ArticlePDF Available

Abstract

Caveat: The first posted pdf of this paper contained extensive misreferencing. Please download this updated version. 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 Scandi-navian 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. https://link.springer.com/article/10.1007/s10728-019-00371-z
Vol.:(0123456789)
Health Care Analysis (2020) 28:25–44
https://doi.org/10.1007/s10728-019-00371-z
1 3
ORIGINAL ARTICLE
Severity asaPriority Setting Criterion: Setting
aChallenging Research Agenda
MathiasBarra1 · MariBroqvist2 · ErikGustavsson3,4 ·
MartinHenriksson5 · NiklasJuth6 · LarsSandman2 ·
CarlTollefSolberg1,7
Published online: 22 May 2019
© The Author(s) 2019
Abstract
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 Scandi-
navian 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 scar-
city, 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 challeng-
ing and important research agenda.
Keywords Severity· Priority setting· Ethics· Health policy· Guidelines· Research
agenda
* Mathias Barra
Mathias.barra@ahus.no
Extended author information available on the last page of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
26
Health Care Analysis (2020) 28:25–44
1 3
Introduction
Priority setting in health care is ubiquitous and inevitable. Broadly, priority setting
in health care can be understood as any mechanism, formal or informal, which delib-
erates between the possible uses of available resources. Priority setting takes place
from the bed-side-level to decisions at the national level [2, 36, 47, 55, 67, 73, 83,
93, 124].
The literature on priority setting criteria—a crucial ingredient of real-world pri-
ority setting—and their ethical underpinnings is as rich as it is diverse. Ethicists,
health care professionals, economists, and policy makers have all contributed to
the debate on suitable principles for priority setting in health care. Arguments from
utilitarian, egalitarian, and prioritarian camps, among others, have been advanced
but no thorough consensus seems to exist [14, 15, 19, 22, 27, 33, 34, 39, 44, 51, 57,
64, 65, 72, 76, 81, 89, 95, 96, 102, 103, 115, 116, 119121]. Moreover, the lack of
attention to underlying values has given a false impression that there exist value-
neutral methods and techniques to inform priority setting [45, 50, 122].
Recent studies investigating values behind policies and methods have disclosed
a greater diversity of priority setting principles and criteria across countries than
expected [8, 15, 58]. Safety, efficiency, cost, and budgetary constraints together con-
stitute classical cost-effectiveness, which in priority setting ethics is built upon utili-
tarian considerations. In Norway and Sweden, however, considerable efforts have
been made to integrate non-utilitarian ethical principles into the nations’ priority
setting policies, and we will briefly recount the work of the past decades below.
A common concern in both Norway and Sweden—and elsewhere—is how to
accommodate a perceived obligation to prioritise those with severe conditions. Both
general and more specific severity criteria have been suggested and implemented
within these nations’ publicly funded health care systems.1 Indeed, severity has been
paramount in the development of official priority setting guidelines and legislation
in Norway and Sweden. On the surface, these criteria appear to be fairly uncontro-
versial and widely accepted as relevant and legitimate. We will argue in this article
that severity—qua priority setting criteria—is, in fact, controversial when operation-
alised, ethically ambiguous, and that it is likely that there exist irreconcilable views
about when and to what extent a condition is severe. Hence, there is a need for more
research within the area of severity. A key ingredient in this research activity on
severity will be to highlight the controversies: exactly what is unknown or contro-
versial? The aim of this article is to set a research agenda from the interdisciplinary
perspective of scholars engaged in priority setting research, focusing on severity.
Although the questions posed below can be seen as mainly philosophical, answer-
ing them has implications for other areas, e.g. health economics. Hence, input from
these other areas is likely to be fruitful, especially when it comes to concrete issues
such as measuring severity. Against this background, the authors represent several
different disciplines.
1 Both Norway and Sweden are generally acknowledged to have fairly extensive universal health care
(UHC) systems, although particularly illegal immigrants are known to suffer from poor access to basic
health care [68, 79].
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
27
1 3
Health Care Analysis (2020) 28:25–44
We will argue that the concept of severity can be viewed as a multidimensional
concept, drawing up research questions related to concepts like need, urgency, fair-
ness, social consequences, mortality versus morbidity, and human dignity. At the
same time, a Scandinavian perspective on severity might be conducive to advancing
the international discussion, given its long-standing use as a priority setting crite-
rion in Norway and Sweden. This is despite having reached rather different con-
clusions—and hence they currently use different formal priority setting criteria (see
next section). Since different accounts of severity are, in fact, prevalent in different
jurisdictions, these diverse accounts need to be explicitly recognised and deliber-
ated. Otherwise, we believe that the long-term legitimacy of official priority setting
policy may be compromised. This concern builds on a literature of the role of the
social contract in health care policy, originating with John Rawls and Norman Dan-
iels [20, 21, 86], but also more recent research on the need for legitimacy in priority
setting [15, 30, 91, 95, 122]. It may be prudent, therefore, to analyse severity both
as an essentially contested concept [16, 32], and severity as (at least temporary) a
basis for incompletely theorized agreements [92, 113]. Considering the framework
of essentially contested concepts may serve to highlight that the labelling of a con-
dition as severe may serve as amechanism though which a claim of higher priority
is mediated; suggesting that (sometimes) severity is a relative concept. The theory
behind incompletely theorized agreements promises a rich framework for analysing
at what level disagreements on definitions of severity occur: Do agents disagree on
fundamental ethics and background theories? Do they diverge on mid-level prin-
ciples for operationalising severity, or is it the classification of specific cases into
agreed-upon abstract categories that causes tensions? Severity matters to people, it
seems. In this paper we highlight a number of points of disagreement on how and
why.
The remainder of this article is structured as follows: first we give a brief history
of the current severity criteria in Norway and Sweden. Next, we give a rudimen-
tary taxonomy of the identified ethical principles and concerns forming the basis
of the severity criterion in the two countries. Thirdly, we present what we think are
the most pertinent questions to answer regarding severity, in order to facilitate deci-
sion making in the context of increased scarcity, and to further the understanding of
underlying assumptions and values that go into these decisions.
A Brief Account oftheHistory ofSeverity asaPriority Setting
Criterion ontheScandinavian Peninsula
Historically, public health services developed largely in parallel in Norway and Swe-
den. A comprehensive welfare state was introduced in the period following the Sec-
ond World War. Both countries have comprehensive publicly funded health care sys-
tems. The total health expenditure as a percentage of GDP has grown steadily from
about 1% in 1945 to around 10% today. Both nations recognised an urgent need to
ration health care, and set up formal priority setting guidelines, starting in the early
1970s, after two decades of rapid growth of services and health budgets [99, 112].
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
28
Health Care Analysis (2020) 28:25–44
1 3
It seems unfeasible to design a priority setting framework intended to curb unsus-
tainable growth of health care expenditure without including some measure of cost-
effectiveness. Both nations have de facto incorporated a cost-effectiveness principle
as part of the backbone of priority setting guidelines. With regard to the meas-
urement of effectiveness, over the last two decades the quality-adjusted life year
(QALY) has become the canonical outcome measure for health technology assess-
ment. The QALY is a preference based outcome measure integrating morbidity and
mortality [118]. However, there seems to be a broad consensus among the public,
politicians, health professionals and bureaucrats that cost-effectiveness alone does
not capture all the salient attributes of illness and disease relevant to public priority
setting, and that there are more to be said before fair and morally acceptable prior-
ity setting can be carried out. Particularly, the idea that an intervention or a treat-
ment targeting patients with particularly severe conditions ought to be prioritised
above treatment targeting patients with less severe health conditions, despite being
less cost-efficient, has broad support in policy and among health care personnel and
the citizens [29, 105]. Both Norway and Sweden have therefore included a severity
criterion. How the severity criteria are being interpreted and implemented, however,
are rather different.
Severity inNorway
The first parliamentary committee concerned explicitly with priority setting in
Norway, was the first Lønning commission in 1987 (Lønning I). As public health
expenditure expanded rapidly from 1960 to 1980, previous commissions had already
considered various aspects of rationing [61, 100], but Lønning I was the first com-
prehensive public inquiry into when and how rationing of health care could be car-
ried out. In the resulting white paper (NOU)2 [59], a very thorough discussion of
priority setting in health care is given, and several criteria are discussed. The com-
mission’s mandate included analysing the de facto practices for priority setting in
the Norwegian health care system, and—if found to be acceptable—to build upon
these. To this end, Lønning I identified degree of severity, egalitarianism, waiting
time, and cost-effectiveness as “relevant dimensions” for priority setting.
It might seem odd to identify waiting time as a criterion of priority setting; sys-
tematically making patients wait for indicated treatment is probably better under-
stood as a mechanism for addressing more urgent needs first, for securing equal-
ity of access, and to some extent to ensure that expectant management is attempted
before more costly treatment options are employed. That is, waiting lists are best
understood as a priority setting tool. The discussion by Lønning I of waiting time in
the health services highlights that patient’s wait for different reasons, and that while
delayed treatment might be unacceptable for some, it is a reasonable rationing mech-
anism for others [59, pp. 77–78]. Lønning I also finds that egalitarianism, phrased
2 In Norway, a white paper summing up the reasoning and conclusions of a governmental committee
deliberating on a topic is referred toa s an NOU (Norsk Offentlig Utredning). The equivalent term for
Swedish white papers is SOU (Statens offentliga utredningar).
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
29
1 3
Health Care Analysis (2020) 28:25–44
as universal and equitable access to sufficient health care for the attainment of one’s
“health potential” should remain an important principle of Norwegian health ser-
vices. Nevertheless, it is severity that the commission considers the paramount
parameter for priority setting, and severity is consistently linked with the concepts
of need, urgency, (risk of) death, and suffering. Cost-effectiveness is also considered
important in Lønning I, but, it seems, subordinate to the severity criterion.
Lønning II appeared in 1997 [60], and was the second parliamentary committee
on general priority setting criteria3 for the Norwegian health services. The mandate
for Lønning II explicitly called for an operationalisation of the principles from Løn-
ning I, including the aim of making them applicable also to individual patients.
It is clear that Lønning II considers that integrating cost-effectiveness and the
severity criterion is inherently threatened by the conflict between consequentialist
and deontological ethics. The resolution of this dilemma is not carried out, and Løn-
ning II recommends rather vaguely that human dignity must be the loadstar of prior-
ity setting, recommending that the different medical specialities must deliberate and
decide howexactly severity is applied to their patients. Equity in health was consid-
ered to be subsumed by these principles [88].
In 2014 the Norheim commission completed the third NOU on priority setting—
Transparent and fair [74]. This commission’s work upheld the focus on cost-effective-
ness, but suggested a radical re-interpretationof severity and health equity. The health
loss criterion—building on lifetime-prioritarianism—was proposed as sufficient for
dealing with the severity issue [70, 72, 81, 82]. The ensuing debate was dismissive [7,
35, 52, 69, 71, 75, 80], and a second commission, led by Jon Magnussen, was appointed
to reassess the severity criterion. The Magnussen report was submitted in 2015 [62], in
which absolute shortfall was proposed as a better alternative to Norheim’s health loss
criterion. Under the health loss criterion, a life-time prioritarian account is employed
[82]. A condition’s severity is quantified by the number of life-time QALYs—consider-
ing both the past and the future—that an individual stand to lose, relative to a norm of
80 QALYs. This results in a priority setting criterion with a strong redistributive com-
ponent. The absolute shortfall criterion differs in two important ways: it does not con-
sider the past, but only considers the expected future QALY loss. Secondly, it does not
assume a norm of 80 QALYs, but instead computes the gap to the age-specific expected
number of remaining QALYs for an individual in good health. The absolute shortfall
thus retains a redistributive aspect, but somewhat less pronounced, and no longer retro-
spectively. Both have in common that the QALY is the sole numeraire for severity.
An important feature of the Norheim-Magnussen debate is that, despite acknowl-
edging that severity is ambiguous and multifaceted, the impact they had on official
documents and priority setting debate was to highlight QALY-based measures of
severity as the standard and to relegate other concerns to the periphery of the debate
[77, 90]. Very simplified, we could say that Norheim’s health loss integrated severity
3 Note that two other commissions—Grundt (remuneration for pharmacological expenses) and Steine
(hospital management principles)—handed over NOUs in 1997, and these commissions’ reports display
substantial overlap in arguments and conclusions [38, 110]. For example, all three reports reproduce the
same figure for an illustration of what has later become known as the “health gap”—the discrepancy
between the technical and the financial constraints on treatment options.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
30
Health Care Analysis (2020) 28:25–44
1 3
and inequity and that Magnussen’s absolute shortfall fix to this (perceived) problem,
largely deposed non-QALY concerns from consideration.
In 2018, another commission—the Blankholm commission—submitted yet
another NOU: The most important first (Det viktigste først) [9]. This NOU discusses
priority setting for municipal services, and largely concurs with Magnussen’s report
on the issue of severity. However, an important deviation is implied by questioning
the applicability of the QALY for non-specialist services—epitomised by the term
mastery as an independent goal for treatment. The Norwegian term employed—
mestring’—is perhaps better translated as coping, although coping here does not
quite capture the full connotations of the Norwegian ‘mestring’, which suggests get-
ting ‘on top of’ (e.g. capability to meet social roles, conduct activities of daily life,
and find meaning and dignity.) rather than merely ‘getting by’. ‘Self-management’ is
also a candidate term. Secondly, the Blankholm commission insists that a notion of
basic needs should be defined and take precedence over severity (and equity) con-
cerns in a priority setting context. The report goes as far as stating that covering
these—still to be defined—basic needs should not be subject to cost-effectiveness
constraints.
Severity inSweden
In Sweden a parliamentary committee on priority setting in health-care was estab-
lished in 1992, resulting in a white paper in 1995 and in legislation in 1997 propos-
ing three principles for priority setting: The Human Dignity Principle, the Need-
Solidarity Principle, and the Cost-Effectiveness Principle [28, 87, 104, 105].
The Human Dignity Principle is the overriding ethical principle and addresses
personal characteristics and functions in society that should not impact on prior-
ity setting (and therefore should not impact the assessment of severity), e.g., talent,
social position, responsibility, income, chronological age, and gender. The concept
of ‘need’ in the Needs-Solidarity principle is defined in terms of providing more
resources to patients with the more severe diseases, but also worse quality of life,
seemingly making a distinction between severe disease and bad quality of life. It is
claimed that the care of severe disease and substantial quality of life decline should
be prioritised before mild conditions, even if the former care is substantially less
cost effective. Later in the white paper it is argued that a patient’s need is likely to
depend both on the severity of the disease but also the duration of disease—seem-
ingly making a distinction between current severity and duration.
It is claimed that a disease can vary in severity over time even for patients with
chronic ill health conditions. It is also claimed that severity can be judged according
to the suffering of the patient, the medical prognosis, the disability, and the existen-
tial despair experienced. In a later operationalisation by several central actors in the
Swedish health-care system of the needs-solidarity principle, all of these different
considerations were in some way subsumed under the concept of severity of a condi-
tion [85].
Moreover, severity has come to play an essential role in determining which treat-
ments are subsidised by the Swedish pharmaceutical and benefits system (TLV), i.e.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
31
1 3
Health Care Analysis (2020) 28:25–44
that which society pays for rather than the patient herself. More specifically, dif-
ferent thresholds of cost-effectiveness are considered acceptable depending on the
degree of severity. For example, during the last few years, decisions indicate that a
threshold of 1,000,000 SEK/QALY is accepted for conditions considered to have the
highest degree of severity, 750,000 SEK/QALY for severe conditions, 500,000 SEK
for conditions of moderate degree, and a similar decrement to the lowest degree. At
present there are, however, different approaches to assessing severity in the Swed-
ish health-care system, causing potential inconsistencies. Nonetheless, the policy of
TLV is clearly different from the absolute shortfall policy of Norway: in Sweden
severity is not measured using shortfall in terms of QALYs. At least not consist-
ently. The Human Dignity Principle and its ban on taking chronological age into
account has generally been interpreted as an obstacle to adopting an absolute short-
fall approach to severity.
Remaining Questions About Severity
There are numerous accounts of severity, as demonstrated by our overview of the
Norwegian and Swedish discourses. A need to further clarify which basic moral
considerations that should be involved is needed. However, no matter how impor-
tant such activities are, deciding upon overarching considerations is not sufficient.
To provide guidance, such considerations need to be specific, enabling them to be
implemented in real world priority setting situations. Clarity regarding normative
basis, as well as precision regarding practical implications, are two desirable traits
of an account of severity. In order to achieve that, a set of questions about severity
needs to be addressed.
The two most fundamental questions that need to be answered are: what is sever-
ity and why does it matter? Of course, it is difficult to see how the first answer could
be answered without at least a tentative answer to the second one. However, the first
Table 1 Questions regarding severity
What is severity? Why does severity matter?
Is severity dependent on individual desires? Is severity an absolute or a relative concept?
What is the relationship between (subjective) well-
being and severity?
Can severity be aggregated?
How should severity be assessed when patients suf-
fer from more than one condition?
How does severity relate to considerations of
equality?
How should severity be viewed from a temporal
perspective?
How does severity relate to urgency and need?
What is the relationship between age and severity?
Is death an independent dimension of severity?
Is severity related to an individual’s social context?
What is the relationship between severity and
prevention?
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
32
Health Care Analysis (2020) 28:25–44
1 3
question is essentially about what aspects or factors that should be included in an
account of severity while the second refers to the feasibility and desirability of com-
paring different states of severity. Exploring these two main questions leads us to a
number of sub-questions (see Table1). Let us elaborate.
Question I About Severity: What isSeverity?
Let us start with the first question: what is severity? Perhaps the most important
thing to determine when answering this question is which aspects should be taken
into account when determining severity. As we have already seen from the Swedish
and Norwegian cases, several suggestions exist for how to do this.
The Swedish white paper suggested that the suffering of the patient, the medi-
cal prognosis, the disability, and the existential despair experienced were all part of
determining the level of severity [28]. At least, it was made clear that both health
and quality of life mattered. Of course, whenever suggesting that more than one fac-
tor determines something, it is desirable to suggest the relative weight of these fac-
tors. Moreover, if one is referring to something as contested as quality of life and
health, these concepts need to be understood unequivocally.
In Norway, a more well-defined but narrow understanding of the aspects deter-
mining severity has been adopted. In brief, the idea has been to understand severity
and effect in the same terms: as quality adjusted life years (see above). Severity is
quantified by some standard health economic measure, such as the preferences peo-
ple express towards different health states as formalised by, for example, an EQ-5D
questionnaire. Such measurements are usually considered to capture some notion of
health-related quality of life [49]. But any such notion necessarily takes a stand on
what is ultimately important for an individual, i.e. quality of life, and no such idea is
uncontroversial [46]. Furthermore, the Norwegian take on severity presuppose that
advantages (effect) and disadvantages (severity) should be understood in the same
terms, which is by no means self-evident.
Is Severity Dependent onIndividual Desires?
One issue is whether the severity of a condition may depend on individual desires
or preferences, or if severity is something which applies to a medical condition
independent of the perceptions of the patient’s attitudes towards her condition. For
example, the severity of infertility seems to depend on whether there is a desire for
having children or not; if the individual has no desire of having biologically related
children whatsoever, it is highly unlikely that the individual in question will perceive
the condition of infertility as severe and unclear why anyone else should consider it
so. It seems plausible to consider desires relevant for determining severity, at least
sometimes and to some degree. But: when and how much? Moreover, will severity
also depend on the strength of such a desire? This takes us to the general point about
the relationship between subjective well-being and severity [42, 97].
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
33
1 3
Health Care Analysis (2020) 28:25–44
What istheRelationship Between (Subjective) Well‑Being andSeverity?
The seminal papers Subjective well-being and The Satisfaction with Life Scale by
Ed Diener etal. have spawned a large literature with branches in psychology, phi-
losophy, and economics. An important question for an account of severity for prior-
ity setting purposes is if and how it should incorporate subjective well-being [11,
2326, 31, 78, 94, 114, 117]. We believe that a general sentiment among priority
setting scholars is that without a clear idea of the problems arising from managing
the gap between ‘objective’ health and ‘subjective’ well-being, policies risk coming
into conflict with ethical ideals. For example, placing too much emphasis on subjec-
tive evaluation of one’s own health may discriminate against those who adapt well,
or are endowed with a naturally positive disposition, while ‘objective measures of
health’ may not measure what people in fact care about. Of course, such problems
also concern the use of any preference based measure (e.g. QALYs).
Should it Be theDisease ortheCondition ofthePatient thatisAssessed?
In the Swedish context, there has been a shift from talking in terms of severity of
disease towards discussing severity of ill health condition. The Swedish 1996 white
paper about priorities in Sweden, stated that “[t]he diagnosis or disease is not impor-
tant, the decisive issue is instead the condition at every particular time of need of
health care” [87]. However, in the international discussion, both concepts are used.
If the severity of disease assesses the disease regardless of treatment status, and the
severity of a condition is sensitive to whether the condition has been treated or not,
this may have a major impact on priority setting decisions, e.g. insituations where
there is ample access to treatments reducing the severity of the disease [98].
How Should Severity be Assessed When Patients Suer fromMore thanOne
Condition?
Normally, when severity is applied as a priority setting criterion in the Swedish
or Norwegian systems, a specific condition is assessed (for instance, chronic heart
failure with a specific NYHA level, prostate cancer at a specific stage etc.) in rela-
tion to a potential treatment targeting that condition (so-called condition-treatment
pairs). This approach means that when severity is taken into account as a criterion
for priority setting it is employed as the extent to which patients are badly off with
respect to the condition that is targeted by the treatment (condition-specific sever-
ity). While there may be several practical reasons for this approach it is not clear
whether it accounts for the morally relevant sense of being worse off. One alterna-
tive is to assess severity as the extent to which the patient is worse off when all of
the patient’s conditions are considered [41]. However, this approach has a number of
practical difficulties and it remains to be seen how plausible this approach is when
related to other relevant criteria for priority setting. Moreover, some treatments tar-
get side-effects of a disease or treatment, for example managing nausea following
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
34
Health Care Analysis (2020) 28:25–44
1 3
chemotherapy. Does this mean that only the severity of nausea should be assessed
or that the severity of the underlying cause of the nausea (in this case cancer) should
also be considered? Or, if the patient suffers from both cancer and diabetes type II—
should both conditions be taken into account in the assessment of severity—even if
treatment only targets one of these conditions?
How Should Severity be Viewed fromaTemporal Perspective?
In a priority setting context, it is essential to have a clear idea of how a severity cri-
terion applies to a condition over the course of treatment. Many conditions lead to
prolonged treatment paths involving several treatment options at different times. It is
important to establish whether the severity of a condition is subject to reassessment
throughout the course of the disease. Another aspect of this is that if the severity of
a condition approach is used, then treatment will affect the severity of the condition
[98]. This implies that the order in which treatment are introduced might affect the
actual prioritisation. For example, say we have two treatments A and B where A has
a moderate effect but only has an acceptable level of cost-effectiveness if targeting a
highly severe condition and B has a moderate effect but is acceptable even if target-
ing mildly severe conditions. If we consider a patient with a very severe disease, if
the patient is given B first, the patient will not get access to A, since that is no longer
acceptable given that the patient’s severity is now reduced. If, on the other hand, the
patient is first given A, both treatments would be acceptable.
Another manifestation of how a temporal dimension of severity makes a differ-
ence is contained in the discussion of health loss versus absolute shortfall above: are
certain life-times ‘severe’, or are certain futures ‘severe’. The latter view is forward-
looking, and would not take into account for how long one has already suffered from
a condition when determining severity. The first view is explicitly backward-look-
ing, and holds that the past should be considered relevant for priority setting. Life-
time prioritarianism, proposed by Norheim etal. in Norway, doesaccommodate the
past [74, 81, 82]. Presently, both the Norwegian—after Magnussen’s report [62]—
and the Swedish policy seem to reject the backward-looking view.
What istheRelationship Between Age andSeverity?
The problems related to age when using utility-like measures for health outcomes
(QALY) and burden of disease (DALY) are well-known. As discussed above, there
have been concerns that the hitherto proposed severity criteria in Norway and Swe-
den discriminate against the elderly. It is perhaps fair to say that any severity crite-
rion that implicitly incorporates a shortfall of QALYs (or similar measures) must, to
some extent, give lower priority to predominantly elderly patients as long as human
longevity remains naturally bounded above. The question, then, is if this age-dis-
crimination is a necessary consequence of those accounts of severity that is ethi-
cally defensible and which the public is willing to accept as legitimate. Moreover,
should it be viewed as a case of age-discrimination (given that the chosen defini-
tion disadvantages those of advanced age)? Alternatively, severity must be described
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
35
1 3
Health Care Analysis (2020) 28:25–44
independently of QALY outcomes, in a manner that does not favour treatments that
target younger patient groups [3, 12, 56, 66, 72, 81, 89, 118].
Is Death anIndependent Dimension ofSeverity?
Related to the former question is the question about severity and end-of-life con-
cerns. There is a rich literature on priority setting in conjunction with end-of-life
treatment, which suggests that many consider imminent death as an especially
severe condition. However, it is also possible that the two issues—demise and severe
conditions—have been inappropriately conflated. 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 evi-
dence to the effect that the general public evaluates health differently when the pros-
pect of death is salient, which indicates that death and severity are closely related,
but not interchangeable [4, 5, 13, 17, 43, 63, 84, 101, 106109, 125].
Is Severity Related toanIndividual’s Social Context?
Is the social context of the individual a dimension of severity? In the early years of
the GBD’s DALY measure, explicit modelling of social context was included. If a
caregiver suffers from a condition, his family or people close to him will most likely
be affected in different ways. For example, the (now abandoned) age-weighting of
the DALY attributed greater weight to illness and dysfunction during the reproduc-
tive years. Normally, in health-care we find that there is some form of obligations
on health care providers also towards family or significant others. Are these obli-
gations an indication for taking into account the effect on significant others’ well-
being when assessing the severity of a patients’ condition, or vice versa, how the
well-being of significant others affect the patient? Is it worse if the health condition
also substantially affects other people, as is the case with e.g., dementia, psychiatric
disease, or withyoung children? Conversely, is the medical condition less severe for
the patient, when care and support from family and significant others are in place?
In particular, if a shift towards more holistic approaches to well-being is advocated,
these are important issues [1, 123]. Both the Swedish and the Norwegian policies
seem to reject social context: the Swedish by explicitly rejecting this in its Human
Dignity Principle, and the Norwegian by its general lack of focus on non-QALY
measurable dimensions. However, the focus on the slightly indeterminate ‘mastery’
from the recent Blankholm NOU might change this in the coming years.
What istheRelationship Between Severity andPrevention?
Can a non-severe condition be urgent because it will, in a near or more prolonged
perspective, become severe untreated? A slight wound from a rabies infected dog is
severe in the sense that if post-exposure prophylaxis is not administered, a fatal out-
come is almost certain. Nevertheless, a dog-bite is often considered relatively minor
in itself. Conversely, a condition leading to slight, but permanent, dysfunction could
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
36
Health Care Analysis (2020) 28:25–44
1 3
reasonably be considered urgent if expedient treatment could restore full function;
severe, however, seems an unfit label. Or is the condition already inherently severe if
urgent measures are needed?
How does the interplay between need, urgency and severity affect how we think
about preventive measures, like vaccination programs, in priority setting contexts?
In the preventive situation, we are treating a group in order for a small number of
potential patients to have a benefit. When assessing severity, should the level of risk
of developing the targeted condition be taken into account? In the Swedish context,
the severity criterion has been recommended for use in assessment of preventive
programmes by assessing the severity of the targeted condition once developed, and
then lowering the severity somewhat given the level of risk to develop this condition
[85]. In the Norwegian context, the severity of the condition in a preventive situation
focuses on those individuals who will benefit from prevention, i.e., the severity of
the condition avoided.
Question II About Severity: Why Does Severity Matter?
Let us turn to the second general question: why is severity important to consider
when prioritising in health care? There are at least two basic moral ideas that can
buttress the importance of severity. First, we have the idea that being bad (or worse,
or worst) off is morally important in itself and gives rise to special entitlements of
receiving assistance from others. This kind of fundamental moral intuition (that can
be labelled “the moral importance of evil”) is expressed in a multitude of specific
ideas about just distribution. One is so-called prioritarianism, that says benefiting
someone matters more the worse off that someone is (absolutely and not relative to
others then). As mentioned, this view was presupposed in Norheim’s report [88].
Another version of the idea is sufficientarianism, saying that we are entitled to ben-
efit when we are worse off than a pre-defined threshold of, say, health. Yet another is
the Rawlsian difference principle, saying that we should make the worst off as well
off as possible [48].
The other basic moral idea that may serve as a rationale for caring about severity
is (comparative) egalitarianism, e.g. the idea that it is bad for oneself to be worse
off than someone else, at least if it is of no fault of one’s own (so-called telic egali-
tarianism) [48]. That is to say, inequalities are intrinsically bad. This idea seems to
be suggested in both the Norwegian and Swedish policies, but it is unclear what the
connection is between egalitarian concerns and severity—see below. One suggestion
is that severity matters because having a severe condition usually means that one is
worse off than others and that we then have a moral reason to remedy this from the
point of view of egalitarianism.
Is Severity anAbsolute oraRelative Concept?
A condition or a disease, it seems, is always severe in relation to something non-
severe, say a normal, healthy state of existence. But apart from that, should the
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
37
1 3
Health Care Analysis (2020) 28:25–44
degree of severity be determined only (or foremost) in relation to how badly off one
is in relation to others or should it be determined on a person-independent scale
that in principle could be applied to any isolated individual (or condition)? That is,
should “worse-offness” (so to speak) be considered relative to other individuals or in
an absolute sense (in terms of how badly off one is regardless of others’ well-being)?
The answer to this question turns on the answer to what the ultimate rationale of
severity is, where the relative account seems to be the one favoured by egalitarians
and the absolute account by those who view severity as founded on some idea about
the moral weight of evil [43].
Can Severity be Aggregated?
One question that an account of severity needs to address is the extent to which, one
should consider severity as amenable to interpersonal aggregation. For instance, let
us assume that we are considering distributing health care resources to one of two
treatments to two separate groups of patients, A and B. Either, we can benefit A or
B, but not both. Let us assume that those in group A suffer from a condition that is
more severe than in group B and, consequently, that those in group B suffer from a
less severe condition, but a condition that still is severe (or so we assume). Let us
furthermore assume that the number of individuals in group A is smaller than in
group B. Should we account for severity in such a way that it allows us to add up
‘severities’ in the respective groups so that the ‘total amount of severity’ in group
B outweighs the total amount of severity in group A (even though all individuals
in group A have more severe conditions than all individuals in group B)? In other
words, should we consider severity as something that we can aggregate or not?
The answer to this question must hinge on the rationale behind caring about
severity, i.e., the answer to the question: why does severity matter? If the answer is
of a prioritarian kind, the answer seems to be yes, since prioritarianism allows all
sorts of value comparison as long as weights are attached on being worse off [48].
On the other hand, if the answer is of a Rawlsian kind, the answer seems to be no,
since the difference principle gives absolute priority to the worst off, regardless of
the size of benefits to others [54]. This also seem to resonate with an account of
severity which considers not having basic needs met—as alluded to by the Blank-
holm NOU—as severe; meeting basic needs of even one person could then com-
promise the needs of a myriad others. In fact, such an account seems to induce a
non-Archimedean priority-ordering, where interventions targeting basic needs are
incommensurably more important than others [37, 108].
How doSeverity andEquity Relate?
In particular, the Norwegian debate has been influenced strongly by prioritarianism
though Norheim’s NOU, and its ethical heritage [6, 10, 20, 36, 53, 73, 74, 81, 82,
86, 111]. Very briefly, prioritarianism can be understood as a form of utilitarianism
that incorporates some idea of equity, and is a normative and prescriptive ethical
stance: severity is—at least in some measure—deprivation in relation to some more
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
38
Health Care Analysis (2020) 28:25–44
1 3
absolute threshold. If on the other hand, the normative background theory is some
version of egalitarianism, severity is assessed relative to how other people are situ-
ated on the severity scale.
How Does Severity Relate toUrgency andNeed?
How does the notion of severity relate to other central concepts such as need and
urgency? Some writers believe that need should be interpreted as either severity or
capacity to benefit. It has also been suggested that a more plausible interpretation
of a person’s needs-based claim on health care resources is dependent on both these
aspects, namely the extent to which one is badly off as well as to what extent one
can benefit from an intervention [18, 40]. According to this interpretation, severity
is an attribute of one’s needs. However, a delicate issue for this proposal is to work
out a more precise answer to how needs-based claims should relate to the trade-off
between these two aspects.
Conclusion
In this article we have identified several crucial shortcomings of the current debate
over the use of severity criteria in priority setting. Our list of questions should be
seen as a work-in-progress and can be used in several ways. The obvious one is as
an inspiration for researchers within the field of priority setting and resource allo-
cation. It can also serve as a point of departure for discussions among policymak-
ers and also as a first step in research on priority setting processes, where different
stakeholders will be engaged in creating consensus on the most urgent issues to pay
attention to in order to facilitate policy development, and more importantly, facili-
tate implementation.
Acknowledgements We thank Meetali Kakad for proofreading of the final manuscript, the two careful
anonymous reviewers whose comments and suggestions helped improve this manuscript.
Compliance with Ethical Standards
Conict of interest All authors declare that they have no conflict of interest.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 Interna-
tional License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons license, and indicate if changes were made.
References
1. Al-Janabi, H., van Exel, J., Brouwer, W., & Coast, J. (2016). A framework for including family
health spillovers in economic evaluation. Medical Decision Making, 36(2), 176–186.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
39
1 3
Health Care Analysis (2020) 28:25–44
2. Angelis, A., Kanavos, P., & Montibeller, G. (2017). Resource allocation and priority setting in
health care: A multi-criteria decision analysis problem of value? Global Policy, 8(S2), 76–83.
3. Arnesen, T., & Kapiriri, L. (2004). Can the value choices in DALYs influence global priority-set-
ting? Health Policy, 70(2), 137–149.
4. Augestad, L. A., Rand-Hendriksen, K., Stavem, K., & Kristiansen, I. S. (2012). Time trade-off and
attitudes toward euthanasia: Implications of using ‘death’ as an anchor in health state valuation.
Quality of Life Research, 22(4), 705–714.
5. Augestad, L. A., Rand-Hendriksen, K., Stavem, K., & Kristiansen, I. S. (2012). What factors
explain willingness to trade in the time trade-off exercises, and what factors are important? In 34th
annual meeting of the society for medical decision making. Hyatt hotel, Phoenix, Arizona.
6. Baeten, S. A., Baltussen, R. M., Uyl-de Groot, C. A., Bridges, J., & Niessen, L. W. (2010). Incor-
porating equity-efficiency interactions in cost-effectiveness analysis—Three approaches applied to
breast cancer control. Value in Health, 13(5), 573–579.
7. Barra, M. (2014). Prioriteringsparadokset. Klassekampen.
8. Biron, L., Rumbold, B., & Faden, R. (2012). Social value judgments in healthcare: A philosophical
critique. Journal of Health Organization and Management, 26(3), 317–330.
9. Blankholm, A., Sandvik, E., Løseth, B., Magnussen, J., Kjellevold, A., Schou, P., etal. (2018).
Det viktigste først - Prinsipper for prioritering i den kommunale helse- og omsorgstjenesten og for
offentlig finansiert tannhelsetjenester. Oslo, Norway: Helse- og Omsorgsdepartementet (p. 148).
(Norges offentlige utredninger). Report No.: 2018:16.
10. Bobinac, A., Van, E., Rutten, F. F. H., & Brouwer, W. B. F. (2012). Inquiry into the relationship
between equity weights and the value of the QALY. Value in Health, 15(8), 1119–1126.
11. Brickman, P., Coates, D., & Janoff-Bulman, R. (1978). Lottery winners and accident victims: Is
happiness relative? Journal of Personality and Social Psychology, 36(8), 917.
12. Broome, J. (1988). Good, fairness and QALYs. Royal Institute of Philosophy Supplements, 23,
57–73.
13. Broqvist, M., Sandman, L., Garpenby, P., & Krevers, B. (2018). The meaning of severity—Do
citizenś views correspond to a severity framework based on ethical principles for priority setting?
Health Policy, 122(6), 630–637.
14. Callahan, D. (1991). Ethics and priority setting in oregon. Health Affairs, 10(2), 78–87.
15. Clark, S., & Weale, A. (2012). Social values in health priority setting: A conceptual framework.
Journal of Health Organisation and Management, 26(3), 293–316.
16. Collier, D., Daniel Hidalgo, F., & Olivia, Maciuceanu A. (2006). Essentially contested concepts:
Debates and applications. Journal of Political Ideologies, 11(3), 211–246.
17. Cookson, R. (2013). Can the NICE “End-of-Life Premium” be given a coherent ethical justifica-
tion? Jornal of Health Politics, Policy and Law, 38(6), 1129–1148.
18. Cookson, R., & Dolan, P. (2000). Principles of justice in health care rationing. Journal of Medical
Ethics, 26(5), 323–329.
19. Coulter, A., & Ham, C. (2000). The global challenge of health care rationing. Buckingham: Open
University Press.
20. Daniels, N. (2001). Justice, health, and healthcare. American Journal of Bioethics, 1(2), 2–16.
21. Daniels, N., & Sabin, J. (1997). Limits to health care: Fair procedures, democratic deliberation,
and the legitimacy problem for insurers. Philosophy & Public Affairs, 26(4), 303–350.
22. Dickenson, D. L. (1999). Can medical criteria settle priority-setting debates? The need for ethical
analysis. Health Care Analysis, 7(2), 131–137.
23. Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95(3), 542.
24. Diener, E. (2009). Subjective well-being. In The science of well-being (pp. 11–58). Dordrecht:
Springer (Social Indicators Research Series). Available from: https ://link.sprin ger.com/chapt
er/10.1007/978-90-481-2350-6_2.
25. Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The satisfaction with life scale.
Journal of Personality Assessment, 49(1), 71–75.
26. Diener, E., Wirtz, D., Biswas-Diener, R., Tov, W., Kim-Prieto, C., Choi, D., et al. (2009).
New measures of well-being. In Assessing well-being. (pp. 247–266). Dordrecht: Springer
(Social Indicators Research Series). Available from: https ://link.sprin ger.com/chapt
er/10.1007/978-90-481-2354-4_12.
27. Dolan, P., Cookson, R., & Ferguson, B. (1999). Effect of discussion and deliberation on the pub-
lic’s views of priority setting in health care: Focus group study. BMJ, 318(7188), 916–919.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
40
Health Care Analysis (2020) 28:25–44
1 3
28. Einhorn, J., Andersson, I., Carlson, L., Hallerby, N., Krook, C., Lindqvist, B., et al. (1995).
Vårdens svåra val. Stockholm, Sweden: Socialdepartementet (p. 255). (Statens offentliga utredn-
ingar). Report No.: 1995:5. Available from: https ://www.reger ingen .se/ratts liga-dokum ent/state
ns-offen tliga -utred ninga r/1995/03/sou-19955 / English translation: Ministry of Health and Social
Affairs. Swedish Government Official Reports (SOU 1995:5) Priorities in Health Care—ethics,
economy, implementation. Final report from the Swedish parliamentary priorities commission.
Stockholm: Fritzes.
29. Elmersjö, C.-Å., & Helgesson, G. (2008). Notions of just health care at three Swedish hospitals.
Medicine, Health Care and Philosophy, 11(2), 145–151.
30. Frankish, C. J., Kwan, B., Ratner, P. A., Higgins, J. W., & Larsen, C. (2002). Challenges of citizen
participation in regional health authorities. Social Science and Medicine, 54(10), 1471–1480.
31. Frey, B. S., & Stutzer, A. (2002). What can economists learn from happiness research? Journal of
Economic Literature, 40(2), 402–435.
32. Gallie, W. B. (1955). Essentially contested concepts. Proceedings of the Aristotelian Society, 56,
167–198.
33. Game, E. T., Kareiva, P., & Possingham, H. P. (2013). Six common mistakes in conservation prior-
ity setting. Conservation Biology, 27(3), 480–485.
34. Gibson, J., Mitton, C., Martin, D., Donaldson, C., & Singer, P. (2006). Ethics and economics: Does
programme budgeting and marginal analysis contribute to fair priority setting? Journal of Health
Services Research and Policy, 11(1), 32–37.
35. Gjessing, H. (2014). Legeforeningen: Prioriteringsdebatten må nyanseres. Aftenposten. Web Edi-
tion. Available from: https ://www.aften poste n.no/artic le/ap-m06l.html. Accessed 11 Jan 2019.
36. Goetghebeur, M., Castro-Jaramillo, H., Baltussen, R., & Daniels, N. (2017). The art of priority set-
ting. The Lancet, 389(10087), 2368–2369.
37. Griffin, J. (1989). Well-being: Its meaning, measurement, and moral importance. Oxford, Oxford-
shire: Clarendon Press.
38. Grund, J., Andrew, M., Cameron, E., Frøyshow, A. O., Grøhn, A., Hagen, S., etal. (1997). Piller,
prioritering og politikk - Hva slags refusjonsordning trenger pasienter og samfunn? Oslo, Norway:
Sosial- og helsedepartementet (p. 248). (Norges offentlige utredninger). Report No.: 1997:7. Avail-
able from: https ://www.regje ringe n.no/no/dokum enter /nou-1997-7/id140 767/.
39. Gruskin, S., & Daniels, N. (2008). Process is the point. American Journal of Public Health, 98(9),
1573–1577.
40. Gustavsson E. (2018). Characterising needs in health care priority setting [Ph.D. thesis].
Linköping, Sweden, Linköping University.
41. Gustavsson, E. (2019). Patients with multiple needs for healthcare and priority to the worse off.
Bioethics, 33(2), 261–266.
42. Gustavsson, E., & Sandman, L. (2015). Health-care needs and shared decision-making in priority-
setting. Medicine, Health Care and Philosophy, 18(1), 13–22.
43. Gyrd-Hansen, D. (2018). Is there additional value attached to health gains at the end of life? A
revisit. Health Economics, 27(1), e71–e75.
44. Ham, C. (1997). Priority setting in health care: Learning from international experience. Health
Policy, 42(1), 49–66.
45. Harrison, S. (1998). The politics of evidence-based medicine in the United Kingdom. Policy &
Politics, 26(1), 15–31.
46. Hausman, D. M. (2015). Valuing health: Well-being, freedom, and suffering. Oxford: Oxford Uni-
versity Press.
47. Hendry, C., & Walker, A. (2004). Priority setting in clinical nursing practice: Literature review.
Journal of Advanced Nursing, 47(4), 427–436.
48. Hirose, I. (2014). Egalitarianism. Abingdon: Routledge.
49. Hirose, I., & Bognar, G. (2014). The ethics of health care rationing: An introduction. Abingdon:
Routledge.
50. Hoedemaekers, R., & Dekkers, W. (2003). Key concepts in health care priority setting. Health
Care Analysis, 11(4), 309–323.
51. Holm, S. (1998). Goodbye to the simple solutions: The second phase of priority setting in health
care. BMJ, 317(7164), 1000–1007.
52. Hornburg, T. B. (2014). Helsetaperne. Aftenposten. Web Edition. Available from: https ://www.
aften poste n.no/artic le/ap-4AEo.html. Accessed 11 Jan 2019.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
41
1 3
Health Care Analysis (2020) 28:25–44
53. Johri, M., & Norheim, O. F. (2012). Can cost-effectiveness analysis integrate concerns for equity?
Systematic review. International Journal of Technology Assessment in Health Care, 28(02),
125–132.
54. Juth, N. (2005). Genetic information - values and rights. The morality of presymptomatic genetic
testing. Gothenburg: Acta Philosophica Gothoburgensia.
55. Kapiriri, L., & Razavi, D. (2017). How have systematic priority setting approaches influenced pol-
icy making? A synthesis of the current literature. Health Policy, 121(9), 937–946.
56. Kappel, K., & Sandøe, P. (1992). Qalys, age and fairness. Bioethics, 6(4), 297–316.
57. Kenny, N., & Joffres, C. (2008). An ethical analysis of international health priority-setting. Health
Care Analysis, 16(2), 145–160.
58. Littlejohns, P., Sharma, T., & Jeong, K. (2012). Social values and health priority setting in Eng-
land: “Values” based decision making. Journal of Health Organization and Management, 26(3),
363–373.
59. Lønning, I., Asbøll, E., Berge, T. E., Evensen, Å. R., Grund, J., Gunbjørud, A. B., etal. (1987).
Retningslinjer for prioriteringer innen norsk helsetjeneste. (p. 108). Oslo, Norway: Sosialdeparte-
mentet. (Norges offentlige utredninger). Report No.: 1987:23.
60. Lønning, I., Album, D., Benkow, J., Brofoss, K., Brundtland, G., Buttedahl, A., etal. (1997). Pri-
oritering på ny - Gjennomgang av retningslinjer for piroriteringer innen norsk helsetjeneste. (p.
225). Oslo, Norway: Sosial- og helsedepartementet. (Norges offentlige utredninger). Report No.:
1997:18.
61. Lønnum, A., Bøe, O. W., Hareide, B., Evensen, S. A., Holm, T., Hanneson, A., etal. (1981). Medi-
sinsk rasjonalisering. Oslo, Norway: Sosialdepartementet (p. 46). (Norges offentlige utredninger).
Report No.: 1981:25. Available from: https ://www.nb.no/items /URN:NBN:no-nb_digib ok_20130
80806 038. Accessed 19 Mar 2018.
62. Magnussen, J., Aaserud, M., Granaas, T., Magelssen, M., Syse, A., Celius, E. G., etal. (2015). På
ramme alvor - Alvorlighet og prioritering. Department of Health (p. 71). English summary avail-
able from: https ://www.regje ringe n.no/conte ntass ets/d5da4 8ca5d 1a4b1 28c72 fc5da a3b4f d8/summa
ry_the_magnu ssen_repor t_on_sever ity.pdf.
63. Mason, H., Collins, M., McHugh, N., Godwin, J., Van Exel, J., Donaldson, C., etal. (2018). Is “end
of life” a special case? Connecting Q with survey methods to measure societal support for views on
the value of life-extending treatments. Health Economics, 27(5), 819–831.
64. McMillan, J., Sheehan, M., Austin, D., & Howell, J. (2006). Ethics and opportunity costs: Have
NICE grasped the ethics of priority setting? Journal of Medical Ethics, 32(3), 127–128.
65. Mitton, C., & Donaldson, C. (2004). Health care priority setting: Principles, practice and chal-
lenges. Cost Effectiveness and Resource Allocation, 2(1), 3.
66. Murray, C. J. L., & Acharya, A. K. (1997). Understanding DALYs. Journal of Health Economics,
16(6), 703–730.
67. Neuberger, J., & James, O. (1999). Guidelines for selection of patients for liver transplantation in
the era of donor-organ shortage. The Lancet, 354(9190), 1636–1639.
68. Nkulu Kalengayi, F. K., Hurtig, A.-K., Nordstrand, A., Ahlm, C., & Ahlberg, B. M. (2016). Per-
spectives and experiences of new migrants on health screening in Sweden. BMC Health Services
Research, 2016(16), 14.
69. Nord, E. (2015). Ufullstendig fra Norheim. Dagens Medicin. Web Edition. Available from: https ://
www.dagen smedi sin.no/artik ler/2015/09/28/ufull stend ig-fra-norhe im/. Accessed 11 Jan 2019.
70. Norheim, O. F. (2010). Priority to the young or to those with least lifetime health? American Jour-
nal of Bioethics, 10(4), 60–61.
71. Norheim, O. F. (2015). Prioriteringsdebatten – og veien videre. Dagens Medicin. Web Edition.
Available from: https ://www.dagen smedi sin.no/artik ler/2015/09/14/prior iteri ngsde batte n–og-veien
-vider e/. Accessed 11 Jan 2019.
72. Norheim, O. F. (2016). Ethical priority setting for universal health coverage: Challenges in decid-
ing upon fair distribution of health services. BMC Medicine, 14(1), 75.
73. Norheim, O. F., Baltussen, R., Johri, M., Chisholm, D., Nord, E., Brock, D., etal. (2014). Guid-
ance on priority setting in health care (GPS-Health): The inclusion of equity criteria not captured
by cost-effectiveness analysis. Cost Effectiveness and Resources Allocation, 12, 18.
74. Norheim, O. F., Allgott, B., Aschim, B., Førde, R., Gjul, G. K., Gundersen, T., etal. (2014). Åpent
og rettferdig - Prioriteringer i helsetjenesten. Oslo, Norway: Helse- og Omsorgsdepartementet (p.
219). (Norges offentlige utredninger). Report No.: 2014:12. Available from: https ://www.regje ringe
n.no/no/dokum enter /NOU-2014-12/id207 6730/.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
42
Health Care Analysis (2020) 28:25–44
1 3
75. Ole Frithjof, N. (2014). Vi prioriterer ikke fordi vi må, men fordi vi vil. Dagens Medicin. Web Edi-
tion. Available from: https ://www.dagen smedi sin.no/artik ler/2014/12/08/vi-prior itere r-ikke-fordi
-vi-ma-men-fordi -vi-vil/. Accessed 11 Jan 2019.
76. Olsen, J. A. (1997). Theories of justice and their implications for priority setting in health care.
Journal of Health Economics, 16(6), 625–639.
77. Olsen, J. A. (2013). Hva menes med «sykdommens alvorlighetsgrad»? Tidsskrift for Den norske
legeforening, 133(1), 64–67.
78. Olsen, J. A., Lamu, A. N., & Cairns, J. (2018). In search of a common currency: A comparison
of seven EQ-5D-5L value sets. Health Economics, 27(1), 39–49.
79. Onarheim, K. H., Melberg, A., Meier, B. M., & Miljeteig, I. (2018). Towards universal health
coverage: Including undocumented migrants. BMJ Global Health, 3(5), e001031.
80. Østby, J. T., & Solli, O. (2015). Alvorlighet og alder bør være to selvstendige kriterier. Dagens
Medicin. Web Edition. Available from: https ://www.dagen smedi sin.no/artik ler/2015/08/28/
alvor lighe t-og-alder -bor-vare-to-selvs tendi ge-krite rier/.
81. Ottersen, T. (2013). Lifetime QALY prioritarianism in priority setting. Journal of Medical Eth-
ics, 39(3), 175–180.
82. Ottersen, T., Mæstad, O., & Norheim, O. F. (2014). Lifetime QALY prioritarianism in prior-
ity setting: quantification of the inherent trade-off. Cost Effectiveness and Resource Allocation,
12(1), 2.
83. Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical
interventions. The Lancet, 373(9661), 423–431.
84. Pinto-Prades, J.-L., Sánchez-Martínez, F.-I., Corbacho, B., & Baker, R. (2014). Valuing QALYs
at the end of life. Social Science and Medicine, 113, 5–14.
85. Prioriteringscentrum. (2017). Nationell modell för öppna prioriteringar inom hälsooch sjukvård
- ett verktyg för rangordning. 3rd ed. Linköping, Sweden: Prioteringscentrum. Available from:
https ://liu.diva-porta l.org/smash /get/diva2 :11440 43/FULLT EXT01 .pdf. Accessed 03 Jan 2019.
86. Rawls, J. (1999). A theory of justice (Revised ed.). Cambridge: Harvard University Press.
87. Regjeringen. (1996). Prioriteringar inom hälso- och sjukvården Proposition 1996/97:60 - Riks-
dagen. 1996/97:60. Available from: https ://www.riksd agen.se/sv/dokum ent-lagar /dokum ent/
propo sitio n/prior iteri ngar-inom-halso –och-sjukv arden _GK036 0/html. Accessed 21 Nov 2018.
88. Ringard, Å., Larsen, B.-I., & Norheim, O. F. (2012). Medisinsk metodevurdering (HTA) for
bedre prioriteringer av helsetjenester. Michael Quarterly, 9(2), 174–182.
89. Robberstad, B. (2009). QALYs vs DALYs vs LYs gained: What are the differences, and what
difference do they make for health care priority setting? Norsk Epidemiologi. https ://doi.
org/10.5324/nje.v15i2 .217.
90. Robberstad, B. (2015). Alder og Alvor. Tidsskrift for den Norske Laegeforening, 135(15),
1376–1378.
91. Rogge, J., & Kittel, B. (2016). Who shall not be treated: Public attitudes on setting health care
priorities by person-based criteria in 28 nations. PLoS ONE, 11(6), e0157018.
92. Ruger, J. P. (2004). Health and social justice. The Lancet, 364(9439), 1075–1080.
93. Rumbold, B., Weale, A., Rid, A., Wilson, J., & Littlejohns, P. (2017). Public reasoning and
health-care priority setting: The case of NICE. Kennedy Institute of Ethics Journal, 27(1),
107–134.
94. Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological
well-being. Journal of Personality and Social Psychology, 57(6), 1069.
95. Sabik, L. M., & Lie, R. K. (2008). Priority setting in health care: Lessons from the experiences of
eight countries. International Journal of Equity Health, 7, 4.
96. Sabin, J. E. (1998). The second phase of priority setting. Fairness as a problem of love and the
heart: A clinician’s perspective on priority setting. BMJ, 317(7164), 1002–1004.
97. Sandman, L. (2018). The importance of being pregnant: On the healthcare need for uterus trans-
plantation. Bioethics, 32(8), 519–526.
98. Sandman, L., & Hofmann, B. (2018). Why we don’t need “Unmet Needs”! on the concepts of
unmet need and severity in health-care priority setting. Health Care Analysis, 27(1), 26–44.
99. Schiøtz, A., & Skaset, M. (2003). Folkets helse - landets styrke 1850-2003 (Det offentlige hel-
sevesen i Norge 1603-2003 (Vol. 2, p. 640). Oslo: Universitetsforlaget Oslo.
100. Selvaag, O., Borchgrevink, C. F., Nilsen, T., & Nordan, J. W. (1973). Forslag til veiledende kost-
nadsrammer for sykehusbygg. Oslo, Norway: Sosialdepartementet (p. 26). (Norges offentlige
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
43
1 3
Health Care Analysis (2020) 28:25–44
utredninger). Report No.: 1973:32. Available from: https ://www.nb.no/items /URN:NBN:no-nb_
digib ok_20110 52706 026.
101. Shah, K. K., Tsuchiya, A., & Wailoo, A. J. (2018). Valuing health at the end of life: A review of
stated preference studies in the social sciences literature. Social Science and Medicine, 204, 39–50.
102. Sibbald, S. L., Singer, P. A., Upshur, R., & Martin, D. K. (2009). Priority setting: What constitutes
success? A conceptual framework for successful priority setting. BMC Health Services Research,
9(1), 43.
103. Singer, P. A. (2000). Medical ethics. BMJ, 321(7256), 282–285.
104. Socialdepartementet. (1982:763). Hälso- och sjukvårdslag (1982:763). 1982:763 1982. Available
from: http://www.riksd agen.se/sv/dokum ent-lagar /dokum ent/svens k-forfa ttnin gssam ling/halso –
och-sjukv ardsl ag-19827 63_sfs-1982-763. Accessed 03 Jan 2019.
105. Socialdepartementet. (2017:30). Hälso- och sjukvårdslag (2017:30), SFS 2017:30 2017. Available
from: https ://beta.lagru mmet.se/rinfo /publ/sfs/2017:30. Accessed 31 Jan 2019.
106. Solberg, C. T. (2019). Epicurean challenges to the disvalue of death, chapter6. In E. Gamlund &
C. T. Solberg (Eds.), Saving people from the harm of death (pp. 91–104). New York: Oxford Uni-
versity Press.
107. Solberg, C. T., & Gamlund, E. (2016). The badness of death and priorities in health. BMC Medical
Ethics, 17, 21.
108. Solberg, C. T., Norheim, O. F., & Barra, M. (2018). The disvalue of death in the global burden of
disease. Journal of Medical Ethics, 44(3), 192–198. https ://doi.org/10.1136/medet hics-2017-10436
5.
109. Sorenson, C. (2012). Valuing end-of-life care in the United States: The case of new cancer drugs.
Health Economics, Policy and Law, 7(4), 411–430.
110. Steine,V. O., Børresen, H., Børsheim, E. L., Gården, T., Haffner, J., Haugstvedt, Y., etal. (1997).
Pasienten først! Oslo, Norway: Sosial- og helsedepartementet (p. 119). (Norges offentlige utred-
ninger). Report No.: 1997:2.
111. Stolk, E. A., Pickee, S. J., Ament, A. H. J. A., & Busschbach, J. J. V. (2005). Equity in health care
prioritisation: An empirical inquiry into social value. Health Policy, 74(3), 343–355.
112. Sundin, J., & Willner, S. (2007). Social change and health in Sweden : 250years of politics and
practice. Swedish National Institute of Public Health. Available from: http://urn.kb.se/resol ve?urn
=urn:nbn:se:liu:diva-11323 . Accessed 21 Nov 2018.
113. Sunstein, C. R. (1995). Incompletely theorized agreements. Harvard Law Review, 108(7),
1733–1772.
114. Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., etal. (2007). The Warwick-
Edinburgh mental well-being scale (WEMWBS): Development and UK validation. Health and
Quality of life Outcomes, 5(1), 63.
115. Ubel, P. A., DeKay, M. L., Baron, J., & Asch, D. A. (1996). Cost-effectiveness analysis in a setting
of budget constraints—Is it equitable? New England Journal of Medicine, 334(18), 1174–1177.
116. Viergever, R. F., Olifson, S., Ghaffar, A., & Terry, R. F. (2010). A checklist for health research
priority setting: Nine common themes of good practice. Health Research Policy and Systems, 8(1),
36.
117. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures
of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology,
54(6), 1063.
118. Weinstein, M. C., Torrance, G., & McGuire, A. (2009). QALYs: The Basics. Value in Health,
1(12), S5–S9.
119. Williams, A. (1988). Priority setting in public and private health care: A guide through the ideo-
logical jungle. Journal of Health Economics, 7(2), 173–183.
120. Williams, A. (1992). Cost-effectiveness analysis: Is it ethical? Journal of Medical Ethics, 18(1),
7–11.
121. Williams, A. (1997). Intergenerational equity: An exploration of the ‘Fair Innings’ argument.
Health Economics, 6(2), 117–132.
122. Williams, I., Dickinson, H., & Robinson, S. (2012). Rationing in health care: The theory and prac-
tice of priority setting. Bristol: Policy Press.
123. Wittenberg, E., & Prosser, L. A. (2013). Disutility of illness for caregivers and families: A system-
atic review of the literature. PharmacoEconomics, 31(6), 489–500.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
44
Health Care Analysis (2020) 28:25–44
1 3
124. World Health Organisation. (2015). 2015 global survey on health technology assessment by
national authorities. Available from: http://www.who.int/healt h-techn ology -asses sment /MD_
HTA_oct20 15_final _web2.pdf?ua=1. Accessed 06 Nov 2018.
125. Wouters, S., van Exel, J., Baker, R., & B F Brouwer, W. (2017). Priority to end of life treatments?
Views of the public in the netherlands. Value in Health, 20(1), 107–117.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Aliations
MathiasBarra1 · MariBroqvist2 · ErikGustavsson3,4 ·
MartinHenriksson5 · NiklasJuth6 · LarsSandman2 ·
CarlTollefSolberg1,7
1 The Health Services Research Unit – HØKH, Akershus University Hospital, Sykehusveien 25,
Postboks 1000, 1473Lørenskog, Norway
2 Department ofMedical andHealth Sciences, The National Centre forPriorities inHealth,
Linköping University, Linköping, Sweden
3 Department ofCulture andCommunication, Centre forApplied Ethics, Linköping University,
Linköping, Sweden
4 Division ofHealth Care Analysis, Department ofMedical andHealth Sciences, Linköping
University, Linköping, Sweden
5 Department ofMedical andHealth Sciences, Center forMedical Technology Assessment,
Linköping University, Linköping, Sweden
6 Stockholm Centre forHealthcare Ethics (CHE), LIME, Karolinska Institutet, Solna, Sweden
7 Global Health Priorities, Department ofGlobal Public Health andPrimary Care, Faculty
ofMedicine, University ofBergen, Bergen, Norway
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center
GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers
and authorised users (“Users”), for small-scale personal, non-commercial use provided that all
copyright, trade and service marks and other proprietary notices are maintained. By accessing,
sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of
use (“Terms”). For these purposes, Springer Nature considers academic use (by researchers and
students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and
conditions, a relevant site licence or a personal subscription. These Terms will prevail over any
conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription (to
the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of
the Creative Commons license used will apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may
also use these personal data internally within ResearchGate and Springer Nature and as agreed share
it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not otherwise
disclose your personal data outside the ResearchGate or the Springer Nature group of companies
unless we have your permission as detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial
use, it is important to note that Users may not:
use such content for the purpose of providing other users with access on a regular or large scale
basis or as a means to circumvent access control;
use such content where to do so would be considered a criminal or statutory offence in any
jurisdiction, or gives rise to civil liability, or is otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association
unless explicitly agreed to by Springer Nature in writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a
systematic database of Springer Nature journal content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a
product or service that creates revenue, royalties, rent or income from our content or its inclusion as
part of a paid for service or for other commercial gain. Springer Nature journal content cannot be
used for inter-library loans and librarians may not upload Springer Nature journal content on a large
scale into their, or any other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not
obligated to publish any information or content on this website and may remove it or features or
functionality at our sole discretion, at any time with or without notice. Springer Nature may revoke
this licence to you at any time and remove access to any copies of the Springer Nature journal content
which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or
guarantees to Users, either express or implied with respect to the Springer nature journal content and
all parties disclaim and waive any implied warranties or warranties imposed by law, including
merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published
by Springer Nature that may be licensed from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a
regular basis or in any other manner not expressly permitted by these Terms, please contact Springer
Nature at
onlineservice@springernature.com
... This means that interventions targeting severe conditions should receive a higher priority than interventions targeting less severe conditions. However, it is contentious why and how this should be done more specifically, see eg, [20]. ...
... Second, the question of whether the presence of alternatives affects the severity of a condition should also be kept separate from the question of how the assessment of severity should be adapted in situations (such as here) where we are not dealing with the severity of an established condition, but rather with the severity of a situation where there is a risk for a condition. One crucial question to decide for severity assessments for preventative measures is whether the assessment of severity should start with assessing the severity of the potentially resulting condition, and then reduce the severity with respect to the likelihood of getting this condition or simply assess the severity of the resulting condition, see eg, [20]. However, our discussion about alternatives as an aspect of severity does not hinge on a particular answer to that question. ...
... We will now investigate a final way in which the possible moral relevance of the presence of alternatives may be explained. In priorities setting, the severity of the patient's condition is commonly considered an important aspect [20]. There are several different characteristics that may make one condition worse than some other condi-this would need further analysis to be considered relevant to priority setting. ...
Article
Preexposure prophylaxis for HIV is a drug that reduces the risk for an HIV-negative person to acquire HIV if taken prior to sex. It has been suggested that it is important for resource allocation decisions that there are alternatives (such as abstinence, masturbation, etc.) for individuals potentially benefitted by this prophylaxis. In this paper we explore this idea from an ethical perspective in relation to three notions often discussed in priority setting ethics, namely responsibility, outcomes, and severity of disease. While the relevance of alternatives may be explained in terms by responsibility-sensitive priority setting, such a view comes with several challenges. We then discuss two other ways in which this intuition could be better explained: (a) in terms of total outcome of health, and (b) in terms of severity of the condition.
... roughout the Norwegian priority setting discourse, the issue of how to operationalize the severity criterion has been the crux. Internationally, there is a rich literature on how this might be accomplished [14]. Currently, the Norwegian severity criterion is operationalized as an absolute shortfall on a group level [15]. ...
Article
Full-text available
Background: In an ideal world, everyone would receive medical resources in accordance with their needs. In reality, resources are often scarce and have an alternative use. Thus, we are forced to prioritize. Although Norway is one of the leading countries in normative priority setting work, few descriptive studies have been conducted in the country. To increase legitimacy in priority setting, knowledge about laypeople's attitudes is central. The aim of the study is therefore to assess the general population's attitudes towards a broad spectrum of issues pertinent to priority setting in the Norwegian publicly financed health care system. Methods: We developed an electronic questionnaire that was distributed to a representative sample of 2 540 Nor-wegians regarding their attitudes towards priority setting in Norway. A total of 1 035 responded (response rate 40.7%). Data were analyzed with descriptive statistics and binary logistic regression. Results: A majority (73.0%) of respondents preferred increased funding of publicly financed health services at the expense of other sectors in society. Moreover, a larger share of the respondents suggested either increased taxes (37.0%) or drawing from the Government Pension Fund Global (31.0%) as sources of funding. However, the respondents were divided on whether it was acceptable to say "no" to new cancer drugs when the effect is low and the price is high: 38.6% somewhat or fully disagreed that this was acceptable, while 46.5% somewhat or fully agreed. Lastly, 84.0% of the respondents did not find it acceptable that the Norwegian municipalities have different standards for providing care services. Conclusion: Although the survey suggests support for priority setting among Norwegian laypeople, it has also revealed that a significant minority are reluctant to accept it.
... The challenges identified by the respondents are also consistent with the literature. Competing criteria and the difficulties in measuring equity means that equity often is trumped in favour of other more easily operationalizable PS criteria [8,10,[40][41][42]. Notably, criteria like feasibility and efficiency have been found to overrule the equity criterion whereby the operational context of the proposed interventions make them too difficult or cost prohibitive [8,38] or when it may not be feasibility to identify the most marginalized in each context [43]. ...
Article
Full-text available
Background There is increasing acceptance of the importance of social values such as equity and fairness in health care priority setting (PS). However, equity is difficult to define: the term means different things to different people, and the ways it is understood in theory often may not align with how it is operationalized. There is limited literature on how development assistance partner organizations (DAP) conceptualize and operationalize equity in their health care prioritization decisions that affect low-income countries (LIC). This paper explores whether and how equity is a consideration in DAP priority setting processes. Methods This was a qualitative study involving 38 in-depth interviews with DAPs involved in health-system PS for LICs and a review of their respective webpages. Results While several PS criteria were identified, direct articulation of equity as an explicit criterion was lacking. However, the criterion was implied in some of the responses in terms of prioritizing vulnerable populations. Where mentioned, respondents discussed the difficulties of operationalizing equity as a PS criterion since vulnerability is associated with several varying and competing factors including gender, age, geography, and income. Some respondents also suggested that equity could be operationalized in terms of an organization not supporting the pre-existing inequities . Although several organizations’ webpages identify addressing inequities as a guiding principle, there were variations in how they spoke about its operationalization. While intersectionalities in vulnerabilities complicate its operationalization, if organizations explicitly articulate their equity focus the other organizations who also have equity as a guiding principle may, instead of focusing on the same aspect, concentrate on other dimensions of vulnerability. That way, all organizations will contribute to achieving equity in all the relevant dimensions. Conclusions Since most development organizations support some form of equity, this paper highlights a need for an internationally recognized framework that recognizes the intersectionalities of vulnerability, for mainstreaming and operationalizing equity in DAP priority setting and resource allocation. Such a framework will support consistency in the conceptualization of and operationalization of equity in global health programs. There is a need for studies which to assess the degree to which equity is actually integrated in these programs.
... This can be understood as an operationalisation of severity that is concerned with the effects of disease over the lifetime-in the terms I used in section 3, this understanding of severity combines a concern for how badly off a patient has been in the past and how badly off a patient is expected to become if not treated. More generally, Norway and Sweden take severity seriously in healthcare priority-setting 43 -not only in the case of rare diseases-and are currently tackling the challenge of incorporating this complex concept into policymaking. ...
Article
Orphan drug policy often gives ‘special treatment’ to rare diseases, by giving additional priority or making exceptions to specific drugs, based on the rarity of the conditions they aim to treat. This essay argues that the goal of orphan drug policy should be to make prevalence irrelevant to funding decisions. It aims to demonstrate that it is severity, not prevalence, which drives our judgments that important claims are being overlooked when treatments for severe rare diseases are not funded. It shows that prioritising severity avoids problems caused by prioritising rarity, and that it is compatible with a range of normative frameworks. The implications of a severity-based view for drug development are then derived. The severity-based view also accounts for what is wrong with how the current system of drug development unfairly neglects common diseases that burden the developing world. Lastly, the implications of a severity-based view for current orphan drug policies are discussed.
... 34, -2016. For example, severity has a long standing as a priority setting criterion in Norway: If the condition to be treated is "severe," we have been willing to pay more for it (Barra et al., 2019). If severity 7 , for example, can be stratified into classes or degrees θ, we could vary the threshold value accordingly and investigate whether For some interventions, both costs and health benefits occur within one year or less, rendering discounting (which we usually base on one-year increments) somewhat irrelevant. ...
Article
Full-text available
The aim of this article is to examine the arguments for and against the practice of discounting future health benefits. A more general, but related, question is whether we should discount future well-being. We begin with an explanation of what discounting means and how it is used as a method in the evaluation of health interventions. Next, we consider the most central arguments for and against discounting future health benefits. This includes well-known arguments such as the argument of diminishing marginal returns, the risk argument, the delay argument, and the consistency argument. We also discuss pure time preferences. In addition, we consider less debated arguments, including the instrumental argument and the argument for distributive justice, as well as discontinuous discounting, as an alternative form of discounting. We conclude openly and leave it to you as the reader to reflect further on this important issue.
Article
Background Efforts to understand how treatments affect patients and society have broadened the criteria that health technology assessment (HTA) organizations apply to value assessments. We examined whether HTA agencies in eight countries consider treatment novelty in methods and deliberations.Methods We defined a novel pharmaceutical product to be one that offers a new approach to treatment (e.g., new mechanism of action), addresses an unmet need (e.g., targets a rare condition without effective treatments), or has a broader impact beyond what is typically measured in an HTA. We reviewed peer-reviewed publications and technical guidance materials from HTA organizations in Australia, Canada, England, France, The Netherlands, Norway, Sweden, and the United States (US). In addition, we explored how HTA organizations integrated novelty considerations into deliberations and recommendations related to two newer therapies—voretigene neparvovec for an inherited retinal disorder and ocrelizumab for multiple sclerosis.ResultsNone of the HTA organizations acknowledge treatment novelty as an explicit value criterion in their assessments of pharmaceutical products. However, drugs that have novel characteristics are given special consideration, particularly when they address an unmet need. Several organizations document a willingness to expend more resources and accept greater evidence uncertainty for such treatments. Qualitative deliberations about the additional unquantified potential benefits of treatment may also influence HTA recommendations.Conclusion Major HTA organizations do not recognize novelty as an explicit value criterion, although drugs with novel characteristics may receive special consideration. There is an opportunity for organizations to codify their approach to evaluating novelty in value assessment.
Article
Importance: Rising health care costs are a major health policy challenge globally. Norway has implemented a priority-setting system intended to balance cost-effectiveness and concerns for fair distribution, but little is known about this strategy and whether it works in practice. Objective: To present and evaluate a systematic drug appraisal method that uses the severity of disease to account for a fair distribution of health in cost-effectiveness analysis, forming the basis for price negotiations and coverage decisions. Design, setting, and participants: This cross-sectional study uses confidential drug price information and publicly available data from health technology assessments and logistic and linear regression analyses to evaluate drug coverage decisions for the Norwegian specialized health care sector from 2014 to 2019. Main outcomes and measures: Drug coverage decisions by Norwegian authorities and incremental cost-effectiveness and severity of disease measured as absolute shortfall of quality adjusted life years. Results: Between 2014 and 2019, a total of 188 drugs were appraised, of which 113 were cancer drugs. The overall coverage rate was 73% (138 of 188). The number of annual appraisals increased during the observation period. Based on 83 chosen decisions, regression analysis showed that incremental cost-effectiveness ratios (ICER) based on negotiated drug prices, adjusted for severity-differentiated cost-effectiveness thresholds, was the variable that best projected drug approvals (OR, 0.60; 95% CI, 0.42-0.86). An increase in the ICER by $10 000 was associated with a reduction in the odds for approval of 40% for drugs assessed from 2018 to 2019. Conclusions and relevance: This cross-sectional study demonstrated how concerns for efficiency and fair distribution of health can be implemented systematically into drug appraisals and reimbursement decisions. New, expensive drugs are expected to escalate health care costs in the years to come, and it may be feasible to control costs by negotiating the prices of new drugs while appraising both their cost-effectiveness and how their health benefits are distributed.
Article
There is strong evidence that individuals and the public assign relatively greater value to health gains from relatively more severe health states. This preference is increasingly reflected in health technology assessment, with some consideration of severity incorporated by health technology assessment bodies in, among others, The Netherlands, England and Wales, Norway, Sweden, and the United States. If a societal “severity premium” is to be considered fairly and consistently, we argue that a more explicit and quantitative approach is needed. We highlight drawbacks of categorical approaches, especially discontinuities between severity categories that arguably violate concepts of vertical equity, and argue that a more continuous approach to understanding severity is needed. We also note challenges to more explicit approaches, including implications of a lower threshold for less severe conditions and the relative complexity of calculating a continuous severity adjustment.
Article
Full-text available
Illness severity is a priority setting criterion in several countries. Age seems to matter when considering severity, but perhaps not small age differences. In the following article we consider Small Differences (SD): small differences in age are not relevant when considering differential illness severity. We show that SD cannot be accommodated within utilitarian, prioritarian or egalitarian theories. Attempting to accommodate SD by postulating a threshold model becomes exceedingly complex and self-defeating. The only way to accommodate SD seems to be to accept some form of relevance view, where some age differences are irrelevant. This view can accommodate SD, but at the expense of consistent priority orderings. Severity thus becomes unsuitable for systematic decision-making. We argue that SD should be dismissed and that we should accept a continuous relationship between severity of illness and age.
Article
Full-text available
As countries throughout the world move towards universal health coverage, the obligation to realise the right to health for undocumented migrants has often been overlooked. With unprecedented millions on the move – including refugees, asylum seekers, internally displaced persons, and returnees – undocumented migrants represent a uniquely vulnerable subgroup, experiencing particular barriers to health related to their background as well as insecure living and working conditions. Their legal status under national law often restricts access to, and affordability of, healthcare services. While striving to ensure health for all, national governments face challenging priority setting dilemmas in deciding: who to include, which services to provide, and how to cover out-of-pocket expenses. Building on comparative experiences in Norway, Thailand and the United States – which reflect varied approaches to achieving universal health coverage – we assess whether these national approaches provide rights-based access to affordable essential healthcare services for undocumented migrants. To meet the shared Sustainable Development Goal on universal health coverage, the right to health must be realised for all persons – including undocumented migrants. To ensure universal health coverage in accordance with the right to health, governments must evaluate laws, regulations, policies and practices to evaluate: whether undocumented migrants are included, to which services they have access, and if these services are affordable. Achieving universal health coverage for everyone will require rights-based support for undocumented migrants.
Article
Full-text available
In health care priority setting different criteria are used to reflect the relevant values that should guide decision-making. During recent years there has been a development of value frameworks implying the use of multiple criteria, a development that has not been accompanied by a structured conceptual and normative analysis of how different criteria relate to each other and to underlying normative considerations. Examples of such criteria are unmet need and severity. In this article these crucial criteria are conceptually clarified and analyzed in relation to each other. We argue that disease-severity and condition-severity should be distinguished and we find the latter concept better reflects underlying normative values. We further argue that unmet need does not fulfil an independent and relevant role in relation to condition-severity except for in some limited situations when having to distinguish between conditions of equal severity (and where other features also equals each other).
Chapter
In global health, several practices rely on the assumption that death has a disvalue for those who die. This includes the fact that we prioritize extending human lives rather than creating new ones, the combination Y ears Lived with Disability (YLD) and Years of Life Lost (YLL) into Disability-Adjusted Life Years (DALYs), as well as managing the trade-off between morbidity and mortality reduction in a health priority setting. According to Epicureanism, however, death cannot have any disvalue for those who die. Three main arguments are offered on behalf of Epicureanism: the view that we cannot experience death (the experience argument), the view that there is no time where death harms us (the time argument), and the view that there is a symmetry between the nonexistence before and after our lives (the symmetry argument). I show that all three arguments fail to convince.
Article
There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition‐specific severity). In this paper I argue that giving priority to the worse off in terms of condition‐specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).
Article
Researchers have recently provided proof of concept for uterus transplantation, giving rise to a discussion about priority setting. This article analyses whether absolute uterine‐factor infertility (AUFI), the main indication for uterus transplantation, gives rise to a healthcare need and the extent to which such a need places justified claims on public funding in a needs‐based welfare system. It is argued that, regardless of the concept of health to which one subscribes, there is a healthcare need for uterus transplantation in women with AUFI. The provision of alternative ways of addressing this need, such as surrogacy and adoption, reduces its severity. Hence, where such alternatives are publicly funded, uterus transplantation is unlikely to become cost‐effective. However, where surrogacy and adoption are not publicly funded, uterus transplantation should be given a similar priority level to other assisted reproductive technologies. In these circumstances, public funding for uterus transplants may well be justified, particularly in well‐funded healthcare system with relatively generous cost‐effectiveness thresholds.