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

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.

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.

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.

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.