Social Movement Organization and Communication Ethics: An Ethical Analysis of Consumer-Directed Health Care Communication Campaign of Tea Party Patriots (TPP)

In the United States, health care reforms have been led by the social elites who did not consider mobilizing ordinary peoples’ support for the cause of health care. According to Hoffman, the reforms for national or universal health care in the United States began at the start of twentieth century. After the Second World War, Harry S. Truman tried several times to introduce national health insurance. Truman did not make a large effort to secure public support, and instead used a top-down approach. Serious grassroots movements came from the opposition. The American Medical Association (AMA) ran an unprecedented campaign, funded by a twenty-five dollar assessment on each of its members, to defeat Truman’s national health plan. “The AMA hired a professional public relations firm and directed its members, and directed its local branches to distribute campaign literature condemning Truman plan as socialized medicine” [1]. The physicians then directly handed the campaign literature to the patients. According to Hoffman, AMA’s campaign was stunningly successful, helped along by the Cold War. According to a contemporary research poll, public support for national health insurance dropped from 75% in 1945 to 21% in 1949, and Truman lost many congressional supporters in the election.

insights into the TPP's grassroots social movement on the issue of health care are rare. Social movements, according to McCarthy and Zald, are "born at the margins of the political system rather than through existing party structures" [6]. They lack formal representation or ties to government officials [7]. Grassroots social movements such as the TPP and consumer-directed health care movements, by contrast, consist of elite organizations-insurance companies and financial institutions favored by the Republican Party. Since many of Republican Party members are also TPP activists, they have ample resources and the capacity to utilize the party system to their advantage.
These grassroots organizations including the TPP have mainly sought to influence the policy process through tactics and strategies. One example is the recent publication of TPP's "The Health Care Compact" in which the states have been urged to make their own laws that defy the federal regulations. The Compact states, "All Member States …take joint and separate action to secure the consent of Congress to this Compact. All Member States further pledge themselves to improve health care policy within their respective jurisdictions and according to the judgment and discretion of each Member State" [4]. The HCC is a document of TPP's campaign against ACA, and argues that the legislatures of member states have the primary responsibility to regulate health care in their respective states, and thus challenges federal regulation. These characteristics and tactics of TPP and consumerdirected health care movements share the fundamental principles of social movement organizations' grievances against the health care system, a desire to challenge the status quo (that there is ACA with universal health care, though not fully implemented yet), a need to devise strategies to use their resources to best political advantage and a desire to gain access to the policy process.
Apart from discussing the challenges of communication ethics of social movement organizations, this paper describes the tactics and strategies of the TPP's consumer-directed health care movement by demonstrating how well-funded and well-organized elites seek to influence the policy-making process. By showing this aspect, the paper aims to effectively analyze the challenges of communication ethics of social movement organizations, particularly the TPP. The paper also argues that in addition to the ordinary tactics and approaches, TPP's consumer-directed health care social movement aligns with the conservative political ideology of the nation which opposes the welfare state and favors the privatization of social services. Because TPP's consumer-directed health care movement cherished, refined, and strengthened the agenda and ideology of the powerful conservative party of the nation (i.e. Republican Party) at a grassroots level, the movement has naturally gained a wider acceptance in a very short time.
At the backdrop of TPP's social movement, it seems that the social movement is basically communicating the potential and moral crisis caused by immense health care costs. They are arguing that the immensity of health care cost is adding much pressure to the already fragile economy, which is relying on foreign debt. Apart from this, one of the fundamental aspects of the movement is that in case implemented, ACA 2010 will snatch American peoples' individual freedom.

The statement of problem and the rationale of study
According to the latest Census Bureau estimates, the United States has a population of three hundred million [8]. Almost forty-seven million people are uninsured, which also means that 16% of the total United States population has no health insurance. Millions more have inadequate coverage and are in danger of losing that. Private, corporatized medical coverage, structured by the insurance industry, is the basis for the current system [9]. However, the fact is that the United States spends more money on health care than any other advanced country, and yet it ranks the worst on many key indicators of health quality [10]. Many patients receive more than they need, many receive less care than medical practice guidelines prescribe and many receive the wrong kind of care. The malpractices and some social-cultural problems in delivery of health care, for example, are blamed more than the widespread inefficiencies and inequities of the U.S. health care system for the growing public dissatisfaction, and collective action for reform is suggested [10]. One of the mediums of expressing public dissatisfaction is the social movement.
Past studies show that social movements and American health care reform have mainly focused on a select few health-related actions, such as workers' campaigns to promote occupational safety, civil rights' movement's claims for racial equality in health care [1], health claims relating to abortion, breast cancer, smoking, and AIDS. However, there is virtually no history of a large-scale grass-root social movement seeking fundamental transformation in the American health care system. Despite a huge population of uninsured and underinsured people who have wide-spread dissatisfaction over the existing American health care provisions, the grass-root social movement for such reform has remained counter-intuitive due to various reasons. This paper examines the moral and ethical paradigms of a wellknown social movement organization of America-TPP's consumer directed health care movement. One reason of conducting this research in the context of American health care reform, and the role of a social movement organization is that scholars who study social movements related to specific medical illness or environmental threats, or attempts to promote major change in health insurance, there have been no attempts to systematically analyze health care related social movements activity from the perspective of ethics or to connect activism to moral perspectives [1,11].
The Tea Party Movement in general emerged in early 2009 in reaction to economic stimulus legislation, corporate bailouts and president Obama's health insurance reform effort [12]. The movement, according to Katel, "proved essential with the surprise victory of Republican senator Scott Brown in Massachusetts" [12]. To take the historical context of the name of organization, Tea Party Movement takes its name from the Boston Tea party-the 1773 protest against British taxation. Tea Party Patriots (TPP) is one of the major wings of the Tea Party Movement in America and it claims to be a national grassroots organization of individuals and it supports the strength of grassroots organization powered by activism and civic responsibility at a local level [4]. In its mission statement, TPP has stressed that the impetus for the Tea Party movement is excessive government spending and taxation, and has mentioned three core values of-fiscal responsibility, constitutionally limited government and free markets" [5]. This paper has examined the controversy surrounding TPP's campaign against Obama health care reform (named as "Patient Protection Affordable Care Act, 2010", particularly on the questions of the utility and ethicality of the health care reform for greater social benefit.

Literature Review
While most communication ethics scholarship focuses on corporate, not-for-profit or government organizations, the review of literature shows that the current scholarship lacks research on the ethicality of the social movement organizations, such as TPP.
The gap in the scholarship and literature surrounding the conflicting issues of ethical principles' universality in application, particularly involving social movement organizations (SMO hereinafter) and other organizations-government, corporate and non-government organizations-are the thrusts for conducting this study. In short, one of the main research questions is: What are TPP's communication campaign's strengths and weaknesses from the standpoint of public relations ethics? Along with this overarching research question, the paper also addresses the question: are the ethical principles of persuasion and public relations equally relevant to, or equally irrelevant to, all of the organizations? This study explicates the ethical dimensions of TPP's campaign against ACA, 2010.

Conceptualization
This study aims to explore a social movement organization's setting to determine the extent to which ethical communication management is taking place, what type of decision making process is in movement, and which paradigm of ethics is employed.
Ethical thought can be divided into two broad approaches: teleological and deontological. The teleological approach, which emphasizes outcomes, is best summed up by utilitarianism that values efficiency, and results through maximizing the greatest good for the greatest number within society's limited resources [13]. According to their definition, right actions will have right results and wrong actions will have wrong results.
The deontological approach suggests that some acts are bound by duty and must be executed regardless of the consequences. In general, deontologists believe that moral principles are upheld when people act with good attitudes. However, Macdonald and Beck-Dudley are not satisfied with what these two lines of thoughts suggest [13]. They argue that "the current discussions of ethics usually consider deontological and utilitarian approaches. What is missing is a discussion of traditional teleology, often referred to as "virtue ethics" (p. 615). This approach has its roots in the work of Plato and Aristotle, emphasizing moral character rather than rules and consequences. Deontology, teleology, and virtue ethics are contrasted by ethical relativism that holds that "there are no moral absolutes" [14]. Right and wrong are based on social norms and evolve over time. In general, deontology as a philosophy emphasizes rationality and moral reasoning of human beings through moral autonomy and values the moral duty, encourages ethical behavior. Philosopher Rawls approach was also the deontological one and he developed it into the theory of justice which argues that all decisions should strive to uplift justice for them to be considered ethical.
While mentioning deontology, situational ethics is also an important aspect for the conceptualization wherein each situation is approached individually and is not bound by consistent guidelines. The situational perspectives focus regularly and primarily on the elements of the specific communication situation at hand [14]. In situational ethics perspective, everything is absolute and universal standards have no meaning, and even the criteria from political, human nature, dialogical, or religious perspectives have less value [14]. In my mind, persuasive communication can be broadly put under the situational ethics. Referring to David L. Martinson, Johannesen mentions that the most public relations practitioners have little background in moral philosophy, and as a result, they tend not to think deeply about their moral responsibilities. Johannesen further mention, "when confronted with an ethical dilemma, the tendency is to set aside moral rules and principles in order to "just deal" with the situation…many undoubtedly respond by 'doing what needs to be done'-leaving 'worries' about ethical questions until 'later' [14]. "Martinson rejects this attitude saying that individuals-particularly those who claim to be professionals-must come to ethical decision-making in something at least approaching a systematic fashion" (Ibid.). Martinson's approach on ethical decision making is that self-interest should never be the starting point for ethics in public relations. He has mostly argued for the acts that are morally right to do.
Bowen and Jiang's study is a relevant one that attempts to fulfill the gap in literature. Bowen and Jiang's study explores the implementation of ethics in issues management in a non-profit activist coalition committed to the promotion of global justice [15]. The authors identify the decision making process used in ethical considerations, and also explore the values and group consensus considerations that influence their decisions. The authors highlight the importance of dealing ethical dilemmas in issues management appropriately and to communicate effectively with publics. This research qualitatively explores an activist setting to determine the extent to which ethical issues management is taking place. This study also assesses the process of the decision making in the coalition, and also assesses the paradigms of ethics. The authors build upon the deontological issues management process designed previously by Bowen and explore whether that approach exists or not within an activist environment.

Persuasive Communication Ethics
This paper builds a case for distinguishing the ethical communication principles most relevant for health social movement communicators, specifically building some utilitarian considerations into the TARES deontological guidelines. Baker and Martinson's TARES framework explicates the notion of practitioner accountability toward the message receiver in persuasive communication. The TARES, through a fivepart test, establishes ethical boundaries for persuasive communication.
Since this study attempts to examine the communication ethics appropriate for the social movement organization (and non-profit organization (vis-à-vis for-profit), the TARES principles are sought to be an important theoretical foundation for the study. With the help of the theoretical approach of TARES principles, this paper examines the TPP's persuasive approach on ACA 2010, particularly against the deontological questions. The five interconnected principles in the normative model follow: truthfulness of the message, authenticity of the persuader, respect for the persuadee, equity of the persuasive appeal, and social responsibility for the common good. According to Baker and Martinson (2001), although professional persuasion is a means to an instrumental end, ethical persuasion must rest on or serve a deeper, morally based final (or relative) end. We suggest that these five principles, taken together, comprise the legitimate end of professional persuasive communications and that these communications are ethical and morally justified if they adhere to the principles of truthfulness, authenticity, respect, equity, and social responsibility.
The basic principles of truth, justice, and minimization of harm are perhaps the most fundamental and overarching values associated with ethical persuasion today [16]. To prevent harm to the public, Steiner suggested that an ethic of care should inform persuasion [17]. To show respect and minimize harm also requires truthfulness, as Bok noted falsehoods can harm the public by restricting their ability to make intelligent, informed life decisions.
Similarly, examining the development of professional responsibility theory of PR, Fitzpatrick and Gauthier state that PR professionals have dual obligations to serve both the client organizations and the public interest. According to the authors, the general notion of PR as a totally selfish industry is built because the field hasn't developed the parameters of PR, and the field is not fully separate from journalism. The authors mention that "the modern day public relations efforts include both selfinterested persuasive tactics as well as genuinely benevolent initiatives" [18]. At the same time, the authors also claim that values and ethics of the organizations are confused with the values and ethics of the individuals. "When an institution is the subject of public criticism for perceived irresponsible behavior, the public relations representative shares the blame-regardless of his or her involvement in or knowledge of alleged bad acts. This 'guilt by association' has become detrimental to the public relations industry as more and more organizations fail to meet public expectations" [18]. To get rid of these problems in public relations, the authors provide three principles of professional responsibility: the comparison of harms and benefits, respect for persons (no deceptions manipulation, and coercion), and distributive justice.
While this paper focuses on the challenges of communication ethics of a social movement organization, it is pertinent to discuss the responsible communication approach for social movement organizations. Public relations scholar Elizabeth Dougall pointed out that an "organization-centric" approach to understanding activism has been criticized for contributing to a biased body of knowledge that prescribes "organizational solutions" to the problems. The objective of this paper is not to mirror this tendency, but rather to explain how the communication ethics of a social movement organization can be different from a for-profit organization. One of the major assumptions of this paper is that responsible and effective communication ethics of a social movement organization (which is different from a for-profit corporate organization) has to do with the two-way symmetrical model of public relations. In this model, the role of public relations is to help organizations understand and respond to the voices of all their public [19]. Considering that the review of previous literature and theoretical development in a two-way symmetrical model of communication could be relevant to this project, the model is reviewed in the following section.

Democratic (two-way symmetrical) and persuasive communication
Scholars who believe that asymmetrical (one-way) communication favors companies and advocacy groups, and ignores the receiving-end of the message (the public) have put an emphasis on the importance of two-way (symmetrical) communication. According to these scholars, the two-way symmetrical approach promotes healthy public dialogue and democratic community [20]. Grunig proposed that the symmetrical model of PR was both most efficacious and ethical, encouraging organizations and their publics to fully understand each other's concerns and mutually adapt to accommodate some of the other's needs.
However, this approach has also been critiqued for being too idealistic in overlooking power differentials preventing equal compromise or fair dealings between powerful organizations and the less powerful public. Holtzhausen argued that the two-way symmetrical model is too narrowly defined as an organizational meta-narrative and does not fully take into account the broader socio-political context in which PR operates. Because PR scholarship often ignores activist organizations, Holtzhausen alleged that PR theory largely exists to support the maintenance of hegemonic power structures. While activists are often portrayed as troublemakers, as "the real voices of democracy", they do not deserve for scholars to portray them as the enemies of social institutions. Similarly, Barney and Black classified public relations practitioners as "an adversary group" (p. 67) and concluded that "persuasion needs a body of moral discussion that will provide the moral foundation on which realistic persuasion ethics structures can be built" (p. 67). Guth and Marsh have rejected the objectivity/advocacy bifurcation and called the conflict a "misleading ethics debate" (p. 167).
The entire objectivity-versus-advocacy debate seems to be based on a misleading question: Are public relations practitioners objective communicators or are they advocates? What if the answer is "none of the above"? Many practitioners respond to the debate by saying that public relations practitioners are, first and foremost, relationship builders…Sometimes relationship building calls for delivering unpopular truths, either to a public or to the organization itself. And sometimes relationship building involves being an advocate-even if that means advocating the viewpoint of an important public within your own organization (pp. 170-171).
One of the most well-known and cited of existing public relations standards is the Public Relations Society of America (PRSA)'s Code of Ethics. The PRSA Code emphasizes "serving the public interest; avoiding misrepresentations to clients, employers and others; and the continuing development of public relations practitioners" [18]. Lieber attempted to address the shortcomings of PR via exploratory, quantitative analysis of Baker and Martinson's TARES test of ethical considerations for public relations practitioners.
Recently, Lee and Cheng have also examined the ethical dimensions of public health communication, with a focus on antismoking public service announcements. This analysis content analyzed television ads to have empirical testing of Baker and Martinson's TARES Test. The study found significant relationships between ethicality and message attributes, in which the ads that portrayed smoking as damaging to health and socially unacceptable score lower in ethicality than ads that focus on tobacco industry manipulation, addiction, dangers of secondhand smoke, and cessation. Emotional appeals of anger and sadness are associated with higher ethicality than shame and humor appeals.
Generally, the fear approach in health communication is considered one of the highly popular theoretical approaches in the teleological and utilitarian perspectives that appear to drive public health communication work. Generally, in health communication, messages are taken as a means to an end, and are valued not so much for their intrinsic moral worth but for their outcome. Based on such a notion, it is reasonable to ''harm'' a few individuals to achieve a larger public good for society as a whole. The authors argue that humor is negatively correlated with truthfulness, authenticity, respect, and social responsibility, and only slightly correlated positively with equity indicates a questionable appeal (p. 69).

Public health care and moral philosophical foundation
The United States and numerous developing countries do not provide universal health care coverage to their populations. They have adopted a neo-classical approach to health insurance coverage, assuming that individuals make rational decisions to maximize their preferred outcomes, and businesses make rational decisions to maximize profits [21]. According to this approach, individuals who are at risk will purchase health insurance to reduce variation in the cost of health care between healthy and sick periods. However, it is also important to mention some prior studies which show that individuals do not always make rational choices. They rather find it difficult to assess their health risks and to know how much insurance they need.
At the same time, it is also pertinent to discuss the public moral norms of the health reform. According to Ruger, "public moral norm is a moral value that pertains to our individual and collective morality in the public sphere…public moral norm contrasts with an individual moral norm in that the moral value pertains not just to individual action but also to collective action regarding the public sphere (e.g. norms about procedural justice, rules of accuracy, trust, ethicality, and neutrality)" (p. 14). In the context of the United States where there is a history of consistent failure of health care reform efforts can be understood by first analyzing the extent of individual, societal, and political internalization of necessary public moral norms. For this to happen, one needs to have an ethical commitment to make financial sacrifices to support the universal access to health care. In this paper, the author argues that in the United States, with the help of the strong grass roots social movements such as TPP and strong public distrust of centralized government which is also reflected in the founding documents of the U.S. federal system, it is hard to garner support for the public moral norms.

Research method and sample selection
This paper employed a textual analysis approach and used the campaign materials of TPP's consumer directed health care movement, such as interactive videos, TPP's "Health Care Compact" (TPP, 2011), campaign's mission statements, fliers, templates, and legislative outreach materials, including tips and strategies for developing campaign outreach materials available on TPP's website (http://www. teapartypatriots.org/Healthcare.aspx).
For the selection of the samples, the author downloaded the available campaign literature that mentioned the terms such as health care, ACA, health care bill, or Obama health care reform related materials from TPP's official website since the December 2010 (the date the ACA bill was passed) until December 2011. Materials that were not directly related were removed from the data. Materials that were important only from the newsworthy point of view were not included into the data pool. Similarly, campaign materials such as video PSAs, informative video presentations on health care reform/ act, and other PDF/word materials were downloaded from one of TPP's associated organization called healthcarecompact.org (link as cited in TPP's homepage: http://www.teapartypatriots.org/resources/ health/). Here too, the news items on the health care reform or law were not included into the data because this research was strict only to persuasive campaign materials related to health care reform issued and propagated by the TPP (and associated grass root organizations as cited into the TPP's main website as partner or associated organizations). Similarly, I downloaded campaign's mission statement, fliers and press releases, templates and outreach materials that either opposed ACA, or appealed for the repeal of health care reform bill, from TPP's main web-site. The paper evaluated TPP's campaign according to TARES principles. The findings section is organized around three main communication elements: the sender, receiver and the message content.

Analysis of the Findings
According to Baker and Martinson, the TARES requires a series of questions to be asked about a message; to pass the test, answers must fulfill the five principles. There are some prior empirical quantitative studies primarily based on TARES principles. The TARES did not receive any empirical testing until Lieber conducted an online survey of public relations practitioners. Lieber's study found that the TARES is better suited for a three-factor configuration of moral knowledgecivility, integrity, and credibility-factors that classify someone as morally virtuous. Lieber's work is significant for its contribution toward the operationalization and quantification of the ethical knowledge of public relations practitioners.
Unlike Lieber's, this research project is based on qualitative/textual analysis of TPP's consumer-directed health care communication campaign. This study qualitatively tests the TARES; it builds on the work of Baker and Martinson by directly examining the content of persuasive messages for truthfulness, authenticity, respect, equity, and social responsibility in a specific category of persuasive messages: TPP's campaign materials on consumer directed health care communication campaign. As yet, no study has qualitatively operationalized the TARES to assess the ethicality of TPP, an American grassroots social movement organization and its communication campaign.
To gain a more comprehensive understanding of the TARES, this paper explores the relationship between the TARES principles and TPP's social movement campaign messages, tactics, thematic frames, source, and target audiences. This paper structures the analysis on the basis of three communication elements: the sender, the content (message) and the receiver (audience/society).

The sender
One of TPP's campaign literature used as an important resource material for this research is "Health Care Compact", in which it states that Obama's ACA, 2010 is unfair for citizens to continue paying federal taxes for health care without any reciprocal benefit [4]. According to the literature, the "Compact" is to free member states from federal regulation and allow them to create a health care system in their state that will increase each person's ability to manage his or her own health care decisions [4]. Before getting into the core of the analysis, it is pertinent to understand how deontological approaches to ethics work.
Deontological approaches to ethics attempt to ascertain the content of duty without considering the consequences of particular ways of acting. This approach is also called a duty-based approach. Deontologists believe that the moral principles are ascertained through some sort of logical test of consistency, as Kant maintained, "It is impossible to conceive of anything in the world, or indeed out of it, which can be called good without qualification save only a good will" [22]. For the conceptual understanding and clarity of Kant's approach on deontology, it will require knowing what he means by "good will". According to Kant, it means "acting out of respect for the moral law, i.e., for the sake of duty" (p. 74). "Good will means acting for the sake of duty, mind you, not merely in accord with it. …Yet there is no moral merit following morally unguided inclinations, even when such inclination results in external actions consistent with morality" (ibid.).
Deontological or duty based ethics evaluate any ethical concerns over the actions and motives of the communicator. Duty based ethics evaluate the goodness of inner act which is distinct from the external act. According to this approach, moral character of an action should match the moral intent of the action.
From Kantian perspective, TPP's campaign on "Health Care Compact" and its motive cannot be interpreted something as "evil" because the ultimate objective, according to the mission statement of TPP on health care, is to provide individual freedom of choice. According to the Compact, it is unfair for citizens to continue paying federal taxes for health care without any reciprocal benefit, however, from the consequentialist point of view, TPP's social movement's act of blocking the ACA, 2010 ("Obamacare" as TPP terms it) will eventually bar the greatest social benefit for the greatest number who are in need of the health service. From this perspective, TPP's social movement can be criticized for discriminating against those most in need, especially the disabled and poor, among others.
At the same time, the same movement may uplift for the individual freedom, whereas the introduction of ACA, 2010 might ignore individual freedom. This ignoring of individuality (by ACA 2010) is a moral failure of a policy, and does violate the Kantian principle of respect for individuals as moral agents. According to this interpretation, individuals cannot be used solely to assist other individuals (in this case-the poor and underprivileged ones).
TPP's grassroots social movement that aims to uplift the moral and philosophical agenda that the welfare programs should not be based at the cost of individual freedom is not an immoral; however, the question of how to prioritize goods and social services to the neediest is definitely an important challenge. At the same time, it is also important to set limits so that individual freedom remains intact while delivering the social services to the needy population is a fundamental ethical challenge. It is a fundamental challenge in the communication of a grassroots social movement organization such as TPP.
TARES suggests that the sender or communicator's actions must be authentic, which involves showing integrity, virtue, and sincerity. At the backdrop of TPP's grassroots social movement which fosters individual liberty, is sincere in its objective to respect for the individual choice, however, as per the virtue ethics, it does not show adequate compassion, charity and altruism toward the poor and disadvantaged people who cannot afford the private insurance cost when they are sick. In this sense, the movement upholds the individual's choice but does not contribute properly to reduce harm and suffering of the masses of the common public. These are the ethical challenges based on several moral philosophical perspectives that do not have a definite single answer.
Similar case of a non-profit advocacy organization called People for the Ethical Treatment of Animals (PETA) might also be important to refer here in the context. In July 2004, the animal rights organization PETA launched a communication campaign drawing the attention of the stakeholders regarding the abuses in commercial poultry farms, but while undertaking such campaign, PETA adopted unethical tactics that were inconsistent with responsible advocacy [23]. According to Fitzpatrick and Bronstein, nonprofits may be less likely to raise public ire for employing such tactics because their goals serve the greater social good-as opposed to the financial self-interest that motivates most corporate actions (p. 80-81). In this perspective, being a non-profit social movement organization, TPP also cannot ignore its social responsibility and cannot have a similar perspective on social welfare issues that tune up more with the private insurance companies. If the nonprofit grassroots movement organization likes TPP employ irresponsible practices in its communication campaign, it must recognize that it runs the risk of undermining its reputations and accomplishments, and violating the rights and interests of the public.

The content or message
Baker and Martin's TARES test suggests truthfulness of the message as the first test. There are two components of truth: accuracy and the context [16]. According to the principles of truthfulness, TPP's grassroots social movement campaign sounds truthful. One of the campaign literature, "Health Care Compact (HCC)" states that the "Compact is an interstate compact which is simply an agreement between two or more states that is consented by the congress-that restores authority and responsibility of health care regulation to the member states" [4]. The HCC returns the power to regulate health care to the states which pass the Compact (the Member States). According to this compact, each member state will be able to write its own health care laws, creating more effective and efficient health care policy for its citizens. Once the member state creates its own health care policy, its citizens will no longer be subject to federal health care laws and regulations, including "ACA 2010" or "Obamacare." By blocking the federal health care law and regulation, TPP's social movement has begun a campaign for the HCC which allow states to discard the federal law and formulate their own regulations. There is no inaccuracy or deceit in the facts used in the campaign literature, and the context too seems appropriate because the ACA 2010 is in the process of implementation. The campaign of TPP's social movement truly mentions that the Compact actually frees the member states from federal regulation and allow them to create a health care system in their state that will increase each person's ability to manage his or her own health care decisions. While stating this, the campaign gives the states a real possibility of its happening. The main interactive video posted on TPP's website step-by-step and quite clearly indicates how it is possible to stop the federal law (ACA, 2010). The interactive mentions that an interstate compact is a contract or agreement between states and such a practice is not new. According to the interactive, there are already over 200 such compacts existing today, representing agreements between states on a wide variety of issues. Some compacts address regional issues such as state borders and interstate transportation networks, while others address issues of national scope such as overlapping state taxation, criminal background checks, and the supervision of former prisoners. An interstate compact can range in size from 2 states to all 50 states (TPP, 2011). The campaign claims perfectly sound truthful and accurate.
In terms of respect, the content of the campaign message is indicating that when the member states are allowed to formulate the required health care regulation through the HCC, the individuals would not be coerced to pay for the insurance premiums. It gives a sense that the TPP's social movement campaign ultimately speaks for the individual respect and dignity. The campaign denies the view that the society has an obligation to provide health resources to its citizens, however, the same message can be interpreted from a different angle too. It is always a challenging question of whether individual or social preferences and values should prioritize social goals and interventions aimed at reaching those goals. the standards responsible for a movement that works for the cause of the common public (including poor, disadvantaged, marginalized and disables). TPP's campaign insists for the upholding of individual rights and fiscal responsibility over social responsibility, however, the bottom line is that the responsible movement requires the campaigners to figure out what action and decision might be fair to all involved (rights versus responsibilities) in a given situation, as opposed to that which might generate the most publicity (for petty political benefit).

Receiver/audience
Audience is one of the important ethical determinants for any persuasive communication [16,20]. In this research project, I would argue that TPP's communication campaign comprises the largest ethical lapses in this particular area. Beginning with the TARES principle of respect for the audience, it can be argued that TPP's communication campaign did not show proper respect for the feelings of the general audiences or uninsured population who are marginalized, disadvantaged, and financially poor. A person's inability (due to various social and individual reasons)-or lack of capability-to obtain medical remedy for ailments is a hugely disturbing deprivation and utterly unethical from the social and distributive justice point of view. Demands of social justice cannot be ignored with the simple logics of cost-benefit and individual freedom. The healthy society is also an important pre-requisite for the individual freedom and his/ her overall development. When the campaign insists that individual freedom is entirely a separate (independent) issue and challenges the disadvantaged groups of people to take care themselves while they need the help of society, it is a show of irresponsibility and disrespect. TPP's communication campaign messages at times ignore the social responsibility for the sake of individual rights and freedom. Another important tenet of TARES principle is whether the communication actually induced harm to the public or not.

Discussion
The findings of this research demonstrate that health care is a complex topic and it is hard to suggest a single ethical perspective. Utilitarian, libertarian, communitarian, and even democratic (twoway symmetrical) approaches have fallen short of providing either adequate theoretical and ethical grounding or sufficient practical impetus for a communication ethics suitable for a social movement organization, such as TPP. Findings revealed that there is no single and fully accepted ethical approach that represents the communication of social movement organization; however, there are various approaches appealing to different ethical perspectives and worldviews.
In response to the campaign's strengths and weaknesses, truthfulness and authenticity are campaign strengths, while equity and social responsibility would be questionable, and respect for the audience would likely be the largest weakness. Expanding the evaluation beyond just TARES principles, other strengths include the campaign's design and implementation by TPP.
As mentioned above in the analysis section, TPP's campaign literature supports the HCC stating that ACA (also referred by TPP as "Obamacare") is unfair for citizens to continue paying federal taxes for health care without any reciprocal benefit. According to the literature, the Compact is to free member states from federal regulation and allow them to create a health care system in their state that will increase each person's ability to manage his or her own health care decisions [4]. But when the same phenomenon is argued from a different perspective, circling back to TPP's health related social movement, we come across a hard truth that the health insurance industry is consistently backing the grassroots social movement for consumer directed health care movement for a long time.
At the same time, such a nexus between the grassroots social movement and the private insurance companies has been consistently successful in preventing enactment of a national health insurance program that would bring medical care to millions of poor people. Giving the detail of how the private insurance companies and other advocacy organizations are working together, Quadagno states, "First the American Medical Association, then organizations or insurance companies and employer groups have been able to defeat national health plans because they had superior resources and an organizational structure that closely mirrored the federated arrangements of the American state" (p. 25) [1]. As Quadagno states, powerful stakeholders like insurance companies and other associated advocacy groups "also manufacture grassroots protests to convince political leaders that their interests represent the public will" (p. 40) [1]. Analyzing such tendency from the TARES principle's Equity/fairness of the appeal to the audience, and Social responsibility for common good, TPP's social movement can be termed unethical or at least insensitive for the cause of the greater good. The movement has not made an ethical commitment to make financial sacrifices to support the expansion of health insurance (which would be a public norm of a pro-social movement). The paper suggests that there must be a greater understanding of who will be the benefactors of health care reform, and it requires analyzing the extent of individual, societal, and political internalization of this norm. To get rid of the problems and challenges in formulating a communication ethics suitable for the social movement organization (which should be different from any for-profit corporate organization), first there must be a willingness to pay for one's own and others' health care coverage, and it must be internalized. When it is internalized and agreed upon at the social and political level, it will then create a different ethical norm for the communication suitable to a social movement organization.

Conclusion
The idea of TPP's grassroots social movement that uplifts the moral and philosophical agenda of individual freedom and denounces the welfare programs relying at the cost of individual freedom is an important argument; however, the question of how to prioritize goods and social services to the neediest is a fundamental ethical challenge. It is a fundamental challenge in the communication of a grassroots social movement organization such as TPP. It is very important to determine what it means for health inequalities to be unjust and how efforts to reduce them are morally justified. TPP's communication campaign is a one way road that simply defends the inherent rights of individuals but does not consider the vicious cycle of health inequalities if the problem is not addressed with responsible manner. While this paper is working to delineate the appropriate communication ethics suitable for a social movement organization, it is important to weigh how much priority disadvantaged groups should receive, and whether an investment on health care should be par to societal resources. Therefore, it is important to consider with the pragmatism while delineating the communication ethics suitable for a social movement organization. With respect to communication ethics appropriate for a health social movement organization, the paper argues that TPP as a social movement organization should attempt to strike a balance between a consequentialist focus on health outcomes and costs, and a due respect for autonomy and integrity of individual freedom of choice. The paper asserts that TPP as a grassroots social movement organization must maintain its ethical distance, and be different from any for-profit