Written by: Carl Tollef Solberg, Senior Research Fellow, Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen.
Espen Gamlund, Professor of Philosophy, Department of Philosophy, University of Bergen.
In 2015, there were 56.4 million deaths worldwide (WHO 2017).[i] Most people would say that the majority of these deaths were bad. If this is the case, why is it so, and are these deaths equally bad?
Death is something we mourn or fear as the worst thing that could happen—whether the deaths of close ones, the deaths of strangers in reported accidents or tragedies, or our own. And yet, being dead is not something we will ever live to experience. This simple truth raises a host of challenging philosophical questions about the negativity surrounding our sense of death, and how and for whom exactly it is harmful. The question of whether death is bad has occupied philosophers for centuries, and the debate emerging in the philosophical literature is referred to as the “badness of death.” Are deaths primarily negative for the survivors, or does death also affect the decedent? What are the differences between death in fetal life, just after birth, or in adolescence? When is the worst time to die? These philosophical questions, although of considerable theoretical interest, is particularly relevant for how we evaluate deaths in global health, and policy-makers spending money to finance different health programs need to know how to answer them.
Two Disconnected Debates
The ancient philosopher Epicurus (341–270 A.D.) would not have thought that the deaths of the 56.9 million people mentioned above were bad for them. Epicurus argued that death is not prudentially bad for us because “as long as we exist, death is not with us; but when death comes, then we do not exist” (Epicurus 1940, 30–34). Many contemporary philosophers disagree with Epicurus and believe that death can be bad for those who die. Most notably, Thomas Nagel (1970) argued that death can be bad for those who die when and because it deprives them of the good life they would have had if they had continued to live. This marks the beginning of the debate emerging in the philosophical literature referred to as the “badness of death.” Moreover, Nagel’s so-called Deprivation Account has come to be regarded as the orthodox view as to why death is prudentially bad.
There are a few trends in the current philosophical debate that are worth mentioning. First, the debate is secular in tone with the assumption that permanent non-existence follows death. Second, the focus is on the instance of death rather than on the process of dying. Third, most of the discussion is concerned about whether death can be prudentially bad for those who die, rather than bad for everyone else but the decedent, such as family, friends and society.
Up until the 1940s, epidemiology was primarily concerned with mortality rates, such as the crude death rate and age-specific death rates (Dempsey 1947). The crude death rate is merely the number of deaths per year per 1,000 people, while age-specific death rates are crude death rates restricted to an age group. Following mortality rates, none of the 56.4 million deaths is ranked as worse or better than the other. Descriptive measures have their virtues as they are simple, transparent, and inherently universal. It can be argued, however, that this leaves out something of importance. First, clearly some deaths are worse than others, and these descriptive measures are silent about this fact. Second, one may question whether descriptive mortality measures—without further adjustments—are suited for comparison and aggregation with morbidity measures. These and similar concerns can be addressed by mortality measures that are to some extent evaluative.
Evaluating Deaths
Consider the deaths that occurred worldwide in 2015. Of these 56.4 million deaths, 2.7 million were those of infants, and 5.9 million were those of children from birth and up until 5 years of age. The deaths of people from 5 to 14 years of age counted 1 million. The majority of the 56.4 million deaths were those of older adults. Furthermore, there were roughly 2.6 million stillbirths not included in this WHO statistic of the total number of fatalities. Do we want to say that all these deaths are equally bad?
It would seem that our answer to this question depends on our theoretical starting point. If deaths are bad for those who die primarily because of what they are deprived of, then it would appear that the earlier in life death occurs, the worse it is. Newborn deaths, for instance, would be worse than adolescent deaths because newborns are deprived of a greater future than adolescents. While many philosophers seem to accept this conclusion (Marquis 1989; Feldman 1992; Broome 2004; Bradley 2009), others seek to defend intuitions that conflicts with it. The latter group considers the death of an adolescent to be worse than the death of a newborn, even if the newborn is deprived of a longer future (see, e.g., Dworkin 1993; McMahan 2002). Most philosophers would say that stillbirths should be included in WHO’s statistics because the death of late-term fetuses, although not a great misfortune for them, is nevertheless bad enough to be counted.
How we should evaluate the quality of life or well-being as such has been thoroughly discussed in both philosophy and in medicine. How we should evaluate deaths has not received similar attention. The question of the harm of death for the individual who dies is undoubtedly complex. However, by answering this question carefully, we can seek to design appropriate evaluative measures that can guide health policy around the world. To avoid the question, or to answer it rashly, is to risk getting global health priorities wrong. If we are mistaken in our evaluation of death, then our monitoring and assessing of the burdens of different diseases become impaired. For example, contrary to current practice, decisive arguments exist as to why one should include the annual 2.6 million stillbirths (2015) in the evaluation of deaths. Moreover, an illumination and improvement of the way we evaluate deaths can have consequences for how organizations such as WHO monitor health in the global disease burden study (GBD) and, not least, it may give us a better tool for prioritizing between major health programs that are intended to prevent deaths in different age groups. Ultimately, it will have consequences for the clinical work to prevent premature deaths in general and stillbirths in particular.
Future Discussions
We have recently edited and published an anthology—Saving People from the Harm of Death—which discusses how to evaluate deaths. In this volume, leading philosophers, medical doctors, and economists discuss different views on how to evaluate death and its relevance for health policy. This includes theories about the harm of death and its connections to population-level bioethics. For example, one of the standard views in global health nowadays is that newborn deaths are among the worst types of death, while stillbirths are neglected. This raises difficult questions about why birth is so significant, and several of the book’s authors challenge this standard view.
This is the first volume to connect philosophical discussions on the harm of death with discussions on population health, adjusting the ways in which death is evaluated. Changing these evaluations has consequences for how we monitor health and compare health outcomes, prioritize different health programs that affect individuals at different ages, as well as how we understand inequality in health. Our hope is that academics and policy-makers alike will be much more concerned and engaged in the question of how to evaluate deaths in the future.
References
Bradley, Ben. 2009. Well-Being and Death. New York: Oxford University Press.
Broome, John. 2004. Weighing Lives. New York: Oxford University Press.
Dempsey, Mary. 1947. “Decline in Tuberculosis: The Death Rate Fails to Tell the Entire Story.” American Review of Tuberculosis 61, 2: 157–164.
Dworkin, Ronald M. 1993. Life’s Dominion: An Argument about Abortion, Euthanasia, and Individual Freedom. New York: Vintage Books.
Epicurus. 1940. “Letter to Menoeceus.” In the Stoic and Epicurean Philosophers, edited by W. J. Oates, translated by C. Bailey, 30–34. New York: Modern Library.
Feldman, Fred. 1992. Confrontations with the Reaper: A Philosophical Study of the Nature and Value of Death.
Gamlund, Espen and Carl Tollef Solberg (eds.). 2019. Saving People from the Harm of Death. New York: Oxford University Press.
Marquis 1989 1989. “Why Abortion is Immoral.” The Journal of Philosophy 86, 4: 183–202.
McMahan, Jeff. 2002. The Ethics of Killing: Problems at the Margins of Life. New York: Oxford University Press.
Nagel, Thomas. 1970. “Death”. Nagel, Thomas. 1970. “Death.” Noûs 4, 1: 73–80.
WHO. 2018. “The Top 10 Causes of Death.” http://apps.who.int/mediacentre/factsheets/fs310/en/index.html (Visited 14.05.19).
[i] This essay is a shortened and revised version of the introduction in Gamlund and Solberg (2019).