The Badness of Death: A Review

Siden 1970 har det utviklet seg en særegen og sofistikert diskurs om døden innen analytisk filosofi. Denne debatten oppsto som følge av en direkte imøtekommelse av Epikurs sekulære filosofi om døden. Epikur argumenterte indirekte for at døden ikke kan være et onde for den som dør. Kjernen i denne såkalte «badness of death»-debatten kan oppsummeres i to spørsmål: For det første, kan døden være negativ for den som dør? For det andre, hva gjør døden negativ for den som dør? Målet med denne artikkelen er først og fremst å redegjøre for og systematisere utviklingen av denne filosofiske debatten som døden på norsk, samt løfte frem og ikke minst drøfte de mest sentrale argumentene som har vært fremsatt i debatten.Since the 1970s, a distinctive and sophisticated discourse on the badness of death has developed within analytical philosophy. This debate arose as a result of a direct response to the Epicurean secular philosophy of death. Epicurus indirectly argued that death cannot be an evil to the one who dies. The core of this so-called badness of death debate can be summarized into two questions. First, can death be negative for the person who dies? Second, what makes death negative for the one who dies? The aim of this article is first and foremost to explain and systematize the development of this philosophical debate in Norwegian, as well as to present and discuss the most central arguments that have been put forward in the debate.publishedVersio

Attitudes towards priority setting in the Norwegian health care system: a general population survey

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 there- fore 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 Norwegians 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.publishedVersio

Can Geographically Targeted Vaccinations Be Ethically Justified? The Case of Norway During the COVID-19 Pandemic

This article discusses the fairness of geographically targeted vaccinations (GTVs). During the initial period of local and global vaccine scarcity, health authorities had to enact priority-setting strategies for mass vaccination campaigns against COVID-19. These strategies have in common that priority setting was based on personal characteristics, such as age, health status or profession. However, in 2021, an alternative to this strategy was employed in some countries, particularly Norway. In these countries, vaccine allocation was also based on the epidemiological situations in different regions, and vaccines were assigned based on local incidence rates. The aim of this article is to describe and examine how a geographical allocation mechanism may work by considering Norway as a case study and discuss what ethical issues may arise in this type of priority setting. We explain three core concepts: priority setting, geographical priority setting and GTVs. With a particular focus on Norway, we discuss the potential effects of GTV, the public perception of such a strategy, and if GTV can be considered a fair strategy. We conclude that the most reasonable defence of GTV seems to be through a consequentialist account that values both total health outcomes and more equal outcomes.publishedVersio

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

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

Should we discount future health benefits? Pro et contra

Målet med denne artikkelen er å undersøke de viktigste argumentene for og imot diskontering av fremtidige helsegevinster. Et mer generelt spørsmål dreier seg om hvorvidt vi bør diskontere fremtidig velferd (eng. well-being). Vi begynner med en redegjørelse av hva diskontering er, og hvordan diskontering påvirker evaluering av helsetiltak. Deretter tar vi for oss de mest sentrale argumentene for og imot diskontering av fremtidige helsegevinster. Dette inkluderer velkjente argumenter som grensenytteargumentet, risikoargumentet, utsettelsesargumentet, konsistensargumentet og rene positive tidspreferanser. I tillegg drøfter vi to lite diskuterte argumenter, nemlig det instrumentelle argumentet og argumentet for fordelingsrettferdighet, samt en alternativ form for diskontering, nemlig diskontinuerlig diskontering. Vi konkluderer åpent og lar det være opp til deg som leser å reflektere videre omkring dette viktige spørsmålet.The aim of this article is to examine the arguments for and against the practice of discounting future health benefits. A more general question is whether we should discount future well-being. We begin with an exposition of what discounting means and how this method is used 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, the consistency argument, and discussions concerning pure positive time preferences. In addition, we discuss two less debated arguments, that is, 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 a reader to reflect further on this important issue.publishedVersio

Mandatory childhood vaccination: Should Norway follow?

Systematic public vaccination constitutes a tremendous health success, perhaps the greatest achievement of biomedicine so far. There is, however, room for improvement. Each year, 1.5 million deaths could be avoided with enhanced immunisation coverage. In recent years, many countries have introduced mandatory childhood vaccination programmes in an attempt to avoid deaths. In Norway, however, the vaccination programme has remained voluntary. Our childhood immunisation programme covers protection for twelve infectious diseases, and Norwegian children are systematically immunised from six weeks to sixteen years of age. In this article, we address the question of whether our country, Norway, should make the childhood vaccination programme mandatory. This question has received considerable public attention in the media, yet surprisingly little academic discussion has followed. The aim of the article is to systematically discuss whether it is morally justified to introduce a mandatory childhood vaccination programme in Norway. Our discussion proceeds as follows: We begin by presenting relevant background information on the history of vaccines and the current Norwegian childhood vaccination programme. Next, we discuss what we consider to be the most central arguments against mandatory childhood vaccination: the argument from the standpoints of parental rights, bodily integrity, naturalness, mistrust, and immunisation coverage. After that, we examine the central arguments in favour of mandatory childhood vaccination from the standpoints of harm, herd immunity, and as a precautionary strategy. We conclude that there are convincing moral arguments in favour of adopting a policy of mandatory childhood vaccination in Norway.publishedVersio

Is COVID-19 severe? The Norwegian severity criterion for priority setting meets the pandemic

Koronapandemien har synliggjort nødvendigheten av prioriteringer i helsetjenesten vår. Helseprioriteringer i Norge skal gjøres etter de tre kriteriene nytte, ressurs og alvorlighetsgrad. Nytte- og ressurskriteriene utgjør til sammen et kostnadseffektivitetskriterium: Høyere prioritet tilfaller tiltak som skaper mye helse med få ressurser. Alvorlighetskriteriet innebærer at en mer alvorlig tilstand kan og skal prioriteres høyere enn kostnadseffektiviteten alene tilsier. I denne artikkelen undersøker vi det norske alvorlighetskriteriet for helseprioriteringer i møte med koronaepidemien i Norge. Vi beskriver utviklingen av alvorlighetskriteriet i den norske prioriteringsdiskursen. Videre diskuterer vi hvordan koronaepidemien fremhever uenigheter og tvetydigheter rundt begrepet «alvorlighet» hva gjelder dødsrisiko, komorbiditet og hastegrad. Vi drøfter også hvordan den norske pandemiberedskapen passer inn i dette landskapet og etterlyser en klarere forståelse av alvorlighet i skillet mellom behandling og forebygging av sykdom. Til sist drøfter vi om det norske alvorlighetskriteriet for helseprioriteringer også kan være relevant for prioriteringer utenfor helsevesenet.publishedVersio

The Devils in the DALY: Prevailing Evaluative Assumptions

In recent years, it has become commonplace among the Global Burden of Disease (GBD) study authors to regard the disability-adjusted life year (DALY) primarily as a descriptive health metric. During the first phase of the GBD (1990–1996), it was widely acknowledged that the DALY had built-in evaluative assumptions. However, from the publication of the 2010 GBD and onwards, two central evaluative practices—time discounting and age-weighting—have been omitted from the DALY model. After this substantial revision, the emerging view now appears to be that the DALY is primarily a descriptive measure. Our aim in this article is to argue that the DALY, despite changes, remains largely evaluative. Our analysis focuses on the understanding of the DALY by comparing the DALY as a measure of disease burden in the two most significant phases of GBD publications, from their beginning (1990–1996) to the most recent releases (2010–2017). We identify numerous assumptions underlying the DALY and group them as descriptive or evaluative. We conclude that while the DALY model arguably has become more descriptive, it remains, by necessity, largely evaluative.publishedVersio

Abort og fosterreduksjon: En etisk sammenligning

De siste årene har fosterreduksjon i økende grad vært gjenstand for debatt i Norge, og intensiteten nådde et foreløpig maksimum da Lovavdelingen leverte tolknings-uttalelsen § 2 - Tolkning av abortloven i 2016 som svar på at Helse- og omsorgs-departementet (i 2014) ba Lovavdelingen om å vurdere hvorvidt Lov om svangers-kapsavbrudd åpner for fosterreduksjon av friske fostre ved flerlings-vangerskap. Lovavdelingen konkluderte med at abortloven åpner for fosterreduksjon ved flerlingsvangerskap innenfor de rammene som loven ellers oppstiller. Debatten har ikke stilnet, og utover høsten 2018 ble den ytterligere tilspisset i forbindelse med KrFs veivalg og signaler fra Høyre om å vurdere å fjerne § 2.3c, samt å forby fosterreduksjon. Mange av argumentene i fosterreduksjonsdebatten fremstår tilsynelatende like de argumentene som verserer i abortdebatten, og det mangler en analyse av hva som stiller seg annerledes ved fosterreduksjon. Målet med denne artikkelen er følgelig å undersøke hvorvidt det finnes en moralsk relevant forskjell mellom abort og fosterreduksjon av friske fostre. Vi tar for oss typiske argumenter fra den norske debatten, og belyser dem med fagartikler fra forskningslitteraturen. De mest sentrale argumentene mot fosterreduksjon har vi identifisert som skadeargumentet, skråplansargumentet, intensjonsargumentet, sorgargumentet, psykologiske langtids-effekter for kvinnen og sorteringsargumentet. Vi kommer frem til at motargumentene ikke holder mål hva gjelder å påvise en moralsk relevant forskjell mellom abort og fosterreduksjon av friske fostre. Konklusjonen vår er derfor at det – på tross av hva flere debattanter synes å mene - ikke finnes en moralsk relevant forskjell mellom de to. Når vi derfor tillater abort, så bør vi også tillate fosterreduksjon. Nøkkelord: Abort, etikk, fosterreduksjon, medisinsk etikk, selektiv fosterreduksjon   English summary: Abortion and multifetal pregnancy reduction: An ethical comparison  During recent years, multifetal pregnancy reduction has increasingly been subject to debate in Norway, and this debate reached an apex when the Legislation Department delivered the interpretation statement § 2 - Interpretation of the Abortion Act in 2016 in response to the Ministry of Health and Care Services, who had (in 2014) requested the Legislation Department to assess whether the Abortion Act allowed for multifetal pregnancy reductions of healthy fetuses. The Legislation Department concluded that the Abortion Act does regulate and permit multifetal pregnancy reductions within the framework that the law otherwise stipulates. The debate has not subsided, and in the autumn of 2018, it was further intensified in connection with the Norwegian Christian Democratic Party´s (KrF) "crossroads choice" and the signals from the Norwegian Conservative Party that they would consider reverting the Abortion Act’s section 2.3c [regulating second trimester abortions due to fetal anomalies], as well as a ban on multifetal pregnancy reduction. Many of the arguments in the multifetal pregnancy reduction debate appear very similar to the arguments pending in the general abortion debate, and an analysis of what makes multifetal pregnancy reduction significantly different from abortion is wanting. The aim of this article is, accordingly, to investigate to what extent there is a morally relevant distinction between abortion and multifetal pregnancy reduction of healthy fetuses. We take on board typical arguments from the Norwegian debate and consider them in light of the scholarly literature. We have identified the most central arguments against multifetal pregnancy reduction as the harm argument, the slippery slope argument, the intent argument, the grief argument, the regret argument (concerning long-term psychological effects for the woman), and the sorting argument. We argue that these counter-arguments do not succeed in establishing a morally relevant difference between abortion and multifetal pregnancy reduction of healthy fetuses. Our conclusion is, therefore – that despite what is often held – there is no morally significant difference between the two. Therefore, when we allow abortion, we should also allow multifetal pregnancy reductions. Keywords: Abortion, ethics, fetal reduction, medical ethics, multifetal pregnancy reductio