Arts in health interventions often have a clear positive aim: to provide support and enjoyment to an individual or group, by improving experience and/or improving outcomes. Consequently, it is easy to see why people might ask are there any real ethical implications for arts in health interventions? Are ethics anything more than a tick-box exercise to allow a project to move forwards? How can a consideration of ethics add any value to a project?
In 2000, medical sociologist Professor Dame Sally Macintyre and her colleague Mark Petticrew wrote an article in the Journal of Epidemiology and Community Health entitled ‘Good intentions and received wisdom are not enough’.(1) In this editorial, Macintyre and Petticrew discussed the relevance of ethics through some examples of projects that, like many arts in health interventions, had only good intentions. For example:
- 1. Implementing school-based bicycle safety education programmes (‘Bike Ed’) to reduce the risk of bicycle injury in children
- 2. Organizing visits to prison for juvenile delinquents so that adult inmates could discourage them from getting involved in criminal activity
- 3. Lying babies on their fronts to reduce the risk of inhaling vomit or choking
- 4. Prescribing vitamin E supplements to smokers to reduce the incidence of cancer
However, these projects are in fact examples of the dangers of assuming that good intentions are enough, as these studies actually had rather alarming results:
- 1. A case-control study involving 278 children aged 9-14 found that ‘Bike Ed’ encouraged more risk-taking behaviours and led to twice as many accidents for boys (2)
- 2. A systematic review of ‘Scared Straight’ programmes showed that meeting inmates normalized prison to juvenile delinquents, leading to an increase in delinquency rates (3)
- 3. Lying babies on their fronts led to a 4.6-fold increase in SIDS (sudden infant death syndrome) deaths, and for babies who were unaccustomed to sleeping on their fronts, the death rate was nearly 20 times higher (4)
4. A meta-analysis of 11 RCTs showed that vitamin E supplementation was associated with an increase in all-cause mortality (5)
Consequently, far from being ethically risk- free, these studies are pertinent examples of precisely why ethical considerations are so important: not only did a good intention not have any positive benefit, but it actually led to dangerous results. Arts in health interventions may set out with only good intentions, but it is still possible that they lead to unanticipated negative outcomes.
Ethics are typically brought to the fore of any intervention or research at the point that ethical approval needs to be secured for the project to move ahead. However, ethical considerations should pervade any research project, from its inception through to its conclusion. In this chapter, we will consider both general ethics of conduct when working in arts in health as well as returning to the research journey mapped out in Chapter 10 and considering the importance of ethics across the lifespan of a research project.