Hence, we feel that it is inappropriate to exclude the two mentioned PES trials from the meta-analysis.

PES was associated with a more than 10-times greater chance of treatment success as compared to sham in these trials, so their inclusion in the meta-analysis would have most likely impacted on the estimated treatment effect of PES.


Second, the authors focused on the effect of PES on penetration aspiration scale score rather than relevant clinical measures such as the dysphagia severity rating scale [10].

A previous meta-analysis found that PES improved DSRS [11].


Third, the authors suggested that “NMES may have more promising effects compared to PES” [1].

We are unaware of any head-to-head comparisons of the two techniques (and none were presented in the systematic review), so it is inappropriate to comment on the superiority of one technique over the other based on the indirect comparison of the meta-analysis results.

For example, the between-group lower and upper confidence limits of effect overlapped (NMES 0.105 to 0.760; PES −0.170 to 0.368) which is compatible with no difference in efficacy.


Lastly, the introduction of interventions into routine clinical practice requires more than just evidence of efficacy; we also need evidence that interventions are cost-effective, and this information is missing from this and other meta-analyses.


In conclusion, it is likely that both techniques are effective and have a clinical role in overlapping groups of patients.

However, as the authors say, large trials are needed, and these should include both clinical and health economic outcome measures.

We are delighted to announce that the UK government-funded Pharyngeal Electrical Stimulation for Acute Stroke Dysphagia Trial (PhEAST) is studying the clinical and cost effectiveness of PES versus control in 800 patients with dysphagia after a recent stroke (https://stroke.nottingham.ac.uk/pheast/, accessed 4 March 2022).


Our systematic review and meta-analysis of pharyngeal electrical stimulation (PES) and neuromuscular electrical stimulation (NMES) in patients with oropharyngeal dysphagia (OD) is the first paper (Part I) [1] of two companion papers.

The second paper (Part II) [2] reports on brain stimulation (i.e., rTMS and tDCS).

In addition, a third paper [3] has been published, reporting on behavioural interventions in people with OD.

All three systematic reviews use similar methodologies and are based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and checklist [4,5].

The overall aim of the three reviews is to determine the effects of non-invasive brain stimulation (NIBS) techniques and behavioural interventions for people with OD and to provide an overview of the findings based on the highest level of evidence, namely conducting meta-analyses of randomised controlled trials (RCTs).


In a commentary about our review on PES and NMES (Part I), Dziewas and Bath argue that our review did not provide the full picture regarding the treatment of PES [6].

The authors list four arguments, which this current paper will address consecutively:


First, Dziewas and Bath state that we excluded two of eight identified randomised-controlled trials of PES (Dziewas et al. [ 2018] [7] and Suntrup et al. [ 2015] [8]) because we assumed that there was ‘no confirmation of OD diagnosis prior to treatment’ in these studies.

We would like to clarify that we did not exclude these two studies from our systematic review.

Both studies met all eligibility criteria; however, they were excluded from the meta-analysis based on the need to reduce heterogeneity of the measures used to report on outcomes between studies when conducting meta-analyses.

As such, we report on both studies in detail in our outcome tables (Tables 2 and 3), including their use of fibreoptic evaluation of swallowing recordings (FEES) as part of their protocol.


As summarised in the results section, of the ten studies that met the eligibility criteria of this review, eight studies compared PES to a sham version of the treatment, while two studies compared PES with other types of neurostimulation.

Of these ten studies, five studies were excluded from the meta-analyses.

We excluded these studies from meta-analyses due to an overlap in the participant population between studies, insufficient data reported for meta-analyses, a lack of confirmation of OD diagnosis by instrumental assessment prior to treatment and to ensure that the outcome data are as homogenous as possible.

The studies by Dziewas et al. ( 2018) [7] and Suntrup et al. ( 2015) [8] were excluded from meta-analyses for reasons of heterogeneity, as clearly described in the discussion:


For instance, meta-analyses based on both patients’ self-reported health-related quality of life and visuoperceptual evaluation of instrumental assessments would very likely lead to inappropriate estimated overall effects.

Thus, to reduce heterogeneity between outcome measures, some studies were excluded from the meta-analysis.

This strong focus on reducing heterogeneity between studies when performing meta-analysis also implies that data other than the authors’ primary outcomes may have been preferably included in this analysis.

For example, the primary outcome for Dziewas, Stellato, Van Der Tweel, Walther, Werner, Braun, Citerio, Jandl, Friedrichs, Nötzel, Vosko, Mistry, Hamdy, McGowan, Warnecke, Zwittag and Bath [7] and Suntrup, Marian, Schröder, Suttrup, Muhle, Oelenberg, Hamacher, Minnerup, Warnecke and Dziewas [8] was readiness for decannulation, which was considered too different from outcomes in the other included studies.


As stated under the Methods section, when selecting outcome measures for inclusion in the meta-analysis, reducing heterogeneity between studies was a priority.

If heterogeneity is not within reasonable limits, the results of meta-analyses cannot be adequately interpreted [9].

Therefore, in line with current guidelines on conducting meta-analyses, outcomes that are too disparate should not be combined in meta-analyses as unequivocal differences in effects may be obscured [9].


On the continuum of the heterogeneity of dysphagia treatment outcomes, we prioritised visuoperceptual measures of instrumental assessment (VFSS and FEES).

If no visuoperceptual measure was available, we considered non-instrumental clinical assessments (e.g., oral intake measures).

Oral intake measures were only included if no other clinical data were available, whereas screening tools and patient self-report measures were excluded from the meta-analyses altogether.

We considered ‘decannulation’ vastly different from any of the other outcome parameters, and, therefore, based on the guidelines for conducting meta-analyses, decided not to include both trachea studies [7,8].


The core issue at hand is the argument put forward by Dziewas and Bath to group patients with dysphagia who have been tracheotomised using readiness for decannulation as an outcome with patients who have not been tracheotomised using visual perceptual measures of FEES or videofluoroscopy (VFSS) to evaluate dysphagia severity in the same meta-analysis.

To us, and we suspect for many others in the dysphagia field, the outcomes used are clearly very different and should therefore not be combined in the same meta-analysis under the principle of avoiding heterogeneity when conducting a meta-analysis to determine the effects of PES.


Second, Dziewas and Bath state in their commentary that we focussed on the effects of PES using the Penetration Aspiration Scale (PAS) and ignored relevant clinical measures, such as the Dysphagia Severity Rating Scale (DSRS).

VFSS and FEES are widely supported in the literature as ‘gold standard’ assessments in the diagnosis of OD and determining OD severity.

This view was confirmed in the recently published whitepaper by the European Society for Swallowing Disorders on screening and non-instrumental assessment for dysphagia [10].

This supported our argument for using PAS data (a visuoperceptual measure of FEES and VFSS) over DSRS data (an oral intake measure [11,12]) as a preferred outcome measure when conducting meta-analysis.

Therefore, the decision to only include PAS data for meta-analysis was made for two reasons: (i) all five PES studies eligible for meta-analyses used PAS as an outcome measure, thus ensuring the included outcome measures were homogenous, and (ii) PAS, as opposed to the DSRS, is a visuoperceptual measure of ‘gold standard’ assessments.


Despite our argument for only including PAS outcome data, to be fastidious, we conducted the PES within- and between-group meta-analysis again to determine the differences between the results when including non-instrumental clinical assessment data (i.e., DSRS) with PAS data, against using PAS data only.

Two [Jayasekeran et al. ( 2010) and Vasant et al. ( 2016)] of the original five studies included in the meta-analyses provided both DSRS and PAS data.


When conducting meta-analyses based on combined PAS and DSRS data, the following results were found for a between-group comparison: using a random-effects model, an overall non-significant no effect between-group total effect size favouring PES was found (z(4) = 0.825, p = 0.410, Hedges’ g = 0.109, and 95% CI = −0.150–0.367).

In comparison, the original results, as reported in Speyer et al. ( 2022), were a non-significant no effect between-group total effect size favouring PES (z(4) = 0.718, p = 0.473, Hedges’ g = 0.099, and 95% CI = −0.170–0.368).


When conducting meta-analyses based on combined PAS and DSRS data, the following results were found for a within-group comparison: using a random-effects model, an overall significant moderate within-group total effect size favouring post-intervention was found (z(4) = 4.562, p < 0.001, Hedges’ g = 0.591, and 95% CI = 0.337–0.844).

In comparison, the original results, as reported in Speyer et al. ( 2022), were an overall significant moderate within-group total effect size favouring post-intervention (z(4) = 3.983, p < 0.001, Hedges’ g = 0.527, and 95% CI = 0.268–0.786).

In summary, for both within-group and between-group analysis, even if we had included DSRS data instead of PAS data for two of the five studies, the substantive results would have been the same as those reported in our meta-analysis.


Third, in their commentary, Dziewas and Bath dispute our conclusions in relation to the interpretation of our reported effects for PES.

When conducting meta-analyses, we found significant, large pre-post treatment effects for NMES and moderate pre-post treatment effects for PES.

In line with our results, we suggested:


‘... that NMES may have more promising effects compared to PES.

However, NMES studies showed high heterogeneity in protocols and experimental variables, the presence of potential moderators, and inconsistent reporting of methodology.

Therefore, only conservative generalisations and interpretation of meta-analyses could be made’.


We formulated our conclusions with great caution.

We disagree with the statement by Dziewas and Bath that interventions can only be compared within the same meta-analysis.

When direct comparisons are unavailable, an indirect comparison meta-analysis should evaluate the magnitude of treatment effects across studies [13].

As such, the presentation of the effect sizes of PES and NMES presents a legitimate first step in comparing intervention efficacy.


However, to be prudent, we conducted an additional between-subgroup meta-analysis including all NMES and PES studies in the same meta-analysis to compare the effect sizes between both types of neurostimulation.

Between-subgroup analyses using a random-effects model showed significant differences between NMES and PES (p = 0.011) with a small effect size in favour of NMES (Hedges’g = 0.269; 95% CI = 0.061–0.477; z-value = 2.537).

These results support our previous cautious conclusions formulated in our review in favour of NMES.


Fourth, Dziewas and Bath also argue that interventions need to be cost-effective and that this information is missing from our meta-analysis.

We are somewhat surprised by this argument as the purpose of our systematic reviews was clearly not to target cost-effectiveness.

We agree that the cost-effectiveness of interventions is important, but this topic is outside the scope of our current publication on treatment effects.

Combining clinical dysphagia outcomes with measures of cost-effectiveness in our meta-analyses would have introduced unacceptable heterogeneity.


In summary, we disagree with the arguments put forward by Dziewas and Bath.

Reducing heterogeneity in meta-analyses is essential.

By ignoring heterogeneity, the results from meta-analyses are not trustworthy and do not contribute to the research or, in this case, evidence-based dysphagia care.

We provided an objective overview of the highest level of evidence (meta-analyses of RCTs) in the treatment of dysphagia.

Our conservative conclusions are based on meta-analyses taking into account the heterogeneity between studies.


The final statement by Dziewas and Bath that it is very likely that both NMES and PES are effective and have a clinical role may be true; however, this needs to be confirmed by further research using robust methodologies, as suggested in our reviews.

In particular, discussion around outcome measurement of dysphagia severity needs further consideration and ongoing debate.

Further, to facilitate comparisons of studies and determine intervention effects, there is a need for more randomised controlled trials with larger sample sizes and greater standardisation of protocols and guidelines for reporting.

Finally, while we appreciate the authors’ candour in reporting that one of the authors received financial compensation for being a board member of Phagenesis Ltd., a manufacturer of PES technology, it is worth pointing out that there is a need for further research involving independent researchers without any conflict of interest to replicate the current evidence of PES as an important intervention in tackling the challenges associated with dysphagia.


Nasal cavity is an uncommon site of cancer in most countries (2), and the Inuit are no exception to this rule despite the elevated frequency of naso-pharyngeal tumours.

There were no cancers registered to this site in any of the regions in 1969- 1973 in men, nor at any time period in Canada in women (Tables 1,2).

In all, only 8 nasal cavity cancers were reported in men and 5 in women in the whole Circumpolar region during the years 1969- 1988.

Nevertheless the SIRS with each comparison population for both sexes approximated to 2, though the lower 95% confidence interval (C1) was less than 1 .O.


The nasal cavity is a site for which little or nothing is known about etiology, though some tumours have been attributed to use of snuff.

It is possible that the non-signifi- cant excess of nasal tumours may be a reflection of the elevated rates of nasopharyngeal cancer, and due to similar etiological factors.


There were 233 lung cancers reported in women and 430 in men in the whole Circumpolar region over the 20-year period of the study (Table 5 ) , comprising 20.6% of all cancers reported.

Eighty-one per cent of all Inuit lung cancers were histologically verified (Table 6).

The male-to-female ratio always exceeded one, except for the Canadian ratio in 1974-1978.

The rates in Canadian Inuit women were particularly high, often exceeding the rates in men in Alaska and Greenland.

The general trend with time for both Inuit men and women is for an increase in rates throughout the time period, though in Canada there was a fall in 1984- 1988 (Figs 1,2).

The age-specific rates (Table 7) are highly variable due to small numbers of cases in most groups.

Further, with only four time periods used and the small number of cases, it is not possible to determine whether the trends relate to birth cohorts or are cross-sectional.


Cancer incidence data for Circumpolar Inuit populations were developed and compiled from Greenland, Canada and Alaska from 1969 to 1988 to provide the largest possible base of data for documenting the unusual patterns of cancer previously reported for these populations.

Cancer incidence and population data were transferred to the Danish Cancer Registry.

Coded information from various ICD-classifications and codes for the basis of diagnosis were transformed to one format, enabling joint analysis.

Standard descriptive analysis was carried out with presentation of number of cases, crude incidence rates (CR), age-standardized rates (world) (ASR), cumulative rates to age 64 years, and indirectly standardized ratios (SIR) to the populations of Connecticut (USA), Canada and Denmark.

The resulting database can be used to support collaborative international research among the Inuit populations.


The value of presenting cancer incidence data from different parts of the world in a comprehensive and standard format has been clearly demonstrated by the series ‘Cancer Incidence in Five Continents’, published by the International Association of Cancer Registries and the International Agency for Research on Cancer, WHO, Lyon.

Cancer data related to the Inuit populations of the north have never formed part of these publications, primarily because population-based data from the small, scattered Inuit populations were not available.


Data from Greenland were previously published in two monographs [1, 2], with a description of the cancer registration system.

Data on Canadian Inuit are now available after the development of a cancer registration system for the Inuit of Canada [3]; data for Inuit of the central and western Arctic had been published previously [4, 5].

Cancer incidence data from Alaska were available at the Center for Disease Control, Anchorage, following WHO standards and since 1984 in a format compatible with the National Cancer Institute, USA, Surveillance, Epidemiology and End Results (SEER) programme.

Earlier data have previously been published [6-8].


The objectives of the present study on cancer among Circumpolar Inuit, were to compile systematically collected cancer incidence data and to present this to the scientific community in a comprehensive tabular format supported by graphical presentation.

A further objective was to provide sufficient background information [9-11] to assist in the interpretation of the findings.

The compilation of these data into a standard registry format is hoped to stimulate further research uses of the database, such as international case-control studies or the evaluation of cancer control intervention studies among the Inuit populations.

The current paper documents the methods used to analyse the combined Circumpolar data set, as presented in site-specific papers of this volume of Acta Onocologica [12-20].


Low rates of skin cancer, both melanoma and non-melanoma, were observed in Inuit after 20 years of observation.

Tumours of the brain and central nervous system, of the thyroid, bone and connective tissues and other specified sites occurred with rates similar to those in comparison populations in Denmark, Connecticut and Canada.

These findings support that neither UV and ionizing radiation from nuclear fall-out, nor pollution of herbicides and pesticides in the Arctic area have yet had any noticeable impact on cancer risk.

However, unspecified and secondary neoplasms constitute 74% of the total Circumpolar cancer incidence and the pattern of rare cancers must be interpreted with caution.

Increased diagnostic efforts with a higher precision in the future are warranted.

The cancers dealt with in this paper constitute a heterogeneous group.

Of the possible risk factors mentioned by Lanier [1], Nielsen & Storm [2] and Gaudette et al. [ 3] in particular the Asian heritage of the Inuit, the Arctic environment and the performance and constitution of health services in terms of sub-optimal diagnostic possibilities are important.

Since cancers of the brain and nervous system, bone and connective tissues, the thyroid and all the ‘other specified sites’ [4] are rare even in populations of a substantial size, the Inuit rates in a population below around 110,000 become even more unstable.

However, in view of the interesting high rates of cancers of the salivary glands, nasopharynx [5] and of the nasal cavities [6] in Inuit, rare cancers are worth studying in these populations, with a view to further studies on the carcinogenic process.


Material and Methods Cancer incidence data from 1969 to 1988 from the Inuit populations of Alaska, Canada and Greenland were collected and compiled into a standard format for the purpose of this analysis.

The definitions, methods and data sources are fully described previously [4].

The accompanying site-specific tables give, by calendar period, country and sex, the total number, crude rate, age-standardized incidence rate (ASR), cumulative rate up to and including the age of 64 (Cum 64) and standardized incidence ratio (SIR), (or indirect standardized rate) to the comparison populations of Connecticut (USA), Canada and Denmark.

Age-specific rates are presented for the combined Circumpolar area for the 20-year study period as a whole.

Basis of diagnosis is given for the 20 years by region.

In the following, the results for each site are dealt with separately followed by a brief discussion.


Melanoma of skin (ICD-9 172) Results.

Only six cases of melanoma of the skin in women and two in men were reported in the entire Circumpolar region from 1969 to 1988, with ASRs of 1.1 and 0.3 respectively (Table 1).

This places the Inuit among the low-risk populations of the world [7].

Consequently, in both sexes for the total time period, the SIRS were very low.

There was no change in incidence over time.

Discussion.

It seems likely that the skin pigmentation of the Inuit constitutionally protects them against melanoma of the skin, constitutional factors being very relevant in the etiology of this cancer [8, 9].

It remains to be seen whether the increase in ultraviolet radiation exposure associated with the ozone holes over the Arctic will result in any change in this situation.


Skin excluding melanoma of skin (ICD-9 173) Results.

Only two cancers of this site were registered in Alaska, one each in both sexes in 1984-1988, while in Greenland 9 cases were reported in women and 13 in men, and Canada reported 5 cases in women and 6 in men (Table 2).

Many cancer registries do not register this site, but of those that do, only registries in China and Japan have as low rates as in the Inuit [7].

The rates in Denmark and Canadian registries are substantially higher, thus the SIRS for the Inuit are very low, with the upper 95% CIS substantially below 1.0.

Discussion.

Non-melanoma skin cancer is strongly related in Western populations to chronic sunlight exposure as well as to some occupational factors, exposures not common among Inuit.

With the destruction of the ozone layer in the Arctic, however, exposure of Inuit to carcinogenic ultraviolet radiation will probably increase.

It would be desirable, therefore, to monitor closely the trends of skin tumours (both melanoma and non-melanoma) among Inuit closely in the future.


Brain and central nervous system (ICD-9 191, 192) Results.

There were 36 brain and CNS cancers reported in women and 28 in men in the whole Circumpolar region over the 20 year-period of the study (Table 3).

Although the ASRs for these sites were low, they are not very different from many of the reported rates from registries around the world [7].

The SIRS have to be interpreted with caution, given the inclusion of benign brain tumours in the Greenland and Denmark data, and their exclusion in Canada and the United States.

When the appropriate SIRS are used (comparing Alaskan rates with Connecticut, Greenland rates with Denmark and Canadian Inuit rates with Canada), most of the SIRS are seen to be less than 1.0, though most of the upper 95% CIS are greater than one.

In women, more cases were reported overall, though not in Canada; some of the rates in Greenland in women were higher than in men.

Indeed, except for in 1974-1978, when only two cases were reported, the SIR for Greenland women approximated to 1.0 in comparison with Denmark.

Discussion.

The etiology of tumours of the brain and central nervous systems is largely unknown, except for some occupational exposures which can be expected to be rare in the Inuit.

Although the ASRs fluctuate wildly with time (Figs 1, 2), there is a suggestion of an increase of incidence with time, perhaps particularly in women, as has been seen in some registries elsewhere [10].

Increasing trends for brain tumours in many countries appear in part to be related to improvement in diagnosis, with separation of brain tumours from haemorrhagic strokes [11].

This separation may be more advanced in Greenland than in Canadian Inuit, and perhaps also so in Alaska.


Thyroid (ICD-9 193) Results.

In Western populations, thyroid cancer is much commoner in women than in men [7], and this differential appears also in the Inuit (Table 4).

Although the number of cases was small (with 27 thyroid cancers reported in women and 7 in men in the whole Circumpolar region over the 20-year period of the study), the ASRs for Alaskan and Greenlandic Inuit were similar to those in many other countries, except those for Iceland, which are surprisingly high, while ASRs for Canadian Inuit were low.

In women, most of the cases were reported from Alaska and Greenland, only two from Canada.

In the 20 years studied, the SIRS approximated to 1.0, with no evidence of a trend.

There were no thyroid cancers reported in 1969-1973 and in 1984-1988 in men, and only 7 in the three Inuit populations overall.

Of these, only one was reported from Canada.

Nevertheless, in spite of the small numbers, the SIRS for men in 1974-1978 in Alaska and Greenland and in 1979-1983 in all three areas approximated to 1.0.

Discussion.

The only major cause of thyroid cancer so far identified that could affect the Inuit is exposure to ionizing radiation.

There is some reason to be concerned that the exposure of Inuit to radioactive fall-out may be greater than in some other areas of the world, both from atmosphere testing of nuclear bombs in the 1950s and 1960s and perhaps especially from Chernobyl.

However, the latter exposure occurred too recently to have any effect on the reported rates.


Bone (ICD-9 170) Results.

This is a rare cancer in the Inuit with only 6 cases reported overall in women and 9 in men (Table 5), and most, as would be expected, in young people (Table 6).

This is also a rare tumour in the world [7].

However, the SIRs are greater than 1.0 in Alaska, though less than 1.0 in Greenland and Canada. Discussion. there are no particular etiologic factors known for these tumours which seem likely to affect Inuit.


Connective tissue (ICD-9 171) Results.

Again this is a rare cancer, with 10 cases in women and 7 in men overall (Table 7).

However, the cancer is also rare in other parts of the world [7].

Thus, although the SIRs are usually less than 1.0, the 95% CIS do not exclude the possibility of no difference with the comparison populations.

Discussion.

Connective tissue cancers are part of the grouping 'soft tissue sarcomas', suspected in some studies as being increased by exposure to herbicides and pesticides [12], known to accumulate both in the environment and eventually in some of the traditional sources of the Inuit diet.

It is reassuring that no obvious increase occurred in the incidence of cancers of this site, though in view of their small numbers the confidence to be placed in this observation is probably low.


Eye (ICD-9 190) Result.

Only three cases of eye cancer were reported in men and none in women, including two from Alaska and one from Greenland (Table 8).

The two from Alaska were both in the age group 0-4 years, presumably indicating retinoblastomas in infants.

The case from Greenland is a malignant melanoma in an Inuit man aged 35-39 years.

Discussion.

There are no known etiologic factors for such cancers that would seem to be particularly relevant to the Inuit.


Unspecified and secondary tumours There were 128 such cancers in women and 122 in men for the whole Circumpolar region, accounting for 7.5 and 7.9% respectively of a total number of cancers, 1712 in women and 1538 in men (Table 9).

For each Inuit population, the SIRS were significantly greater than 1.0, except for men in Canada.

There is no particular indication that the rates of these unspecified tumours decrease with time in either sex.

Only 62% were histologically verified (Table 10).

The presence of such large numbers of cancers in these categories suggests that some caution is necessary when attempting to interpret apparently reduced rates in Inuit in sites with small numbers of cancers.

Only for sites, such as breast, where it seems unlikely that a major failure to make a diagnosis would occur, is it appropriate to consider the reduced incidence in the Inuit as being confirmed.

It is important that in the future every effort be made to reduce unspecified sites and primary unknown cancers to a more reasonable level, recognizing the difficulties of obtaining accurate cancer registration from remote and isolated populations.


Other specified sites There were 43 cases of cancers in other specified sites in women and 26 in men overall (Table 11).

The sites included in this category are: peritoneum and retroperitoneum, ill defined sites of digestive organs, pleura, mediastinum and ill defined sites of thorax, uterus NOS, unspecified female genital organs, urethra and unspecified sites of urinary system, endocrine glands, ill defined sites and tumours of unspecified nature.

For women the SIRS in comparison with the Canada and Denmark cancer registries approximate to 1.0, except for the Canadian Inuit.

For men the SIRS approximated to 1.0.

However, further exploration of these findings are not possible considering them as a group.

Nevertheless, there is not the same concern about these cancers as compared with the unspecified and secondary cancer group, as they cannot impact on the interpretation of the findings on other specified sites.


Detailed tabular material by 5-year calendar periods 1969-1988 is available upon request.

Please contact the Danish Cancer Registry, Danish Cancer Society, Strandboulevarden 49, DK-2100 Copenhagen, Denmark.


A total of 242 citations were identified by the literature search, and 7 articles were deemed potentially eligible (Figure E2, online).

Of these, 3 placebo-controlled ran- domized trials included venous thromboembolic events as a primary outcome and were analyzed according to cancer subgroups.

6-8 The baseline characteristics of the included studies are depicted in Table 1.

None of the studies reported a definition for cancer status.

These 3 major trials included 307 cancer patients out of 5134 total study subjects (6%) and compared thromboprophylaxis (enoxaparin 40 mg, dalteparin 5000 IU, or fondaparinux 2.5 mg daily) with placebo.

11-13 The pooled relative risk of venous thromboembolic events was 0.91 (95% confi- dence interval, 0.21-4.0; I 2 : 68%) among hospitalized patients with cancer who were receiving thromboprophy- laxis compared with placebo (Figure 1).

None of the trials reported the rates of major bleeding episodes according to the cancer status.


An additional 4 placebo-controlled randomized trials reported symptomatic venous thrombo- embolic events as a secondary end point.

14-17 However, none of the trials reported the rates of symptomatic venous thromboembolic events or major bleeding episodes ac- cording to cancer status, and cancer-specific venous thromboembolic events rates for analysis were not made available by the primary authors or primary funding sources.


The study quality of the included randomized controlled trials was adequate.

All randomized controlled trials reported adequate sequence generation, allocation conceal- ment, blinding, and outcome reporting.

Only 1 of the trials 7,18 had a study protocol available, but all expected outcomes were reported for all other studies.


We acknowledge that the limited amount of data included in the pooled analysis is problematic; however, these same data guide the formulation of clinical practice guideline recommendations and Medicare-type pay-for-performance incentives.

Hospitalized patients with cancer constitute a unique population with increased risks for both venous thromboembolic events and major bleeding.

Our analysis highlights the fact that the risk-benefit ratio of current doses of thromboprophylaxis administered to all patients with cancer who are admitted for medical illness is unclear, and additional randomized trials are necessary to establish which cancer cohorts benefit from the routine administration of low molecular weight heparin.


A systematic literature search strat- egy was conducted using MED LINE, EMBASE, the Cochrane Register of Controlled Trials, and all Evidence-Based Medicine Reviews to identify all random- ized controlled trials comparing a low molecular weight heparin with placebo in hospitalized medically ill patients (Figure E1, online).

References of included studies and narrative reviews were reviewed for additional potential studies.

The protocol and systematic search strategy of the review are documented online (International Prospective Register of Systematic Reviews [PROSPERO] registry - CRD42012002845).

The search was restricted to humans.

There were no restrictions on language or publication year.


With the use of a structured question format to aid the literature search strategy, all abstracts were reviewed.

Potentially relevant articles were reviewed in full length to ensure that they satisfied 3 criteria: (1) prospective enroll- ment of consecutive hospitalized medically ill patients; (2) patients were randomized to parenteral pharmacological thromboprophylaxis or placebo; (3) one or more of the primary or secondary outcomes were reported according to the cancer status.


The primary end point was venous thromboembolic events.

Venous thromboembolic events were defined as a composite outcome of: deep vein thrombosis by protocol scheduled screening studies; symptomatic deep vein thrombosis (distal or proximal) or pulmonary embolism; fatal pulmonary embolism; or sudden death without another plausible cause.


Secondary end points included major bleeding episodes and symptomatic venous thromboembolic events (lower limb deep vein thrombosis and pulmonary embolism).

Two reviewers (MC and PM) independently assessed the eligibility of articles identified in the initial search strategy for inclusion in the review; discussed those deemed potentially eligible; independently extracted data (baseline characteristics, definition of outcomes, numbers of events) using a standardized data abstraction form; and assessed studies' methodological quality using the Risk of Bias Assessment Tool from the Cochrane Handbook for ran- domized trials.

9 Corresponding authors of articles were contacted if the primary or secondary out- comes could not be extracted from the original article.


Relative risk using a random effect model was used as the pri- mary measurement with 95% con- fidence intervals.

The I 2 statistic was used to estimate total variation among the pooled estimates across studies.

An I 2 greater than 50% was considered as high level.

10 Analyses were performed using StatsDirect software version 2.7.3 (StatsDirect Ltd, Cheshire, UK).


No benefit was found for the use of primary thromboprophylaxis with anti- coagulants to prevent venous thrombo- embolism in all patients with cancer who were hospitalized for medical illnesses.

The safety of primary thromboprophy- laxis in hospitalized medically ill pa- tients with cancer is unknown because the rates of major bleeding episodes have never been reported.


This is the first systematic review and pooled analysis assessing the efficacy of parenteral thromboprophylaxis among patients with cancer who were hospitalized for medical reasons.

In our analysis, only 3 randomized trials were used, and we observed no benefit for the use of low molecular weight heparin or fondaparinux to prevent venous thromboembolic events in hospitalized patients with cancer.


The apparent lack of efficacy of thromboprophylaxis in hospitalized patients with cancer might be explained by a number of reasons.

First, heterogeneity between studies was apparent (I 2 : 68%).

It is possible that fondaparinux is less efficacious compared with dalteparin or enoxaparin in can- cer cohorts.

However, in patients undergoing cancer-related major abdominal surgery, fondaparinux was as effective as dalteparin in the prevention of postoperative venous thromboembolic events.

19 Likewise, fondaparinux seems to be as effective and safe as low molecular weight heparin or unfractionated heparin for the treatment of patients with cancer with acute venous thromboembolic events.


Second, the recommended thromboprophylactic doses might not be optimal for hospitalized patients with cancer.

Previously published studies assessing higher doses of low molecular weight heparin as primary thromboprophylaxis agents in ambulatory patients with cancer undergoing chemotherapy reported higher relative risk reduction of venous throm- boembolic events 21,22 compared with studies using standard dosing.


Third, none of the included studies random- ized patients according to their cancer status or stratified patients according to their underlying risk of venous thromboembolic events, which was shown to be influenced by biomarkers, tumor type, and body mass index for The American Journal of Medicine, Vol 127, No 1, January 2014 chemotherapy-associated venous thromboembolic events in outpatients.


Finally, a relatively small number of patients were included in the 3 studies (N ¼ 374), reflecting inade- quate power to detect a small relative benefit.

The popula- tion of patients with cancer enrolled in clinical trials assessing mortality as the primary end point could not be included in this analysis.

However, the low rates of symp- tomatic venous thromboembolic events reported in these trials and the concern regarding the lack of accuracy as a secondary end point 26 are unlikely to significantly change our conclusions.


The risk of bleeding for hospitalized patients with cancer receiving thromboprophylaxis remains unknown because none of the included trials reported rates of major bleeding episodes among patients with cancer nor were we provided access to these data.

Therefore, it is currently impossible to accurately assess the riskebenefit ratio of thromboprophy- laxis in patients with cancer who were hospitalized for medical reasons.


New oral direct Xa inhibitor anticoagulants (rivaroxaban and apixaban) have been evaluated as thromboprophylactic agents in hospitalized medically ill patients.

27,28 A recent trial assessing the efficacy of rivaroxaban 10 mg daily for 35 days has showed that rivaroxaban was noninferior to enoxaparin at 10 days and superior to enoxaparin and pla- cebo at 35 days. 28 However, rivaroxaban was associated with an increased risk of major bleeding at both 10 and 35 days.

A subgroup analysis including 592 patients with active cancers yield similar conclusions.

Therefore, the risk- benefit ratio of thromboprophylaxis with oral anti-Xa in hospitalized patients with cancer remains uncertain, and future trials are needed.


To the Editor:


We read with great interest the literature review by Carrier et al [1] indicating the lack of evidence to support thromboprophylaxis in hospitalized medical patients with cancer.

However, this paper will change little if any of our clinical practice.

The authors acknowledge that only 3 placebo-controlled studies, including 307 cancer patients, were analyzed.

Moreover, the site and the stage of the cancers were not indicated, whereas patients with cancer are at high risk for deep vein thrombosis and pulmonary embolism, a common cause of death, depending on both tumor site and disease stage.

Of note, several current guidelines strongly recommend routine thrombophylaxis [2].

Indeed, pathogenesis of thromboembolic complications involves venous stasis due to immobilization and venous compression, endothelial damage related to chemotherapy and venous catheters, and blood hypercoagulability such as thrombocytosis and hyperﬁbrinogenemia [3].

Risk factors for venous thromboembolism in cancer patients are well known, including patient-related factors (age >65 years, comorbid conditions, prior history of venous thromboembolism, heritable thrombophilia), cancer-related factors (pancreatic, gastrointestinal, lung primary site; initial 3-6 months after diagnosis; current metastatic disease), and treatment-related factors (such as current hospitalization, active chemotherapy, active hormonal therapy, and thalidomide or lenalidomide therapy) [2].

Thromboprophylaxis is recommended, at least in these patients with acute illness at high risk for thromboembolic events.

Conversely, thromboprophylactic treatment is clearly underutilized in nonsurgical cancer patients with acute medical illness (<40% of patients) [4].


In conclusion, we will continue to prescribe thromboprophylactic treatment in our hospitalized medical patients with cancer at high risk when there are no contraindications to such therapy, and we encourage our colleagues to improve compliance to current guidelines.


We thank Bachmeyer and Budman [1] for their comments on the evidence regarding the use of thromboprophylaxis in hospitalized patients with cancer.

As discussed in our article, we do not recommend avoiding the use of thromboprophylaxis among patients with cancer who are hospitalized with medical illness [2].

We aimed to highlight that the strong recommendations from clinical practice guidelines supporting the use of thromboprophylaxis in this population are based on limited evidence and largely derived from data on patients without cancer [3], [4].


Furthermore, a number of uncertainties regarding the efficacy and safety of thromboprophylaxis among hospitalized medically ill patients with cancer are worth reemphasizing.

The current recommended thromboprophylactic doses may not be optimal for hospitalized patients with cancer, especially considering that higher doses of parenteral thromboprophylaxis in ambulatory patients with cancer have been shown to be efficacious [5], [6].

It remains unclear whether all patients with cancer who are hospitalized with medical illness require pharmacologic parenteral thromboprophylaxis.

Risk-adjusted models, such as the Padua scoring system, include additional risk factors (e.g., elderly age ≥70 years, previous venous thromboembolism, reduced mobility for at least 3 days) for patients with cancer to be considered high risk for venous thromboembolism during their hospitalization [7].


Finally, patients with cancer who are receiving anticoagulant therapy are at increased risk of bleeding compared with patients without cancer [8].

The rates of major bleeding episodes among hospitalized medically ill patients with cancer receiving parenteral thromboprophylaxis have never been reported and represent an important knowledge gap.

Therefore, it is currently impossible to accurately assess the risk-benefit ratio of thromboprophylaxis in patients with cancer who are hospitalized for medical reasons.

Additional prospective and randomized controlled trials assessing the efficacy and safety of routine administration of parenteral thromboprophylaxis in hospitalized medically ill patients with cancer are desperately needed.


Since the nineties, curriculum making has been characterized by global pervasiveness and great diversity across state school systems (Rosenmund, 2016).

As part of the global alignment in curricu- lum making, Norway, as other European states, has moved from being primarily based on inputs and Didaktik, to being more concerned with outputs and teacher efficiency (Mølstad, 2015).

This relates to Hopmann's (2003) observations of a shift from process-control to product-control in state curriculum making, and the associated description of the way western states deal with welfare problems shifting from 'management by placements' towards 'management by expectations' (Hopmann, 2008).

The latter strategy entails a tendency to solve ill-defined problems with more clearly defined expectations, such as benchmarks, goals and standards, made visible by the massive impact of internationalized accountability policies (Hopmann, 2008).


There is now a substantial amount of research that discusses the global convergence of account- ability-policies and out-put and competency-based models for curriculum control, although varia- tion exists in terms of explaining why such global ideas spread and what happens to them in the encounter with national and local curriculum contexts (Anderson-Levitt, 2008; Hilt et al., 2019; © 2021 The Author(s).

Published by Informa UK Limited, trading as Taylor & Francis Group.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

Nordin & Sundberg, 2018; Winter, 2012) Although the spatialized processes of curriculum making in a global, complex world seems to be a rather well-covered research theme, however, the temporal aspects of curriculum making is, except for a few recent studies (Bachmann et al., 2021; Hansen & Puustinen, 2021; Hansen et al., 2021; Lee, 2021), a rather unexplored field of curriculum research.


It is pertinent to assume that the shift towards product-and output-control has consequences for the construction of time in curriculum making.

Following a line of thought from Niklas Luhmann's systems theory, curriculum-makers now deal with risks by constructing cognitive expectations on the basis of prospective, future conditions (Luhmann, 2000, p. 266; Sivesind et al., 2016), rather than referring to past decisions, heritage or tradition.

Thus, one can assume that in a regime of 'manage- ment by expectations', the future, rather than the past, becomes the reference point for curriculum- changes.

However, efforts at turning to the past by restoring tradition and a lost moral heritage in curriculum making can also be observed (e.g. Ball, 1993; Neumann et al., 2020), reflecting what Zygmunt Baumann (2017) calls the 'retrotopia' of an ideal past.


The contribution of this paper lies in understanding the complex evolution of global educational reforms as a temporal process in which policymakers try to come to terms with an uncertain future by reconciling the educational present with conceptions of the future and the past (See also Mangez & Vanden Broeck 2020).

To do so, we will analyse curriculum changes in Norway through concepts from the late Luhmann's (1998, 2013, 2011) 'theory of difference', to give meaning to the different communicative strategies used by Norwegian policy makers, in their efforts at dealing with complex- ity and an uncertain future.

The empirical case for investigation is a diverse range of material, documenting curriculum changes in Norway in the time span of 1988-2020.

However, processes related to the newest reform in Norway, Renewal of the Knowledge Promotion Reform (LK20), implemented in 2020, will be at the forefront of the analyses.


This temporal analytical approach will add complexity and richness to our understanding of new curriculum reforms.

The paper illuminates how policymakers, in their attempts at reconciling present pasts and present futures in curriculum making processes, are faced with paradoxes and indetermi- nacies that needs to be solved communicatively.

The paper suggests that in the period of 1988- 2020, Norwegian policy makers use increasingly complex de-paradoxification strategies to solve curricular indeterminacies, finally resulting in hybridization of 'old-' and 'new curriculum' in the newest reform LK20.


Firstly, a well-known, and perhaps also controversial, use of systems theory in curriculum studies, is the so-called constructivist theories of learning (e.g. Rasmussen, 2001) in which Luhmann's concepts and distinctions are used to theorize the relationship between psychic and social systems of meaning.

According to Terhart (2003), Luhmann-inspired constructivist theories of learning is a central theoretical component of the heterogenous conception of 'constructivist didactics', emphasizing principles for teaching and learning, such as pupils' own construction of knowledge, self-monitoring, and autonomy, as well as learning in real-time situations.

Speaking in general terms, these ways of engaging with Luhmann's theory use his rather abstract vocabulary to re-describe pedagogical phenomena in new and proposedly more fruitful ways.


Secondly, Luhmann's theory has been used to sketch out a reflection-theory of education and curriculum-making, to encounter the 'crisis of didactics' and the problems of connecting theory to practice in education.

A pertinent example is a recent study by Vollmer (2021), who builds a theory of General Subject Didactics (GSD), inspired by Luhmann's philosophy of science and his notion of observations of different orders.

Vollmer's theory of GSD consists of three observational layers (first, second, and third-order observations), used to conceptualize the process of didactic theory- building: from teachers' and pupils' observations in context of subject specific teaching and learning, via observing and researching these observations systematically in the context of subject didactics (SD), to finally comparing and generalizing experiences and observations at the level of General Subject Didactics (GSD).

Vollmer (2021) thus applies systems theory to build a fruitful reflection- theory, enabling teachers to build powerful educational knowledge that combine personal experi- ences with both empirical evidence and abstract thinking.


Thirdly, Luhmann's theory has inspired researchers interested in studying curriculum changes through the lens of systems theory as a sociological theory of education.

These studies tend to use Luhmann's theory heuristically and on a second-order level of observations, studying curriculum changes as representations of the educational systems relationship with its societal environment, consisting of politics, economy, family etc.

The works of Hopmann (2003, 2008) on school govern- ance and the evaluation of curriculum reforms may be seen as being inspired by systems theory, in his emphasis on the role of institutions and systems as means for problem-solving in a modern society.

Other studies from JSC that apply perspectives and concepts from systems theory are studies of the governing of the teaching profession (Lee, 2021; Wermke & Höstfält, 2014), teaching- communication in the age of accountability (Aasebø et al., 2017), the relationship between schools and parents (Gellert, 2005), as well as the relationship between education and the economy (Bank, 2012).


An important work in the use of systems theory in comparative research of curriculum making, is Rosenmund's (2016) analytical framework for comparison of school reforms between different countries, showing how systems theory is suitable for studying non-linear processes of curriculum change within the framework of an all-encompassing systems theory of society.

Furthermore, two very recent studies in JCS observe, equal to our study, aspects of temporal constructions in curriculum making from a systems theory perspective.

Hansen and Puustinen (2021) studies of how society is presented in Finnish social studies textbooks, contributes to studying curricular representations of temporal forms of knowledge in a functionally differen- tiated society, while Bachmann et al. ( 2021) analyses teachers work plans in Norwegian schools through the lens of Luhmann's (2000) distinction between conditional and purposive programmes.


This paper is positioned in the third category of Luhmann-inspired studies of curriculum change, that is observations of curriculum changes by utilizing the elementary form of social systems (system/environment) heuristically.

Such a sociological and abductive application of Luhmann's theory does not necessarily entail a subscription to for instance, constructivist learning theories.

The paper is rather inspired by Luhmann's (1995) own encouragement to redescribe society by the means of his theoretical instruments at the level of second order observations.

However, as the use of systems theory in curriculum studies is manifold, we will build our presentation of the analytical framework in the next sections mainly on Luhmann's own works.


In the following sections, we will give an introduction to systems theory as analytical framework for analyses.

From the late 1980s and onwards, Luhmann's writings are much inspired by the logician George Spencer-Brown's (1969) seminal work Laws of forms, marking a difference-theoretical turn of systems theory (Borch, 2011).

This paper will present concepts related to this late phase of Luhmann's oeuvre.

Spencer-Brown's theory of distinctions allows Luhmann to refine his theory of social systems as autopoietic (self-producing) systems of communication, by engaging with con- cepts such as observation, distinction, form, re-entry, paradox, and de-paradoxification.

These concepts highlight the temporal primacy of systems theory, which offers a unique contribution to understanding curriculum change as efforts at dealing with temporality.


A basic claim of system theory is that education is one of many global, 'autopoietic', functional systems (politics, economy, science, art, etc.) in the world society, serving as an ever-emerging communicative and semantic complex-reproducing its own particular forms of meaning (Hilt, 2016a; Luhmann, 1995).

This has consequences for how we think about educational and curricular change, and thus for the analytical approach selected for this paper.

Firstly, and in agreement with Rosenmund (2016), we suggest that systems theory is suitable for studying non-linear processes of curriculum change within the framework of an all-encompassing systems theory of society.

Secondly, however, as a global, functional system, education is not restricted by spatial or regional boundaries (Luhmann, 2013), thus calling attention instead to the temporal characteristics of curriculum change.

Thirdly, global functional systems, such as education, serve as (ever-emerging) reservoirs of meaning that are available for communicative selections, conceptualized as semantics (Hilt, 2016a; Luhmann, 1995).

This makes systems theory a well-suited approach for studying curriculum changes as semantical changes, that is as emerging forms of meaning.


In this section, we will start with presenting concepts that are of relevance for studying curriculum change from a systems theoretical perspective, namely meaning, distinctions and forms.

According to Luhmann, meaning is the fundamental concept of sociology (Habermas & Luhmann, 1971), defining it as a distinction between actuality and possibility: 'everything actual has meaning only within a horizon of possibilities indicated along with it' (1995, p. 65).

This implies that meaning, in a systems theoretical perspective, is a processing of information according to distinctions (Luhmann, 1995) Something is indicated, while all else constitutes a horizon of further possibilities.

This conceptualiza- tion of meaning allows Luhmann to incorporate Spencer-Brown's (1969) Logic of forms into his theory, and the injunction 'Draw a distinction'.

Without a distinction, nothing will happen; no meaning-making process will emerge.


The theory of distinctions, further developed in Luhmann's later works, thus entails that one always observes by drawing a line between this and something else. ( Luhmann & Behnke, 1994).

A distinction, for example, education/environment, is selected, and one of the two sides is indicated as a marked space, for example, 'education'.

Even though it is the indication that is made explicit, an observation is always a distinction.

The other side, in this case 'environment', is always present, but the distinction is hidden; it constitutes an 'unmarked space'.

All observations are based on a distinction and an indication, which together are conceptualized as a form of meaning (Luhmann & Behnke, 1994).

Form and distinction can be illustrated like in Figure 1.

Luhmann (1995) states that a social system is not a given entity but emerges as a difference between a system (self-reference) and its environment (other-reference).

A system thus develops through the kind of boundary-making implied in Spencer-Brown's theory of difference, creating itself as a chain of distinctions (Luhmann, 2006a).

The distinction between education and its societal environment is, for instance, being constituted when the same type of operations, communication with the intention to educate, are selectively connected (Luhmann, 2006b), thus setting the boundary between educational operations and everything else.

It is thus the recursive meaning-making and self-production of distinctions that constitutes the autopoietic functioning of social systems- communication that connects to further communication (Luhmann, 2006a, p. 46).

Engaging with systems theory in analyses of curriculum changes, implies being committed to 'second order observations' of the educational system.

In a so-called first-order observation, the observer only sees the marked side of the distinction, unaware of the contingency and blind spot of the observation.

A second-order observation is more advanced, however, and occurs when the same or different observer observes the distinctions used in the first observation, illuminating the double- sidedness and contingency of forms (Luhmann & Behnke, 1994).

In this paper we will thus 'observe observations', uncovering the educational forms and distinctions that emerge in Norwegian curri- culum in the timespan 1988-2000.


Luhmann (1998, p. 67) states 'As never before, the continuity from past to future is broken in our time'., thus turning attention to the problem of temporality in social systems.

In modern society, each of the functional sub-systems establishes a highly selective set of system/environment relations (Luhmann, 1995), leaving each perspective with the burden and privilege of constituting its own world (Corsi, 2020).

Due to this global, differentiated nature of worldwide communication, contin- gency is a defining feature.

The complexity of society increases at an accelerated pace, rendering the future fundamentally uncertain.


Systems must deal with this complexity, and the excess of opportunities related to meaningful communication, either by self-organization on the operative (structural) level and/or by selection at the semantic level (Luhmann & Schorr, 2000, p. 58).

On the structural level, distinctions are opera- tively accomplished by self-organization, the 'simple continuation of their own operations' (Luhmann, 1998, p. 10).

Social systems are thus characterized by a fundamental instability.

Elements have the character of events-they vanish immediately after their appearance and are continually replaced by other elements (Luhmann, 1995).

Thus, social systems are not spatialized, but radically temporalized systems.


Still, although the production of meaning emerges as unstable and changeable events in the world, some forms of meaning are preserved by social systems and constitute a semantic reservoir for communication.

On the semantical level, one can thus observe preserved structures of meaning, in other words: 'a supply of possible themes that are available for quick and readily understandable reception in concrete communicative processes' (Luhmann, 1995, p. 163).

Hence, while meaning is seen as specific operations, semantics are condensed, durable and generalized forms of meaning (Hilt, 2016b).


Semantics are produced as the system observe, reflect, and describe its own identity-as distinct from its environment.

If the system can distinguish between itself and the outside, so that it does not Figure 1. become enmeshed with its environment, operations can be observed, accounted for, and controlled.

Self-observations thus allow for reflexivity.

The system can observe either its system side (self- reference), its environment side (other-reference), or the unity of the system/environment distinction (identity, rationality) (Luhmann, 1998).


In the educational system, observations set a difference between the pedagogical intention to educate (self-reference) and the educational outcome (other-reference).

Curriculum, as programmed education, ensures the wholeness or unity of this distinction (identity, rationality), limits the space of opportunities related to meaningful education, and conditions further educational communication (Luhmann, 2006b; Luhmann & Schorr, 2000).

In Luhmann's (2006b) theory, curriculum is thus conceptualized as selected meaning (semantics) or 'decision-making programmes', in which the system observes and describes itself and its environment.


Systems observe and describe themselves through semantics in a factual (what), social (who), and most importantly for our analyses, a temporal dimension (when) (Luhmann, 1995).

Time, in a systems theoretical perspective, is thus the interpretation of reality in light of the difference between (present) past and (present) future (Luhmann, 1995, p. 78).

This implies that the educa- tional system creates its own time horizon, that is, its own past and future.

By observing itself through the form of time, the system can make selections on the basis of prospective, future conditions, either by trying to attain certain situations or to avoid them (Luhmann 1990, p. 4; Hilt, 2016b).


Based on self- and external observations the educational system produces reflection theories (Luhmann & Schorr, 2000) and more durable forms of meaning (semantics) in the form of 'pro- grammed education' such as curriculum and reforms.

However, as decision-making programmes these are constituted by a unity of the observed distinction: the difference between the education system and its environment.

Thus, they are inherently paradoxical.


Decision-making programmes depend on the educational system observing its own environment to structurally couple and adjust to it, but as systems are operationally closed, the educational system does not have access to a real world-only a world that is constructed by the system itself.

The question is then: How can the educational system create forms of meaning relevant to its outside world, aka curriculum, when it does not have access to this world per se?

Furthermore: How can the educational system make decisions about the intentions to educate and the content of curriculum when the future is fundamentally open and insecure?

The educational system is thus faced with paradoxes and indeterminacies that must be solved by inner-systemic means (See also Mangez & Vanden Broeck, 2020).


According to Luhmann, systems may use different communicative strategies to postpone, hide, or solve their own paradoxical state, and we will now present four different strategies that are used abductively in our analyses.

First, as every observation is a distinction between two sides, constitut- ing a form of meaning, the paradox may result in a standstill.

In the case of crossing, the system merely crosses back and forth between the indicated side and the outside (Luhmann & Behnke, 1994).

It is thus not unfolding the paradox, but merely oscillating between its two sides, for instance, between education and non-education (e.g. politics, global forms of meaning).

Oscillation entails that the system is unable to select and continue its operations in one or another direction; no new meaning is created.


In the case of asymmetrisation, however, the system observes both sides of a distinction (the indicated side and outside), but the indicated side is lopsided.

The form is asymmetrical, as the indication serves as a preferred side, while the outside serves as the disregarded selections.

While this enables the system to move on, it does not really solve the paradox; it merely postpones it.

The strategy of externalization implies that the system selectively connects to its environment to provide additional meaning and continue its own communication.

Curriculum-makers may, for instance, selectively connect to values or value-laden ideology, history, and traditions, or external 'world situations' such as internationality/globality, in order to solve curricular paradoxes and problems (Luhmann & Schorr, 2000; Schriewer, 1989).

Externalization thus operates like floodgates, in which a system opens or closes to its environment according to internal criteria (Luhmann & Schorr, 2000).


The most abstract way of dealing with paradoxes is to dissolve the paradox by internalization (re- entry).

The distinction system/environment now occurs twice in the system, as the initial operative distinction, and as a self-observing 'representation' of the first distinction (Luhmann & Behnke, 1994).

This duplication of the system/environment distinction both changes and maintains the paradox between the positive and negative value by reformulating the paradox as a distinction within the distinction.

In Teubner's words: 'the frame reappears in the picture, the boundary becomes part of the territory' (Teubner et al. 1997, p. 156).

This highly abstract systemic function of re-entry may thus result in systemic duplications and systemic growth.


Based on the presented theoretical framework we conducted document analyses (Lyngaard, 2010) of policy and curriculum documents.

Key policy and curriculum-documents constituting the new Norwegian reform, Renewal of the Knowledge Promotion Reform (LK20) are our prime focus.

However, to show development in meaning over time, material from the two previous reforms, Reform 1997 and the Knowledge Promotion Reform 2006, as well as research on these curriculum developments, are included.

The reading of policy and curriculum documents was structured in four phases, described as followed:


We read a vast amount of Norwegian policy and curriculum documents, as well as research on policy and curriculum changes, covering the timespan 1988-2020.

Some documents were selected for further analyses, some as 'forefront-documents' documenting changes in the latest reform, LK20, others as 'background-documents' illuminating semantical changes up until this reform.


2nd phase: A reading of curriculum changes in Norway from 1988 to 2014-up until the preparations of LK20.

This period of curriculum change in Norway is already well-documented in policy- and curriculum research.

To reconstruct the most significant semantical changes of the period until the last reform, we did extensive reading of central policy- and curriculum documents, in combination with findings of existing research.


3rd phase: Analysis of curriculum changes in Norway in the timespan 2014-2020-from the initiation of the latest reform LK20 to its implementation.

This is a recent phase in Norwegian curriculum making, less documented by research.

We thus performed a document analysis, including Norwegian white papers, official Norwegian reports, as well as documents from transnational policy networks that have been inspirational for the reform (See appendix 1 for overview of documents).


The reconstructed semantics from the previous analytical phases were analysed as a whole, applying systems theory as analytical framework.

The analysis of forms as binary schemes, the temporal distinction between past and future, as well as the different deparadoxification- strategies presented in the theoretical section, were used abductively to give meaning to curriculum changes in Norway in the timespan 1988-2020.


In this section, we will explore how changing observations of the past and the future have served as legitimizing points of reference for emerging reforms.

The Norwegian school system has been characterized by social democratic values and a strong emphasis on equity, participation, and democracy (Arnesen & Lundahl, 2006; Møller & Skedsmo, 2013).

Based on the European tradition of Didaktik, the essential aim of education has been Bildung, understood in terms of growth and autonomy through individual engagement with the subject matter (Willbergh, 2016).

Consequently, curricula have traditionally been based on knowledge, teaching, and content (Sivesind & Karseth, 2019), combined with a strong sense of national integration and reconstructions of Norwegian cultural heritage (Hilt, 2020).


During the 1980s, a gradual shift in educational semantics has been observed by researchers, in which the educational system at a global scale became increasingly oriented towards its economic and political environment (Wiborg, 2013; Hansen 2011; Telhaug et al., 2006).

Market-oriented ideas, originally developed in the US and Great Britain, were picked up by the most influential supra- national actors in education, such as the EU, OECD, and the World Bank (Dale, 2005).

From the perspective of systems theory, this can be conceptualized as externalizing efforts, in which the system selectively connects to its environment to solve inner-systemic problems and provide additional meaning to continue its own communication.


In Norway, an early trace of such externalizing efforts is to be found in an Official Norwegian Report from 1988 (Ministry of Education, 1988), describing adjustments to a society where the economy is increasingly dependent on the production of human capital.

Concomitantly, the concept of competence was introduced in Norwegian education policy, and the concept has since, gradually substituted and/or complemented the concept of 'knowledge' (Tolo, 2017).

In a systems theory perspective, policy and curriculum makers' externalizing efforts resulted in semantical changes, in which new forms of meaning emerged, and existing forms of meaning changed.

Expressed in the language of the theory of distinctions, the form of competence is emerging, constituted by the distinction between competence (indication) and knowledge (outside).


These changes followed a period (1970s and 80s) where Norwegian schools and teachers had enjoyed considerable autonomy due to reforms emphasizing de-centralization, school-based development and community-based curricula (Aasen, 2003; Lauvdal, 1993).

As the economic crisis hits Norway along with the rest of the world, growing critique of the welfare state led to a general push towards market-oriented policies (Telhaug et al., 2006).

In education, a growing concern regarding the quality of schools and teachers and the ability of education to serve the economy, spurred debates about the governing of education (Aasen, 2003).

A set of internal reports and a report from the OECD (1989) questioning the decentralized system and lack of central control, underpin a White Paper issued in 1991 (Ministry of Church and Education, 1993) introducing the principle of management by objectives.

Described as a period of neo-liberal and neo conservative turn in educational governance (Telhaug et al., 2006), implementation of these principles, how- ever, is claimed to take yet another decade (Aasen, 2003; Imsen et al., 2017; Imsen & Volckmar, 2014).


Nevertheless, reforms addressing structure as well as substance of education were issued.

In 1997 a reform reinstalling central governing of education through a national curriculum evolving around the normative ideal of the unified school, presents very detailed expectations of content and teaching methods (See Ministry of Church and Education, 1996).

This reform has been described as a turn towards instrumentalist and elitist values (Hovdenak, 2004), and it was followed by a revision of the Education Act in 1998, changing the definition of education from a common good to an individual right (Imsen et al., 2017).


However, the 97-reform is also described as a revitalization of a 'nation building project' where educational content is founded on construction of what should be considered national heritage (Haug, 2003; Hilt 2020; Trippestad, 1999).

Thus, in this period, new forms of meaning (competence, life-long learning) and traditional ones (heritage, content, knowledge, Bildung) co-existed in the Norwegian curriculum.


Aasen (2003) interprets the policy of the 90s as a defence of the Scandinavian social-democratic model in the context of a cultural crisis resulting from postmodernist, relativist, influence on educational discourse.

Economic growth is promoted by combining concerns for the national economy with concerns for the distribution of wealth and securing the social democracy.

According to Aasen (2003) social-democratic ideas are now rearticulated as a need to improve the educational level of the population, thus combining human capital and management by objectives with a revitalization of social democratic progressivism.


From the perspective of systems theory, we can interpret these developments as efforts at dealing with the paradox and indeterminacy of selecting forms of meaning and educational content on the basis of observation of an uncertain future.

In response to the critique from OECD as well as internal actors, Norwegian policymakers combine two seemingly opposing strategies to continue the sys- tems communication.

The system temporally observes 'itself' (the system-side), resorting to past events and expectations (Bildung, national heritage, knowledge, and teaching), while also observing its environment, externalizing to an anticipated future, to 'world situations' and economic and political 'irritations'.


Accordingly, the evolution of educational structures in Norway was not a straightforward or linear process of replacing Bildung, national heritage, and 'input-based education' with competency-based education and 'management by objectives'.

The deparadoxification-strategy set in motion in the 90s, is rather one of crossing or occilation.

Based on our reading, Norwegian curriculum-makers resorted to temporal observations of the present past (past events, heritage, 'tradition'), and present future (future societal needs, competency, output-orientation), and crossed back and forth between these two forms of observations.


Based on this reading, one may ask if this strategy of oscillation made it difficult to re-specify the universal intention to educate in a concrete and coherent curriculum programme.

Rather than solving the systemic paradox, the system merely pendulates between observations of past and future, thus hiding the indeterminacy of the system.

This interpretation is supported by for instance, Jarning (2010), suggesting that Norway slowly adjusted to output-based education, while at the same time continuing a Norwegian tradition of input-based management of education through pre- set regulations such as selection of curricular content and structural conditions.

Observed through the perspective of systems theory, the state of Norwegian curriculum making can be interpreted as being at a standstill: by crossing back and forth between observations of past and future, the system is unable to select and continue its operations in one or the other direction.


In the PISA tests published in 2001, the performance of Norwegian pupils was shown to be mediocre compared to those from other OECD countries.

This so-called 'PISA shock' spurred new debates in Norway on educational quality and how to ensure educational outcomes relevant to future society (Hopfenbeck et al., 2013).

Observed through the lens of systems theory, one can interpret this as a rupture in the semantic evolution of Norwegian curriculum making, opening up a floodgate of externalizing efforts to the semantics of transnational organizations.

Governmental documents from this period (e.g.: Ministry of Education, 2003) show a strong inclination towards competency-based education, moving away from more 'traditional' educational forms, such as content decisions based on selections of what is considered a common national heritage.


These semantic developments culminated in the publication of a new Norwegian reform in 2006, the Knowledge Promotion Reform (K06), considered the first outcome-based curriculum in Norwegian history.

Rather than referring to past decisions, 'tradition', heritage, or subject content, the reform focuses on learning, learning outcomes, and measurable competence goals (Ministry of Education, 2003, section 4.2).

The forms of meaning that were given prominence in this curriculum reform, were basic skills (ferdigheter) and learning outcomes, while knowledge and content more or less disappeared and became 'blind spots' of the curriculum (See Ministry of Education, 2003).

Quality and output in schools were supposed to be governed through 'management by objectives' at individual as well as systems level (Ministry of Education, 2008)


Observed through the optics of systems theory, Norway was faced with the indeterminacy of an uncertain future in the wake of the 'PISA shock'.

The system thus observed itself in the temporal dimension to achieve future success and avoid new failures.

We cannot continue with 'business as usual', but at the same time, we do not know what the future will bring.

The deparadoxification strategy in this period, is one of asymmetrisation.

The system observes both sides of a distinction, i.e. new outcome-based education and old content-based curriculum, but as different from the strategy of crossing, the indicated side becomes lopsided.

The form is asymmetrical, as the indication (new outcome-based education) serves as a preferred side, while the outside serves as the disregarded selections (old content-based curriculum).


Still, semantical developments related to a strictly future-oriented, out-put based curriculum is not yet fully realized in the Norwegian curriculum of 2006.

As the core curriculum from 1993 (L93) was kept in an unrevised version and thus was still in effect in the 2006 reform, different rationales and intentions were expressed in different documents.

Due to this unrevised core curriculum (Ministry of Church and Education, 1993), traditional forms of general Bildung, normative integration, and cultural heritage had at least symbolic value and effect.


In this section, we will focus on the result of our systems theoretical analyses of policy and curriculum initiating documents leading up to the new reform, Renewal of the Knowledge Promotion Reform (2020), displaying the forms of meaning and deparadoxification strategies that are in force in this period.

In the aftermath of the previous reform (K06), evaluations displayed that learning outcomes were insufficient, and that the curriculum lacked coherence, with too many goals, unclear progres- sion, and a core curriculum that was not up to date with the latest educational developments (Ministry of Education, 2016, pp. 6-7).

These evaluations legitimized the need for curriculum revi- sions, opening up a new floodgate of externalizing efforts, thus leading up to the recent reform in Norway.


The process was initiated in 2013 by a White Paper (Ministry of Education, 2013) calling attention to two problems in the educational systems environment: a) increased diversity in pupils' needs and abilities and b) uncertain demands of future society and work life.

Policymakers were thus reflecting on how to ensure the inclusion of pupils (the social dimension) and secure outcomes based on the anticipation of an uncertain future (temporal dimension).

The White Paper in question suggested the appointment of an expert committee to reassess which competences and skills are needed in future society.


NOU 2015:8 (p. 9) expresses a clearly future-oriented vision: Society is changing at a more rapid pace than ever before, making it pertinent to promote suitable competences for the future.

Faced with a risky and undecidable future, the committee expresses externalizing efforts by turning to the semantics of the twenty-first-century skills movement to deal with future indeterminacy.

When comparing NOU 2015:8 with documents from OECD (2018) and KeyCoNet (2014, 2018), they are strikingly similar in meaning.

All documents promote competences and skills suitable for societal needs in the twenty-first century, and question whether the contents of national curricula ade- quately prepare pupils for life in and after school-so called 'real-world' situations.


The documents thus present an observation of the future as fundamentally uncertain, and questions whether it is possible to know what kind of knowledge that will be of relevance in the future.

The solution in all three documents is described as a major curriculum change in order to prepare students for a society that is completely different from societies of the past.

Competence- oriented curriculum designs seem to be the only solution to an unpredictable future, stating that national curricula are out of touch with present societal needs and thus are ripe for major moder- nization.

For example, KeyCoNet (2018, p. 6) expresses the advantages of a competence-oriented curriculum:


Competence-oriented education is regarded as advantageous in a time when the knowledge base of our societies is developing at an immense speed and when the skills required need to be transferred to and developed in many different societal contexts, including those unforeseen in the future.

These future-oriented observations, describing accelerated change and unanticipated needs, result in observations and descriptions of present-day education as being out of step with societal needs, pertinently described as the problem of curriculum overload (OECD, 2018, p. 6; KeyCoNet, 2014, pp. 6, NOU 2015,8, 43).

National curricula are considered generally overburdened with content, which is an obstacle to acquiring the skills necessary for leading a successful life or creating 'future-ready students' who exercise agency in their own education and throughout life (OECD, 2018, p. 5).


Accordingly, all three sources express strong scepticism towards content-based curriculum designs that are strongly associated with risks of being out-dated and insufficiently preparing students for the future (e.g. KeyCoNet, 2014, p. 6, 2018, pp. 6-8).

This example from KeyCoNet (2014, p. 5) illustrates this tendency: 'The key competence framework, with its emphasis on the application of knowledge in real world situations represents a significant departure from "traditional" content- based approaches (. . .)' From the perspective of Luhmann's theory of distinctions, the form of meaning in force, can be illustrated like in Figure 2.


The strategy of asymmetrisation implies that the indication (new outcome-based education) serves as a preferred side, while the outside serves as the disregarded selections (old content- based curriculum).

The system thus observes itself in the temporal dimension and finds little or less of importance in the past.

Traditional curricula based on content-decisions are associated with risk and, as the outside of the form of competency-based education, disregarded as a valid commu- nicative selection in the process of curriculum making.

Our reading thus suggests that Norway, faced with uncertainty and rapid changes in society, as well as a seemingly inadequate curricula, externa- lizes to the semantics of twenty-first-century skills, thus pushing the system forward and legitimizing a need for new reform.

While asymmetrisation enables the system to move on, it does not solve the paradox and the problem of relevance.

As will become clear in the next section-it merely post- pones it.


We will now turn to the governmental reform documents and the measures that finally became selected, uncovering the forms of meaning and paradoxification strategies that are displayed in the official curriculum.

According to Baek et al. ( 2018), the new Norwegian reform LK20 is designed as a two-pronged effort, targeting the two distinct but interrelated policy domains of curriculum and quality monitoring.

We will focus on the curriculum part, as it is introduced in White Paper 282,015/ 2016 (Ministry of Education, 2016, hereafter WP28), and the new core curriculum (Ministry of Education, 2017).


WP28 was published after the public hearing 3 of NOU 2015:8 and is structured in the following sequence: 1) policy suggestions from NOU 2015:8, 2) comments from the hearing, 3) the govern- ment's opinion.

The document can thus be understood as a second-order observation of the policy- initiating process, in which decisions are made as differences between past and future events in the system.

One of the main purposes of LK20 is to renew school subjects so as to enable more in-depth learning.

This decision is legitimized by a temporal observation: National subject curricula have previously been characterized by crowded curricula (WP28, p. 7).

If we are to prepare ourselves for an unknown future, stronger prioritization and cuts in the curricula will have to be made.


In agreement with KeyCoNet (2014, p. 5) and OECD (2018, p. 6), as well as the policy initiating NOU 2015: 8, the Norwegian government now argues for a broader concept of competences that include social and emotional aspects of pupils' learning, calling for a higher prioritization of knowledge, skills, attitudes, and values.

Furthermore, WP28 underscores the need for a new curriculum to better prepare students for 'life outside of school' by emphasizing transversal skills (p. 14).

Social and emotional skills, such as curiosity, resilience, self-regulation, collaboration, and creativity, are con- sidered of great importance for education, work, citizenship, health, and life coping in general (p. 14).


At first glance, the reform documents show the same tendency towards asymmetrisation as we observed in the policy-initiating process: 'new curriculum' promoting in-depth learning and social and emotional competences is privileged, while the 'old curricula', construed as over-crowded and promoting surface learning, is disregarded.

WP28 is thus externalizing to the semantics of twenty- first-century skills, now making these ideas and concepts an official part of Norwegian curriculum.

There are, however, also important differences, showing how the Norwegian government selectively connected to educational forms from the policy-initiating process.


The Norwegian government thus took a rather moderate stance on the issue, stating that social and emotional competences are not to be incorporated in the subjects' learning outcomes, and they are not to be assessed.

Schools may guide and train pupils' social and emotional competences, as they are preconditions for learning, but it is the pupils' knowledge and competences in the subjects that are to be assessed (WP28, p. 23).

As different from the policy initiating sources, WP28 relates social and emotional skills to the pedagogical intentions (self-reference) rather than the pedagogical outcome (other-reference).

The government externalizes to transnational policy-actors promoting social and emotional learning, but selectively connects to these observations in order to reconcile conflicts in the system.

As Baraldi and Corsi (2016) point out, reforms make visible differences of interest that otherwise would be only latent and left to discussions in organizational interactions.

When reforms produce controversial and sometimes contradictory self-descriptions, resistance and conflicts are made visible and dealt with in communication.

This way, the systems' self-descriptions are more realistic, increasing the decision-making potential of reforms by making it possible for organizations and persons with different viewpoints to accept and follow up on the initiatives.


Perhaps a bit surprisingly, the Norwegian government brings the concept of Bildung into the curriculum equation.

WP28 emphasizes familiarity with, and inauguration in, the Norwegian cultural heritage and explicitly states the importance of Bildung in the sense that pupils are to get knowledge of and eventually feel obliged to follow foundational norms and values of Norwegian society (WP28, p. 21).

As an educational form, Bildung adheres to the Didaktik tradition that has held strong prominence in curriculum-making in Norway. 5 However, in the process leading up to the reform, Bildung was more or less a blind spot.


At first glance, the new reform may be understood as an attempt at balancing competence-based education with Bildung, in alignment with traditional semantics in the Norwegian educational context: 'The educational system [kindergarten and school] must give children and young people the Bildung and education they need in order to master the future' (WP28, p. 5), 6 and in the core curriculum (p. 8): 'The purpose of schooling is both education and Bildung [danning]'.

Although the reform documents recognize the continuity with 'management by objectives' from the previous reform, they also reflect on the need for a common cultural framework based on ancestry and common values, as well as the need to provide teachers with guidance when selecting content.

Seemingly, at this point, LK20 does not create the same asymmetrical binary between new and old curriculum.


The question is, then, is LK20, similar to the reforms of 2006 and 1997, merely oscillating between educational traditions and external observations-between 'new' and 'old curriculum'? We will argue that we are rather dealing with a creative deparadoxifying strategy, a way of walking between the impasse of past and future in the system.


Looking more closely at the government's solutions, 'new' outcome-based education still has a structural primacy.

As stated in WP28 (p. 44): 'Curricula are not to be overcrowded by content-descriptions . . . .

A significantly stronger definition of concrete content in the curriculum is problematic'.

Despite symbolic intentions at preserving the notion of Bildung, LK20 is reluctant to select and define a curriculum content that might have 'Bildung potentiality'.

Rather, the balance between content and competence-orientation is to be ensured by indicating what kind of content, in terms of knowledge and skills, pupils are to acquire in order to reach competence goals.

This is in agreement with how Luhmann (2006b, pp. 212-213) described the semantic shift from Bildung towards 'outcome-based curriculum': The selection criteria no longer refer to the 'inner value' of the educational content, but to what degree the content enables pupils to practice their 'abilities to learn'.


Bildung is now not defined in traditional terms as pupils' self-realization in the encounter with a pedagogical content of value, but more as a kind of life-mastery in which pupils are to use their skills, values, and attitudes to deal with an uncertain and risky future (see, e.g. WP28, p. 21; Ministry of Education, 2017, p. 8).

Bildung is thus considered dependent on the development of competence and becomes oriented towards adaptability rather than autonomy.

The paradoxical unity of the difference between Bildung as the pedagogical intention and competence as pedagogical outcome seems to be temporally relocated: While competences are primarily about the pupils' learning outcomes in subjects, measured by annual benchmarks, Bildung is a kind of long-term output of education-oriented towards 'life itself', building explicitly on competences, but adding time.

Consequently, Bildung is now understood as 'lifelong learning' (see, e.g. WP28, p. 21)-re-entering the difference between intention and outcome.

The pupils are to develop knowledge, skills, and attitudes in order to participate in work life and communities-and to master their lives indefinitely.


Accordingly, Bildung does not have the same meaning in LK20 as in previous reforms but becomes 'competence-Bildung'.

The system moves beyond oscillation and asymmetrisation of old and new forms of education.

Rather, 'old' forms of education become relevant on the premise of future-orientation and 'new curriculum'.

The educational system thus internalizes the distinction between Bildung and competence to solve the paradox of identity and difference-it re-enters the distinction on the inside of the system, resulting in systemic morphogenesis, illustrated by the theory of distinctions in Figure 3.


The global tendency of emphasizing skills and output regulation has entailed a transformation of foundational concepts in curricula worldwide, from teaching, knowledge, and Bildung to learning outcomes, competences, and lifelong learning.

This relates to Hopmann (2003) observations of a shift from process-control to product-control in state curriculum making, and the related con- ceptualization of western states ways of dealing with welfare problems as a move towards 'management by expectations' (Hopmann, 2008).

If we were to interpret these shifts in curriculum making spatially, nation states with their local contingencies would be seen as increasingly adapting to the (teleological) processes of global standardization, fuelled by the powers of transnational organizations.

In this picture, the emergence of outcome-based education, as illuminated in our analysis of Norwegian curriculum reforms, would seem both evident and unavoidable, supported by large-scale measurement systems such as PISA.


This paper, however, has explored a different analytical perspective to illuminate the semantical evolution of outcome-based education, calling attention to the way educational forms and reforms come about in and through the observation and construction of temporality.

We have illuminated the evolution of curriculum in Norwegian education from 1988 to 2020 by utilizing concepts from the late Luhmann's highly temporal 'theory of distinctions', focusing on the forms of meaning and deparadoxification strategies that national policy makers use when dealing with future uncertainty.


In the late 1980s and 1990s, Norwegian policymakers turn to externalizing efforts observing the political and economic environment.

Semantics inspired by human resource management are introduced and neoliberal ideas about governing gains support in the face of increasing critique of the expenditure and quality of education.

This is in line with research showing how observations from international actors provoke systemic externalizations often conceptualized as international 'policy borrowing' (e.g. Steiner-Khamsi & Waldow, 2012).


Nevertheless, the evolution of 'new curriculum' in Norway was by far a straightforward process.

The 1990s reforms externalized not only to observations from the environment (e.g. policy- borrowing) to deal with future uncertainty, but also to observations of the national past, reconstruct- ing semantical forms of Bildung and national heritage.

The oscillation between future competency needs and past traditions thus made Norwegian curriculum quite contradictory in content, making it difficult to re-specify the educational intention.

Furthermore, the 'PISA shock' of 2001 prompted a floodgate of externalization, moving towards a clearer tendency of asymmetrisation, in which 'old curriculum' was called into question, while 'new curriculum', focusing on skills and learning out- comes, was seen as increasingly more incontrovertible.


The strategy of asymmetrisation was further strengthened in the policy-initiating process leading up to the most recent educational reform in Norway, LK20. ' Old curriculum', emphasizing educa- tional inputs and selected content, was now associated with the risk of being outdated-unsuitable for anticipating the uncertain demands of the future. ' New curriculum', however, emphasizing social and emotional skills, transversal competences and learning in 'real-time-situation', was considered timely.

Although this strong assymetrisation of 'new curriculum' made it possible to hide the paradoxical impasse of Norwegian education, the reform process leading up to LK20 emerged in more complex directions.


The reform documents of LK20 selectively connect to policy initiatives from OECD and KeyCoNet, mediated by the policy-initiating Norwegian Official Report NOU 2015:8.

Still, the reform documents proved to be selective in terms of which forms to introduce, and clearly modifies their semantic meaning.

This is especially evident in the way the reform chooses to dissolve the paradox of past/ future.

Rather than merely oscillating between 'old' and 'new' curriculum, or leaning in favour of 'new curriculum', the reform creates a new, hybrid form of education: 'new-old curriculum'.

Bildung is now re-conceptualized as life-long learning, a process resting on competences, with the purpose of mastering 'life itself'.

The distinction between competence-based education and Bildung is thus re- entered into the system, creating a new educational form of meaning: 'competence-Bildung'.

This new understanding of Bildung appears to play an important role in mediating between the time horizons of the (present) past and the (present) future in the documents of the LK20 reform.

Luhmann's (2006b) and Luhmann and Schorr (2000) historical-semantic investigations identify important shifts in educational meaning as modern society evolves from segmentary to stratificatory and functional differentiation.

Previously, Bildung 7 ensured the autonomy of the educational system by an idealized relationship between a canonized body of academic knowledge, representing 'the world', and individual self-cultivation.

Self-cultivation was indispensably related to educational content and school education.

The semantics of Bildung thus emphasized the autonomy of educa- tion, leaving little room for external societal demands (Luhmann & Schorr, 2000, pp. 88-94).


However, as Luhmann (1998, p. 4) states: 'The semantic apparatus of old Europe is no longer taken for granted as the common foundation of education'.

The emergence of mass schooling gradually undermined the canonical certainties of schooling, and the ability to learn has gradually replaced Bildung as the primary educational form ('contingency formulae').

This implied a semantic shift in which the autonomy of education no longer depended on a given body of educational content, and selection of educational content came to the forefront of education.

Education is no longer striving to ensure continuity between past and present by selecting heritage and normative integration patterns.

Rather, education, as any other functional system of modern society, becomes increasingly oriented towards the future by constructing cognitive expectations of educational outcomes and goals.