Mapa de la ubicación de los puntos de muestreo de Mamíferos.

In discussions around smacking and a total ban on smoking, focus group participants spoke of difficulties in the enforcement of certain laws. For example, irrespective of whether participants were in favour of a ban on smacking children, many expressed concern about the difficulty of enforcing such a ban in private spaces such as the home, and the concern that children, neighbours, or anybody with a grudge against the parents could accuse the parent of smacking the child out of spite:

ÒI've got something against my neighbour. Yeah exactly. I'll report that he hits his kidÓ.

Belgium/female/45-60/married/children/further education

ÒThere are certain areas where the state just canÕt go any further, can the law go into the bedroom, into the house, how far can the law go, how can the state monitor that.Ó

Ireland/male/45-60/single/no children/further education

Thus, while participants may have viewed the end goal as desirable (for example, a reduction in the physical abuse of children, or fewer people smoking), there was some scepticism about the means of achieving those goals while trying to maintain a balance between public and private interest, responsibility and action.

7.11.6 Discussion

Public health policies are intended to promote and/or protect the health of (sections of) the population through encouraging socially positive behaviour and collective responsibility and discouraging or punishing negative behaviours. As such, they may involve incentives or punishments for acting or failing to act in certain, specified ways. Incentives may be financial (cash rewards, subsidised products) or non-financial (provision of food vouchers, social or professional pressure). They can be targeted at the individual patient/subject or towards the health care professional (for example, bonus payments for reaching particular targets). Incentives are used to encourage positive, healthy behaviours: for example, the provision of free or subsidised nicotine patches aims to help people quit smoking, free or subsidised fluoride tablets aim to improve dental health, and vaccinations free at the point of use aim to encourage immunisation and maintain herd immunity. By contrast, disincentives and punishments are used to discourage negative choices or unhealthy behaviours: for example, taxation on tobacco products aims to reduce tobacco consumption, and fines for failure to have oneÕs child fully immunised aim to encourage high levels of immunisation. However, providing financial rewards or incentives to individuals or to health care professionals is ethically problematic. Incentives have a disproportionate impact on lower socio-economic groups for whom the reward or incentive is relatively greater than for those in higher socio- economic groups; and the public perception that financial incentives to health care professionals may impact upon their professional judgment may affect public trust and the doctor-patient relationship.

Examples of State use of incentives and enforcements can be found in relation to policies on immunisation, smoking, fluoridation, smacking, and many others. The use of incentives and enforcements varies widely between policy areas and European countries, and raises a number of issues. Firstly, such measures may be ethically contentious in that they may infringe upon civil liberties or freedom of choice and they imply that the State (via the public health agencies acting on its behalf) is the best judge of what is in the publicÕs interest. Although the State may have superior access to scientific and expert knowledge, issues around vested interests, individual choice and private interest must also be addressed. Secondly, particular laws and policies may be difficult to enforce. For example, while child health and immunisation records may mean that compulsory immunisation can be monitored, a ban on smacking children is difficult to enforce in private spaces, notably in the home. Thirdly, striking the balance between incentive and punishment can be problematic. For example, while an outright ban on smoking would be impossible to enforce and would likely lead to a rebellion, the banning of smoking in public places affects the normalisation and cultural acceptability of smoking and helps to reduce tobacco consumption. Public policy makers therefore need to produce policies that can be gradually accepted by the public whose health they are intended to promote and protect.

There has been limited recent research on public opinion relating to the use of incentives and enforcement in public health policy across Europe. This paper forms part of a study on the ethics of public health practice; it considers public opinion on tensions between private and public interest on a range of public health policy issues. One of the studyÕs objectives was to provide information to give policy makers across Europe a better understanding of public opinion to population approaches to improving health, in particular in relation to reasons for supporting specific public health policies and their enforcement. This paper reports the findings in relation to public attitudes toward the use of incentives, enforcements, and concepts of the greater good and best judge in relation to policies on immunisation, smoking, fluoridation and smacking.

7.12 Trust