The Effect of Perspective, Duration, and Views on Death on the Valuation of Severe Health States

Objectives: Composite time trade-off utilities typically vary by perspective: adults tend to assign lower utilities to health states for themselves (self-perspective) than for children (proxy-perspective). Utilities also differ between proxy-perspectives: i.e., deciding for a child (proxy1) vs imagining what a child wants (proxy2). This can cause health states to be evaluated as better than dead (BTD) under one perspective, yet worse than dead (WTD) under another. We investigate how such WTD preferences vary with health states across durations and perspectives, alongside sociocultural factors such as religion and attitudes toward death. As a secondary analysis, we explore the maximal endurable time hypothesis to assess the consistency of WTD preferences. Methods: We surveyed 1000 UK respondents, stratified into 2 groups by religious affiliation (religious vs nonreligious). Each completed BTD tasks from a self-perspective and a randomly assigned proxy perspective (proxy1 or proxy2), involving 5 health states across 4 durations. Respondents also ranked all health states (without duration) and immediate death. Results: In ranking tasks without duration, WTD preferences were unaffected by perspective or religious affiliation, whereas the proportion of states considered WTD increased with longer durations in paired comparisons in the BTD tasks among nonreligious participants. WTD preferences were associated with stronger support for euthanasia and lower religiousness. Maximal endurable time preferences showed minimal differences across perspectives or religious affiliations. Conclusions: Perspectives, duration, religious affiliation, and views on euthanasia shape WTD preferences. Future research is encouraged to consider religion in sampling and how to deal with the potential duration dependency of QALY-anchored utilities.