Footnotes

• Contributors Single author with acknowledgements to others for feedback and suggestions on earlier versions of this commentary.

• Funding The author has 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 Commissioned; internally peer reviewed.

• ↵I use the authors’ definition in the text from page 3. This is the clearest of a number of definitions the authors provide. For example, this definition is distinct from the “Total value of met health needs possible to generate” mentioned in figure 2 because the former definition makes no reference to total value but instead just to the resources themselves. As Munthe et al correctly note, because available healthcare resources do not always contribute to such value (eg, empty ICU beds), it is important to distinguish resources from such value. Nevertheless, my arguments apply mutatis mutandis to this ‘total value’ definition. There is another definition of positive dynamics on page 3 that makes no reference to need and instead invokes intertemporal consistency in the use of principles: “a resource allocation according to the operational principles positively affects the available outcome value possible to generate through a future resource allocation that uses these principles”. Given that Munthe et al believe that one can change the principles (eg, by adding a sustainability principle) and that different allocators over time (even in the same health system) may use different principles, including intertemporal consistency of use is not practically useful to incorporate into the definition of positive dynamics.