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There has been considerable debate over the importance of the health selection hypothesis for explaining social gradients in health. Although studies have argued that it may not be an important explanation of social gradients in health, previous analyses have not estimated, simultaneously, the relative effect of health on changes in social position and of social position on changes in health (social causation). Cross-lagged longitudinal analyses using structural equation models enable the estimation of the relative size of these pathways which would be useful in determining the relative importance of the health selection hypothesis over the social causation hypothesis. Data from four phases of the Whitehall II study (initially consisting of 10,308 men and women aged 35-55 in the British civil service) were collected over a 10 year period. There was no evidence for an effect of mental (GHQ-30 and SF36) or physical health (SF-36) on changes in employment grade. When financial deprivation was used as a measure of social position, there was a significant effect of mental health on changes in social position among men although this health selection effect was over two and a half times smaller than the effect of social position on changes in health. The results suggest that the development of social gradients in health in the Whitehall II study may not be primarily explained in terms of a health selection effect. Keywords: Health selection; Social causation; Health inequalities; United Kingdom

In the last 30 years, cardiopulmonary resuscitation (CPR) has evolved from an intervention indicated only in cases of acute insult to an otherwise healthy body to a default measure employed in virtually all cases of cardiac failure. The high cost and low efficacy rate of CPR has provoked questions about the moral and economic wisdom of its routine use, particularly for elderly patients with serious comorbidity. This paper presents the results of a comparative study of decision making practices concerning 'Do-Not-Resuscitate' (DNR) orders in British and American hospitals. Thirty-four physicians and nurses in one American and one British hospital were interviewed about their decision making practices. Qualitative methods of data analysis were employed. The study revealed that while the American and British hospitals had adopted similar formal protocols for DNR decision making, in practice the British physicians often made DNR decisions unilaterally, whereas the American physicians sought the patient's or surrogate's consent in every instance, even where it was not legally required. The British decision making model enables physicians to reduce the inappropriate use of resuscitation, but at the expense of patient autonomy. In contrast, the American approach fully respects patient autonomy, but except in cases of medical futility grants physicians no authority to refuse to render treatments that are in their judgment contraindicated. [C] 1998 Elsevier Science Ltd. All rights reserved Key words--CPR, resuscitation, clinical ethics, autonomy, decision making

This review outlines the possible uses of subjective health status measures in the evaluation of medical treatment, and possible limitations and pitfalls that potential users of such measures must be aware. Whilst much has been written about the requirements of measures in terms of reliability, validity and responsiveness, many existing measures which have gained widespread use have serious shortcomings. In this paper, the limitations of some existing questionnaires are outlined. It is argued that whilst outcomes measurement has the promise to positively influence medical care, done without due consideration of its limitations and weaknesses it could lead to inaccurate or inappropriate data. In the current climate, in which health outcomes data is viewed as central to monitoring and evaluation, inappropriate or unconsidered use of measures could have drastic effects. Key words - subjective health assessment, efficacy, reliability, validity, responsiveness

In recent years much attention has been paid to the development of measures of subjective health status yet, although statistical criteria of reliability and validity have been quite rigorously tested, there has been little consideration of the different theories of disability which underlie the design. The sociology of disability may illuminate such tacit theories. It is suggested that the development of health status questionnaires has not been one of simple rational accumulation in response to methodological advances. Through an examination of the content of health assessment questionnaires, four distinct models of disability are identified. These are shown to influence not only the focus of the content and phrasing of the questions but also, crucially, the way that they perform and how responsive they are to change. The models (the functional, subjective distress, comparative and dependence) are illustrated and discussed in terms related to research design.

There is currently much interest in the measurement of self reported health status. A number of health status measures have been designed. However, such questionnaires are often long and complicated, or are disease specific. The most famous generic British health status instrument is the Nottingham Health Profile (NHP) which is a short questionnaire designed for ease of completion. However, this paper addresses a number of related issues concerning the weights attached to particular items on this questionnaire. It is argued that the weighting of items by Thurstone's method of paired comparisons is inappropriate and can lead to logically inconsistent results. Key words--Nottingham Health Profile, weighting, Thurstone scaling, health status