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Hope or despair: a response to ‘Do not despair about severity—yet’
  1. Daniel Hausman
  1. Department of Philosophy, University of Wisconsin-Madison, Madison, WI 53711, USA
  1. Correspondence to Dr Daniel Hausman, Department of Philosophy, University of Wisconsin, Madison, WI 53711, USA; dhausman{at}


This is a brief response to ‘Do not despair about severity—yet’ by Barra et al. It argues that they have no serious criticisms of Daniel Hausman’s essay, ‘The Significance of Severity’” and that indeed their work lends further support to his view that there is no justification for prioritising severity. As policy-akers, Barra and his coauthors are more constrained by popular attitudes, which apparently favour prioritising severity.

  • allocation of health care resources
  • ethics
  • health care economics
  • philosophy of medicine

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Barra1 and coauthors use their superb essay, ‘Severity as a priority setting criterion: setting a challenging research agenda’,2 as the basis both for their hopes that prioritising severity can be a justified and practical criterion for assessing healthcare interventions and for their complaints that my essay, “The significance of ‘severity’,”3 is too dismissive. By ‘prioritising severity’, my critics and I mean at least assigning weight to the severity of illness or risk beyond what cost-effectiveness demands. Barra et al’s argument is ironic, because their superb essay (which I wish I had known of when writing mine) accentuates and extends my critique of prioritising severity rather than in any way mitigating it.

Barra et al have two small criticisms to make of my essay. They maintain that I should be less disturbed by the ambiguities in the notion of ‘severity’ or by the absence of any principled account of how to trade off concern for severity against other relevant moral considerations. They object to the rough and ready meaning I assign to ‘severity’, which at least disentangles severity from implicit age weighting. But they defend no specific alternative analysis of severity, and they do not show that my scepticism about the justification of prioritising severity depends on the rough analysis I rely on.

These criticisms are not, however, where the action is. Whereas I argued that the glass is nearly empty, Barra et al insist that there still some juice in it. Engaged as Barra et al are in public policy, they find it unimaginable that in all the smoke of public concern for severity, there are no fires, no coherent principles.

Situated as I am, in contrast, in my philosopher’s armchair, I concluded my essay with the following words, against which Barra et al have nothing to say:

This paper has questioned whether there is solid moral argument in defence of prioritising severity. It argues first, that it is hard to define ‘severity’. Measuring severity as HRQoL if untreated leads to absurd results unless one limits comparisons to health states that have the same duration. Measuring severity by absolute or proportional shortfalls in QALYs or life-expectancy implies age-weighting, which is foreign to the concerns about severity. Second, neither egalitarianism nor prioritarianism support prioritising severity, as it is conceived in this paper, let alone provide any guidance concerning how much priority severity ought to have. Third, popular attitudes toward severity draw a morally arbitrary distinction between, on the one hand, relevant differences in impairments, which result from salient health threats, and, on the other hand, irrelevant differences in impairments, which result from differences in pre-existing health states. Finally, although compassion and solidarity lead to dissatisfaction with cost-effective healthcare allocation, they have no clear bearing on a policy of prioritising severity. Some might argue that health policy must be guided by popular attitudes, even if they have no moral defence and, like prioritising severity, imply fewer aggregate health improvements. As a political matter, conforming to popular attitudes may be unavoidable. But there is a role for opposition and criticism, particularly when popular attitudes are conflicted as well as unjustified.



  • Contributors DMH is the sole contributor.

  • 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.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

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