Thinking and Deciding

330 UTILITY MEASUREMENT
their health affects their own lives. When we ask patients about their utility, we can
ask them either before or after they experience the health state in question. For example,
in using the standard gamble to assess the utility of chest pain, we can ask
patients who have chest pain what probability of death they would accept in order to
be rid of it, or we can describe chest pain to those who do not have the pain and then
ask the same questions.
Several studies have asked whether patients who are experiencing some condition
evaluate it differently from those who simply imagine it. Some studies find no difference
(for example, O’Connor, Boyd, Warde, Stolbach, and Till, 1987; Llewellen-
Thomas, Sutherland, and Theil, 1993), but other studies find that those in a condition
assign it a higher utility (that is, closer to normal health) than those not in it (for example,
Boyd, Sutherland, Heasman, and Tritchler, 1990; Gabriel, Kneeland, Melton,
Moncur, Ettinger, and Tosteson, 1999). Researchers must, and often do, make sure
that the descriptions given to those not in the state are accepted as accurate by those
in the state.
One possible reason why evaluations might differ is that patients adapt to their
conditions over time. This is especially true when conditions can be described as
handicaps rather than illnesses. Such adaptation may account for the differences
between patients and nonpatients (people with and without a condition) because the
nonpatients do not imagine all the ways of adapting. For example, blind people
can now “read” ordinary text with the help of optical-character-recognition and textto-speech
software. Blindness is still bad, but less bad than would be apparent to
someone who did not know of this possibility.
It may also be that adaptation occurs more in some measures than in others
(Loewenstein and Ubel, 2006). In particular, adaptation is often total, or nearly total,
when measured in terms of experience, for example, questions about overall happiness
or moment-to-moment ratings of mood. Yet the same patients can still place a
high value on prevention or cure of their condition, even to the point of being willing
to give up some of their life expectancy or take some risk of death. This situation
may be one in which utilities are not fully captured by experience.
Adaptation may also occur because people change their goals to adapt to what
they can do, a sour-grapes effect (Elster, 1983). People who become blind can lose
their interest in the visual arts and in the beauty of nature, thus being less frustrated
by their handicap. Is this rational? Should we take it into account in evaluating the
utility of a disorder such as blindness? These are very deep questions, and this short
discussion cannot do justice to them, but a couple of suggestions are in order.
It may well be rational for people to change their goals to adapt to reality. As
we shall discuss in Chapter 19, some of our decisions affect the existence of goals
(in ourselves and others). One property of a goal that we might consider, in deciding
whether to bring it into existence or increase its strength (or the reverse) is whether
it can be achieved. If we favor goals that are achievable, we can increase total utility.
Changing goals can be irrational. People may “give up too soon.” They convince
themselves that something is unachievable and stop wanting it, when, in fact, they
could achieve it. For example, some people with severe handicaps can work.