Do people have a preference for increasing or decreasing pain? An experimental comparison of psychological and economic measures in health related decision making

Scarce resources in the health care sector force decision makers to allocate treatments in a way that as much quality of life for as much people as possible is preserved. On an international level, the QALY concept is the most frequently used approach to measure quality of life.

One important factor for the measurement of quality of life is a good understanding of patients' preferences. Such preferences include, among others, the development of well-being in the course of a treatment. The QALY concept, based on Rational Choice Theory, assumes patients to be neutral in terms of this course, in case that the overall health state within a period is equal for two treatments. However, research, e.g. on the peak-end-rule (Kahneman et al. 1993), demonstrates the relevance of the distribution of health levels throughout the experience.

Results deviating from Rational Choice Theory mainly occur in studies using methods like questionnaires or rating scales, which exclude real consequences from decisions or answers. Research on the hypothetical bias emphasizes the importance of real consequences to gain reliable decisions of subjects.

In this study, we investigate whether the QALY assumption of neutrality towards the timing of health states is adequate. In particular we analyze if the described QALY assumption represents subjects' real preferences and if subjects are indifferent for the timing of painful events. We combine both, a questionnaire to evaluate bell-being and a standard economic measurement (WTP). We use monetary consequences and health-related consequences realized with the cold pressor test, a standard procedure to induce pain. Subjects in our experiments experience two painful sequences, with the same overall intensity but different temporal distributions of intensity.

We find that the questionnaire significantly reveals that subjects prefer one of the experiences. However, given real consequences subjects are indifferent on average. We conclude that although the rated difference between both experiences was clinically important the difference was not strong enough to be measureable with the other instrument using real consequences.

Our findings are relevant in terms of criticism on the QALY concept. Though some measurement methods indicate the relevance of the timing of well-being levels, the method we used including real consequences makes this preference disappear. Therefore the QALY assumption on neutrality towards timing was confirmed as correct and no adjustment is necessary to adequately represent subjects' preferences.

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