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Saving People from the Harm of Death
POPULATION-LEVEL BIOETHICS
Ethics and the Public’s Health
Series Editors
Nir Eyal, Harvard Medical School
Dan Wikler, Harvard School of Public Health
Editorial Board
Dan Brock, Harvard University
John Broome, Oxford University
Norman Daniels, Harvard University
Marc Fleurbaey, Princeton University
Julio Frenk, Harvard University
Frances Kamm, Rutgers University
Daniel Hausman, University of Wisconsin-Madison
Michael Marmot, University College, London
Christopher Murray, Institute for Health Metrics and Evaluation, University of Washington
Amartya Sen, Harvard University
Volumes in the Series
Inequalities in Health:
Concepts, Measures, and Ethics
Edited by Nir Eyal, Samia A. Hurst, Ole F. Norheim, and Dan Wikler
Valuing Health:
Well-Being, Freedom, and Suffering
Daniel M. Hausman
Identified versus Statistical Lives: An Interdisciplinary Perspective
Edited by I. Glenn Cohen, Norman Daniels, and Nir Eyal
Saving People from the Harm of Death
Edited by Espen Gamlund and Carl Tollef Solberg
Foreword by Jeff McMahan
1
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2019
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Gamlund, Espen, 1976- editor. | Solberg, Carl Tollef, 1988- editor. | McMahan, Jeff, writer of foreword.
Title: Saving people from the harm of death / edited by Espen Gamlund and Carl Tollef Solberg ; with a foreword by Jeff McMahan.
Description: New York, NY : Oxford University Press, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018024331 (print) | LCCN 2018049747 (ebook) | ISBN 9780190921446 (online content) | ISBN 9780190921422 (updf) | ISBN 9780190921439 (epub) | ISBN 9780190921415 (cloth : alk. paper)
Subjects: LCSH: Death—Moral and ethical aspects. | Death—Social aspects. | Mortality—Statistics. | Medical policy. | Values.
Classification: LCC BJ1409.5 (ebook) | LCC BJ1409.5 .S28 2019 (print) | DDC 128/.5—dc23
LC record available at https://lccn.loc.gov/2018024331
9 8 7 6 5 4 3 2 1
Printed by Sheridan Books, Inc., United States of America
Derek Parfit, who possessed a native genius for philosophy, was the great progenitor of the debates in the following chapters. We dedicate the book to him.
CONTENTS
Foreword by Jeff McMahan ix
Acknowledgments xv
List of Contributors xvii
Introduction: Perspectives on Evaluating Deaths and Their Relevance to Health Policy 1
ESPEN GAMLUND AND CARL TOLLEF SOLBERG
PART I } Policy
1. Quantifying the Harm of Death 21 ERIK NORD
2. The Badness of Death: Implications for Summary Measures and Fair Priority Setting in Health Care 33 OLE FRITHJOF NORHEIM
3. Life Years at Stake: Justifying and Modeling Acquisition of Life Potential for DALYs 48 ANDREAS MOGENSEN
4. Putting a Number on the Harm of Death 61 JOSEPH MILLUM
5. Age, Death, and the Allocation of Life-Saving Resources 76 ESPEN GAMLUND
PART II } Theory
6. Epicurean Challenges to the Disvalue of Death 91 CARL TOLLEF SOLBERG
7. The Badness of Dying Early 105 JOHN BROOME
8. Early Death and Later Suffering 116 JEFF MCMAHAN
9. A Gradualist View about the Badness of Death 134 BEN BRADLEY
10. The Badness of Death and What to Do about It (if Anything) 146 F. M. KAMM
11. Deprivation and Identity 163 JENS JOHANSSON
12. How Death Is Bad for Us as Agents 175 SUSANNE BURRI
PART III } Population Ethics
13. Against “the Badness of Death” 189 HILARY GREAVES
14. People Aren’t Replaceable: Why It’s Better to Extend Lives than to Create New Ones 203 MICHELLE HUTCHINSON
15. The Worseness of Nonexistence 215 THERON PUMMER
PART IV } Critical Perspectives
16. The Badness of Death for Us, the Worth in Us, and Priorities in Saving Lives 231
SAMUEL J. KERSTEIN
17. How Much Better than Death Is Ordinary Human Survival? 243 IVAR R. LABUKT
18. Health Care Rationing and the Badness of Death: Should Newborns Count for Less? 255 TIM CAMPBELL
19. In Defense of the Time-Relative Interest Account: A Response to Campbell 267 JEFF MCMAHAN
Index 279
FOREWORD
Jeff McMahan
Various philosophers in the ancient world—particularly Epicurus and Lucretius but also Cicero, Seneca, and others—thought seriously about the nature and evaluation of death. They asked how, on the assumption that to die is to cease to exist, death could be bad for us and, if so, how bad. Their concern was not whether a person’s death could be bad for those who remain, but whether and to what extent it could be bad for the person herself. Epicurus and Lucretius concluded that it could not be, or at least that there is no reason for us to fear death for our own sake.
Yet with the rise of certain religions, such as Christianity and Islam, that promised—or threatened—an unending afterlife, philosophers largely ceased to discuss whether death is bad for us, good for us, or neither. And even those who did discuss death, such as Montaigne and Schopenhauer, did not go very deep. I suspect that a significant part of the explanation of this philosophical neglect is that, particularly in those regions in which philosophy was most ardently pursued, it was for many centuries heretical and thus dangerous to profess or even to discuss the view that when we die we simply cease to exist. So even while people continued to fear death, sought to avoid it themselves and to save others from it, and grieved for those who had succumbed to it, they were unable to discuss freely whether their attitudes and practices were rationally justified. Together with a threat of eternal damnation as punishment for suicide, the refusal to permit questioning of the relevant theological dogmas was self-protective for those religions that offered the faithful a blissful afterlife. For that offer certainly seems to provide a reason for believers to end their own lives and the lives of those they love, which would hardly promote church attendance or provide remunerative work for the clergy, apart from conducting funerals. So better to leave people’s instinctive aversion to death alone, even while asserting doctrines that suggest that the aversion is irrational.
It was not until 1970, with the appearance of a short but brilliant essay by Thomas Nagel, which was closely followed by another by Bernard Williams, that serious philosophical discussion of death resumed after almost two millennia of reticence.1 Over the decades since Nagel broke the silence, the
1 Nagel (1970); Williams (1973).
philosophical literature on death has burgeoned. Both Nagel and Williams, along with other early contributors to the renewed discussion, addressed the arguments advanced by Epicurus and his Roman disciple Lucretius. Epicurus argued that death cannot be bad for those who die, since when a person dies there is no longer anyone for whom anything can be bad. There cannot be a misfortune without a subject of that misfortune. One influential response to this challenge was to argue that the evaluation of death does not require the identification of a postmortem victim of misfortune. We can instead simply compare the life that a person has given that she dies at t with the life she would have had if she had not died at t and, if the latter would have been a better life overall, conclude that her death at t was bad for her because it caused her to have the less good of two possible lives.2 I have elsewhere referred to this as the Life Comparative Account of the badness of death.3 It is a natural inference from this view that the difference in goodness between the two possible lives is also the proper measure of the extent to which a death is bad for the victim. A death is bad because, and to the extent that, it deprives the victim of the additional good life she would have if that death were not to occur.
Lucretius’s challenge was quite different. He sought to dispel the fear of death by observing that we are not disturbed by the fact that there was an indefinite period before our lives began during which we did not exist; therefore, we should be equally undisturbed by the fact that there will be an indefinite period after we die in which we will not exist. Since we do not regret that we began to exist later than we might have, we ought not to care that we will cease to exist earlier than we might.
Those who thought that the Life Comparative Account provided a satisfactory reply to Epicurus thus faced a challenge from Lucretius. Suppose that a person who died at t at the age of 70 could have begun to exist 10 years earlier, so that although she would still have died at t, she would have lived for 80 years rather than 70. Suppose that of these two possible lives, the longer would have been better. The Life Comparative Account then implies that it was bad for this person to have begun to exist later rather than earlier, in the same way that it would be bad for her to die earlier rather than later. Both beginning to exist later and ceasing to exist earlier deprive a person of good life that she might have had.
Contemporary philosophers have suggested many plausible responses to Lucretius’s challenge. But the Life Comparative Account faces another and arguably more serious objection. For it implies that the worst death an individual can suffer is death immediately after that individual begins to exist, for that is the death that results in the greatest possible difference between the
2 Feldman (1991, 1992).
3 McMahan (2002).
actual life and the possible life the individual would have had in the absence of the death—in other words, the death that deprives the victim of the most good life is the earliest one possible. Most of us believe that we begin to exist either at conception or, perhaps more plausibly, sometime between conception and birth. If we also accept the Life Comparative Account, we seem committed to the view that the worst deaths are those of zygotes, embryos, or fetuses. Philosophers who have found this implication hard to believe have therefore sought to find an alternative to the Life Comparative Account to explain why and to what extent death is a misfortune for the one who dies.
Philosophers have in recent decades discussed many other questions about the evaluation of death: for example, which of the many ways of understanding what would be involved in a person’s not dying is relevant to evaluating her actual death, with what possible life span a person’s actual life should be compared in determining how much life she has lost in dying, and so on. But the question about the relative badness of death at different ages, to which the Life Comparative Account gives an intuitively implausible answer, is especially important for a range of practical issues. Indeed, in recent years it has come to be debated in discussions with potentially highly important consequences among theorists in the field of population health.
One exceptionally influential and important project in that field that has been in progress for almost three decades is the Global Burden of Disease Study, directed primarily by Christopher Murray, which seeks to quantify in a systematic way the burdens that different diseases impose on people throughout the world. As Andreas Mogensen points out in chapter 3 of this volume, Murray and his colleagues initially deployed age-weighting and discounting in their calculations, which enabled them to accommodate the belief that the death of an adolescent is a greater misfortune for that person than the death of a newborn infant is for the infant. Later, however, they abandoned these functions, thereafter using the Life Comparative Account to evaluate the badness of different deaths, beginning at birth. On these new assumptions, the death of an infant immediately after birth is a substantially greater harm or misfortune than the death of a 20-year-old. And while death immediately or soon after birth is a greater misfortune than death at any subsequent point, the death of a fetus immediately prior to birth does not count as a loss or misfortune at all. But unless we begin to exist at birth, the fetus and the newborn are one and the same individual, and it can hardly make a difference to the misfortune that the individual suffers in dying where the death occurs—that is, inside or outside of the mother’s body.4
4 The question of when we begin to exist is a question in the area of metaphysics concerned with personal identity. Jens Johansson addresses some of the relevant issues in chapter 11, this volume.
If used in guiding the formulation of policies governing the distribution of health-care and life-saving resources, these assumptions would give substantially greater priority to the prevention and treatment of diseases that cause death in early infancy over the prevention and treatment of diseases that tend to be fatal primarily among older children and young adults. This would be highly controversial. Concern about this and other such possibilities has prompted serious reflection about how death at different ages should be evaluated among many of those who work in population health and health metrics. This in turn has led some of these theorists to examine the hitherto rather obscure philosophical debates about death that have appeared during the period since the publication of Nagel’s seminal essay.
Until quite recently, philosophers writing about metaphysical and evaluative issues raised by death and theorists working on summary measures of population health have worked largely in isolation from one another—to the detriment of both. Saving People from the Harm of Death is a milestone in collaborative engagement across these fields. Some of the chapters explore the relations among philosophical evaluations of death, the measurement of population health, and health policy. Others are explicitly concerned to suggest ways in which insights from the philosophical literature can be integrated into our thinking about how, for example, deaths at different ages should count in measurements of the burden of disease. In other chapters, philosophers who have made substantial contributions to our understanding of the evaluation of death offer revisions of their original views or, in some instances, advance objections to other views or investigate foundational assumptions presupposed by those views.
The making of the book involved substantial interaction and discussion among the contributors, many of whom are primarily philosophers but others of whom work in population health, in bioethics, or even directly in the practice of medicine. We have extensively discussed one another’s ideas and arguments in workshops in Oslo and Oxford and have continued the discussions over email and through further personal contacts. I think I speak for all the contributors in saying that we have learned a great deal from one another. I would like to be able to say that we have achieved a consensus, but that is of course too much to expect from a group containing so many philosophers. But I do believe that the hard thinking that has gone into this project has advanced the debates with which the chapters are concerned, and I am optimistic that this book is just the beginning of extensive collaborative efforts among thinkers from the various fields that have been brought together here. Ultimately our hope is that these efforts will result in policies governing both national and global distributions of resources for preventing and treating disease that will be more rational and more just than those that might otherwise be adopted.
I will conclude by acknowledging a special debt that many of the contributors to this book owe to Derek Parfit, who died in January 2017. Many of
the chapters are concerned in one way or another with what Joseph Millum and others refer to as “gradualism,” a term that covers any view that implies that death can be a lesser misfortune early in life, gradually becomes a greater misfortune, eventually reaches a peak at some later age, and then gradually becomes a lesser misfortune. The account of the misfortune of death for which I have argued—the Time-Relative Interest Account (or TRIA)—was one of the earlier versions of gradualism to appear in the philosophical literature on death. It draws very directly on Parfit’s work on personal identity and what matters in survival. To the extent that some of the chapters in this book discuss the TRIA or related gradualist views, they too are indebted to Parfit’s pioneering work. With this in mind, I approached Parfit shortly before he died about the possibility of his writing a foreword or afterword for the book in which he might develop his current thinking on the debates in the chapters that had been prompted by his earlier work. He read the chapters in draft and greatly admired them. He told me that he would happily write an enthusiastic endorsement, or “blurb,” for the back cover and also offered, with characteristic generosity, to write comments on all the chapters for the benefit of the authors. But, he said, he needed to think more about whether he had enough to say before committing himself to writing a substantive comment on the relevant issues. He died unexpectedly shortly thereafter. The chapters in this book—a book on death—are among the last pieces of philosophical writing he read. To honor the great progenitor of the debates in the following chapters, the editors decided, with my encouragement, to dedicate this book to Derek.
References
Feldman, Fred. 1991. “Some Puzzles about the Evil of Death.” Philosophical Review 100: 205–227.
Feldman, Fred. 1992. Confrontations with the Reaper. New York: Oxford University Press. McMahan, Jeff. 2002. The Ethics of Killing: Problems at the Margins of Life. New York: Oxford University Press.
Nagel, Thomas. 1970. “Death.” Noûs 4, 1: 73–80. Reprinted in Nagel, Mortal Questions, 1979, 1–11. Cambridge: Cambridge University Press. Williams, Bernard. 1973. “The Makropulos Case: Reflections on the Tedium of Immortality.” In Problems of the Self, 82–100. Cambridge: Cambridge University Press.
ACKNOWLEDGMENTS
This book came out of the conference “Saving Lives from the Badness of Death,” University of Oslo, in 2015. A follow-up workshop was arranged at Corpus Christi College, University of Oxford, in 2016. We thank all the authors for their valuable contributions. The process of editing this volume has gone better than expected, much due to the generous assistance of several people. Sorin Bangu, Ole Hjortland, and Reidar K. Lie provided helpful comments on our book proposal. Several people have been collaborators along the way. Among them is Ole Frithjof Norheim, who assisted us in an early phase of the project. Norheim also helped us with funding for the conference in Oslo through his research group Global Health Priorities at the University of Bergen. Reidar K. Lie gave us valuable advice on many occasions, for which we are very grateful. We also appreciate the generous funding received from the Ethics Program, University of Oslo, and the Department of Philosophy, University of Bergen. Thanks to Christel Fricke and Olav Gjelsvik, and the Centre for the Study of Mind in Nature (CSMN), University of Oslo, both for funding and hosting the conference in Oslo and for funding the workshop in Oxford. Special thanks go to Jeff McMahan, who made it possible for us to host the workshop at Oxford. Jeff has been extremely helpful and supportive along the way, and this book would not exist if it weren’t for him. We are also very pleased that Jeff accepted our invitation to write a foreword for the book. Preben Sørheim has served as a research assistant on the volume, eagerly helping us with practicalities in relation to the conference and workshop. Sørheim also provided valuable feedback on several chapters. Mathias Barra has been an adviser on issues relating to health axiology. We are very grateful to Barra for his valuable comments and advice on several of the chapters. We must also express our gratitude to Lucy Randall and Hannah Doyle at OUP for swift and careful assistance in the production process. Also, a huge thanks to Mary Becker for rigorous copy editing, and to Sofie Lekve for making the index. Finally, we would like to thank series editors Nir Eyal and Dan Wikler for their valuable comments, for support along the way, and for including our book in their Population-Level Bioethics series.
Espen Gamlund
Carl Tollef Solberg
CONTRIBUTORS
Ben Bradley, Syracuse University, Allan and Anita Sutton Professor of Philosophy and Department Chair, is author of Well-Being and Death (OUP) and Well-Being (OUP), among other works.
John Broome, University of Oxford, Emeritus White’s Professor of Moral Philosophy, and Australian National University, Adjunct Professor, is author of Weighing Lives (OUP) and Rationality Through Reasoning (OUP), among other works.
Susanne Burri, London School of Economics, Assistant Professor of Philosophy, works on normative ethics and philosophy of death.
Tim Campbell, Institute for Futures Studies and Stockholm University, researcher in philosophy, works on issues in ethics and moral philosophy.
Espen Gamlund, University of Bergen, Professor of Philosophy, works on topics in ethics and moral philosophy.
Hilary Greaves, University of Oxford, Professor of Philosophy and Director of the Global Priorities Institute at the University of Oxford. Her research spans many areas of moral philosophy, including interpersonal aggregation, population ethics, effective altruism, and issues at the interface of ethics and economics.
Michelle Hutchinson, Giving What We Can, Executive Director, has a PhD in philosophy from the University of Oxford.
Jens Johansson, Uppsala University, Professor of Philosophy, is coeditor of The Oxford Handbook of Philosophy of Death (OUP), and author among other works.
F. M. Kamm, Harvard University, Professor of Philosophy, is author of Morality and Mortality, 2 vols., (OUP), Intricate Ethics (OUP), and Bioethical Prescriptions (OUP), among other works.
Samuel J. Kerstein, University of Maryland, Professor of Philosophy, is author of How to Treat Persons (OUP), among other works.
Ivar R. Labukt, Arctic University of Tromsø, Associate Professor of Philosophy, works on normative ethics and metaethics.
Jeff McMahan, University of Oxford, White’s Professor of Moral Philosophy, is author of The Ethics of Killing (OUP) and Killing in War (OUP), among other works.
Joseph Millum, Clinical Center Department of Bioethics and Fogarty International Center, National Institutes of Health, Staff Scientist in Bioethics, is coeditor of Global Justice and Bioethics (OUP), and is the author of other works. He recently published a book with OUP, The Moral Foundations of Parenthood, 2018.
Andreas Mogensen, University of Oxford, Associate Professor of Philosophy, works on topics in ethics and moral philosophy.
Erik Nord, Norwegian Institute of Public Health, Senior Researcher, and Department of Pharmacy, University of Oslo, Professor of Health Economics, is author of Cost Value Analysis: Making Sense Out of QALYs (CUP), among other works.
Ole Frithjof Norheim, University of Bergen, medical doctor, Professor of Medical Ethics, and Harvard University, Adjunct Professor of Global Health and Population, is coeditor of Inequalities in Health, Concepts, Measures, and Ethics (OUP) and lead author of Making Fair Choices (WHO), among other works.
Theron Pummer, University of St. Andrews, Senior Lecturer in Philosophy and Director of the Centre for Ethics, Philosophy and Public Affairs, works on ethics, political philosophy, and metaphysics.
Carl Tollef Solberg, University of Bergen, medical doctor and philosopher, PhD in medical ethics, a practicing physician and affiliate at the University of Oslo, works on issues in bioethics.
Introduction
PERSPECTIVES ON EVALUATING DEATHS AND
THEIR
RELEVANCE TO HEALTH POLICY
Espen Gamlund and Carl Tollef Solberg
According to the World Health Organization (WHO), there were 56.4 million deaths throughout the world in 2015. The most common causes of death in high-income countries were ischemic heart disease and stroke, while those in low-income countries were diarrheal disease and lower respiratory infections (WHO 2017).
Most people would say that the majority of these deaths were bad, but it is not easy to explain why or to what extent this is so. The question of how to evaluate deaths has occupied philosophers for centuries. A debate has emerged in the philosophical literature that is referred to as the badness of death (Nagel 1970; Feldman 1992; Broome 2004; Bradley et al. 2012). This debate is not concerned with the fear of death that many people have. Nor is it concerned with the pain or suffering associated with the process of dying. Rather, the debate is concerned with how bad it is to lose one’s life and, as it is generally assumed, thereby to cease to exist.
There have been debates in the field of population health on the issue of how mortality and morbidity can be measured. The intention has been, among other things, to produce measures of public health that can guide the formulation of policies governing the distribution of health care resources. However, there are many questions concerned with the evaluation of death that have not been carefully addressed in the literature on population health but that have been extensively discussed in the philosophical literature on death. Conversely, there are debates in population health about whether and how to summarize mortality and morbidity that have largely escaped the attention of philosophers. The purpose of this book is to bring these two general debates— the one in philosophy and the one in population health—into dialogue with
one another, with the aim of evaluating deaths and examining the relevance of such evaluation to health policy.
1. Two Debates about Death
The ancient philosopher Epicurus (341–270 a.d.) would not have thought that the deaths of the 56.4 million people mentioned above were bad for them. Epicurus argues that death is not bad for us because “as long as we exist, death is not with us; but when death comes, then we do not exist” (Epicurus 1940, 30–34). Many contemporary philosophers disagree with Epicurus and believe that death can be bad for those who die. Most notably, Thomas Nagel (1970) argued that death is bad for those who die when and because it deprives them of the good life that they would have had if they had continued to live. Nagel’s view marks the beginning of a debate on the badness of death in analytic philosophy. Death has come to be seen as bad because it deprives one of a better life that one would otherwise have had.1
Until the 1950s, epidemiology was mainly concerned with mortality rates, such as the crude death rate and age-specific death rates (Dempsey 1947). The crude death rate is merely the number of deaths per year per 1,000 people, while age-specific death rates are crude death rates restricted to an age group. For example, the child mortality rate indicates the crude death rate for individuals from 0 (birth) to 5 years of age (Porta 2014). These descriptive metrics of mortality avoid evaluative assumptions, which means that no deaths are ranked worse than others. However, these descriptive metrics also have their shortcomings. First, such metrics are silent about whether some deaths are worse than others. Second, there is a reason to question whether descriptive mortality indicators are—without further adjustments—suited to direct comparison with morbidity indicators. But these and similar concerns can be addressed by measures that are to some extent evaluative. In order to address the shortcomings of descriptive mortality indicators, we can treat certain deaths as more significant than others, most commonly according to the decedent’s age. This approach involves ranking deaths according to their badness and is an evaluative approach.
Consider the deaths that occurred worldwide in 2015. Of these 56.4 million deaths, 2.7 million were those of newborn infants,2 and 5.9 million were those of children from birth to 5 years of age. The deaths of people from 5 to 14 years of age counted 1 million. The majority of the 56.4 million deaths were those of older adults. Furthermore, the roughly 2.6 million stillbirths were not
1 See, e.g., Feldman (1992), Broome (2004), and Bradley (2009).
2 This refers to deaths from birth to 1 month of age.
included in the WHO statistics of the total number of fatalities (Lawn et al. 2016).3
If deaths are bad for those who die primarily because of what they are deprived of, then it would appear that the earlier in life death occurs, the worse it is. For example, newborn deaths would be worse than adolescent deaths because newborns are deprived of a greater future than adolescents. While some people accept this conclusion (Marquis 1989; Feldman 1992; Broome 2004; Bradley 2009; Murray et al. 2012a, app.), others seek to defend intuitions that conflict with it. The latter consider the death of an adolescent to be worse than the death of a newborn, even if the newborn is deprived of a longer future (see, e.g., Dworkin 1993; McMahan 2002).
The question of the badness of death for the individual who dies is undoubtedly complex. However, by answering this question carefully we can seek to design appropriate evaluative measures that can guide health policy around the world. To avoid the question, or to answer it rashly, is to risk getting global health priorities wrong. If we are mistaken in our evaluation of death, then our monitoring and assessing of the burdens of different diseases become impaired. This will lead to the measuring of health inequities on false premises and the suboptimal ranking of health programs.
2. The Purpose of the Book
Although philosophers have written numerous articles and books on the badness of death, they have paid very limited attention to the connection between their discussions and health policy.4 Likewise, medical doctors, health economists, and epidemiologists have been concerned with evaluating deaths, but have not paid sufficient attention to whether and why death is bad or to death’s comparative badness for different people, particularly people of different ages (see, e.g., Murray 1996; Gold et al. 2009; Murray et al. 2012a, 2012b; Lawn et al. 2016).
There are at least four sets of questions that require further thinking.
1. Can an individual’s death be bad for her and, if so, how? This question concerns the nature of the harm of death. If we understand the harm that death involves, then we can more competently answer when the worst time to die is. Until now, there has been little focus on how the nature of the harm of death should inform our practices
3 Stillbirths are deaths from the 28th gestational week to birth.
4 The two major handbooks on the badness of death—The Oxford Handbook of the Philosophy of Death (2012) and The Cambridge Companion to Life and Death (2014)—fail to address the issues discussed in this book.
in global health. Debates in population health that are concerned with measuring the burden of disease assume that death is among the greatest disease burdens. Therefore, the badness of death can be compared with and weighed against the badness of other effects of disease, such as suffering. However, many issues surrounding death remains. Even the assumption that death is among the burdens of disease has been challenged and debated by philosophers since the time of Epicurus.
In order to construct meaningful evaluative measures that can guide health policy, we need to understand whether things other than being deprived of a valuable future contribute to the harm of death. The most important of these involve the frustration of a person’s projects and the loss of her agency, her past, and her consciousness.5 Only by developing a solid grip on the different elements that contribute to the harm of death will we be able to assess whether, for example, an adolescent’s death is worse than the death of a fetus. In the Global Burden of Disease (GBD) study, it is assumed that death begins to be bad at birth and that the burden of death is greatest immediately after birth. While there are political considerations that favor adopting such assumptions and while there are some philosophers who defend the view that death is worst immediately after an individual begins to exist, these views are in many ways counterintuitive and have been challenged by the work of other contemporary philosophers, including some of the contributors to this book.
In order to guide health policy coherently, it is essential to understand the nature of the harm of death and how it relates to evaluative mortality measures and priority setting in health care. For example, if there are different dimensions to the badness of death, as Frances Kamm and Susanne Burri claim in chapters 10 and 12, respectively, in this book, this raises questions about whether they can be aggregated and whether evaluative mortality measures should take such dimensions into account.
2. When is the worst time to die? This issue concerns the size of the harm of death. Do the methods routinely used for quantifying the harm of death in epidemiology make sense? Should every potential year of life lost have equal value, irrespective of when and by whom it is lost? Is the death of an adult worse than the death of an infant and, if so, why? Does psychological development affect how bad death is? There is significant disagreement concerning when death is
5 These issues are discussed in the chapters of part II of the book.
worst for its victim. Given the lack of this consensus, how are we to quantify the harm of death? A further underexplored issue concerns the relationship between priority setting in health care and the harm of death. Which principles should we use when allocating life-saving resources, such as organ transplantation?
3. How do considerations concerning the badness of death relate to population ethics? Population ethics is concerned with the problems that arise from causing individuals to exist. While discussions on the badness of death and population ethics have been conducted in parallel, several questions at the intersection of these two areas of research require further clarification. How do issues about our beginning to exist relate to concerns about our continuing to exist? That is, is it more important to bring a new individual into existence or to prolong the life of an already existing individual? How much weight should we place on family planning and procedures such as in vitro fertilization in comparison with extending the lives of senior citizens? Summary measures of population health combine information on morbidity and mortality into a single number, but are such measures capable of handling the difference between extending lives and creating new ones? And how can it be bad to die if it is not bad never to exist?
4. Can we set sensible priorities in health care without relying on any view of the badness of death? Not everyone is convinced that questions concerning death and its badness have policy relevance. For example, is minimizing the badness of death a reasonable principle for health prioritization? How should a principle of respect for persons figure into our calculations for priority setting in health care? And are we able to apply accounts of the badness of death to summary measures of population health without inconsistency?
In this book, we have challenged philosophers, medical doctors, and health economists to address several ignored and unresolved issues at the intersection of the badness of death and health policy. The book consists of four parts, each of which responds to one of the four challenges identified above. Part I, “Policy,” responds to the second challenge; part II, “Theory,” contains chapters that primarily discuss the first challenge; part III, “Population Ethics,” responds to the third sets of questions; and the chapters in part IV, “Critical Perspectives,” discuss the questions raised by the fourth challenge. The overarching aim of the book is to help us understand the harm involved in death and to connect discussions on the badness of death to debates concerning health metrics and distributive issues in population health.
3. Background and Structure of the Book
In what follows, we present the chapters of the book and provide some background to their discussions.
3.1. PART I: “POLICY”
The first part of the book focuses on practical challenges. It considers the health policy questions that should prompt further theoretical analyses. This part connects the philosophical discussion on the badness of death to the policy issues that are typically alluded to by terms such as Disability-Adjusted Life Years (DALYs), Quality-Adjusted Life Years (QALYs), and age-specific allocation principles, or by other attempts to quantify the harm of different deaths. The justification for starting the book with policy challenges is twofold. First, the book is situated within the tradition of population-level bioethics and serves as a bridge between two debates. Second, we believe that the gaps outlined in section 2 will be more clearly understood if the issues are encountered by means of an applied perspective.
Health care systems serve at least two chief purposes, namely to improve people’s quality of life and to prolong their lives. If successful, they reduce morbidity and mortality. Because health resources are scarce, we need to know how to allocate them rationally and fairly. It seems reasonable to prioritize interventions that have proved most effective. Moreover, an intervention’s cost also matters. By combining these two considerations, we arrive at costeffectiveness (Garber and Phelps 1997).
One standard way of measuring effectiveness is to use summary measures of population health. Those used most frequently are the QALYs gained and the DALYs lost (Weinstein et al. 2009). Such measures enable us to describe the multidimensional concept of health’s impact on quality of life (QALY) and to summarize morbidity and mortality in a single number (DALY, QALY).
The QALY measure was developed against the background of expected utility theory and emerged under its current name in the late 1970s and early 1980s (Von Neumann and Morgenstern 2007). In the QALY model, one year of full health is conventionally valued at 1, and values of life years typically range from 0 to 1 (Weinstein et al. 2009).6 The DALY measure was developed in the early 1990s as an integral part of the Global Burden of Disease (GBD) study. This measure estimates the weights given to particular health states (Salomon et al. 2015). On the DALY scale, 1 represents full disability (equivalent to death), while 0 represents no disability (Gold et al. 2002).
6 The QALY can also include negative values for health states that are evaluated as worse than death.
The GBD study is the most extensive attempt to measure epidemiological trends worldwide. It measures disease burden in DALYs. The first GBD study contained data from 1990. From GBD 1990 to GBD 2010, the worst deaths were considered to be those of 10-year-olds (Murray 1996; Murray et al. 2012a, 2012b). From GBD 2010 to GBD 2015, the deaths of infants were considered the worst. Even in the GBD 2015 study, stillbirths did not generate any disease burden (Wang et al. 2016).7 This raises questions concerning the moral significance of birth and whether there are reasons for including stillbirths in the DALY count.
In the economic evaluation of health interventions and measurements of the burden of disease, one routinely quantifies the harm of death. However, the question arises of whether this makes sense. In chapter 1, Erik Nord explores the various attempts that have been made to account for the badness of death in economic terms. A relatively straightforward approach is that of a societal valuation perspective. This seeks to study how many averted cases of a given health loss people think an averted death is equal to in value and priority merit. Nord is concerned that there is a considerable random error involved in measuring such preferences, as people do not have precise and stable perceptions about the harm of death. Nevertheless, according to Nord, the results of such studies can help policymakers prioritize health programs in a manner that is consistent with the values of the population. Nord concludes that most of the existing approaches fail to represent the values held by the wider society.
Jeff McMahan’s Time-Relative Interest Account (TRIA) suggests that the deaths of adolescents are typically worse than the deaths of infants. In chapter 2, Ole Frithjof Norheim explores whether this account is consistent with the summary measures of health and their implications for priority setting in health care. Norheim argues that there are at least two possible interpretations of the TRIA. The extreme version implies that the deaths of infants tend to be less bad than the deaths of adolescents, even though infants lose a significantly longer future. The moderate version suggests that the deaths of infants tend to be less bad than the deaths of adolescents if both infants and adolescents lose a similar number of good life years. He argues that the extreme interpretation of the TRIA is incompatible with the standard practice of measuring population health by using life expectancy at birth as an indicator. This is because implementing a policy that always saves adolescents rather than children would lower a population’s life expectancy. Norheim considers this implication untenable and argues that one should therefore reject the extreme version. Nevertheless, he considers the moderate version of the TRIA to be compatible with earlier attempts to measure the burden of disease.
7 The term “stillbirth” may appear ambiguous, but it simply means the death of a fetus older than 28 weeks of gestational age.
