Ethical challenges, responses and reasoning in co-creation for health promotion: a scoping review

Background: People involved in co-creation act as embedded moral agents as they bear a relational responsibility. The approaches taken or decisions made by individuals when facing ethical challenges during co-creation have important ethical ramifications for the process. Literature in the field of co-creation lacks an in-depth and systematic exploration of individual responses and reasoning that shape ethical decision-making. The current scoping review aims to identify authors’ responses and related moral reasoning as reported within the academic literature, to the ethical challenges encountered during co-creation for health promotion. Methods: A scoping review was conducted to identify articles that reflected on ethical challenges encountered during co-creation. Fifteen scientific articles were included following the title, abstract and full-text screening. Subsequently, a qualitative interpretative analysis was performed to extract and link the following data items: ethical challenge, response and (moral) reasoning. The resulting coding schemes, consultation with ethicists and researcher memos contributed to the synthesis of the results. Results: Integrating discussions throughout co-creation in combination with adopting a flexible attitude and communicating expectations were frequently reported responses. Institutional procedures and pragmatic considerations influenced responses greatly. Moral reasoning was partly shaped by principles of co-creation, normative ethical frameworks and, personal moral codes, values and perceptions. Conclusions: Academic authors' responses to ethical challenges in co-creation were largely influenced by their intention or willingness to adhere to the principles of research integrity within this context. Ethical frameworks like the ethics of care and public health ethics provided guidance, though some authors did not explicitly engage with these frameworks, suggesting a disconnect between theory and practice. An extensive description of authors’ moral reasoning remains absent. Future research might consider performing meta-ethnographies to account for more detailed information about moral reasoning in responding to ethically challenging situations in co-creation for health promotion.