Fluent Essays

This discussion board forum will focus on Chapter 5 of the textbook, Chronic Disease Prevention and Health Promotion, Johnathan Mark's TED talk, In Praise of Conflict, and the Believed podcast, Gaslighting. This forum closes on the Thursday of Week 7.  Please see attached. All posts should be written in your own words and be referenced and cited with at least one scholarly peer-reviewed journal article to support your position. That means even if you are replying to another person’s posts, your post still needs to be original, and referenced, and cited with a scholarly peer-reviewed journal article. The reason that PRJA citations and references are a requirement is that it elevates the discussion. The citation also allows readers to understand exactly what portion of the post is paraphrased from the reference. No direct quotes are allowed - paraphrasing is expected. The source in which you are required to reference and cite in your discussion posts needs to come from a peer-reviewed journal article. A book (textbook or otherwise) is not appropriate. Your post and reference need to be original - not something that another student has posted and or used. You must include an APA or AMA formatted citation and reference in your post. Discussion participants may include the instructor or students. The post must pertain to the discussion board issue in which it is being posted. Posts must be respectful of peers and show an insightful response to a topic related to ethics in health care. Your post will be evaluated using the following criteria: Quality of Post (content, logic, depth, breadth) – 8 points: The quality (8 of the 20 points) of the post is of primary importance. The content, logic, depth, and breadth of your post are central to my assessment of the post's quality. It should be your original writing and the material you cite and reference to support should be of the highest quality. It is not purely a message indicating your opinion. The support must come from at least one Peer-Reviewed Journal Article (PRJA). The lack of a PRJA affects the overall quality of the post. The support of a peer-reviewed journal article – 4 points: How the PRJA supports the content of the post is critical (4 of to 20 points). The PRJA should provide meaningful evidence to the cited portion of your message. Grammar, construction, academic tone – 4 points: The tone of the Required Discussion Board forums is formal. It is wise for you to evaluate the writing of your post using an editor, like grammarly.com. The basic grammarly.com editor (not the premium version) is an essential tool for you to use. Grammarly.com is free and gives you nearly immediate feedback with suggestions for improvement. Reference properly constructed – 3 points and Citation properly constructed - 1 point: The reference (3 points out of 20 points) and the citation (1 point out of 20 points) should be properly constructed. A folder on the course website contains resources that will help you with APA and AMA style. These two styles are the only ones accepted in this class. Pick one and use it throughout an assignment. To post a message, click the name of the forum on the left side of the page. On the next page, click the phrase "Create Thread". Follow the prompts to indicate a subject and enter your message. Finally, click "Submit". Peer-reviewed articles (PRJA) are a subset of scholarly articles. They are special because they are published in academic journals that explicitly state that submitted manuscripts will undergo peer-review. In academic publishing, the goal of peer review is to assess the quality of articles submitted for publication in a scholarly journal. Before an article is deemed appropriate to be published in a peer-reviewed journal, it must undergo the following process: · The author of the article must submit it to the journal editor who forwards the article to experts in the field. Because the reviewers specialize in the same scholarly area as the author, they are considered the author’s peers (hence “peer review”). · These impartial reviewers are charged with carefully evaluating the quality of the submitted manuscript. · The peer reviewers check the manuscript for accuracy and assess the validity of the research methodology and procedures. · If appropriate, they suggest revisions. If they find the article lacking in scholarly validity and rigor, they reject it. Because a peer-reviewed journal will not publish articles that fail to meet the standards established for a given discipline, peer-reviewed articles that are accepted for publication exemplify the best research practices in a field. PRJAs do not come from magazines or newspapers. Magazine and newspaper articles sometimes identify peer-reviewed journal articles, so it is possible to use them in order to find a peer-reviewed journal article. A published journal is the entity that defines whether or not its articles are peer reviewed. Once you find an article that appears to support your response, you should check with the journal to determine if it is peer reviewed or not. These days virtually all journals will have a website. Let’s say that you have articles from 3 periodicals that appear to support your response. They are The Journal of the American Medical Association, Nature, and The New York Times. If a journal does not state that it is peer-reviewed, it is not. Do not cite or reference sourced without an explicit statement that it is peer-reviewed on the journal’s website. You will see that both JAMA and Nature are peer-reviewed, but the New Your Times is not. 137© The Author(s) 2016 D.H. Barrett et al. (eds.), Public Health Ethics: Cases Spanning the Globe, Public Health Ethics Analysis 3, DOI 10.1007/978-3-319-23847-0_5 Chapter 5 Chronic Disease Prevention and Health Promotion Harald Schmidt 5.1 Introduction Chronic diseases include conditions such as heart disease, stroke, cancer, diabetes , respiratory conditions, and arthritis. In high-income countries, chronic diseases have long been the leading causes of death and disability. Globally, more than 70 % of deaths are due to chronic diseases, in the United States , more than 87 % (World Health Organization [WHO] 2011 ). Almost one in two Americans has at least one chronic condition (Wu and Green 2000 ). Aside from the cost in terms of human welfare, treatment of chronic disease accounts for an estimated three quarters of U.S. health care spending (Centers for Disease Control and Prevention [CDC] 2012 ). Chronic diseases directly affect overall health care budgets, employee pro- ductivity, and economies. Globally, noncommunicable diseases account for two- thirds of the overall disease burden in middle-income countries and are expected to rise to three-quarters by 2030, typically in parallel to economic development (World Bank 2011 ). Of particular concern to many low- and middle- income countries is that threats to population health occur on two fronts simultaneously: “In the slums of today’s megacities, we are seeing noncommunicable diseases caused by unhealthy diets and habits, side by side with undernutrition” (WHO 2002 ). Four modifi able risk factors are principal contributors to chronic disease , associ- ated disability, and premature death: lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption (CDC 2012 ). One in three adult Americans is overweight , another third is obese, and almost one-fi fth of young people between The opinions , fi ndings , and conclusions of the author do not necessarily refl ect the offi cial position , views , or policies of the editors , the editors ’ host institutions , or the author ’ s host institution . H. Schmidt , MA, PhD (*) Department of Medical Ethics & Health Policy, Center for Health Incentives and Behavioral Economics , University of Pennsylvania , Philadelphia , PA , USA e-mail: [email protected] mailto:[email protected] 138 6 and 19 years of age is obese, even though rates are not increasing at previous lev- els (Katz 2013 ). Although smoking has declined considerably over recent decades, about 20 % of Americans still smoke . Rates of smoking are markedly different across socioeconomic groups, and much higher among economically disadvantaged people (Garrett et al. 2011 ). Globally, deaths from smoking are expected to increase dramatically in low-income countries. In the twentieth century, tobacco-use killed around 100 million people worldwide. In the twenty-fi rst century, an estimated one billion will die prematurely—a tenfold increase. By 2030, more than 80 % of deaths attributable to tobacco will be in low-income countries (WHO 2012 ). In principle , if a risk factor can be modifi ed, then much illness and suffering (morbidity) and early death (mortality) can be avoided or prevented . Therefore, prevention and health promotion policies seek ways in which the impact of modifi - able risk factors can be reduced. How one analyzes the causal pathways that lead to the development of risk factors may encourage one to explore a range of different interventions. An obvious starting point is to focus on individual behavior or life- style , because what an individual does (or fails to do) typically plays a central role in chronic disease . Consider the following line of thought by John H. Knowles, an outspoken critic of the American health care system in the 1970s: Prevention of disease means forsaking the bad habits which many people enjoy—[but the] cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, and not an individual, responsibility. This is justifi ed as individual free- dom —but one man’s freedom is another man’s shackle in taxes and insurance premiums. I believe the idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health—a public duty if you will. The individual then has the ‘right’ to expect help with information , accessible services of good quality , and minimal fi nancial barriers (Knowles 1977 ). Knowles comment is interesting on several counts. First, it underscores that even though population health usually features centrally in health promotion , cost con- siderations are never far removed and are equally prominent in current debates, especially in political fora. 1 Second, in invoking three of the deadly sins (gluttony, sloth, and lust), Knowles illustrates in a frank way that discussions about health promotion are not confi ned to medical or public health concepts. Implicitly or explicitly, these discussions almost always entail moral concepts (such as personal responsibility or deserving- ness) that are embedded in deeply held normative frameworks. 1 For an example of such a political debate, see the 2012 platform of the U.S.’s Republican Party: “… approximately 80 % of health care costs are related to lifestyle —smoking, obesity, substance abuse —far greater emphasis has to be put upon personal responsibility for health maintenance …” (GOP 2012 ). Reforming Government to Serve the People is available at https://www.gop.com/ platform/ . This quote also illustrates the inaccurate use of statistics. Although the burden of chronic diseases is indeed roughly 80 %, it is an exaggeration to claim that personal responsibility alone accounts for the total burden. Exact estimates may not be straightforward due to complex interac- tions of different factors. Consequently, a more realistic estimate attributes 40 % to personal behavior, 30 % to genetic predispositions, 15 % to social circumstance, 10 % to inadequate health care, and 5 % to environmental causes (Schroeder 2007 ). H. Schmidt https://www.gop.com/platform/ https://www.gop.com/platform/ 139 And fi nally—although Knowles acknowledges elsewhere in his essay the role of taxes and other measures to improve health and eradicate poverty—he concludes by stating “the costs of individual irresponsibility in health have now become prohibi- tive. The choice is individual responsibility or social failure ” (Knowles 1977 ). The policy interventions he mentions aim for broader recognition of personal responsi- bility and therefore focus on education and information campaigns to empower people to behave responsibly. But this analysis is shortsighted. It fails to consider the responsibility of those who produce, market, and sell products (e.g., unhealthy foods, drinks, or tobacco ) and of those who regulate markets or set business stan- dards (e.g., trade groups or national or regional policy makers). His point could best be made if all people lived in similar environments and conditions, had suffi cient disposable income, had ready access to healthy and affordable food, had equal opportunity to exercise, and experienced other health-conducive conditions. But this is not the case. People live in vastly different contexts, and many different fac- tors determine health (Fig. 5.1 ). Although Fig. 5.1 provides a useful overview of many factors that affect health, the concept of “ lifestyle ,” commonly encountered in the broader debate around chronic diseases is problematic. It can suggest that people choose, for example, smoking or heavy drinking as others might decide between taking up golf or tennis as a hobby. The point is that “ lifestyle ” implies degrees of freedom and the possibil- ity of genuine opportunity and choice. But assume that you grew up in an inner-city Fig. 5.1 Factors determining health and chronic diseases (Originally published in Dahlgren and Whitehead ( 1991 ). Reproduced from Acheson ( 1998 ). Reproduced with permission) 5 Chronic Disease Prevention and Health Promotion 140 borough as a child of low-income obese and smoking parents . Many in your family and social environment smoke and are obese. Compared to the national average, you are among the most overweight , and you fail to lose weight as an adolescent. You remain obese. Calling your obesity a matter of lifestyle makes little sense. Now assume you started smoking as a minor (<18 years of age) just as 88 % of U.S. adults who smoke daily (U.S. Department of Health and Human Services 2012 ). It can be cynical to treat this “ lifestyle ” as voluntary and freely chosen if, for example, many of your role models smoke and if smoking in your social setting and challeng- ing environment functions as a coping mechanism to relieve stress. The different spheres in the diagram therefore need to be understood as highly interdependent. Regarding terminology, the concept of lifestyle factors should be replaced with that of personal behavior . Doing so acknowledges that powerful constraints can severely infringe on the development of healthy habits and behavior. In the worst case, these constraints may thwart development of healthy habits and behaviors altogether, even when individuals have the best of intentions. Focusing on just the individual is therefore overly narrow when identifying poli- cies to prevent chronic diseases . Yet, removing the individual from the equation is also unhelpful (Schmidt 2009 ). The central ethical issues surrounding health pro- motion and prevention of chronic diseases concern the relative responsibilities of all agents whose actions infl uence the health of others. These agents include, in addi- tion to individuals, health workers, governments (at different levels), and corporate entities. 5.2 Individuals Except for some genetic conditions and extremely toxic environments (i.e., chemi- cal exposure), individual behavior typically plays a causal role in bringing about bad—as well as good—health. People may or may not eat healthily; they may or may not use tobacco or illegal drugs; they may consume alcohol excessively or in moderation; they may exercise too little or too much; and they may regularly brush their teeth, go for medically recommended checkups, and take their medications — or fail to do so. However, it is important to recognize that implementation of mea- sures such as praise or blame, or fi nancial rewards, or penalties —although they presuppose a certain degree of causal responsibility—do not mean that individuals also automatically need to be held fully responsible in a moral (or legal) sense. Causal responsibility in the present context simply means that a person has behaved in ways that contributed to, say, poor health. Therefore, a smoker with lung disease arguably has some causal responsibility for the condition. But if it turns out that the smoker started becoming addicted as a child, it is clear that the outcome cannot simply be treated as the result of an entirely voluntary choice . Where there is no, or limited, opportunity of choice, there is the risk of “ victim blaming ” (Crawford 1977 ) and holding people responsible for factors that are, in fact, beyond their H. Schmidt 141 control. Conversely, ignoring the scope of possible behavior change can lead to fatalism and resignation (Schmidt 2009 ). For individuals to take causal and other responsibility for their health, they require, among other things, information that they can understand, affordable access to health care, and, oftentimes far more important, environments conducive to health in which capabilities may be developed so that one can fl ourish in life (e.g., residen- tial, work, and play settings) (Venkatapuram 2011 ; Ruger 2006 ). According to the adage “ought implies can,” we can only hold people responsible for their actions if they could have acted otherwise. Of course, it is true in some sense that people who smoke , or overconsume unhealthy food, or fail to exercise, could oftentimes have acted otherwise, in principle : it was not literally impossible for them to act other- wise. However, the relevant question is not whether it is literally possible to engage in healthy behavior, but whether it reasonably feasible for people to engage in healthy behavior. Talk of personal responsibility therefore requires a clear focus on the settings in which people live and on their behaviors when presented with differ- ent choices. Consideration should also be given to the possibility that policies implementing personal responsibility through, for example, rewards and penalties , may impact core values underlying a health system, such as a sound doctor-patient relationship , equity , or risk sharing , which may affect their overall acceptability in positive or negative ways (Schmidt 2008 ). 5.3 Formal and Informal Health Workers Health professionals play a central role in chronic disease prevention and health promotion (Dawson and Verweij 2007 ). In primary prevention , they focus on avert- ing poor health in the fi rst place and on promoting good health. In secondary pre- vention , they offer information , tests, and screenings aimed at early detection and treatment of diseases. Diabetes , blood pressure, and some cancer screenings can have utility, especially when targeting at-risk populations in a nonstigmatizing way. Primary care physicians are often in a good position to decide on the appropriate- ness of screenings. Their knowledge of patient background and overall situation can help them tailor tests on the supply side to the actual needs on the demand side, bearing in mind patient preferences and individual risks. Cost effectiveness aside, a physician would be wrong to offer every available test to every patient because the clinical benefi t is not always clear. A recent systematic review and meta-analysis of randomized controlled trials concerning general health checkups (i.e., comprising health risk assessments and biometric screening for high blood pressure, body mass index, cholesterol, and blood sugar) found no association with lower overall mortality or morbidity (Krogsbøll et al. 2012 ). On the basis of these fi ndings, the researchers caution that checkups may needlessly increase diag- noses and use of drugs. They recommend clinically motivated testing of individuals to initiate preventive efforts but discourage screening at the population-level for 5 Chronic Disease Prevention and Health Promotion 142 lack of evidence. The authors acknowledge limitations in their research , including that most of the trials were relatively old and that changes in interventions and care pathways reduce applicability to current practice. All studies entailed voluntary invitations to get checkups , so selection bias may have overrepresented privileged people (in typically better health to start with) and not reached those needing atten- tion the most (Krogsbøll et al. 2012 ). The focus on all-cause mortality has also been criticized as setting too high a threshold (Sox 2013 ). Yet despite the somewhat intui- tive appeal of using general health checkups in secondary prevention , there is little robust evidence from randomized controlled trials to show any major impact on overall mortality. An ethical problem arises when offering preventive screenings that do not fol- low evidence-based guidelines (U.K. National Screening Committee 2013 ). Such screenings may increase the number of “worried well” who oftentimes are con- fused by complex probabilities of detecting and preventing diseases . Clinicians must therefore do their utmost to understand risks and benefi ts of screening tests and communicate these to patients in ways that are easily comprehensible and not misleading (Wegwarth and Gigerenzer 2011 ). For example, a physician might tell his 50-year-old patient that she should undergo breast cancer screening because it reduces risk by 14 %. But this information is incomplete, as relative risk rates alone obscure the basic reference point against which the comparison is made. Another way of providing the same information would be to use absolute risk rates and to say that if one screens 1000 women for 20 years, four breast cancer deaths can be averted, even though eight among all screened women still die from breast cancer. In addition, over the 20 years, the 1000 women taking part in screening experience 412 false positives, and of 73 women who are diagnosed with breast cancer, 19 experience overdetection and are treated for a cancer that would not have developed into a lethal tumor, with treatment typically consisting of hormone- radio- or chemo- therapy, and partial or full surgical breast-removal (Hersch et al. 2015 ). This way of presenting data (Fig. 5.2 ), especially when com- bined with other relevant information about screening accuracy and rates of over- diagnoses, provides more adequate context for considering benefi ts and risks—yet, this presentation method is far from being universally adopted (Gigerenzer et al. 2010 ). Adequate risk information in secondary prevention matters not only from a patient-empowerment perspective but also because it can mitigate real or perceived confl icts of interests of physicians. Physicians, anyone who markets or manufac- tures screening equipment, and those who analyze data typically experience fi nan- cial gain when more patients undergo screening . Therefore, a central ethical issue of secondary prevention is not only how to avoid premature mortality in the most effi - cient and cost effective way but also how to eliminate potential confl icts of inter- ests. Patients can become entangled in competing interests, as illustrated by the controversy surrounding prostate-specifi c antigen, or PSA, testing to detect prostate cancer. Although physicians and others experienced fi nancial gain, patients experi- enced no reduced mortality and instead higher morbidity and loss of quality of life H. Schmidt 143 due to the entailed procedures (Ablin 2010 ). The question of “what is the magnitude of benefi ts and risks , and to whom?” is therefore an important one to ask in all sec- ondary prevention , especially because the net gain for patients is not always obvious. For these and other reasons, many in the public health community are skeptical about the relative utility of secondary prevention in a clinical context. Often this is paired with a call for shifting political and fi nancial support to primary prevention and the broader sphere of public health (Sackett 2002 ; Mühlhauser 2007 ). Here, the objective is to avoid poor health in the fi rst place by empowering people with differ- ent ways to lead healthy lives. Too often, only the privileged few in certain popula- tions have this capability (WHO 2008 ). Of course, this way of thinking immediately broadens the concept of health pro- fessional . Clearly, it is outside the scope of, say, a hospital-based general internist to reduce junk-food outlets or to increase exercise opportunities in a low-income part of town, even if the internist has good reasons to believe these structural features are key contributors toward rising levels of obesity among patients. But once we recog- nize how differences among settings in which people live can affect the incidence and prevention of chronic diseases, it becomes apparent that public health profes- sionals outside the clinical context have as much, if not more, of a role to play compared to physicians when it comes to chronic disease prevention and health promotion. A range of corresponding interventions are relevant to this discussion, including literacy, safe sex, hygiene and health awareness campaigns, fi nancial subsidies for healthy food or gyms, exercise stations in parks, breastfeeding rooms in workplaces, Relative risk data can be misleading or confusing. Absolute risk data can provide more appropriate information and minimize possible conflicts of interest. Visual illustrations similar to the ones shown below are helpful as part of evidence-based mammography screening decision-aids. Fig. 5.2 Communicating benefi ts and harms of breast screening (Originally published in Hersch et al. ( 2015 ). Used with permission) 5 Chronic Disease Prevention and Health Promotion 144 and fl uoridation of water. The public health fi eld is heterogeneous and comprises numerous different actors both in and outside a clinical context. Public health, despite its many contexts and support from government and private sectors, is typi- cally underfunded. This is especially true for informal grassroots campaigns, which often have a considerable competitive advantage over formal program structures. Grassroots campaigns evolve from the communities they seek to help. Because nearly every intervention that addresses chronic diseases has to do with how one lives one’s life, top-down interventions are often experienced as intrusive forms of external meddling (Morain and Mello 2013 ). Conversely, initiatives led by a com- munity member can be perceived more sympathetically than instructions from men in white coats who speak in formal and technical terms (unless, of course, that hap- pens to be the target population , which, typically, it is not). Health professionals working on chronic disease prevention and health promo- tion therefore span a wide fi eld. In a looser sense, many professionals not generally seen as concerned with health could be included too, such as teachers, architects, town planners , or spiritual leaders. Each has perspectives that can be highly infl uen- tial, but each is inherently limited in scope because chronic conditions result from complex interplay of different factors. This raises another key ethical issue involv- ing how to determine the optimal mix of strategic approaches, bearing in mind the relative strengths and weaknesses. Further, just as users and payers of health care should have a keen interest in hav- ing systematic studies and evaluations done to determine which of several drugs aimed at reducing, for example, severe headache, is most effi cacious (and cost effective), we should be interested in the evidence base for possible benefi ts and harms of different interventions being implemented by health professionals con- cerned with chronic conditions. Yet, in an almost tautologic approach, health profes- sionals often assume any preventive method will be good because its aim is prevention. But several strategies could be aimed at the same problem. Given that budgets are generally limited, it can be useful to determine which intervention is most effective and, for example, how its relative effectiveness and cost compare with its intrusion into peoples’ lives. Such comparisons can help achieve value for money, even if the complex interplay of agents complicate this process. 5.4 Governments (At Different Levels) Chronic disease prevention and health promotion policies often face criticism for promoting a “ nanny state .” This means that although government may legitimately use taxes and other measures to create health-conducive infrastructure that pre- vents chronic disease such as clean water supplies, sanitation services, or clean air acts, it should otherwise stay out of people’s lives, and, in particular, refrain from telling citizens how to live their life (Childress et al. 2002 ; Gostin 2010 ; Dawson H. Schmidt 145 and Verweij 2007 ). Many good reasons support this viewpoint. Still, many vari- ables related to chronic diseases are linked to legitimizing governments in the fi rst place. For example, consider the U.S. Declaration of Independence. It declares that “all men are created equal; that they are endowed by their Creator with certain unalienable Rights; and that among these are Life, Liberty , and the pursuit of Happiness.” Numerous countries express similar sentiments in legal frameworks and charge states with providing environments that enable conditions for a good life, and prevent harm . Moreover, building on the United Nations’ (U.N.) International Covenant on Economic , Social and Cultural Rights of 1966 and clarifying General Comment 14 by the U.N.’s Committee on Economic, Social and Cultural Rights, several countries have incorporated the right to health in their constitutions (WHO 2013 ). Yet, not all people live equally long, nor are they equally happy (in a nontrivial sense). For example, life expectancy differs widely, not just between countries at different levels of development, but also within countries, and sometimes with differences of almost 30 years across just 10 miles (see the data on two areas in Glasgow, Scotland, located near one another, Fig. 5.3 ). Chronic diseases are a major contributor to this variation. Going back to the focus on personal responsibility , one might argue this variation in life expectancy is due to some people simply not wanting to be healthy or living long. But this is clearly myopic. Government planning at different levels has immense impact on both the prevalence and prevention of chronic diseases. It is sometimes argued that the best prevention is to instill in people the desire to live long and healthily (Rosenbrock 2013 ). For some, this might entail a state- guaranteed minimum income (irrespective of whether one works), since economic livelihood is Fig. 5.3 Male life expectancy, between- and within-country inequities, selected countries (Figure is adapted from World Health Organization ( 2008 )) 5 Chronic Disease Prevention and Health Promotion 146 of course a major factor in how one views one’s own future. While a positive impact of such policies on the incidence of chronic disease and mortality would certainly be plausible, there is a wide range of less radical and politically more feasible options in the menu of different levels of government action. These include town planning, zoning laws , school and university meal plans, and, of paramount impor- tance, regulation of industry where markets fail. These and other interventions can only be implemented by governments. An important part of chronic disease preven- tion and health promotion is to monitor where differences in morbidity and mortal- ity are such that government action is warranted, and to impress on elected offi cials their responsibility in creating appropriate environments. The monolithic notion of “the” government is, of course, an overly simplistic one. Key personnel in health departments may well wish to limit the size of, for example, soft drinks. Or they may wish to standardize ways in which nutritional content is shown on food packaging. Such measures would enable more informed consumer choice, and, more indirectly, incentivize producers to reconsider whether food composition can be optimized for health impact, given the second- ary “showcasing” effect of labeling. 2 But their colleagues in trade or industry, as well as in the treasury, may point out the risk of tax shortfalls that could result from lower consumption. Or they may worry about pushback from lobbyists in the corporate sector who fear losing profi ts for their clients . Politicians may often be more concerned with their short-term re-election prospects than with making substantial (or even just incremental) longer-term progress on chronic disease prevention. These confl icting perspectives within government are inevitable . But only government can determine the playing fi eld and ground rules for industries producing, selling and marketing food, drink, tobacco , and other products contrib- uting to unhealthy behavior. In liberal economies that, typically, pursue a hands- off approach toward regulating markets, the central ethical challenge then is to decide at which points markets are considered to have failed, other options of market regulations are unfeasible, and government action is warranted, despite possible drawbacks. A second closely related question is what intervention to pursue once the need for action has been identifi ed. Figure 5.4 shows the Intervention Ladder published in a report by the Nuffi eld Council on Bioethics ( 2007 ) on public health ethics. The model suggests that governments have a range of different options at their disposal that become increasingly intrusive or paternalistic the higher one moves up the lad- der. At the …