Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in (...) Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

This article explores the main similarities and differences between Derek Parfit’s notion of imprecise comparability and a related notion I have proposed of parity. I argue that the main difference between imprecise comparability and parity can be understood by reference to ‘the standard view’. The standard view claims that 1) differences between cardinally ranked items can always be measured by a scale of units of the relevant value, and 2) all rankings proceed in terms of the trichotomy of ‘better than’, (...) ‘worse than’, and ‘equally good’. Imprecise comparability, which can be understood in terms of the more familiar notions of cardinality and incommensurability, rejects only the first claim while parity rejects both claims of the standard view. -/- I then argue that insofar as those attracted to imprecise comparability assume that all rankings are trichotomous, as Parfit appears to, the view should be rejected. This is because imprecise equality is not a form of equality but is a sui generis ‘fourth’ basic way in which items can be ranked. We should, I argue, understand imprecise equality as parity, and imprecise comparability as entailing ‘tetrachotomy’ – that if two items are comparable, one must better than, worse than, equal to, or on a par with the other. Thus those attracted to the idea that cardinality can be imprecise should abandon trichotomy and accept parity and tetrachotomy instead. -/- Finally, I illustrate the difference between Parfit’s trichotomous notion of imprecise comparability and parity by examining how each notion might be employed in different solutions to the problem posed by the Repugnant Conclusion in population ethics. I suggest that parity provides the arguably more ecumenical solution to the problem. (shrink)

A recent study of moral intuitions, performed by Joshua Greene and a group of researchers at Princeton University, has recently received a lot of attention. Greene and his collaborators designed a set of experiments in which subjects were undergoing brain scanning as they were asked to respond to various practical dilemmas. They found that contemplation of some of these cases (cases where the subjects had to imagine that they must use some direct form of violence) elicited greater activity in certain (...) areas of the brain associated with emotions compared with the other cases. It has been argued (e.g., by Peter Singer) that these results undermine the reliability of our moral intuitions, and therefore provide an objection to methods of moral reasoning that presuppose that they carry an evidential weight (such as the idea of reflective equilibrium). I distinguish between two ways in which Greene's findings lend support for a sceptical attitude towards intuitions. I argue that, given the first version of the challenge, the method of reflective equilibrium can easily accommodate the findings. As for the second version of the challenge, I argue that it does not so much pose a threat specifically to the method of reflective equilibrium but to the idea that moral claims can be justified through rational argumentation in general. (shrink)

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same (...) way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications. (shrink)

BackgroundThe state of the world is one with scarce medical resources where longevity is not equally distributed. Given such facts, setting priorities in health entails making difficult yet unavoidable decisions about which lives to save. The business of saving lives works on the assumption that longevity is valuable and that an early death is worse than a late death. There is a vast literature on health priorities and badness of death, separately. Surprisingly, there has been little cross-fertilisation between the academic (...) fields of priority setting and badness of death. Our aim is to connect philosophical discussions on the badness of death to contemporary debates in health priorities.DiscussionTwo questions regarding death are especially relevant to health priorities. The first question is why death is bad. Death is clearly bad for others, such as family, friends and society. Many philosophers also argue that death can be bad for those who die. This distinction is important for health priorities, because it concerns our fundamental reasons for saving lives. The second question is, ‘When is the worst time to die?’ A premature death is commonly considered worse than a late death. Thus, the number of good life years lost seems to matter to the badness of death. Concerning young individuals, some think the death of infants is worse than the death of adolescents, while others have contrary intuitions. Our claim is that to prioritise between age groups, we must consider the question of when it is worst to die.ConclusionsDeprivationism provides a more plausible approach to health priorities than Epicureanism. If Deprivationism is accepted, we will have a firmer basis for claiming that individuals, in addition to having a health loss caused by morbidity, will have a loss of good life years due to mortality. Additionally, Deprivationism highlights the importance of age and values for health priorities. Regarding age, both variants of Deprivationism imply that stillbirths are included in the Global Burden of Disease. Finally, we suggest that the Time-Relative Interest Account may serve as an alternative to the discounting and age weighting previously applied in the Global Burden of Disease. (shrink)