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Consistency is not overrated
  1. Carl Tollef Solberg1,
  2. Ole Frithjof Norheim1,2,
  3. Mathias Barra3
  1. 1 Department of Global Public Health and Primary Care, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
  2. 2 Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
  3. 3 The Health Services Research Unit—HØKH, Akershus University Hospital, Lillestrøm, Akershus, Norway
  1. Correspondence to Dr Carl Tollef Solberg, Department of Global Public Health and Primary Care, Universitetet i Bergen Det medisinsk-odontologiske fakultet, Bergen 5020, Norway; carl.solberg{at}

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In a recent paper—The disvalue of death in the global burden of disease 1—we question the commensurability of the two components of the disability-adjusted life year (DALY)—years lived with disability (YLDs) and years of life lost (YLLs)—and offer a tentative solution to this problem. In an exciting and constructive reply—Is consistency overrated? 2—philosopher S Andrew Schroeder argues that our concern about the DALY may be missing the mark by accepting the DALY as what he refers to as an index reflecting nothing ‘beyond the importance we place in each (DALY component)’. According to Schroeder, our consistency requirement is then made redundant.

Recall our main argument: the DALY is the arithmetical sum of two components, YLDs and YLLs. The YLDs represents the individual disease burden that occurs while we are alive, while YLLs represents the individual disease burden resulting from our death. ‘Death’, in this context, is not the process of dying, which happens within life and which is captured by YLDs, but rather the incidence in which the life of a person has ended. Understood this way, the DALY is the aggregate of life and death, and we argue that these are incommensurables.

Why are YLDs and YLLs incommensurables? In our article, we present several reasons for this. Briefly, YLDs measure disease burden that happens to an individual, whether it be painful experiences or loss of function. YLDs have a duration and are usually something we experience, such as pain. YLLs, on the other hand, are instantly generated when the life of that individual has expired. We do not experience YLLs, and they happen where we are not. When YLLs are generated, the life in question has already ended. On a secular account, death is the irreversible cessation of the mind and the senses, and …

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  • Contributors CTS and MB wrote the initial draft and OFN revised it. All three authors approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer Norheim is a co-author on several GBD papers.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Patient consent for publication Not required.

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