Public preferences for saving lives versus life-years: evidence from a person-trade-off experiment in 12 countries during the COVID-19 pandemic

Health technology assessment (HTA) often prioritises outcomes measured in life-years or Quality-Adjusted Life Years (QALYs), implying a focus on maximising (quality-adjusted) life-years rather than saving lives. This study investigates public preferences for prioritising lives versus life-years across 12 geographically and economically diverse countries. We also explore whether preferences depend on factors such as age and employment status. We conducted an experiment involving 14,345 adults, using quota sampling to ensure representative educational and demographic characteristics. Respondents were randomly allocated to one of four scenarios involving hypothetical COVID-19 vaccine allocation decisions. The primary comparison asked whether to save a 55-year-old (30 years life expectancy) or a 75-year-old (10 years life expectancy). Further questions assessed trade-offs between saving one 55-year-old versus up to six 75-year-olds, with scenarios varying employment status. When both age groups had the same employment status, respondents equated one 55-year-old to 2.34 75-year-olds (95% CI: 2.28–2.39). However, a working 55-year-old was valued over 3.16 non-working 75-year-olds (95% CI: 3.07–3.24), and a working 75-year-old was favoured over 1.96 non-working 55-year-olds (95% CI: 1.89–2.03). Findings reveal that public preferences diverge from HTA’s normative focus on maximizing life-years. Instead, decisions reflect a balance between lives and life-years, and are influenced by factors such as employment status.