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Health Care Anal. 2020 Mar;28(1):25-44. doi: 10.1007/s10728-019-00371-z.

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

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The Health Services Research Unit - HØKH, Akershus University Hospital, Sykehusveien 25, Postboks 1000, 1473, Lørenskog, Norway.
Department of Medical and Health Sciences, The National Centre for Priorities in Health, Linköping University, Linköping, Sweden.
Department of Culture and Communication, Centre for Applied Ethics, Linköping University, Linköping, Sweden.
Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden.
Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Solna, Sweden.
The Health Services Research Unit - HØKH, Akershus University Hospital, Sykehusveien 25, Postboks 1000, 1473, Lørenskog, Norway.
Global Health Priorities, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway.


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.


Ethics; Guidelines; Health policy; Priority setting; Research agenda; Severity

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