Death and the valuation of health-related quality of life

BACKGROUND AND OBJECTIVES. Despite evidence to the contrary, a common assumption in the area of health status measurement is that the state "dead" is the worst possible health state and by definition should be assigned a value of 0. However, the value of the state "dead" and the notion of states worse than "dead" have never been fully addressed as a research topic. This article demonstrates the extent of the variation in the value given to the state "dead" by individuals and the effects of transformation on individual and aggregate values using data elicited with 2 methods (visual analog scale rating and ranking) that place no constraint on the value given to the state "dead." RESEARCH DESIGN. Face-to-face interviews were conducted with 253 adults in North Yorkshire, UK in 1998. Each participant performed ranking and visual analog scale rating exercises for 19 EuroQol EQ-5D health states. CONCLUSIONS AND RESULTS. Data showed that there is a small group of individuals who, when given the option, choose to place relatively high value on the state "dead" compared with other health states. This did not appear to be due to artifact. Evidence also suggested that the usual assumptions underlying the transformation of health state values, for which the distance between full health and "dead" is used to define the denominator, may not hold for these individuals and may distort aggregate preference structures. The authors stress the need for more systematic inquiry in this field.