manipulated than they would otherwise be. The article explains how counter-manipulation might work and the limits to its scope. The upshot is that counter-manipulative health promotion could respect the independence people are owed in virtue of their autonomy. However, autonomy is not the only consideration, and the article discusses further potential problems. Counter-manipulative health promotion might be misapplied, it might undermine trust, it might infringe on some norms for role behaviour and it might encourage a regrettable social practice. These objections are likely to be decisive against the counter-manipulation in some but not all cases. Introduction For years, tobacco firms have insinuated that smoking is sexy and manly through advertisements, sponsorship and product placement. One might well object not only to their aim, which is to sell a dangerous product, but also that their method is manipulative, and manipulation is wrong. Consider now anti-smoking advertisements such as this one, paid for by the California Department of Health Services: a glamorous-looking youngish man at a black-tie event lights up a cigarette as a beautiful woman walks towards him; alas, his cigarette wilts; her face shows a flash of horror, then resignation and she walks away. Then the same thing happens again, to three men in a row! The voiceover says: ‘Now that medical researchers believe that cigarettes are a leading cause of…impotence, you’re going to be looking at smoking a little differently. Cigarettes. Still think they’re sexy?’1 The advertisement is funny, to a non-smoker anyway, but a purist might think that using humour can be manipulative (Shabbir and Thwaites, 2007), and even a non-purist might find the advertisement manipulative in playing on widespread male fears, in glossing over the distinction between being a ‘leading cause of impotence’ and impotence being likely to happen and in showing remarkably young men being victims.2 Some instances of health promotion are clearly not manipulative and some are not clearly manipulative or non-manipulative. If some example of health promotion is accused of being manipulative, a sufficient defence would be to show that it is not. But I am interested in a second defence, that manipulative health promotion is really counter-manipulation. Health promoters frequently point out that people are subject to all sorts of manipulative ‘illness promoting’ influences by tobacco, alcohol or food firms (e.g. Holland, 2007; Marmot, 2015: 75). Why not use the tactics of the ‘illness promoters’ to counter their manipulative messages and thereby make people healthier? The answer depends on what counter-manipulation does. Manipulation is generally wrong, especially if it infringes on autonomy. But counter-manipulation might prevent manipulation or at least leave people no more manipulated than they would otherwise be. In either event, this article will argue, counter-manipulative health promotion need not interfere with autonomy. There are other objections to using manipulative methods besides autonomy, but this article will argue that they are not invariably decisive. Here are a few preliminaries. First, this article is concerned with health promotion taken broadly as ranging from population measures, such as social marketing for health, to individual measures, such as a doctor’s giving health advice to a patient. Secondly, and for the sake of argument, let us bracket a couple of possible problems with copying the techniques of commercial firms: that the techniques might be ineffective, or less effective, than enforced price rises for the unhealthy products or a regulated reduction in their availability (Toomath, 2016), and that the techniques might be stigmatizing, which would be bad in itself and likely to fail to promote health (Goldberg and Puhl, 2013). Thirdly, not all counter-manipulation attempts to manipulate. It would not be manipulative to unmask the methods of the manipulator by truthfully telling people what they are. This article, however, focuses on manipulative counter-manipulation. Finally, health promotion aims to make people healthier. However, we should not assume that we are therefore discussing only paternalism, understood as supplanting people’s choices for their own good. One could aim to make people healthier not for their benefit but for the sake of their families, their employers or taxpayers. Ethical questions about manipulative health promotion are not entirely questions about paternalism. As a first step in understanding the ethics of counter-manipulation, we need a sense of what manipulation is and what makes it ethically questionable. Manipulation and Counter-Manipulation Manipulation and the associated ideas of manipulating, being manipulated and someone’s being manipulative, are familiar to most people. It has been claimed that manipulation has its place in most languages and that people often agree on whether given cases do or do not involve manipulation (Kligman and Culver, 1992: 175). On the other hand, analysing manipulation has been tricky. Writers have tried to spell out what makes manipulation different from rational persuasion, giving incentives, threatening and using force. In my view, a fair amount concerning the concept of manipulation remains to be resolved. The account in this section is in no sense complete, given the complexity of manipulation, but it should be recognizable, given the familiarity of manipulation. The section begins with the concept of manipulation and moves to the ethics. The conditions for manipulation can be developed in different competing ways; this paragraph just sets out the rough essentials. To begin, it is widely accepted that the manipulation of a person has an agency condition. Thus manipulation must be done by agents as opposed to non-agents such as natural forces. It is also widely agreed that manipulation presupposes some intention condition: the agents must in some sense intend to influence their targets. However, truthful warnings can meet both conditions without being manipulative so it looks as if we also need some methods condition: the agent tries to shape the target’s decisions, beliefs, emotions, values or desires using some method that is manipulative. Many writers agree that a manipulator has many methods to choose from, and certainly more than just lying (Cialdini, 2007 is a classic presentation). But determining what makes a method manipulative is hard. For instance, it seems unlikely that we can say of any method that it is essentially manipulative because we can always find contexts in which the method seems not manipulative (Wilkinson, 2013). Take framing information: it can be a way to enhance as well as reduce understanding, so one cannot say that framing is essentially manipulative. Writers have proposed various general explanations of when a method is manipulative, such as ‘non-rationally influencing’ or ‘shaping people in ways they would not endorse’, but these have their problems too (Wilkinson, 2013; Coons and Webber (eds) 2014). Finally, manipulation also has a success condition: for manipulation to occur, the target must have been manipulated. Put another way, A can act manipulatively towards B, and yet B would not be manipulated by A if A’s attempt failed. By way of example of these conditions, consider Iago, as he appears in Shakespeare’s Othello. Iago is (1) an agent who (2) intentionally influences Othello, Cassio, Desdemona and Roderigo. Iago (3) uses manipulative methods, such as suggestion and outright deception, that generally work through Iago’s analyses of the characters’ vulnerabilities. Finally, (4) he succeeds; the characters act as he wishes because of his manipulation. Iago even obligingly tells us he is manipulating them, for instance in Act One, Scene Three, where he says ‘Thus do I ever make my fool my purse’. Iago’s soliloquies avoid the problem of determining whether someone has a manipulative intention. In real life, people tend not to admit or agree that they are manipulating. In the case of the anti-smoking advertisement, California’s Department of Health Services may have said it was merely informing, not manipulating, but then the tobacco firms have claimed the same of their advertisements. In sum, we can take manipulation this way: A manipulates B when A intentionally succeeds in influencing B using a manipulative method. I am only too well aware that this definition is loose and certainly does not give a complete operational test for when manipulation has occurred. I also think that no one has a tight accurate complete operationally usable definition of manipulation. Never mind: for the purposes of this article, which is about manipulation as counter-manipulation, the loose definition will do.3 Manipulation is a pejorative term and those who use it generally imply that manipulation is at least prima facie wrong. Manipulation may be wrongly against the target’s interests, betray trust, conflict with authenticity or express a vicious attitude on the part of the manipulator. But the leading explanation of its wrongness is that manipulation infringes on autonomy. Autonomy requires self-rule, in turn broken down into ruling oneself and being free from the rule of others. One can fail to rule oneself because of lacking capacity or being wildly misinformed and possibly—it is controversial—because of addictions and compulsions. One can fail to be free from the rule of others because of coercion and manipulation. It is important to see that the problem with both coercion and manipulation does not lie just in the difficult choices coercion might produce or the mistaken thinking manipulation might produce. One can face difficult choices or make mistakes for all sorts of reasons and remain autonomous. The point is that coercion and manipulation are especially damaging to autonomy because they are forms of intentional control by other agents. As Daniel Hausman and Brynn Welch put it in the case of manipulation, ‘Even when unshaped choices would have been just as strongly influenced by deliberative flaws, calculated shaping of choices still imposes the will of one agent on another’ (Hausman and Welch, 2010: 133). In Joseph Raz’s terms, coercion and manipulation violate independence from the will of others, a dimension of autonomy (Raz, 1986: 377–378). The distinct requirement of independence for autonomy explains the distinct importance of counter-manipulation, as we can see if we consider some possible arguments for manipulative health promotion. One possible argument would say that the gain in health outweighs the loss in autonomy, and this argument must defend sacrificing autonomy. Another possible argument would claim that people are often unhealthy for reasons such as a failure of self-control and manipulating them into being healthy would give them what they really want and so make them more autonomous. This argument sacrifices the independence component of autonomy for the sake of gains in the self-rule component. A third argument says that people are already subject to manipulative influences.4 This is the counter-manipulation argument. Unlike the previous argument, it claims that manipulative health promotion comes at no further cost to the targets’ independence. The counter-manipulation argument neither sacrifices autonomy to health nor one part of autonomy to another. It is thus a distinctive and distinctively powerful argument.5 Let us now turn to the question of why counter-manipulation might not harm its targets’ autonomy. As I said, counter-manipulation is sometimes described in writings on health promotion, but they generally leave vague how it is supposed to work. Take an influential description (but not quite endorsement) of counter-manipulation: [P]eople are already being manipulated in a plethora of ways…This helps justify health promotion because the alternative is not complete freedom to choose one’s health behaviours…health promotion is counter-manipulation, as opposed to manipulation proper; it is one of the myriad forces motivating our health behaviours, but one intended to counteract those forces that motivate unhealthy choices…The social marketer [for health promotion] is merely levelling the playing field by combating `illness promotion’ with health promotion (Holland, 2007: 128–129). I can see two importantly distinct interpretations of counter-manipulation in this quotation. The first is that manipulative health promotion does manipulate people, but it is justified because they would be manipulated anyway and better that they are healthy and manipulated than unhealthy and manipulated. The second, suggested by such phrases as ‘levelling the playing field’6 and ‘as opposed to manipulation proper’, is that manipulative health promotion cancels out the manipulative promotion of unhealthy products and leaves people unmanipulated. Because it would be better to prevent manipulation, I explore the second interpretation first.7 Preventing Manipulation How might counter-manipulation prevent manipulation? Here are some ways, partly adapted from writings on free speech and commercial advertising: Competing messages might jolt people into realizing that there is a second side to the story. As a result, they no longer mindlessly accept the initial manipulation or endorse the counter-manipulation message. Instead, they deliberate for themselves. On an optimistic Millian story, the one-sidedness of advocacy joined to competition is a good way to make people think for themselves (Mill, 1982: ch. 2). Less optimistically, people might dismiss as lies or distortion what everyone said on a topic and move to a state of disbelief. Either way, they are no longer manipulated. Competition may put people on their guard. The idea here is that that their general attitude changes, whereas the preceding point was about attitudes to specific messages. People might become sceptical voters or cynical consumers. It is harder to manipulate the wary. (1) and (2) prevent manipulation by putting people in a position where they deliberate for themselves. They do not take messages at face value. They evaluate with critical distance what they are told. They may in the end do what one side wants, but they have not been manipulated into it because they have not been under the control of that side. The independence component of their autonomy would be preserved. (3) Messages may cancel each other out (Hausman and Welch, 2010: 131). One reason could be psychological. Perhaps so many messages are given that they become white noise. Consider the idea that adverts must manipulate people into excessive consumerism because they are exposed to so many of them (Miller, 2009: 76). The idea seems plausible in the light of estimates that ‘[b]y the time we reach the age of sixty-six, most of us will have seen approximately two million television commercials’ (Lindstrom, 2009: 37). But the idea may be wrong if our minds simply screen them out, a proposition for which there is some evidence. For instance, a 2007 ACNielsen phone poll of 1000 people found that on average they recalled only 2.21 TV advertisements.8 (3) prevents manipulation in a different way from (1) and (2). Whereas (1) and (2) involved receiving the message and then evaluating it, (3) involves not receiving the message. Manipulation requires success. No matter how clever your manipulatory telephone manner, I would not be manipulated if you try it on me when the line is dead. (4) Cancelling could also occur because competing messages give opposing reasons, as when competing firms denigrate each other’s products. Counter-manipulation may then cause people to do what they would have done in the absence of any manipulative attempts, which might count as preventing manipulation. Consider a possible health example. Suppose someone would drink 21 units of alcohol per week if he were exposed to no marketing at all. However, the alcohol industry convinces him that drinking will bring good cheer which, in the absence of further influence, would cause him to drink 28 units per week. Enter anti-alcohol marketing, which convinces him that drinking more than 14 units per week risks his health. Suppose both sides exaggerate. The drinker weighs the good cheer against the health and drinks 21 units per week. The anti-alcohol manipulation cancels out the pro-alcohol manipulation. This final cancelling out case differs in one important respect from the others in being focused on the outcome, what the drinker did, and not the process, how the drinker came to do it. Manipulation is essentially about the process by which one comes to believe, decide or value and not about what one believes, decides or values. The final cancelling out case is thus less clearly one where manipulation is removed. The man who drinks 21 units as a compromise between two manipulative influences still decides as the result of a manipulated process, even though he does what neither the pro-alcohol nor pro-health promoters would like and even though he does what he would have done if he were not manipulated at all. I would be inclined to say that the counter-manipulation still manipulates the man. However, one might also say that the counter-manipulation enhances his autonomy in one respect, by preventing his actions being controlled by either pro- or anti-alcohol marketers, even as it damages his autonomy in another respect, by adding manipulated beliefs about the dangers of alcohol to his manipulated beliefs about its benefits. We have seen that counter-manipulation could block manipulation by preventing its success. The focus has thus been on what happens to the potential targets not on what the manipulative agents are doing. If instead we evaluate the behaviour of those doing the counter-manipulating, it would be a mistake to think they are off the hook whenever their attempts do not cause people to be manipulated. One can be blameworthy for failed attempts to do wrong. But it would make a difference what counter-manipulators thought they were doing. On the one hand, some would realize that they are in a competition which would result in no manipulation; some indeed could welcome that result. It does not seem generally wrong or even manipulative to use manipulative methods when one has both the intention of preventing the target being manipulated and a reasonable belief that the method would prevent manipulation. On the other hand, health promoters who do try to manipulate would be doing something prima facie wrong even if, as it happened, their efforts did prevent manipulation. The main aim in this section was to show how counter-manipulative health promotion may respect the independence component of autonomy by preventing manipulation. Whether health promotion actually does prevent manipulation is in part an empirical question that turns on such matters as whether advertisements stick in our minds. Manipulation for a Better Result The previous section pointed out that counter-manipulation might not manipulate. But it could, and what if it did? Consider this argument: counter-manipulation that indeed manipulates leaves people no more manipulated than they would otherwise be. However bad manipulation is, manipulation is a constant across the two cases of initial manipulation and counter-manipulation. Thus in determining the badness of counter-manipulation, we have to go to the next consideration, which we can suppose is the quality of the results. If the results of the counter-manipulation are better, then the counter-manipulation is all-things-considered justified. By way of example, remember the anti-smoking advertisement described at the start. Suppose people would be manipulated by tobacco firms unless they were manipulated by the anti-smoking advertisement. Either way, they would be manipulated. But it is better if people do not smoke, let us suppose. So the anti-smoking advertisement is justified counter-manipulation. California’s Department of Health Services could say to tobacco firms: ‘our manipulation is better than yours’. Call this the `better result’ argument. What needs to be the case for the better result argument to work? The manipulation really must have a better result. The ‘better result’ could be that the counter-manipulated people are all-things-considered better off for being healthier or that society is all-things-considered better off for their being healthier. However, being healthier need not be all-things-considered better because, for instance, health is not the only good. Nonetheless, being healthier is plausibly all-things-considered better in many cases. There is no alternative. The tacit assumption is that the only two options are manipulation by one side or another. In other words, there is no third way where targets are de-manipulated. When it comes to applying the argument in practice, one would have to check that no third way exists. The argument implies that manipulation is a constant across the two options in the sense that either the degree of manipulation is the same and\or that the manipulation is equally bad. However, not all manipulation is on a par (Sunstein, 2015). If A smokes because a wordless cowboy appeared in an advertisement and B smokes because a tobacco firm lied about the health effects, we should likely say that B is more manipulated or manipulated in a worse way than A. Thus for the better result to go through, the manipulative method used in health promotion must either be similar to the manipulation it counters, as when both manipulator and counter-manipulator are lying, or less bad than the manipulation it counters, as when health promoters exaggerate to counter a lie. Supposing the conditions are met, what could be the objection to counter-manipulating for a better result? Here are two that argue from within the value of autonomy. The first is unmotivated and the second is inconclusive. The first argument is about the frequency of manipulation. When someone is manipulated by A, that is bad; when that person is then counter-manipulated by B, that looks worse. Now the target is manipulated twice, not once. So counter-manipulation does not really hold manipulation constant, contrary to what the better result argument says. As against this argument, it is unclear why the frequency of manipulation matters. Frequency should not be confused with duration, which plausibly does matter. It is worse other things equal to manipulate for a longer time than a shorter. But duration is distinct from frequency. Suppose either that someone is manipulated by A for a year or that person is manipulated by A for 6 months and then counter-manipulated by B for 6 months. The duration of manipulation is the same. Leaving aside contingencies, such as one form of manipulation being worse than another, why would it be any worse to be manipulated twice rather than once? Could then counter-manipulation be objectionable because of its longer-run effects? Jennifer Blumenthal-Barby considers the case of a doctor whose patient has been manipulated into smoking; the doctor decides to manipulate the patient into not smoking instead. Blumenthal-Barby considers the argument that the patient’s autonomy, being already at zero, cannot be further impaired by the counter-manipulation, and writes: ‘my intuition is that one way in which it could is that this further manipulation…makes it harder for [the patient] to recover and govern himself, and in that sense does pose a further threat to autonomy’ (Blumenthal-Barby, 2014: 127). Blumenthal-Barby does not explain her intuition in more detail than this, so let me try to find out what she has in mind. She sees autonomy as being recoverable via some process that would be interfered with by counter-manipulation. What could such a process be? The most plausible explanation I can think of is some feedback mechanism, such as learning from one’s mistakes or finding out the truth. However, it is an open question whether counter-manipulation delays recovery. It could have no effect, for instance if the target never would learn from mistakes. Counter-manipulation could even speed up recovery, for instance by starting the target on the process of critical enquiry. Where recovery is no slower for the counter-manipulation, again the argument goes through.9 When it meets all the conditions set out in this section, the better result argument seems to have great power. How many cases would actually meet these conditions is another matter. But one could have powerful versions of the argument even when some of the conditions are not met. For instance, suppose that the effect of counter-manipulation was that the target was slightly more manipulated overall. An extra bit of manipulation might be justified if it prevented, say emphysema or lung cancer from smoking. Or suppose the interference of counter-manipulation did delay the recovery of autonomy but did not prevent it. One might then say that counter-manipulation could be wrong despite a good result if it prevented autonomy but not if it merely delayed autonomy for a time. These revisions to the better result argument would not succeed if the independence component of autonomy had lexical priority over other considerations. But if some independence may be traded off for good results, the revisions may work by showing that counter-manipulation could be justified if it did not reduce independence by much. The better result argument has been put in consequentialist form: counter-manipulation has better consequences because it leads to more of one good thing, health, and no less (or not much less) of another, autonomy. Put another way, counter-manipulation is the lesser of two evils. The argument thus faces the deontological problem of whether one should commit evils oneself to prevent worse evils being committed by others. Of course the problem is too complicated to resolve fully here, but I can make a few remarks. The deontological ideas that underlie the problem can be formulated in many different ways. The better result argument might be able to avoid some versions of the problem and may be able to overcome other versions. Consider patient-centred versions of deontology: these might stress the right not to be manipulated based on the especial badness of being manipulated.10 Such versions may well rule out manipulating people even when doing so would produce large benefits. But it is hard to see how they would rule out manipulating people who are already manipulated since the badness for them would not be changed. Patient-centred deontological objections can be avoided. Other deontological arguments might stress the duties of agents, in this case agents who might manipulate. Yet further arguments might have some hybrid agent–patient relation in mind. These arguments stress the wrongness of manipulating rather than the wrongness in being manipulated. They might say that it is worse to manipulate than to let manipulation happen, or that it is worse to intend to manipulate than to fail to prevent foreseeable manipulation. The better result argument may be unable to avoid these deontological objections—it would depend in part on how the objections were developed. But perhaps the better result argument could overcome the objections. Many writers agree that the duty not to manipulate may be justifiably overridden; it is not absolute (Goodin, 1980; Baron, 2014). They often have in mind manipulating someone for the sake of benefits to others. Still more is the duty likely to be overridden when the benefits come to the target at no further cost in being manipulated. The Scope of Counter-Manipulation To this point, we have focused on the relation between autonomy and counter-manipulation and considered arguments that counter-manipulative health promotion could make people healthier without sacrificing the independence component of their autonomy. These are powerful arguments, but they have an important limit on their scope. Their scope depends on what should be regarded as manipulative attempts to counter. Some writers bundle up too many ideas under the heading of manipulation and so give counter-manipulation too wide a scope. For instance, Holland appears to assume that peer pressure is a form of manipulation that health promoters might counter (Holland, 2007: 128). But peer pressure need not be manipulative in all its forms. If teenagers smoke so as to fit in with their peer group, we cannot infer that they are being manipulated. They may simply see smoking as the price of acceptance and one is not manipulated simply by having a price to pay. This is one example where one should be careful in using counter-manipulation arguments. Their distinctive force is in showing that it is possible to use manipulative methods without failing to respect the independence component of autonomy, but it is essential that the manipulative methods counter influences that do disrespect independence. Not all influences that cause people to act unhealthily, even irrationally, are manipulative. When the influences are not manipulative, using manipulation to counter them would disrespect independence. Further Considerations besides Autonomy The main aim of the article has been to show that counter-manipulative health promotion can respect autonomy, in particular its independence component. Unsurprisingly, there are numerous factors besides autonomy a full account would have to consider. I cannot hope to do justice to them here, but I hope to show that they are unlikely to be decisive against all counter-manipulation. One factor is the danger of misapplication; that using manipulative methods turns out not to be counter-manipulation. Another is that counter-manipulation could conflict with the value of trust. A third is that counter-manipulative health promotion violates some norm for roles. The final factor is that counter-manipulation may contribute to a bad social practice. When using manipulative methods to counter what one sees as manipulation, one could be wrong about whether the targets were manipulated. The mistake could lie in being wrong about what constitutes manipulation, as in the above example of peer pressure, or wrong in the facts, for instance about whether the targets really were fooled. Or one could be over-broad in one’s targeting, hitting some people who are manipulated but also some who are not. The risk of error is compounded by the dangers of wishful thinking. It is tempting, if one thinks that people are acting mistakenly, to see some form of manipulation as the explanation. Finally, the counter-manipulator risks moving from manipulation to manipulativeness. While some manipulation is probably justified, ‘manipulativeness’ is a vice—an unconditionally bad vice, according to Marcia Baron (Baron, 2003: 49). As a vice, it involves an arrogance that leads to taking decisions out of the hands of the people to whom they belong and being too quick to resort to manipulative methods, whether because the manipulative person sees reasoning with the targets as tiresome or, wrongly, as futile. The risk is that after acting manipulatively, the moral barriers are lower, and if the manipulation works, it would be tempting to manipulate again and again. These are serious points. They apply not only to individual health promoters but also to the behaviour and culture of organizations. On the other hand, it is hard to know what to conclude from these points in any given case. They raise a problem of decision: on a given occasion, there may be good reason to use manipulative methods, but a repetition of such good occasions will increase the risk of error and manipulativeness, so what should one do? Regrettably the decision problem has no quick solution, and space precludes attempting a slow one. Now consider the loss of trust.11 If we attempt to manipulate people, we may forfeit their trust and that could be a price too high to pay. As a general practitioner put it in discussing this article, if he attempted to manipulate his patients even in a good cause, it would destroy their relationship. The general practitioner’s point applies to any health promoters or organizations with a reputation to take care of. While I think the general practitioner exaggerated, I agree that in some cases, the risk to trust probably should rule out counter-manipulation. However, if we think through trust, we may see the cases where it should not. Suppose we interpret the trust objection this way: enough of the value of trust would be lost to outweigh the gains from the health promotion.12 Here are a few remarks about the factors that might affect how much trust would be lost. First, the trust involved need not be only between counter-manipulator and target. Third parties may observe the manipulation and trust the health promoters less. Other things equal, the more people whose trust would be lost, the greater is the reason against counter-manipulation. Secondly, how much trust would be lost would depend in part on how much trust already exists. A highly trustworthy institution or person should probably be especially careful to avoid the temptation of ‘reputation mining’ (Akerlof and Shiller, 2015), taking advantage of its reputation to manipulate. The highly trustworthy have more to lose ethically and prudentially than the less trustworthy. Thirdly, the extent of a loss of trust may depend on the means used to counter-manipulate. One could certainly see how a deliberate lie could both be discovered and cause great damage to a relationship. But not all possible manipulation is a deliberate lie; putting on a serious face and lowering the tone of one’s voice are not lies, although they are potential methods of manipulation (Dennett, 2003: 270). Even if a target becomes wise to the trick, when being lectured by a doctor about blood pressure or obesity, a target could still trust the doctor, and be rational to trust the doctor, not to tell an outright lie. Finally, the extent to which trust might be damaged plausibly depends on how targets and observers understand what has been done. They might be more likely to appreciate the point of counter-manipulation than of simple manipulation, since the counter-manipulation does not threaten independence. Health promotion has so many methods and sites that these factors would surely vary in importance. We may conclude that the loss of trust is likely to be a compelling objection to counter-manipulation in some cases but not all cases. Roles may matter or, in other words, who manipulates may matter as well as how and why they do it. For example, some writers object much more strongly to manipulative attempts by the government than by the private sector (White, 2013: ch. 6).13 Some of the arguments are about power. As against government manipulation, one could say that the government should be more restrained than firms because it has greater power than any firm. In reply it could be said that we can at least have some collective control via democratic government of influences on our behaviour, whereas we cannot have such control in the case of private sector influences. The dispute in turn depends in part on whether government power really can be controlled through transparency or other methods (Thaler and Sunstein, 2008; Rebonato, 2012; Barton, 2013). Roles may matter in healthcare too. We might feel entitled to expect more from doctors than private firms too given the power imbalance between doctor and patient, and given the codes of medical ethics supposed to govern medical behaviour (Blumenthal-Barby, 2012: 357). An objection based on roles may or may not be a good one; again I can offer only some brief comments. First, some of the reasons why roles matter may reduce to ones we have already considered, such as the loss of trust. For instance, one reason why some writers are relatively unperturbed by commercial attempts to manipulate is because they think most people do not trust advertising, which is partly a point about how firms do not forfeit trust since they were not trusted anyway. Secondly, the objection has a limit to its scope; it would not apply to counter-manipulation by those other than the government or health professionals. It would not apply, for instance, to those NGOs that had neither the power of government nor the duties of health professionals. Thirdly, one must acknowledge, however, that the boundaries between governments and NGOs are often blurred, since NGOs often receive money from governments. Someone who insisted that governments not counter-manipulate might include government-sponsored NGOs in the restriction. But then one should also acknowledge the role of government in assisting firms that promote unhealthy products through tax relief or subsidies for their marketing activities. At any rate, counter-manipulation will not be entirely ruled out by role norms, either because it does not infringe on those norms or because the norms are not weighty enough. Finally, counter-manipulation may support a regrettable social practice, for instance by sustaining a culture of exaggeration and distortion or undermining the prospects of simple clear reliable communication. Think how tiresome it would be to live in a society where every communication had to be decoded. If someone died, we would have to ask, as Metternich supposedly did of Talleyrand’s death, ‘What did he mean by that?’ On the other hand, recall the Millian-type advocacy mentioned earlier. Advocates may distort, appeal to emotion and so on in various ways that could be manipulative, but given that advocates of all sides are doing so, manipulation would not occur and, moreover, such advocacy is the best way to produce considered opinions in people’s minds. If this good result actually occurred, counter-manipulation would be an element in a game worth playing. Notice that the value of a practice is not reducible to the ethics of behaviour within the practice. By analogy, the prosecutors and defence within an adversarial system should act out their roles, not behave as they might in an inquisitorial system and yet we might judge the inquisitorial method to be better than the adversarial in criminal justice. Even if manipulative health promotion did support a regrettable social practice—which it might not—it might not be wrong to do, given that others would manipulate anyway. Still, the effects on a social practice should not be ignored, and they may be enough, in some cases, to tip the balance away from manipulative health promotion. Conclusion This article has brought together the ideas that manipulation is generally wrong, that at least some health promotion may be considered manipulative and that it often occurs in a context of manipulative ‘illness promotion’. The context matters because manipulative health promotion may then be counter-manipulation. It may enhance or at least not damage further its targets’ independence, the key relevant component of their autonomy. If and when counter-manipulative health promotion cannot be criticized on grounds of autonomy, the leading objection to it is removed. That leaves further objections, such as the loss of trust. Without claiming completeness, this article tried to show that these further objections are unlikely to be decisive. Even someone who takes manipulation to be seriously wrong need not then object to all counter-manipulative health promotion. Footnotes " 1. The advertisement can be seen here: https://www.youtube.com/watch?v=fYu8crlRe9g. " 2. Tengs and Osgood (2001) show that the state of evidence at the time did not support the categorical claims made in the advertisement, although the authors concluded that the risk of impotence was a reason to avoid smoking. Tengland (2012: 145) mentions impotence and smoking as a potential example of manipulation. " 3. Some writers, e.g. Goodin (1980), make it part of the definition of manipulation that the target is unaware of being manipulated. I disagree: there is nothing conceptually incoherent in being aware of being manipulated. For a superb example, see the picture in Cialdini (2007: 23) of the businessman paying for a flower at an airport; he is being manipulated and he knows it. " 4. Barton (2013) would be willing to sacrifice independence for self-rule but also thinks that cigarette warnings counter-manipulate too. " 5. A further argument might be that manipulative or counter-manipulative health promotion people would not infringe on independence when its targets consent. Although I set it aside here, consensual manipulation is both possible and would respect autonomy. See e.g. Wilkinson, 2013. " 6. Womack (2012: 224) also uses the phrase ‘level the consumer playing field’, in the context of counteracting food industry influences. " 7. A referee asked: if it is better to prevent manipulation than counter it, why not restrict all sources of manipulation rather than add counter-manipulation? In some cases it is desirable to prevent manipulation, e.g. through truth-in-advertising rules. But it is impossible to prevent all manipulation and undesirable to give the state the power to try (Sunstein, 2015). " 8. The study and suspiciously low figure is cited in Lindstrom, 2009: 37–38. " 9. The open question point also applies to Tengland’s (2012: 145) criticism that manipulative health promotion reduces the ability for self-determination. Maybe or maybe not. " 10. For the contrast between agent-centred and patient (or victim)-centred deontology, see Scheffler (1988). " 11. See also the discussion in Blumenthal-Barby, 2012: 358–359. " 12. To breach trust might also be betrayal, which may not lend itself to the analysis here, and which I have to leave aside. " 13. The arguments about private sector and government manipulation are adapted from discussion of nudging, although I do not think all nudging is manipulative. Put crudely, nudging is supposed to change behaviour without using penalties or rewards. The classic presentation is in Thaler and Sunstein 2008. Acknowledgments Geoff Kemp, Kathy Smits, Steve Wilkinson, Steve Winter and an audience at the Otago Bioethics Centre. References Akerlof G. , Shiller R. ( 2015 ). Phishing for Phools: The Economics of Manipulation and Deception . Princeton : Princeton University Press . Google Scholar Crossref Search ADS Google Scholar Google Preview WorldCat COPAC Baron M. ( 2003 ). Manipulativeness . 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Public Health Ethics – Oxford University Press

Published: Nov 1, 2017

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