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A study was conducted in the Lorraine region concerning the difficulties encountered in the management of chronic diseases in patients in a situation of precarity based on interviews of the patients concerned and general practitioners. Numerous difficulties as well as several facilitating factors were identified. The elements reported by patients and doctors frequently converged: the importance of living conditions, the frequently pejorative attitudes of doctors, administrative complexities. The doctor-patient relationship is the cornerstone of facilitating factors. Patients attach considerable importance to the relationship of confidence developed with their attending physician. They want their doctor to use simple words and avoid making them feel guilty, allowing them to enter into a real healthcare partnership in which they can actively participate in decisions concerning them. On the basis ofthesefindings, thestudy formulated recommendations for improvement of management, essentially concerning administrative measures of social protection and access to care.

Ethical issues have only recently emerged as a topic of debate in health education. Until recently, health education was seen as "beneficent" by nature and as designed to improve well-being and quality of life. Traditionally, the purpose of health education was to promote behavior change. The idea of intruding into people's private lives raises the question of the objectives and methods of health education. The principles underlying ethical reflection--beneficence, non-malfeasance, autonomy and social justice--provide a basis for identifying a number of problems or abuses. Traditionally, people have tended to be seen as implicitly responsible for their own behavior, a view based on a moralistic, guilt-inducing and didactic approach to health and health behavior. The assumption is that these infringements affect the identity and dignity of persons. In addition, imposing standards and norms of behavior defined by others amounts to undermining or denying the autonomy of individuals. Finally, traditional health education approaches, and in particular communication campaigns, may contribute to the improvement of health, but it is at the cost of increased inequalities. To conclude, ethics is both a statement of values and a method or process. Ethics needs to be debated and discussed in a democratic forum. It is up to citizens, not experts, to establish the link between means and ends. Health promotion has resulted in a shift in perspective--a shift that has provided protection against ethical lapses and violations. This paper argues that health education must create the conditions of autonomy by focusing first on environmental factors and inequalities.