Quality of Life Research

, Volume 25, Issue 12, pp 2997–3008 | Cite as

The impact of a belief in life after death on health-state preferences: True difference or artifact?

  • Michał Jakubczyk
  • Dominik Golicki
  • Maciej Niewada



In most religions, the preservation of one’s own, God-given, life is considered obligatory, while the time trade-off method (TTO) forces one to voluntarily forego life years. We sought to verify how this conflict impacts TTO-results among the religious.


We used the data from the only EQ-5D valuation in Poland (2008, three-level, 321 respondents, 23 states each)—a very religious, mostly Catholic country. We measured the religiosity with the belief in afterlife question on two levels: strong (definitely yes) and some (also rather yes), both about a third of the sample.


The religious more often are non-traders, unwilling to give up any time in exchange for quality of life: odds ratio (OR) equal to 1.97 (strong religiosity), OR 1.55 (some religiosity); and less often consider a state worse than death: OR 0.67 (strong), OR 0.81 (some). These associations are statistically significant (\(p^*<0.001\)) and hold when controlling for possible demographic confounders. Strong religiosity abates the utility loss: in the additive approach by 0.14, in the multiplicative approach by the factor of 2.1 (both \(p^*<0.001\)), especially among the older. Removing the effect of religiosity from the value set reduces the utility by 0.05 on average.


The results may stem from a true difference in preferences or be a TTO-artifact and would vanish for other elicitation methods. Juxtaposing our findings with comments from respondents in other studies suggests the latter. Therefore, this Weltanschauung effect should be removed in cost–utility analysis.


Health-related quality of life Utility Preference elicitation Time trade-off Religion Life after death 



A substantial part of work was done during M. Jakubczyk’s visit at The University of Iowa, thanks to the Fulbright Senior Award. We appreciate the comments during the EuroQol Group Annual Meeting 2015, after the discussion started by H. Bailey; nevertheless, the views expressed here do not necessarily reflect these of the EuroQol Group. The paper has greatly benefited from the remarks of two anonymous reviewers.


  1. 1.
    Al Sayah, F., Mladenovic, A., Gabel, K., Xie, F., & Johnson, J. (2016). How dead is dead? Qualitative findings from participants of combined traditional and lead time time trade-off valuations. Quality of Life Research, 25, 35–43.CrossRefPubMedGoogle Scholar
  2. 2.
    Al-Sharifi, A., Krynicki, C., & Upthegrove, R. (2015). Self-harm and ethnicity: A systematic review. International Journal of Social Psychiatry. doi: 10.1177/0020764015573085.PubMedGoogle Scholar
  3. 3.
    Attema, A., Versteegh, M. M., Oppe, M., Brouwer, W. B., & Stolk, E. (2013). Lead time TTO: Leading to better health state valuations? Health Economics, 22, 376–392.CrossRefPubMedGoogle Scholar
  4. 4.
    Au Eong, K., Chan, E., Luo, N., Wong, S., Tan, N., Lim, T., et al. (2012). Validity of EuroQOL-5D, time trade-off, and standard gamble for age-related macular degeneration in the Singapore population. Eye, 26, 379–388.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Augestad, L., Rand-Hendriksen, K., Stavem, K., & Kristiansen, I. (2013). Time trade-off and attitudes toward euthanasia: Implications of using ‘death’ as an anchor in health state valuation. Quality of Life Research, 22, 705–714.CrossRefPubMedGoogle Scholar
  6. 6.
    Balboni, T., Paulk, M., Balboni, M., Phelps, A., Loggers, E., Wright, A., et al. (2010). Provision of spiritual care to patients with advanced cancer: Associations with medical care and quality of life near death. Journal of Clinical Oncology, 28, 445–452.CrossRefPubMedGoogle Scholar
  7. 7.
    Bansback, N., Brazier, J., Tsuchiya, A., & Anis, A. (2012). Using a discrete choice experiment to estimate health state utility values. Journal of Health Economics, 31, 306–318.CrossRefPubMedGoogle Scholar
  8. 8.
    Bleichrodt, H., Wakker, P., & Johannesson, M. (1997). Characterizing QALYs by risk neutrality. Journal of Risk and Uncertainty, 15, 107–114.CrossRefGoogle Scholar
  9. 9.
    Boguszewski, R. (2012). Zmiany w zakresie wiary i religijności Polaków po śmierci Jana Pawła II. Komunikat z badań. BS/49/2012. Technical report, Centrum Badania Opinii Społecznej.Google Scholar
  10. 10.
    Boguszewski, R. (2015). Kanon wiary Polaków. Komunikat z badań CBOS. Nr 29/2015. Technical Report, Centrum Badania Opinii Społecznej.Google Scholar
  11. 11.
    Brooks, R., & De Charro, F. (1996). EuroQol: The current state of play. Health Policy, 37, 53–72.CrossRefPubMedGoogle Scholar
  12. 12.
    Danyliv, A., & O’Neill, C. (2015). Attitudes toward legaliing physician provided euthanasia in Britain: The role of religion over time. Social Science & Medicine, 128, 52–56.CrossRefGoogle Scholar
  13. 13.
    Devlin, N., 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, 348–361.CrossRefPubMedGoogle Scholar
  14. 14.
    Dolan, P., Gudex, C., Kind, P., & Williams, A. (1996). The time trade-off method: Results from a general population study. Health Economics, 5, 141–154.CrossRefPubMedGoogle Scholar
  15. 15.
    Ellis, L., Wahab, E., & Ratnasingan, M. (2013). Religiously and fear of death: A three country comparison. Mental Health, Religion and Culture, 16, 179–199.CrossRefGoogle Scholar
  16. 16.
    Eurobarometer. (2005). Social values, Science and Technology. Technical Report, European Commission. http://ec.europa.eu/public_opinion/archives/ebs/ebs_225_report_en.
  17. 17.
    Gallup. (2004). Religion in Europe: Trust not filling the Pews. Technical Report, Gallup. http://www.gallup.com/poll/13117/religion-europe-trust-filling-pews.aspx.
  18. 18.
    Gielen, J., Van den Branden, S., & Broeckaert, B. (2009). The operationalisation of religion and world view in surveys of nurses’ attitudes toward euthanasia and assited suicide. Medicine, Health Care, and Philosophy, 12, 423–431.CrossRefPubMedGoogle Scholar
  19. 19.
    Golicki, D., Jakubczyk, M., Niewada, M., Wrona, W., & Busschbach, 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, 289–297.CrossRefPubMedGoogle Scholar
  20. 20.
    Golicki, D., Jakubczyk, M., Niewada, M., Wrona, W., & Busschbach, J. (2013). Is extending of a TTO experiment to 23 states per respondent justifiable? An empirical answer from Polish EQ-5D valuation study. Journal of Health Policy & Outcomes Research, 1, 110–117.Google Scholar
  21. 21.
    Gray, J., Lie, M., Murtagh, M., Ford, G., McMeekin, P., & Thomson, R. (2014). Health state descriptions to elicit stroke values: Do they reflect patient experience of stroke? BMC Health Services Research, 14, 573.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Green, C., Brazier, J., & Deverill, M. (2000). Valuing health-related quality of life. A review of health state valuation techniques. Pharmacoeconomics, 17, 151–165.CrossRefPubMedGoogle Scholar
  23. 23.
    Hall, S., & Beatty, S. (2014). Assessing spiritual well-being in residents of nursing homes for older people using the FACIT-Sp-12: A cognitive interviewing study. Quality of Life Research, 23, 1701–1711.CrossRefPubMedGoogle Scholar
  24. 24.
    Herdman, M., Gudex, C., Lloyd, A., Janssen, M., Kind, P., Parkin, D., et al. (2011). Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Quality of Life Research : An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 20, 1727–1736.CrossRefGoogle Scholar
  25. 25.
    Jakubczyk, M. (2009). Impact of complementarity and heterogeneity on health-related utility of life. Central European Journal of Economic Modeling and Econometrics, 1, 139–156.Google Scholar
  26. 26.
    Leightner, J., & Inoue, T. (2012). Solving the omitted variables problem of regression analysis using the relative vertical position of observations. Advances in Decision Sciences. doi: 10.1155/2012/728980.Google Scholar
  27. 27.
    Matza, L., Boye, K., Feeny, D., Johnston, J., Bowman, L., & Jordan, J. (2014). Impact of caregiver and parenting status on time trade-off and standard gamble utility scores for health state descriptions. Health and Quality of Life Outcomes, 12, 48. doi: 10.1186/1477-7525-12-48.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Nord, E. (1992). Methods for quality adjustment of life years. Social Science & Medicine, 34, 559–569.CrossRefGoogle Scholar
  29. 29.
    Nord, E. (1995). The person-trade-off approach to valuing health care programs. Medical Decision-Making, 15, 201–208.CrossRefPubMedGoogle Scholar
  30. 30.
    Nord, E., Daniels, N., & Kamlet, M. (2009). QALYs: Some challenges. Value in Health, 12(Supp. 1), S10–S15.CrossRefPubMedGoogle Scholar
  31. 31.
    Papageorgiou, K., Vermeulen, K., Leijten, F., Buskens, E., Ranchor, A., & Schroevers, M. (2014). Valuation of depression co-occurring with a somatic condition: Feasibility of the time trade-off task. Health Expectations, 18, 3147–3159.CrossRefPubMedGoogle Scholar
  32. 32.
    Phelps, A., Maciejewski, P., Nilsson, M., Balboni, T., Wright, A., Paulk, M., et al. (2009). Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer. Journal of the American Medical Association, 301, 1140–1147.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Robinson, A., Dolan, P., & Williams, A. (1997). Valuing health status using VAS and TTO: What lies behind the numbers? Social Science & Medicine, 45, 1289–1297.CrossRefGoogle Scholar
  34. 34.
    Seale, C. (2009). Legalization of euthanasia or physician-assisted suicide: Survey of doctors’ attitudes. Palliative Medicine, 23, 205–212.CrossRefPubMedGoogle Scholar
  35. 35.
    Sterba, K., Burris, J., Heiney, S., Ruppel, M., Ford, M., & Zapka, J. (2014). “We both just trusted and leaned on the Lord”: A qualitative study of religiousness and spirituality among African American breast cancer survivors and their caregivers. Quality of Life Research, 23, 1909–1920.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Wee, H. L., Li, S. C., Xie, F., Zhang, X. H., Luo, N., Feeny, D., et al. (2008). Validity, feasibility and acceptability of time trade-off and standard gamble assessments in health valuation studies: A study in a multiethnic Asian population in Singapore. Value in Health, 11, S3–S10.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Decision Analysis and Support UnitSGH Warsaw School of EconomicsWarsawPoland
  2. 2.Department of Experimental and Clinical PharmacologyMedical University of WarsawWarsawPoland

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