Why care about severity?

By Mathias Barra, Mari Broqvist, Erik Gustavsson, Martin Henriksson, Niklas Juth, Lars Sandman, and Carl Tollef Solberg

In an ideal world, everyone one of us would receive medical treatments in a timely manner, in the best possible way. There would be an unlimited number of organs available for transplantation. There would be enough health workers everywhere, and they would have sufficient time and knowledge to take care of each and every one of us. We would all live long and meaningful lives, and inequity in the distribution of health would be non-existent. This is not the world we find ourselves in. No resource is unlimited, and no effect is granted. Even in the world’s wealthiest countries, we need to prioritize.

As a starting point, any intervention should at least have some positive health effects. During the later years, so-called flat-of-the-curve medicine and overtreatment have received increasing attention. However, effective medicine also comes at a cost, and there is broad consensus in public health care systems that the relationship between effects and costs should be reasonable, inducing a cost-effectiveness criterion for practical priority setting guidelines. Specific willingness to pay thresholds are highly controversial. Yet, most scholars acknowledge  that at least some weight must be placed on the relationship between costs and benefits (this includes ourselves and Daniel Hausman). So far, so good.

The critical question is: Is cost-effectiveness everything that matters? Here in Scandinavia, public authorities have on several occasions said no to new cancer treatments, citing that it is too expensive in relation to the effect one can realistically hope for. At the same time, some new cancer drugs are offered, although the drugs will most likely displace less expensive and more effective treatments. Overall, we can say that there is (at least) one major controversy in the Scandinavian priority setting debate, and that is severity. It is stipulated in our laws that, in addition to the expected cost-effectiveness, we must also take into account the severity of the target condition. In colloquial terms, this means that we are willing to offer less cost-effective treatment than we really think society can afford if those who receive the treatment suffer a sufficiently severe condition.

Prioritizing severity, however, is somewhat a truism. Severity refers to something very bad, unpleasant, and serious. We say things like “they were all shocked by the severity of her injuries,” and “he did not understand the severity of his situation.” The very intent is to underline that there was something extraordinary going on. And, indeed, extraordinary situations should receive extraordinary attention. But do we agree on what qualifies as severe?

Another problem with the concept of severity arises when people mean almost the same thing. An apparent agreement on severity as a priority setting criterion can lead to conflict in specific cases without properly acknowledging why we disagree.

Daniel Hausman has argued (in the JME) that academics like ourselves should give up the severity criterion in priority setting. We disagree (e.g., in our JME response, and more indirectly in this article). We have recently been granted funding from the Norwegian Research Council for the research project Severity and priority setting in health care (SEVPRI). The aim of SEVPRI is to help improve the public’s understanding of what ordinary people think about severity in general, and in conjunction with priority setting in particular. We also want to examine how close today’s standard health-economic models come to representing Tom, Dick, and Harry’s views on the equitable distribution of health resources. Through SEVPRI, our hypothesis is that severity will prove ethically significant and that Hausman is wrong in his statement that we should give up severity altogether. So, do not despair about severity – yet!


Paper title: Do not despair from severity – yet!



Mathias Barra, Mari Broqvist, Erik Gustavsson, Martin Henriksson, Niklas Juth, Lars Sandman, and Carl Tollef Solberg



Mathias Barra, PhD, The Health Services Research Unit – HØKH, Akershus University Hospital, Norway. ORCID: 0000-0002-0022-4042

Mari Broqvist, PhD, Department of Medical and Health Sciences, The national Centre for Priority Setting in Health Care, Linköping University, Sweden. ORCID: 0000-0002-1664-9846

Erik Gustavsson, PhD, Centre for Applied Ethics, Department of Culture and Communication; Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Sweden. ORCID: 0000-0001-5448-9209

Martin Henriksson PhD, Center for Medical Technology Assessment, Department of Medical and Health Sciences Linköping University, Sweden. ORCID: 0000-0003-1699-3185

Niklas Juth, PhD, Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Sweden. ORCID: 0000-0002-1339-4956

Lars Sandman, PhD, The National Centre for Priorities in Health, Department of Medical and Health Sciences, Linköping University, Sweden. ORCID: 0000-0003-0987-7653

Carl Tollef Solberg, MA, MD, PhD, Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Norway. ORCID: 0000-0003-3321-3793

Competing interests: None declared.

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Mathias Barra, Mari Broqvist, Erik Gustavsson, Martin Henriksson, Niklas Juth, Lars Sandman, and Carl Tollef Solberg





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