Communication in emergencies: response.

In our paper (Lambert et al. 2003), we did not advocate neutral messages in acute emergency response situations and agreed with Morgan and Lave (1990) that we have a responsibility to prevent people from entering harm's way. However, we presented an argument for fostering autonomy rather than the use of manipulation and coercion in these situations.

Hague (1929) distinguished ethical risk communication as an issue of persuasion as opposed to coercion. Faden and Beauchamp (1986) defined these extremes:

   Persuasion is restricted to influence by appeal to
   reason, the intentional and successful attempt to
   induce a person, through appeals to reason, to
   freely accept--as his or her own--the beliefs,
   attitudes, values, intentions or actions advocated
   by the persuader.

According to Faden and Beauchamp (1986), coercion occurs if someone

   intentionally and successfully influences another
   by presenting a credible threat of unwanted or
   avoidable harm so severe that the person is unable
   to resist acting to avoid it.

Faden and Beauchamp (1986) filled the middle ground by distinguishing forms of manipulation. They described manipulation as

   the catch-all term for communication that is neither
   coercion nor persuasion; intentional and
   non-successful non-coercive influence altering the
   available choices of an individual, or a perception
   of those choices and influence that does not
   appeal to reason.

The essence of manipulation is having people unwittingly do what the manipulator intends for them to do. Faden and Beauchamp (1986) argued that ethical health risk communication is persuasion or, at worst, unintentional manipulation because it cannot be avoided.

Unintentional manipulation may occur through several avenues. Tversky and Kahneman (1981) demonstrated that, by framing information in particular ways (for example, in the health context, the probability of dying or living from a given procedure), the choices that people (including health care providers) make can be directed to a significant degree. Therefore, when "mere information" is presented, the presentation itself will include the danger of manipulative elements, and there is a need to recognize this dilemma and confront it. Informational manipulation occurs when the structure of perception of choices is altered by managing information to promote a desired action. Further, to varying degrees, nonsubstantive elements such as tone, manner, and order; word choice; time and setting; and the appearance, style, and charisma of the presenter can be forms of psychologic manipulation.

In his letter, Morgan has clarified his perspective and provided a communication example that does not appear to argue for manipulation. In the case of an acute emergency, Morgan would be satisfied with the following communication: "Madam, I'm Officer Jones.... There has been a terrible chemical accident, so we must get you and your family out of here right now. We'll explain more later."

This communication does allow the woman to "formulate and share the imperative," share the officer's urgency for evacuation, and understand the reason, (i.e., "there has been a terrible chemical accident"). Perhaps if the message also included more context, "that the plume is about to engulf your home," a stronger argument could be made for the woman's ability to formulate the imperative. Further, the woman may be able to spread the risk message to her friends who may not be reached by the police officers. As we argued in our paper (Lambert et al. 2003), this is a beneficial consequence of communication that fosters autonomy as opposed to manipulation. The message concludes with "we'll explain more later." This implies an ongoing relationship and dialogue with the woman to further foster her understanding.

In this example, however, the police officer may introduce "unintentional" manipulation. The police officer, in rushing from door to door telling people to evacuate, by his or her presence, tone, and excitement, will carry the message of the urgency of the evacuation. This will, to some degree, introduce elements of unintentional manipulation.

The communication example does not involve an attempt to manipulate the woman's behavior or defend this approach to prevent her from being harmed. It is consistent with the argument in our paper (Lambert et al. 2003).

The author declares he has no conflict of interest.

REFERENCES

Faden RR. Beauchamp TL. 1986. A History and Theory of Informed Consent. New York:Oxford University Press.

Hague EWJ. 1929. The position and prospects of the sanitary inspector. Can J Public Health 29:26-31.

Lambert TW, Soskolne CL, Bergum V, Howell J, Dossetor JB. 2003. Ethical perspectives for public and environmental health: fostering autonomy and the right to know. Environ Health Perspect 111:133-137.

Morgan MG, Lave L. 1990. Ethical considerations in risk communication practice and research. Risk Anal 10:355-358.

Tversky A, Kahneman D. 1981. The framing of decisions and the psychology of choice. Science 211:453-458.

Timothy Lambert

Department of Community Health Sciences

University of Calgary

Calgary, Alberta, Canada

E-mail: [e-mail]