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

Health Care Analysis pp 1–20 | Cite as Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda AuthorsAuthors and affiliations Mathias BarraMari BroqvistErik GustavssonMartin HenrikssonNiklas JuthLars SandmanCarl Tollef Solberg Open Access Original Article First Online: 22 May 2019 7 Shares 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 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. KeywordsSeverity Priority setting Ethics Health policy Guidelines Research agenda  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 deliberates between the possible uses of available resources. Priority setting takes place from the bed-side-level to decisions at the national level [1, 2, 3, 4, 5, 6, 7, 8, 9]. The literature on priority setting criteria—a crucial ingredient of real-world priority 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 [10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35]. 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 [36, 37, 38]. Recent studies investigating values behind policies and methods have disclosed a greater diversity of priority setting principles and criteria across countries than expected [32, 39, 40]. Safety, efficiency, cost, and budgetary constraints together constitute classical cost-effectiveness, which in priority setting ethics is built upon utilitarian 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 uncontroversial and widely accepted as relevant and legitimate. We will argue in this article that severity—qua priority setting criteria—is, in fact, controversial when operationalised, 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 controversial? 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, answering 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. 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, fairness, 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 criterion in Norway and Sweden. This is despite having reached rather different conclusions—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 deliberated. 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 Daniels [43, 104, 105], but also more recent research on the need for legitimacy in priority setting [26, 32, 38, 44, 45]. It may be prudent, therefore, to analyse severity both as an essentially contested concept [46, 47], and severity as (at least temporary) a basis for incompletely theorized agreements [48, 49]. Considering the framework of essentially contested concepts may serve to highlight that the labelling of a condition 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 (...truncated)