The badness of death and priorities in health

Abstract

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.

Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

“…It is a mere observation that many conditions that lead to an early death are characterised as severe, but it is equally clear that there are non-fatal severe conditions. Furthermore, there is empirical evidence to the effect that the general public evaluates health differently when the prospect of death is salient, which indicates that death and severity are closely related, but not interchangeable [4,5,13,17,43,63,84,101,[106][107][108][109]125].…”

The Devils in the DALY: Prevailing Evaluative Assumptions

“…In the current GBD, the burden of death is assumed to be the greatest at birth, where neonatal deaths incur around 86 DALYs each ( Murray et al , 2012a ). Rationales for gradualism versus non-gradualism are lacking in the GBD literature but can be found elsewhere ( McMahan, 2002 ; Millum, 2015 ; Solberg and Gamlund, 2016 ). The choice of whether gradualism or non-gradualism should apply to the DALY may, arguably, be classified as both descriptive and evaluative.…”

Country contextualisation of cost-effectiveness studies: lessons from Ethiopia

“…There is a risk that a priority to NCDI interventions can diminish the priority to maternal and neonatal interventions and reduce population health levels. Solberg et al are some of the many arguing that saving a newborn life has relatively less value than saving older children or adult lives 29. If less value is given to save newborn lives, it may be justifiable to diverge from obstetric and neonatal interventions.…”