Ethics dilemmas of early detection of obesity.

AIM: To discuss the ethics dilemmas of the early detection of overweight and obesity. METHODS: Analysis of the ethical aspects of early detection. RESULTS: The early detection of overweight and obesity entails a number of ethical dilemmas because it may both be helpful and harmful. It may help people to lead a healthier life and non-detection could be considered neglectful. It may, however, cause anxiety, interfere with people's integrity, focus only on individual causes and responsibilities, cause stigmatization and have adverse effects by inducing weight gain. CONCLUSIONS DOCUMENTATION OF MORE POSITIVE THAN NEGATIVE EFFECTS IS REQUIRED BEFORE EARLY DETECTION IS INTRODUCED.

Governing obesity policies from England, France, Germany and Scotland.

Defining a phenomenon as a political problem could be considered a crucial part of any political process. Body weight, when categorised as obesity, has been defined as a political problem since the beginning of the 21st century and has entered the political agenda in many countries. In this article, I present a study of four plans from four Western European countries: England, France, Germany and Scotland, identifying how obesity is defined as a political issue. The questions addressed are: How is the development in the obesity prevalence explained and who is considered responsible for the development? What are the suggested remedies and who is considered responsible for acting? All plans state that obesity is a political issue because it causes health problems; in fact, weight is almost equated to health. The English and Scottish plans present a bio-political argument, characterising obesity as a serious threat to the countries' economies. So does the German plan, but not with the same emphasis. The plans portray people with obesity as being economically harmful to their fellow citizens. The French plan expresses another concern by focussing on the discrimination and stigmatization of obese people. All plans define the physical and food environment as a crucial factor in the obesity development, but only the Scottish Government is prepared to use statutory means towards industry and other actors to achieve change. The policies convey an unresolved dilemma: To govern or not to govern? The Governments want individuals to choose for themselves, yet they try to govern the populations to choose as the Governments find appropriate. The plans have a legitimising function, showing that the Governments take the issue seriously. Accordingly, in this case, the actual problematisations seem to be less crucial.

Backward- and forward-looking responsibility for obesity: policies from WHO, the EU and England.

BACKGROUND: In assigning responsibility for obesity prevention a distinction may be drawn between who is responsible for the rise in obesity prevalence ('backward-looking responsibility'), and who is responsible for reducing it ('forward-looking responsibility'). METHODS: We study how the two aspects of responsibility figure in the obesity policies of WHO (European Region), the EU and the Department of Health (England). RESULTS: Responsibility for the emergence and reduction of obesity is assigned to both individuals and other actors to different degrees in the policies, combining an individual and a systemic view. The policies assign backward-looking responsibility to individuals, the social environment, the authorities and businesses. When it comes to forward-looking responsibility, individuals are expected to play a central role in reducing and preventing obesity, but other actors are also urged to act. WHO assigns to individuals the lowest degree of backward- and forward-looking responsibility, and the Department of Health (England) assigns them the highest degree of responsibility. DISCUSSION: Differences in the assignment of backward- and above all forward-looking responsibility could be explained to some extent by the different roles of the three authorities making the plans. WHO is a UN agency with health as its goal, the EU is a liberal economic union with optimization of the internal European market as an important task, and England, as an independent sovereign country, has its own economic responsibilities.

English obesity policies: To govern and not to govern.

Problem definitions constitute a crucial part of the policy process. In 2008 the Labour Government presented a plan to reduce the obesity prevalence in England. Only three years later the Conservative-Liberal Government introduced a plan on the same topic, which it presented as new and innovative. The aim of this study is to analyse the respective governments' problematisations of obesity and to identify similarities and differences. Despite the different hues of the two governments, the programmes are surprisingly similar. They seek to simultaneously govern and not to govern. They adhere to liberal ideals of individual choice and they also suggest initiatives that will lead people to choose certain behaviours. Both governments encourage the food and drink industry to support their policies voluntarily, rather than obliging them to do so, although Labour is somewhat more inclined to use statutory measures. The Conservative-Liberal plan does not represent many new ideas. The plans are characterised by the paradox that they convey both ideas and ideals about freedom of choice as well as about state interventions to influence people's choices, which could be seen as incompatible, but as the study shows in practice they are not.

Ethics, equality and evidence in health promotion Danish guidelines for municipalities.

AIM: The Danish National Board of Health has expressed its commitment to social equality in health, evidence-informed health promotion and public health ethics, and has issued guidelines for municipalities on health promotion, in Danish named prevention packages. The aim of this article is to analyse whether the Board of Health adheres to ideals of equality, evidence and ethics in these guidelines. METHODS: An analysis to detect statements about equity, evidence and ethics in 10 health promotion packages directed at municipalities with the aim of guiding the municipalities towards evidence-informed disease prevention and health promotion. RESULTS: Despite declared intentions of prioritizing social equality in health, these intentions are largely absent from most of the packages. When health inequalities are mentioned, focus is on the disadvantaged or the marginalized. Several interventions are recommended, where there is no evidence to support them, notwithstanding the ambition of interventions being evidence-informed. Ethical considerations are scanty, scattered and unsystematically integrated. Further, although some packages mention the importance of avoiding stigmatization, there is little indicating how this could be done. CONCLUSIONS: Including reduction of health inequalities and evidence-informed and ethically defendable interventions in health promotion is a challenge, which is not yet fully met by the National Board of Health. When judged from liberal ethical principles, only few of the suggested interventions are acceptable, i.e., those concerning information, but from a paternalistic view, all interventions that may actually benefit the citizens are justified.

Nudge: a new and better way to improve health?

Nudging, or libertarian paternalism, is presented as a new and ethically justified way of improving people's health. It has proved influential and is currently taken up by the governments in the US, the UK and France. One may question the claim that the approach is new, in any case it has many similarities with the idea of "making healthy choices easier". Whether the approach is better from an ethical perspective depends on the ethical principles one holds. From a paternalistic perspective there could be no objections, but from a libertarian, there are several. Contrary to what the authors state, libertarian paternalism is an oxymoron.

Why the concept ''lifestyle diseases'' should be avoided.

The concept lifestyle disease is used about a number of different diseases such as coronary heart disease, diabetes, lung cancer etc. The concept indicates that people's behaviours cause the diseases. This is only partly true. All diseases, both so-called lifestyle diseases and infectious diseases, have multiple causes. Singling out only one type of causes, such as is implied in the concept of lifestyle diseases can lead prevention to focus only on changing people s behaviours or lifestyles, and thus to neglect other possibilities to improve health. Mortality due to chronic diseases has increased during the last century and the main cause behind this is the decrease in the mortality in infectious diseases among younger people. More people live long enough to develop the chronic diseases. The concept lifestyle disease gives a too narrow picture of causes death and should be abandoned and give place for a broader understanding of causes and preventive options.

Addressing individual behaviours and living conditions: four Nordic public health policies.

AIMS: To identify characteristics of the public health policies of four Nordic countries concerning how they present the causes of ill health, the best ways to deal with these causes, and where to place responsibility; additionally, to investigate whether there is a common Nordic policy. METHODS: Analyses of recent public health programmes in Denmark, Finland, Norway, and Sweden. RESULTS: Focus is on either, or both, individual behaviour and living conditions as causes of ill health; the remedies are classical liberal as well as social democratic policies. None of the programmes is consistent with either ideological strand; each has its peculiar combination of interpretations and policies. The Danish programme is the most liberal focusing on behaviours and individual's choices; the Norwegian programme is the most social democratic or social liberal focusing mostly on the social and physical environment and the politicians' responsibility to improve the population's health. The Swedish and the Finnish programmes lie between those of Denmark and Norway. The Finnish and Norwegian governments stress their responsibility for the health of the population. CONCLUSIONS: No common Nordic political approach to public health exists. All programmes contain contradictory policies and ideological statements with differences regarding the emphasis on individual behaviour versus choice and living conditions and political responsibility. The policies are not entirely predictable from the political stance of the government; national differences seem to play a role.

Appeals to autonomy and obedience: continuity and change in governing technologies in Danish and Swedish health promotion.

The increasingly used concept new public health indicates that a fundamental change has occurred in the goals and methods of disease prevention and health promotion. The change is often said to imply less expert-driven governing of citizens. In this article, governing technologies in the field of public health in Denmark and Sweden are analysed to investigate whether substantial changes have taken place in the governing efforts. In the endeavours unfolded in relation to health examinations for children and pregnant women during the last eighty years, no apparent evidence exists of a significant change in governing technologies. Regulatory, expert-driven and empowering technologies have been used during the whole period; additionally, appeals to autonomy, responsibility and obedience as well as to trust in authorities co-exist throughout the period. The fundamental change is the huge increase in the health authorities' governing ambitions.

Tackling social inequalities in health in the Nordic countries: targeting a residuum or the whole population?

The Nordic countries are often pictured as similar inasmuch as they are egalitarian welfare states with a universal approach to welfare policies. Here, the policies of four Nordic countries towards social inequalities in health are analysed by focusing on how they suggest the inequalities should be tackled. Two types of approach can be identified: universal policies, which target the whole population, benefits and services being offered to every resident, and residual policies, which target only a section of the population with specific characteristics. These residual policies rely on professional discretion in the decisions about who should be targeted and, consequently, benefit from the interventions. In disease prevention a similar distinction is made between population-based, or mass strategies, and high-risk strategies. In mass strategies the interventions target the whole population. In high-risk interventions people are screened to identify those most at risk of death and disease, and the interventions are then targeted at those identified. Furthermore, interventions can be characterised as addressing behaviour or living conditions. As is shown, the four countries' policies differ when it comes to who is targeted and what is targeted.

Why did the stillbirth rate decline in Denmark after 1940?

Stillbirth rates began declining in several industrialized countries simultaneously at the beginning of the 1940s. The reasons for this sudden decline have been discussed ever since. Changes in obstetric care, in risk factors, and in the composition of the population at risk have been suggested. One hypothesis is that it reflects a cohort effect of improved reproductive health status among women born during the first decades of the twentieth century arising from the decline in fertility. Other hypotheses point towards improved antenatal and obstetric care and changes in the prevalence of different risk factors. In this study, all death certificates for the stillborn in Denmark during 1938, 1941, 1945, and 1949 were used to investigate the different hypotheses. As possible contributing factors, the results suggest improvements in relation to the course of the delivery, changed parity distribution, and a cohort effect.

[International comparisons of health systems]. / Internationale sammenligninger af sundhedssystemer.

International comparisons of health systems are widely used as a method for cross country learning, strategy development at the national level, and to demonstrate accountability. Comparisons may comprise entire health systems or subsystems within these, and may include many or few health systems. This paper describes strengths and weaknesses of different types of comparisons and methodological challenges involved in comparing different health systems. Finally, the paper emphasizes that caution must be exercised when transferring ideas from one system to another.

[Prevention in health care--opportunities and limitations]. / Forebyggelse i sundhedsvaesenet--muligheder og begraensninger.

Disease prevention and health promotion performed by the health care sector may in general be characterised as adhering to a high-risk strategy, in which individuals with an elevated risk of falling ill or dying are identified and encouraged to change their behaviour and sometimes take preventive drugs. The approach thus has great similarities and fits well with the other activities in health care. Prevention in the health care sector rarely prevents people from ending up in high risk groups. Interventions therefore become never-ending stories. Public health ethics may turn out as an important future research field.

[Health political analyses--contributing to societal self-reflection]. / Sundhedspolitiske analyser--bidrag til samfundsmaessig selvrefleksion.

An important task for historical and social-science research is to facilitate reflections on what is going on in politics and in society in general. To foster such reflection, researchers should be able to freely ask questions without interference from politicians and research funds. And research should be published not only internationally, but also in the national languages. It is shown that governing technologies in health promotion have not changed substantially during the last century, but that the governing ambitions have increased. This may lead to reflections over which governing technologies are considered appropriate and defendable.

Social inequality in health: dichotomy or gradient? A comparative study of problematizations in national public health programmes.

Recent public health programmes from four countries: Denmark, England, Norway, and Sweden, are studied to analyse how social inequality in health is described, explained and suggested to be tackled, i.e., the problematization or the discursive process whereby the issue is framed and made accessible to political action. Social inequality in health is defined in these programmes both as a disadvantaged minority with major health problems, in contrast to the rest of the population, i.e., as a dichotomy; and as a gradient in which health problems are seen as increasing with lower social class or educational level. The causes of health inequality are identified as behaviour, social relations and underlying social structures. Policies aimed at reducing health inequality can be characterized as either in accordance with a residual welfare state model, targeting the disadvantaged, or a universal model, addressing the whole population. All countries have policies that are mixtures of these problematizations, but with some systematic differences between the countries. In this field England resembles the Scandinavian countries, as much as they resemble each other dispelling the idea of a Nordic or Scandinavian welfare state model.

Public health policies: a Scandinavian model?

AIM: To identify how public health problems are identified, explained, and addressed in Scandinavian public health programmes. METHODS: Recent public health white papers from Denmark, Norway, and Sweden have been studied asking the following questions. How are policies and activities justified? Which problems and causes are identified? What is to be done? To what extent are the interpretations and suggested interventions in accordance with liberal or social democratic political ideals? RESULTS: The programmes studied give similar reasons for dealing with public health, namely the wish to create good lives for citizens and to improve the economy of society. The health problems identified are almost the same: cancer, heart disease, diabetes, musculoskeletal diseases, and mental illness. The Danish programme differs from its Norwegian and Swedish counterparts with regard to explanations and suggested solutions to the problems. It may be characterized as more liberal. While the Danish programme stresses the importance of individual behaviour, responsibility, and autonomy, the two others emphasize social relations, living conditions, and participation in addition to behavioural factors. Political responsibility for the health of the population is emphasized in the Norwegian and Swedish programmes. The Swedish programme, in particular, stresses common values such as equality and equal rights, and the significance of the welfare state. The Norwegian programme underlines the importance of empowering the individual, an ambition that could also be seen as a social liberal ambition to increase the self-determination of citizens. CONCLUSION: There is not one Scandinavian model in public health policy but several: a Danish model mainly adhering to liberal ideals, a Norwegian one that could tentatively be labelled social liberal, and a Swedish model adhering to more social democratic ideals.

Denmark: health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policyinitiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and therole of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. Denmark is a small country with 5.4 million inhabitants; however, it is one of the wealthiest countries in the world. It is a monarchy with fairly autonomous local governments, consisting of 5 regions and 98 municipalities. Population health, as measured by life expectancy, is relatively low in comparison toother European countries, but it has recently increased. The Danish health care sector is dominated by the public sector and is financed by local and state taxes. Somatic and psychiatric health care, carried out at public hospitals, andprimary health services, which are delivered by general practitioners (GPs) and other practising health professionals, are administered by the regions. The regions are financed by the State and to a certain extent by the municipalities. The regions own and run most hospitals, and practising health professionals are self-employed and reimbursed by the regions, mainly using a fee-for-service mechanism. The municipalities are responsible for elderly care, social psychiatry, prevention and health promotion, rehabilitation and other types of care that are not directly related to hospital inpatient care. Access to health care is fairly equal when health status is taken into account. For all citizens with residence permits, access to health care is free of charge at hospitals and from GPs, whereas access to pharmaceuticals, dentists and some other services require co-payment. During recent years, the focus of health care reforms has been on patient choice, waiting times, quality assurance and coordination of care. A major structural reform in 2007 has changed the political and administrative landscape of health care, dramatically reducing the number of regional andlocal units and transferring health care responsibilities for prevention and rehabilitation from the regional to the local level.