J Med Ethics. 2017 Oct 27. pii: medethics-2017-104365. doi: 10.1136/medethics-2017-104365. [Epub ahead of print]

The disvalue of death in the global burden of disease.

Solberg CT1, Norheim OF1, Barra M2.

Author information

1

Department of Global Public Health and Primary Care, Global Health Priorities, University of Bergen, Bergen, Norway.

2

Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway.

Abstract

In the Global Burden of Disease study, disease burden is measured as disability-adjusted life years (DALYs). The paramount assumption of the DALY is that it makes sense to aggregate years lived with disability (YLDs) and years of life lost (YLLs). However, this is not smooth sailing. Whereas morbidity (YLD) is something that happens to an individual, loss of life itself (YLL) occurs when that individual's life has ended. YLLs quantify something that involves no experience and does not take place among living individuals. This casts doubt on whether the YLL is an individual burden at all. If not, then YLDs and YLLs are incommensurable. There are at least three responses to this problem, only one of which is tenable: a counterfactual account of harm. Taking this strategy necessitates a re-examination of how we count YLLs, particularly at the beginning of life.