Review Articles
Is the workplace wellness program doing good?: ethical considerations around health promotion at workplace
2020 Volume 2 Issue 1 Article ID: 2020-0016-RA
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2020 Volume 2 Issue 1 Article ID: 2020-0016-RA
Objective: While the workplace wellness program (WWP) has been widely provided around the world, there was little discussion of ethical issues around WWP. This article describes the overview of how ethical issues arise in WWP, and how practitioners, as well as employers, can mitigate these problems. Methods: The author reviewed the literature addressing the ethical issues around WWP and ethical analytic tools, potentially useful for practitioners to improve WWP from ethical perspectives. Results: The ethical issues in WWP were categorized based on the three principles in bioethics: the principle of autonomy, the principle of beneficence/non-maleficence, and the principle of justice. For each category, various ethical concerns have been discussed in previous research, such as autonomous decision-making under financial incentives, the importance of evidence-based intervention, unexpected consequences of health promotion programs, and disparities among workers under WWP. The author also identified several useful tools and approaches, which practitioners can utilize for improving WWP from ethical perspectives. Conclusion: The employers and practitioners are recommended to conduct ethical analysis with multiple stakeholders to improve their WWPs from ethical perspective during the process of program development and implementation.
Today, the Workplace Wellness Program (WWP) has become a widespread and common concept for companies around the world. The Centers for Disease Control and Prevention (CDC) in the United States defines WWP as “a coordinated and comprehensive set of health promotion and protection strategies implemented at the worksite that includes programs, policies, benefits, environmental supports, and links to the surrounding community designed to encourage the health and safety of all employees”1). Nowadays, 51% of all workplaces in the United States are providing some form of WWP2). Also, the World Health Organization (WHO) is promoting health programs in the workplace3). In the “Healthy Workplace” framework, WHO encourages the comprehensive approach to ensure a healthy workplace environment for all workers by improving the physical work environment, personal health resources, enterprise community involvement, and psychosocial work environment. Moreover, in European countries, governments proactively support the workplace wellness program through their policies4). This trend is also seen in Non-western countries, such as Japan. The Ministry of Economy, Trade, and Industry (METI) in Japan has encouraged employers to consider employees’ health as a management issue and implement WWP as part of their business strategy5). METI also operates a system to certify companies that are proactively investing in improving the health of their employees. Corporate and governmental commitments to the WWP are now quite common throughout the globe.
The market size of the WWP industry has reached 48 billion United States dollars (USD) worldwide in 2017 and is forecasted to be 66 billion USD by 20226). The CDC is promoting comprehensive evidence-based health promotions at the workplace through the use of a checklist system7). This checklist covers 16 different domains: organizational support, tobacco control, nutrition, lactation support, physical activity, weight management, stress management, depression, high blood pressure, high cholesterol, diabetes, signs and symptoms of heart attack and stroke, emergency response to heart attack and stroke, occupational health and safety, vaccine-preventable diseases, and community resources. It is expected that these programs be adequately delivered to the worksites.
The WWP became a phenomenon after the Live for Life program was introduced by Johnson & Johnson in 19798). The previous research examining the economic impact of the WWP showed various benefits, such as reduced healthcare costs, decreased absenteeism and presenteeism, and better performance in the stock market9,10). A meta-analysis indicates that American companies are saving ＄3.27 USD of medical expenses and ＄2.73 USD for absenteeism for every dollar spent on WWP9). In contrast to the many positive findings of WWP, there is some controversy about WWP from ethical perspectives2). This literature review summarizes the ethical considerations about WWP and introduces ethical frameworks, which practitioners can use to improve the contents of WWP.
Ethical discussion in public healthEthical considerations have always been an issue in the field of public health practice. The milestone of ethics in the biomedical field, as well as public health, is “The Principles of Biomedical Ethics” by Beauchamp and Childress11). They proposed three principles in their ethical framework: autonomy, beneficences and non-maleficence, and justice.
The principle of autonomy focuses on self-ruling, since the term “autonomy” came from the Greek auto, which means “self” and nomos, which means “rule” or “law”12). In other words, this concept is about respecting an individual’s right to self-determination and requires they be provided sufficient information to make that decision13). This also includes the people’s right to opt out from the medical intervention based on their own free will. Furthermore, it addresses that ones’ decision-making needs to be free from external constraints, and voluntary decision-making is essential11). In this context, the principle of autonomy has a tight connection with the principle of beneficence and non-maleficence because leaving people out of the decision of what is good or harmful for them can violate the principle of self-rule12). Protecting privacy and confidentiality is considered as prerequisites for ensuring autonomy14).
The second principle consists of two components: beneficence and non-maleficence13). This principle requires medical professionals to conduct their intervention to improve the health status of people. At the same time, medical practitioners are obligated to minimize harmful consequences for the people. There are different views on what is deemed to be good or harmful in public health practice12). From the standpoint of consequentialism, anything that leads to less utility than other alternatives can be interpreted as harm. On the other hand, a deontologist would define harm as what can prevent us from taking actions based on moral laws. From the deontologist’s perspective, good or harm will be judged based on the morally right intentions and actions, regardless of its consequences. Traditionally, the majority of ethical frameworks in healthcare have relied on the consequentialism perspective about the intervention outcomes15). However, in light of the realities of public health practice, it is not possible to fully predict the outcome of an intervention. Therefore, it would be reasonable to interpret that there is an obligation to make sufficient efforts to maximize the anticipated benefits, as well as to minimize the possible harm and burden.
Lastly, for the principle of justice, the benefit and the burden of the intervention should be equitably distributed to people in the community13). The idea of seeking fairness in the distribution of resources is called “distributive justice.” Another major form of justice is called “procedural justice.” Procedural justice indicates fairness and transparency in the process of developing interventions and policies in the public health field12).
In the next section, the author will discuss ethical issues around WWP from these three perspectives.
For the principle of autonomy, self-determination is one of the essential elements; people need to have the choice whether they will participate in WWP or not based on their own free will. Hollander and Hale addressed that the challenge to WWP is to “facilitate knowledge and behavior change without having to resort to manipulative or coercive means, which infringe upon the self-determination of employees”12). When considering autonomy in WWP, of course, voluntary participation should be guaranteed. However, when there is an incentive for participation in the program, the story gets more complicated. Recently, incentives, both financial rewards and penalties, have been widely used in WWP. According to the RAND corporation report, 75% of WWP provided some form of incentive to their employees for participation17). Terry discusses that an excessive amount of incentive can distort decision-making and violate voluntary participation18). Moreover, he encouraged WWP to provide multiple alternative options rather than one single program to get financial rewards so that employees can choose which programs to participate in according to their preferences. For instance, it is preferable to offer several ways to receive incentives (e.g., providing financial rewards when an employee completed either smoking cessation program, physical activity program, or annual health screening, instead of providing incentives only when an employee completed a smoking cessation program). This approach would leave room for employees to voluntarily decide what programs to participate in and would prevent compulsory participation in certain programs through incentives. Rothstein and Harrell also pointed out that those economically vulnerable people, such as less-skilled and lower-paid workers, are least able to resist the financial incentives as well as disincentives19). For these people, the incentive system can easily distort the freedom to choose whether or not they participate in WWP. According to Rothstein and Harrell, “employer-sponsored health plans should not be able to override individual autonomy by adopting a system of incentives and disincentives that, for many employees, might rise to the level of unethical coercion”19). All of these articles criticized the inappropriate incentive program, which coerces people to participate in the program without providing enough options to opt out of the program.
On the other hand, several researchers pointed out that avoiding excessive incentive is not enough to ensure autonomy. Roberts and Leah introduced the evidence of unequal distribution of autonomy among the general population depending on socioeconomic status, where people in the most need had difficulties in making healthy decisions in their best interest20). Therefore, they insisted that WWP should “facilitate” autonomy to maximize the employees’ interest rather than simply let people make a decision by themselves. However, these two ideas are not mutually exclusive. “Facilitating” the autonomy can be interpreted as a process to help people to make an unbiased decision by giving them adequate information or removing causes for cognitive biases. This libertarian paternalistic21) point of view has been widely applied to health promotion programs as “Nudge” these days. However, the idea of nudging people or facilitating people can easily be misplaced into an approach of forcing people to do something. The ethical consideration of nudge in healthcare intervention was previously well articulated elsewhere22).
Matteson and Ivancevich indicated that the pressure to participate in the WWP is the result of the conflict of two ethical principals: “the right of individuals to freedom of action choice, and the duty to protect people who may be unable to do so themselves”23). To this issue, Hollander and Hale mentioned that centralized program implementation can be perceived as overly paternalistic and coercive and may cause some conflict between employers and employees16). Therefore, they suggested involving employees in the whole process of WWP planning to the implementation to reflect their needs and interests. Moreover, the Luxembourg Declaration on Workplace Health Promotion requires employers to involve employees at all levels of health intervention in the workplace24).
ii) The principle of beneficence and non-maleficenceThe principle of beneficence and non-maleficence is mainly about how to ensure the quality of interventions. Since all healthcare interventions are supposed to be implemented to improve health outcomes among participants, there is no wonder that the effectiveness of WWP needs to be scientifically examined. Despite the evidence for saving medical costs9) and the perceived benefit of these interventions, there have been skeptics of the program’s effectiveness. For example, a large-scale randomized controlled trial showed that WWP for physical activity did not improve health outcomes as well as economic outcomes, while it increased the people who did regular exercise13). Also, Jones et al. reported that their WWP did not improve health outcomes and employees’ productivity in the longer term26). Since these WWP were aimed to promote employees’ health with good intentions, it is hard to say that these programs were ethically wrong just because they failed to show effectiveness. However, it can be morally questionable if we promote these interventions when we already knew that these would not be effective from previous literature and interventions. Even when we do not have enough evidence for the intervention, the potential benefit and risk should be communicated with participants, and practitioners need to monitor the results closely. To utilize the extensive evidence in WWP, Policy Evidence Assessment Reports may be an excellent tool for program development27). In these reports, the CDC summarizes the scientific evidence related to the WWP and evaluates the potential public health impact and evidence quality. This tool would be helpful for employers and practitioners to consider which programs to offer and how to prioritize them using scientific evidence.
Also, there are some possibilities that WWP can cause unintended consequences. For instance, if the company implements unnecessary screening programs for the employees, it could introduce new problems related to false positives and over-diagnosis, despite the perceived benefit of screenings. There is evidence that the low-intensity prostate-specific antigen-based prostate cancer screening does not change long-term survivorship28). Also, people who received false-positives in cancer screening showed a higher risk of psychological symptoms29). Considering these “side-effects,” the employer needs to decide what to provide as WWP to its employees carefully. Especially when resources are limited, the impact of the intervention should be examined and prioritized based on the best available scientific evidence rather than using limited resources for controversial interventions. These negative implications do not mean that companies should not commit to WWP, but the best available scientific evidence should be appropriately used during the process of program development and prioritization. At the same time, taking into account the heterogeneity of the scientific evidence, each employer should closely monitor the outcomes, including the unexpected effects of their interventions to achieve meaningful changes.
iii) The principle of justiceThe third principle is justice. One of the significant aspects of justice in WWP regards who has a responsibility for health. Berkel et al. revealed discrepancies in the attitudes about responsibility for health between employers and employees: employers tended to attribute healthcare issues in the workplace to personal factors more than the employees30). Allegrante and Sloan pointed out that the current WWP overly personalizes health issues, ignoring occupational and organizational factors31). They acknowledged the importance of “management practices designed to address organizational-level factors contributing to health risks and approaches that foster the empowerment of workers to engage in system-challenging responses.” Galanter mentioned that “focusing on the victim conveniently diverts attention from other possible causes of the problem, such as conditions of life, work, or housing or the inefficient operations of an institution”32). Based on these arguments, the employer needs to understand that providing individual-level intervention (e.g., health education programs and smoking cessation programs) is not sufficient because the health problems among employees also stem from occupational and organizational factors. It should also be acknowledged that victimizing people with unhealthy status causes conflicts within the organization. For example, Harold et al. discussed the ethical issues of tobacco regulation policy at the workplace. If we promote smoking-free policy without considering support for smoking dependence people, conflict between smokers and non-smokers will occur. Since smoking dependence is a mental and behavioral disorder33,34), the adequate opportunity for cessation should be provided without blaming these smokers35).
Moreover, scholars pointed out that some WWPs unintentionally induce disparities among workers. Previously, it was indicated that some disparities of accessibility to the WWP among employees existed within the same entities because of the working style. For example, off-site and overnight workers reported their difficulties in participating in the WWP compared with other workers36). Also, an increasing number of companies are using penalty programs as well as incentive programs37). Both incentives and penalties based on the participation in the programs or health outcomes are potentially discriminating against people who cannot participate in the program due to their unavoidable conditions, such as illness and social circumstances. When providing any incentives for WWP, the system should be carefully designed not to introduce unreasonable disparities among employees.
Moreover, when employers assess employees’ participation and health outcomes for incentive programs, another issue arises as to how to ensure the confidentiality of personal information. Many employees would be concerned that their private and personal health information could be made public and misused, resulting in embarrassment or discrimination38). Hence, the employers are obligated to make sure that personal information will be appropriately handled with confidentiality, and use these data for improving WWP to achieve better health outcomes without blaming or penalizing participants.
How can WWP be improved from ethical perspectives?In the preceding sections, the author discussed how ethical issues are related to the WWP. Patton et al. suggested that the WWP practitioners need to address ethical concerns relating to their program from multiple dimensions, such as ensuring the fully informed and non-coercive participation and balancing the good and the possible harm from the program39). But how actually can these insights be used to improve the WWP in real-world practice? Ethical analysis is a tool enabling practitioners to evaluate health promotion programs and think about how these programs are ethically justifiable15). For example, Kass introduced a simple six-step analytical tool to evaluate and discuss public health interventions from ethical perspectives40). Moreover, Cater summarized the existing ethical frameworks in his article, and revealed that the ethical analysis tools typically included nine strategies (Table 1), which corresponding to the three principles of ethics in public health15). These strategies stress the importance of a cooperative relationship with each stakeholder. These elements (Strategy #7–9) are associated with respecting autonomy and procedural justice during the program development process rather than program design itself. Ethical considerations for the process of WWP development should be considered as prerequisites for ethically permissible programs. Therefore, the practitioners first should build a cooperative relationship with stakeholders and get them involved in the program development process. In this context, stakeholders can include an employer, program coordinator, employees from different departments, and all other parties potentially affected by the intervention. The author also developed an ethical model for WWP based on this literature review (Figure 1) so that the practitioners can use these questions to guide discussion during the program development and implementation. The ethical analytical tools are readily applicable to the program development by the non-experts in ethics. However, at the same time, it has a tremendous potential impact to improve the quality of WWP in each company.
| Strategies for ethical consideration | Related ethical principles | |
|---|---|---|
| 1. | Ensuring the necessity and effectiveness of intervention | Beneficence/Non-maleficence |
| 2. | Evidence-based justification for the intervention (Especially when the potential harms are expected) | Beneficence/Non-maleficence |
| 3. | Choosing least burdensome and less coacive intervention from all possible alternatives | Beneficence/Non-maleficence Autonomy |
| 4. | Prioritising that preventing people from imposing harms on other people over preventing people from harming themselves | Justice |
| 5. | Prioritising justice in distribution of burdens and benefits | Justice |
| 6. | Aiming on causes of ill health | Beneficence/Non-maleficence |
| 7. | Transparency in decision-making and inclusion of all stakeholders who can be affected by the intervention | Autonomy/Justice |
| 8. | Honest and trustworthy communication and partnership | Autonomy/Justice |
| 9. | Building reciprocal relationships with participants | Autonomy/Justice |
The ethical model for WWP practitioners
In this section, the author will show several hypothetical WWP cases inspired by the existing program and describe how ethical principles and analytic tools can be applied.
Case 1. Hospital group providing physical activity programsHospital group X is a large-scale medical provider, running five general hospitals and ten clinics. Within Hospital group X, approximately 50,000 employees serve in different roles, such as medical professionals, administrative staff, cleaning and maintenance staff, and drivers. Since the medical facilities need to be open for 24 hours, some workers have night shifts. In these few years, The WWP project team in Hospital group X identified that a number of workers were obese due to the lack of exercise. The higher rate of obesity significantly affected productivity and absenteeism at the workplace. Therefore, the WWP project team launched the physical activity program, partnering with sports gyms around their hospitals and clinics. They also decided to provide a financial reward for employees who participated in the programs for certain times. What kind of ethical challenges employers and practitioners may face in this scenario?
First, we need to remember the stakeholder involvement is a prerequisite for the ethical WWP and make sure all possible parties influenced by the intervention are included to the whole process. In this scenario, the stakeholders may include employers, WWP practitioners, workers from different departments/professions, and partnered gyms. These stakeholders need to have opportunities to address their needs and concerns throughout the program development and implementation process. Also, these people can participate in the ethical analysis so that practitioners can take different perspectives and be transparent and accountable for the WWP. Then, take a look at the three principles. First, is the incentive system adequate and not violating the self-determination in this scenario? As the author pointed out before, the practitioners must be careful that financial rewards may distort voluntary participation, especially among low-income people. On the other hand, they have an option to use non-financial incentives, such as giving recognition for high achievers. Also, an incentive system, which allows employees to choose which program to attend, can potentially mitigate this problem (i.e., providing several programs so that each employee can pick one of them based on their preference). For beneficence and non-maleficence, practitioners can take a look at literature and guidelines to examine the scientific evidence of the intervention. Also, practitioners may think of the potential harm; in this case, injury caused by exercise, for instance. They should think about what kind of program design will be less harmful and the most helpful at the same time. For justice in this program, disparities among workers can be problematic. For example, some people with a physical disability or people living far from the gyms, or night-shift workers may have difficulties to get benefit from this program. The program design should not marginalize these people and include the way to provide some benefit to these people as well. The potential option would be providing online exercise classes for people living far from gyms and night-shift workers. Moreover, programs can provide special exercise programs for people with disabilities and medical conditions under supervision by medical professionals.
Case 2. IT company providing wearable devicesCompany Y is a relatively new IT Company. There are about 2,000 employees, including engineers and administrative staff in the office. The company Y decided to use a wearable device to measure various health indicators so that the company can evaluate health-related issues of workers, such as stress level and physical activity level. The company uses the information to provide adequate advice for the employees and improve related organizational and environmental factors. What kind of ethical challenges employers and practitioners may face in this scenario?
First and foremost, the practitioners again need to involve stakeholders so that they can voice their needs and concerns. In terms of autonomy, a major concern could be whether employees are fully informed and understand how the information will be used. Moreover, employees should be informed clearly that they have the right to opt out of the program. Some people with medical conditions may feel uncomfortable to be monitored with specific health measures. For the principle of beneficence and non-maleficence, the practitioners should carefully consider whether this approach is necessary and best solution from various alternatives: are there any evidence that wearable device can actually improve health among people?; are there any other less burdensome approaches to achieve the same goal?; and can we use a questionnaire instead of a wearable device? Lastly, for the principle of justice, collected data must be used within the pre-specified purpose and cannot be used for other purposes than improving employees’ health. Also, WWP needs to make sure not to penalize people based on the health issues identified by these devices.
While WWP has widely provided around the world, the considerations from an ethical perspective remained understated. In this article, the author introduced three ethical principles in the field of public health and discussed how the ethical problems around WWP were related to the ethical principles: autonomy, beneficence/non-maleficence, and justice. Since this article was intended for practitioners, the author also mentioned several useful tools and approaches, which can be utilized for improving WWP from ethical perspectives. When discussing ethical issues in public health intervention, it is rare to reach one single correct answer. However, the process of discussing ethical issues with multiple stakeholders and improving the program is valuable in itself. The issue of “how to provide better programs to the participants” needs to be continuously considered and discussed among practitioners, researchers, and other all stakeholders in this area.
The author would like to thank all contributors in this review article. Douglas Hough reviewed the drafts and provided constructive comments. Yu Igarashi also reviewed this article from the practitioner’s perspective. The author did not receive any financial and material support for this research.
Approval of the research protocol: N/A
Informed Consent: N/A
Registry and the Registration No. of the study/trial: N/A
Animal Studies: N/A
Conflict of Interest: N/A
