Top

Published in:

Open Access 08-02-2024 | Scientific Contribution

Severity and death

Author: Adam Ehlert

Published in: Medicine, Health Care and Philosophy | Issue 2/2024

Abstract

This article discusses the relationship between two theories about the badness of death, the Life-Comparative Account and the Gradualist Account, and two methods of operationalizing severity in health care priority setting, Absolute Shortfall and Proportional Shortfall. The aim is that theories about the badness of death can influence and inform the idea of the basis of severity as a priority setting criterion. I argue that there are strong similarities between the Life-Comparative Account and Absolute Shortfall, and since the Life-Comparative Account is one of the most reasonable accounts of the badness of death, this provides some support for using Absolute Shortfall. I also argue that it is difficult to find support for Proportional Shortfall from theories about the badness of death, and also, that it is difficult to find support for Gradualist Account from theories about severity.

Priority setting should be broadly understood as all decisions regarding resource allocation in health care.

Henceforth severity (for simplicity).

Absolute Shortfall is used in health care priority setting in Norway (Magnussen et al. 2015). Proportional Shortfall is used in the Netherlands (van de Wetering et al. 2013). In the UK, both operationalizations are used (National Institute for Heath and Care Excellence 2022). There are other proposed ways to operationalize severity, for instance, Prognosis and Lifetime Shortfall. These are not used in practice and, arguably, not well suited for use in health care priority setting. For more, see Magnussen et al. (2015).

See Solberg and Gamlund (2016) for further discussion regarding the omission of Epicureanism.

There has been some recent discussion regarding Epicureanism’s eventual suitability in health care priority setting, see for instance Hol and Solberg (2023).

It is subject to debate whether dead people occupy a well-being level or not. I believe that they do not, but in this article, I take no stand on the matter. What is important for our purposes is that 1 year of non-existence equals 0 QALYs. For more on this, see Feit (2016) and Carlson and Johansson (2017).

The examples in this section, as well as the following, are adapted from the Norwegian report on severity and priority setting (Magnussen et al. 2015).

It should be noted that since the number of total expected future QALYs is not always 80, but will vary with age, this will slightly alter the exact proportion of the Proportional Shortfall. (For instance, expected future QALYs at birth might be 80, but expected future QALYs at 75 might be a higher number, say 85, since some people in the age group will have died).

In addition to Nagel (1970), see Bradley (2009), Broome (2004), Ekendahl (2019), Feldman (1991, 1992), Fischer (2020), Johansson (2005), Kagan (2012), Quinn (1984).

This is what is assumed by the termination thesis.

My family and friends would (hopefully) be upset by my death. My death would have a negative impact on their well-being.

For instance, I could die painlessly in my sleep. I go to bed one night and simply die in my sleep. I do not have any experience of pain. I simply do not wake up. But it could also be the case that I could die by being slowly run over by a steamroller. This will be extremely painful. Since this is an experience that I certainly have, the Epicurean allows it to be bad for me. And the Deprivationist agrees.

However, many writers have argued that Deprivationism has implications in these discussions.

The main criticisms posed against Deprivationism and LCA are The Timing Problem and The Asymmetry Problem. For discussion on these, see Johansson (2013a, 2013b), Kaufman (1995), Lucretius (1940), Nagel (1970).

These relevant relations are what McMahan calls the time-relative interests. What they consist of is debated, but they depend on some metaphysical relationship between the person at t and the same person after t.

It should be noted that this way of reasoning may suppose that we accept some view akin to priorism, that is, that the badness of death is chronologically located before death.

Thanks to Erik Gustavsson for this example.

Barra, Matthias, et al. 2020. Severity as a priority setting criterion: Setting a challenging research agenda. Health Care Analysis 28 (1): 25–44.CrossRef

Belshaw, Christopher. 2005. 10 good questions about life and death. Malden: Blackwell.CrossRef

Bognar, Greg. 2008. Well-being and Health. Health Care Analysis 16: 97–113.CrossRef

Bradley, Ben. 2009. Well-being and death. Oxford: Oxford University Press.CrossRef

Bradley, Ben, Jens Johansson, and Fred Feldman, eds. 2013. The Oxford handbook of philosophy of death. Oxford: Oxford University Press.

Brock, Dan. 2002. The separability of health and well-being. In Summary measures of population health: Concepts, ethics, measurement and applications, ed. Murray, Christopher, et al. Geneva: World Health Organization.

Broome, John. 1993. Qalys. Journal of Public Economics 50 (2): 149–167.CrossRef

Broome, John. 2004. Weighing lives. Oxford: Oxford University Press.CrossRef

Broome, John. 2019. The badness of dying early. In Saving people from the harm of death, ed. Gamlund, Espen, Solberg, and Tollef. Oxford: Oxford University Press.

Broome, John, et al. 2002. Measuring the burden of disease by aggregating well-being. In Summary measures of population health: Concepts, ethics, measurement and applications, ed. Murray, Christopher, et al. Geneva: World Health Organization.

Campbell, Tim. 2019. Health care rationing and the badness of death: Should newborns count for less? In Saving people from the harm of death, ed. Espen Gamlund and Carl Tollef Solberg. Oxford: Oxford University Press.

Carlson, Erik, and Jens Johansson. 2017. Well-being without being? A reply to Feit. Utilitas 30 (29): 198–208.

DeGrazia, David. 2003. Identity, killing, and the boundaries of our existence. Philosophy & Public Affairs 31: 413–442.CrossRef

DeGrazia, David. 2007. The harm of death, time-relative interests, and abortion. Philosophical Forum 38: 57–80.CrossRef

Ekendahl, Karl. 2019. The good, the bad, and the dead: An essay on well-being and death. Doctoral Dissertation. Uppsala: Department of Philosophy, Uppsala University.

Epicurus. 1940. Letter to Menoceus. In Oates, Whitney Jennings, trans. The Stoic and Epicurean Philosophers, ed. Cyril Bailey, 30–34. New York: The Modern Library.

Feit, Neil. 2016. Comparative harm, creation, and death. Utilitas 28: 136–163.CrossRef

Feldman, Fred. 1991. Some puzzles about the evil of death. The Philosophical Review 100: 205–227.CrossRef

Feldman, Fred. 1992. Confrontations with the reaper. New York: Oxford University Press.

Feldman, Fred. 2000. The termination thesis. Midwest Studies in Philosophy 24: 98–115.CrossRef

Fischer, John Martin. 2020. Death, immortality, and meaning in life. Oxford: Oxford University Press.

Gamlund, Espen, and Carl Tollef Solberg. 2014. Når er det verst å miste sitt liv? Relevansen av filosofiske grunnlagsteorier for helseprioriteringer. Norsk Filosofisk Tidsskrift 49 (3–4): 205–217.CrossRef

Gamlund, Espen, and Carl Tollef Solberg. 2019. Introduction: Perspectives on evaluating deaths and their relevance to health policy. In Saving people from the harm of death, ed. Espen Gamlund and Carl Tollef Solberg. Oxford: Oxford University Press.CrossRef

Greaves, Hillary. 2019. Against “the badness of death.” In Saving people from the harm of death, ed. Espen Gamlund and Carl Tollef Solberg. Oxford: Oxford University Press.

Hol, Bjørn., and Carl Tollef Solberg. 2023. Epicurean priority-setting during the COVID-19 pandemic and beyond. De Ethica 7 (2): 63–83.CrossRef

Johansson, Jens. 2013. The timing problem. In The Oxford handbook of philosophy of death, ed. Ben Bradley, Jens Johansson, and Fred Feldman. Oxford: Oxford University Press.

Johansson, Jens. 2013b. Past and future non-existence. The Journal of Ethics 17: 51–64.CrossRef

Johansson, Jens. 2005. Mortal beings: On the metaphysics and value of death. Doctoral Dissertation. Stockholm: Acta Universitatis Stockholmiensis.

Kagan, Shelly. 2012. Death. Yale: Yale University Press.

Kaufman, Frederik. 1995. An answer to Lucretius’ symmetry argument against the fear of death. The Journal of Value Inquiry 29: 57–64.CrossRef

Lucretius. 1940. On the nature of things. In Oates, Whitney Jennings, trans. The stoic and epicurean philosophers, ed. Hugh Andrew Munro and Johnstone, 69–219. New York: The Modern Library.

Magnussen, Jon, et al. 2015. På ramme alvor: Alvorlighet og prioritering. Oslo: Department of Health.

McMahan, Jeff. 2002. The ethics of killing: Problems at the margins of life. Oxford: Oxford University Press.CrossRef

McMahan, Jeff. 2019. In Saving people from the harm of death, ed. Espen Gamlund and Carl Tollef Solberg. Oxford: Oxford University Press.

Nagel, Thomas. 1970. Death. Noûs 4 (1): 73–80.CrossRef

National Institute for Health and Care Excellence. 2002. NICE Publishes new combined methods and processes manual and topic selection manual for its health technology evaluation programmes [NewsArticle]. NICE; NICE. https://www.nice.org.uk/news/article/nice-publishes-new-combined-methods-and-processes-manual-and-topic-selection-manual-for-its-health-technology-evaluation-programmes.

Norheim, Ole Frithjof. 2019. The badness of death: Implications for summary measures and fair priority setting in health care. In Saving people from the harm of death, ed. Espen Gamlund and Carl Tollef Solberg. Oxford: Oxford University Press.

Quinn, Warren. 1984. Abortion: Identity and loss. Philosophy and Public Affairs 13 (1): 24–54.

Solberg, Carl Tollef, and Espen Gamlund. 2016. The badness of death and priorities in health. BMC Medical Ethics. https://doi.org/10.1186/s12910-016-0104-6.CrossRef

Van de Wetering, E.J., et al. 2013. Balancing equity and efficiency in the Dutch basic benefits package using the principle of proportional shortfall. The European Journal of Health Economics 14: 107–115.CrossRef

Title: Severity and death
Author: Adam Ehlert
Publication date: 08-02-2024
Publisher: Springer Netherlands
Published in: Medicine, Health Care and Philosophy / Issue 2/2024
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-024-10193-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Severity and death

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 2/2024

Who has a meaningful life? A care ethics analysis of selective trait abortion

No (true) right to die: barriers in access to physician-assisted death in case of psychiatric disease, advanced dementia or multiple geriatric syndromes in the Netherlands

A critical view on using “life not worth living” in the bioethics of assisted reproduction

Living ethics: a stance and its implications in health ethics

Discovering clinical phronesis

Epistemic (in)justice, social identity and the Black Box problem in patient care