Skip to main content
SpringerLink
Log in

Time trade-off and attitudes toward euthanasia: implications of using ‘death’ as an anchor in health state valuation

Quality of Life Research Aims and scope Submit manuscript

Cite this article

Abstract

Purpose

Health state values are by convention anchored to ‘perfect health’ and ‘death.’ Attitudes toward death may consequently influence the valuations. We used attitudes toward euthanasia (ATE) as a sub-construct for attitudes toward death. We compared the influence on values elicited with time trade-off (TTO), lead-time TTO (LT-TTO) and visual analogue scale (VAS).Since the ‘death’ anchor is most explicit in TTO, we hypothesized that TTO values would be most influenced by ATE.

Methods

Respondents valued eight EQ-5D health states with VAS, then TTO (n = 328) or LT-TTO (n = 484). We measured ATE on a scale from −2 (fully disagree) to 2 (fully agree) and used multiple linear regressions to predict VAS, TTO, and LT-TTO values by ATE, sex, age, and education.

Results

A one-point increase on the ATE scale predicted a mean TTO value change of −.113 and LT-TTO change of −.072. Demographic variables, but not ATE, predicted VAS values.

Conclusions

TTO appears to measure ATE in addition to preferences for health states. Different ways of incorporating death in the valuation may impact substantially on the resulting values. ‘Death’ is a metaphysically unknown concept, and implications of attitudes toward death should be investigated further to evaluate the appropriateness of using ‘death’ as an anchor.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

References

  1. Drummond, M. F. (1997). Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press.

    Google Scholar 

  2. Stein, K., Fry, A., Round, A., Milne, R., & Brazier, J. (2005). What value health?: A review of health state values used in early technology assessments for NICE. Applied Health Economics and Health Policy, 4(4), 219–228.

    Article  PubMed  Google Scholar 

  3. Räsänen, P., Roine, E., Sintonen, H., et al. (2006). Use of Quality-Adjusted Life Years for the Estimation of Effectiveness of Health Care: A Systematic Literature Review. International Journal of Technology Assessment in Health Care, 22(02), 235–241. Available at: [Accessed September 6, 2010].

    Google Scholar 

  4. Williams, A. (1990). EuroQol–a new facility for the measurement of health-related quality of life. Health Policy, 16(3), 199–208.

    Article  Google Scholar 

  5. Szende, A., Oppe, M., Devlin, N. J., & Group E. (2006). EQ-5D value sets: Inventory, comparative review, and user guide. Berlin: Springer.

    Google Scholar 

  6. Brazier, J., Ratcliffe, J., Tsuchiya, A., Joshua, S., & Brazier, J. (2007). Measuring and valuing health benefits for economic evaluation. Oxford: Oxford University Press.

    Google Scholar 

  7. Krabbe, P. F., Essink-Bot, M. L., & Bonsel, G. J. (1997). The comparability and reliability of five health-state valuation methods. Social Science and Medicine, 45(11), 1641–1652.

    Article  PubMed  CAS  Google Scholar 

  8. Szende, A., Oppe, M., & de Charro, F. (2007). Comparative review of time trade-off value sets. In A. Szende, M. Oppe, & N. Devlin (Eds.), EQ-5D Value Sets: inventory, comparative review, and user guide (pp. 21–28). Berlin: Springer.

    Chapter  Google Scholar 

  9. Augustovski, F. A., Irazola, V. E., Velazquez, A. P., Gibbons, L., & Craig, B. M. (2009). Argentine valuation of the EQ-5D Health States. Value in Health, 12(4), 587–596.

    Article  PubMed  Google Scholar 

  10. Torrance, G. W., Thomas, W. H., & Sackett, D. L. (1972). A utility maximization model for evaluation of health care programs. Health Services Research, 7(2), 118.

    PubMed  CAS  Google Scholar 

  11. Dolan, P. (1997). Modeling valuations for EuroQol health states. Medical Care, 35(11), 1095–1108.

    Article  PubMed  CAS  Google Scholar 

  12. Shaw, J. W., Johnson, J. A., & Coons, S. J. (2005). US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Medical Care, 43(3), 203–220.

    Article  PubMed  Google Scholar 

  13. Chevalier, J., & Pouvourville, G. (2011). Valuing EQ-5D using Time Trade-Off in France. The European Journal of Health Economics. Accessed online, 21 September 2011.

  14. Wittrup-Jensen, K. U., Lauridsen, J., Gudex, C., & Pedersen, K. M. (2009). Generation of a Danish TTO value set for EQ-5D health states. Scandinavian Journal of Public Health, 37(5), 459–466.

    Article  PubMed  Google Scholar 

  15. Golicki, D., Jakubczyk, M., Niewada, M., Wrona, W., & Busschbach, J. J. (2010). Valuation of EQ-5D health states in Poland: First TTO-based social value set in central and Eastern Europe. Value in Health, 13(2), 289–297.

    Article  PubMed  Google Scholar 

  16. Dolan, P., & Roberts, J. (2002). To what extent can we explain time trade-off values from other information about respondents? Social Science and Medicine, 54(6), 919–929.

    Article  PubMed  Google Scholar 

  17. Dolan, P., & Jones-Lee, M. (1997). The time trade-off: a note on the effect of lifetime reallocation of consumption and discounting. Journal of Health Economics, 16(6), 731–739.

    Article  PubMed  CAS  Google Scholar 

  18. Attema, A. E., & Brouwer, W. B. F. (2010). The value of correcting values: influence and importance of correcting TTO scores for time preference. Value in Health, 13(8), 879–884.

    Article  PubMed  Google Scholar 

  19. Salomon, J. A., & Murray, C. J. L. (2004). A multi‐method approach to measuring health‐state valuations. Health Economics, 13(3), 281–290.

    Article  PubMed  Google Scholar 

  20. Stalmeier, P. F., Lamers, L. M., Busschbach, J. J., & Krabbe, P. F. (2007). On the assessment of preferences for health and duration: maximal endurable time and better than dead preferences. Medical Care, 45(9), 835.

    Article  PubMed  Google Scholar 

  21. Robinson, A., & Spencer, A. (2006). Exploring challenges to TTO utilities: valuing states worse than dead. Health Economics, 15(4), 393–402.

    Article  PubMed  Google Scholar 

  22. Tilling, C., Devlin, N., Tsuchiya, A., & Buckingham, K. (2010). Protocols for time tradeoff valuations of health states worse than dead: A literature review. Medical Decision Making, 30(5), 610.

    Article  PubMed  Google Scholar 

  23. Stalmeier, P. F., Busschbach, J. J., Lamers, L. M., & Krabbe, P. F. (2005). The gap effect: Discontinuities of preferences around dead. Health Economics, 14(7), 679–685.

    Article  PubMed  Google Scholar 

  24. Lamers, L. M. (2007). The transformation of utilities for health states worse than death: consequences for the estimation of EQ-5D value sets. Medical Care, 45(3), 238–244.

    Article  PubMed  Google Scholar 

  25. Craig, B. M., & Busschbach, J. J. V. (2011). Revisiting United States valuation of EQ-5D states. Journal of Health Economics, 30(5), 1057–1063.

    Article  PubMed  Google Scholar 

  26. Augestad, L. A., Rand-Hendriksen, K., Kristiansen, I. S., & Stavem, K. (2012). Impact of transformation of negative values and regression models on differences between the UK and US EQ-5D TTO value sets. Pharmacoeconomics. (in press).

  27. Devlin, N. J., Tsuchiya, A., Buckingham, K., & Tilling, C. (2011). A uniform time trade off method for states better and worse than dead: feasibility study of the “lead time”approach. Health Economics, 20(3), 348–361.

    Article  PubMed  Google Scholar 

  28. Devlin, N. J., Hansen, P., & Selai, C. (2004). Understanding health state valuations: a qualitative analysis of respondents’ comments. Quality of Life Research, 13(7), 1265–1277.

    Article  PubMed  Google Scholar 

  29. Dolan, P., Gudex, C., Kind, P., & Williams, A. (1996). The time trade-off method: results from a general population study. Health Economics, 5(2), 141–154.

    Article  PubMed  CAS  Google Scholar 

  30. Dictionary MW. (2005). Merriam-webster online. Retrieved June. 2005.

  31. Schioldborg, P. (2000). Studenters holdninger til aktiv dodshjelp, assistert suicid og foreslatt lovendring. Tidsskrift for den Norske Laegeforening, 120(19), 2283–2288.

    PubMed  CAS  Google Scholar 

  32. Peterson, R. A. (1994). A meta-analysis of Cronbach’s coefficient alpha. Journal of Consumer Research., 21(2), 381–391.

    Article  Google Scholar 

  33. Parkin, D., & Devlin, N. (2006). Is there a case for using visual analogue scale valuations in cost-utility analysis? Health Economics, 15(7), 653–664.

    Article  PubMed  Google Scholar 

  34. Byock, I. (2002). The meaning and value of death. Journal of Palliative Medicine, 5(2), 279–288.

    Article  PubMed  Google Scholar 

  35. Wang, X. T., et al. (1996). Framing effects: Dynamics and task domains. Organizational Behavior and Human Decision Processes, 68, 145–157.

    Article  PubMed  Google Scholar 

  36. Macran, S., & Kind, P. (2001). “Death” and the valuation of health-related quality of life. Medical Care, 39(3), 217–227.

    Article  PubMed  CAS  Google Scholar 

  37. David Parkin. (2011). What does a health state value of Zero mean?. Available at: http://aheblog.com/tag/eq-5d/. Accessed October 3, 2011.

  38. Flynn, T. N. (2010). Using conjoint analysis and choice experiments to estimate QALY values: Issues to consider. PharmacoEconomics, 28(9), 711–722.

    Article  PubMed  Google Scholar 

  39. Brazier, J., Rowen, D., Yang, Y., & Tsuchiya, A. (2011). Comparison of health state utility values derived using time trade-off, rank and discrete choice data anchored on the full health-dead scale. The European Journal of Health Economics. 1–13.

  40. Devins, G. M. (1980). Contributions of health and demographic status to death anxiety and attitudes toward voluntary passive euthanasia. OMEGA—Journal of Death and Dying, 11(4), 293–302.

    Article  Google Scholar 

  41. Suarez-Almazor, M., Belzile, M., & Bruera, E. (1997). Euthanasia and physician-assisted suicide: a comparative survey of physicians, terminally ill cancer patients, and the general population. Journal of Clinical Oncology, 15(2), 418–427.

    PubMed  CAS  Google Scholar 

  42. Worthen, L. T., & Yeatts, D. E. (2001). Assisted suicide: Factors affecting public attitudes. OMEGA–Journal of Death and Dying, 42(2), 115–136.

    Article  CAS  Google Scholar 

  43. Lancsar, E., & Louviere, J. (2006). Deleting “irrational”responses from discrete choice experiments: A case of investigating or imposing preferences? Health Economics, 15(8), 797–811.

    Article  PubMed  Google Scholar 

  44. Devlin, N. J., Hansen, P., Kind, P., & Williams, A. (2002). Logical inconsistencies in survey respondents’ health state valuations-a methodological challenge for estimating social tariffs. Health Economics, 12(7), 529–544.

    Article  Google Scholar 

  45. Rand-Hendriksen, K., Augestad, L. A., Dahl, F. A., Kristiansen, I. S., & Stavem K. (2012). A shortcut to mean-based time tradeoff tariffs for the EQ-5D? Medical Decision Making.

  46. Lenert, L. A., Cher, D. J., Goldstein, M. K., Bergen, M. R., & Garber, A. (1998). The effect of search procedures on utility elicitations. Medical Decision Making, 18(1), 76.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Health Services Research Centre, Akershus University Hospital, 1478, Lørenskog, Norway

    Liv A. Augestad & Kim Rand-Hendriksen

  2. Department of Health Management and Health Economics, University of Oslo, Pb 1089 Blindern, 0318, Oslo, Norway

    Liv A. Augestad, Kim Rand-Hendriksen & Ivar Sønbø Kristiansen

  3. Department of Pulmonary Medicine, Akershus University Hospital, 1478, Lørenskog, Norway

    Knut Stavem

  4. Medical Faculty, Faculty Division Akershus University Hospital, University of Oslo, Lørenskog, 1478, Lørenskog, Norway

    Knut Stavem

Authors
  1. Liv A. Augestad
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kim Rand-Hendriksen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Knut Stavem
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ivar Sønbø Kristiansen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Liv A. Augestad.

Appendix: TTO and LT-TTO

Appendix: TTO and LT-TTO

The respondents were instructed to imagine a life A: living in the impaired target EQ-5D health state for 10 years, followed by ‘immediate death.’ The aim of the task was to find the respondents′ point of preferential equivalence between life A (always ten years) and life B (consisting of a reduced number of years (t) in perfect health, followed by ‘immediate death’). The web application displayed bars illustrating the length of life A and life B. Life B always started at zero years. The respondents could tick one of the following three boxes: “I prefer life A,” “I prefer life B,” and “Life A and life B are equal”. The web application altered the bar illustrating the length of life B according to the respondents′ choices. The bar was altered following the routing (iterative search procedure) of the UK EQ-5D valuation study, meaning that if the health state was considered better than death, the next offer would be five years in perfect health, and from this point increments or decrements of one year until the respondent was indifferent, or changed preference from life A to life B or from life B to life A [29]. In the two latter situations, a new offer was made half way through the two last offers, that is, increment or decrement of six months. If the respondent was not indifferent at this point, the value was set to either .25 or .75 of a whole year, depending on the respondent’s choices. In other words, the smallest tradable unit was three months.

The time trade-off values (u) were calculated by dividing the number of years in perfect health (t) by the number of years in the target health state:

$$ u = \frac{t}{10} $$

If the respondent preferred life B in the initial choice task, that is, stated that the target health state was WTD, the choice task proceeded in a different manner. Life A was still 10 years, composed of x years in the target health state and 10–x years in perfect health, followed by ‘immediate death.’ Life B was always set at 0 years. The aim of the task was to reach a point of indifference between life B (‘immediate death’) and life A, in which both time in the target health state and time in perfect health simultaneously were varied. The time trade-off values (u) were calculated as the negative number of years in perfect health divided by the number of years in the target health state: \( u = \frac{ - t}{10 - t} \)

This method for eliciting WTD values is different from the better than death values. The WTD valuation is especially challenging for the respondents because the denominator and numerator change simultaneously, and it has been pointed out elsewhere that the method does not differentiate between good and bad health states [45]. Moreover, the negative values have been criticized because they are usually transformed, making them difficult to interpret and questionable to aggregate WTD values with values for states better than death [22, 24–26]. The LT-TTO is a new method designed to overcome issues with the standard WTD elicitation method [27]. Using this method also avoids the initial explicit comparison of whether the target health state is better, worse, or equal to ‘immediate death.’

Life A in our LT-TTO study consisted of a composite life of 20 years, in which the first 10 years were spent in perfect health and the next 10 years were spent in the target health state. Life A was held constant through the valuation task. Life B was < 20 years in perfect health and varied until equivalence with Life A. If the respondent preferred life A, the web application altered the bar of life B to have a duration of 1 year longer. If respondents preferred life B, the bar illustrating life B was altered to last 1 year shorter. If the preferential equilibrium was not elicited on whole years, the routing proceeded as in the TTO task described above, see for instance Lenert [46] for how differences in routing may affect values. To calculate LT-TTO values, we subtracted the lead time from the response and then used the same formula as for positive values in the standard TTO exercise.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Augestad, L.A., Rand-Hendriksen, K., Stavem, K. et al. Time trade-off and attitudes toward euthanasia: implications of using ‘death’ as an anchor in health state valuation. Qual Life Res 22, 705–714 (2013). https://doi.org/10.1007/s11136-012-0192-9

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11136-012-0192-9

Keywords

search

Navigation