Measuring need, not ranking suffering: Severity as a priority setting criterion in healthcare
Healthcare priorities need to be morally sound
Every healthcare system has its limitations. Decisions about resource allocation are a necessary evil. Sometimes it comes down to cost-effectiveness, other times to severity: if your condition is worse, you should be prioritised. But in what way should you be ‘worse off’ to get help first?
Niklas Juth is professor of clinical medical ethics
Severity as a priority setting criterion in healthcare means that whoever has it worse, a patient or patient group, should be prioritised. Many healthcare systems use this criterion to make difficult decisions: the Netherlands, Norway, Sweden, and the UK to name a few. According to the authors of a recent Bioethical Inquiry publication, it has been unclear why this criterion is important for healthcare priority setting.
“It seems quite straightforward: the more severe an illness is to a patient or patient group, the higher their priority to get healthcare should be. But it’s not so easy. To say severity is a viable priority setting criterion in healthcare, we need a clarification of the moral basis of the prioritises set. Without this, we cannot promise equality of health,” says Niklas Juth, professor of clinical medical ethics at Uppsala University’s Centre for Research Ethics & Bioethics and one of the authors.
There are two main lines of reasoning for the moral basis of severity: egalitarianism and prioritarianism. Egalitarianism suggests it is bad to be worse off than others. Prioritarianism suggests we have stronger reasons to help others the worse off they are, regardless of how their condition compares to that of others. Egalitarianism is relational while prioritarianism is not.
According to Niklas Juth and his co-authors, priorities set on the basis of severity should be about how severe your condition is – to you – not in comparison to others. A relational, more egalitarian, approach to the assessment of severity creates unnecessary complexities. For example, the severity of one person’s illness would vary depending on the condition of other people’s conditions even if their own health status has not changed. Prioritarianism and severity share the same moral point of departure: that the worse off someone is, the stronger reasons there are to aid that person.
This has important practical implications for how patients and patient groups should be prioritised in healthcare. Having prioritarianism be the moral basis for severity as a priority setting criterion in healthcare means that we do not have to consider how patients fare relatively to one another but only how bad off they are in absolute terms, aligned with the Norwegian use of severity as a priority setting criterion in healthcare.
“In the end, severity is not a relational concept but an absolute one. It is about the burden it places on a patient’s health and quality of life,” Niklas Juth concludes.
By Anna Holm Bodin
Juth, N., Gustavsson, E. & Sandman, L. The Ethical Basis of Severity as a Priority Setting Criterion in Healthcare—Egalitarian or Prioritarian?. Bioethical Inquiry (2025). DOI: 10.1007/s11673-025-10472-1