In a recent paper— The disvalue of death in the global burden of disease 1—we question the commensurability of the two components of the disability-adjusted life year — years lived with disability and years of life lost —and offer a tentative solution to this problem. In an exciting and constructive reply— Is consistency overrated? 2—philosopher S Andrew Schroeder argues that our concern about the DALY may be missing the mark by accepting the DALY as what he refers to as an (...) index reflecting nothing ‘beyond the importance we place in each ’. According to Schroeder, our consistency requirement is then made redundant. Recall our main argument: the DALY is the arithmetical sum of two components, YLDs and YLLs. The YLDs represents the individual disease burden that occurs while we are alive, while YLLs represents the individual disease burden resulting from our death. ‘Death’, in this context, is not the process of dying, which happens within life and which is captured by YLDs, but rather the incidence in which the life of a person has ended. Understood this way, the DALY is the aggregate of life and death, and we argue that these are incommensurables. Why are YLDs and YLLs incommensurables? In our article, we present several reasons for this. Briefly, YLDs measure disease burden that happens to an individual, whether it be painful experiences or loss of function. YLDs have a duration and are usually something we experience, such as pain. YLLs, on the other hand, are instantly generated when the life of that individual has expired. We do not experience YLLs, and they happen where we are not. When YLLs are generated, the life in question has already ended. On a secular account, death is the irreversible cessation of the mind and the senses, and …. (shrink)

In their insightful article, ‘The Disvalue of Death in the Global Burden of Disease’, Solberg et al argue that there is a potential incoherence in the way disability-adjusted life years are calculated. Morbidity is measured in years lived with disability in a way quite unlike the way mortality is measured in years of life lost. This potentially renders them incommensurable, like apples and oranges, and makes their aggregate—DALYs—conceptually unsound. The authors say that it is ‘vital’ to address this problem, that (...) ‘[n]eglecting [it] is not an option’, and that ‘one cannot add YLLs and YLDs together in [their] current form’.1 Though one might object to their argument in various ways, let us assume the authors are correct that there is a potential inconsistency here. I want to ask why we should be troubled by that. Now, this question may scarcely seem worth asking. Consistency and coherence are regarded as non-negotiable in so many domains that of course we should demand them in a measure such as the DALY. And this desire for coherence is clearly shared by both the architects of the DALY and their critics.2 3 I think, though, that things are more complicated. In 2012, I wrote an article discussing the epidemiological perspective from which DALYs should be calculated.4 Simplifying greatly, here is the problem: both YLDs and YLLs can be calculated either from prevalence data or from incidence data. The most natural way to calculate YLDs bases them on prevalences, because when we think about morbidity our initial thought is of people who are suffering. The most natural way to calculate YLLs bases them on an incidence measure, because when …. (shrink)

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