How to get serious answers to the serious question: “how have
Subjective quality of life (QoL) as an individual experiential emergent
To measure wellbeing, classical
econometric or clinimetric endpoints are increasingly considered overly
reductionistic. The novel area of Quality of Life Research aims to provide
more comprehensive and humanistic measures of wellbeing or happiness.
For example, in evidence-based health-care research, it has become a
health-economical ethical imperative to try and express the primary
endpoints in e.g. Quality Adjusted Life Years (QALYs) or Happy Life
Years (HALYs). The classical endpoints of only health-related functions
cannot provide the 'quality' term in QALYs or HALYs. The major problem
in felicitometrics is the measurement of the Q or H in QALYs or HALYs.
…How do we measure wellbeing? The field of felicitometrics is
rife with dilemmas on many levels. Philosophically, is wellbeing only
subjective or also objective: do we want to measure hedonistic utilitarian
or eudaimonic normative constructs of happiness (Bok 2010)? Are “objective”
goods such as safety, freedom, justice, knowledge, love and capabilities
for self-accomplishment defining values (Nussbaum & Sen 1993), or
is the value of these goods in felicitometrics only as conditions for
QOL (because they promote subjective, experiential QOL)? Another dispute
is psychometric: what are the respective virtues of experience sampling
(e.g. Kahneman & Deaton 2010), single-question uniscales of global
QOL (Veenhoven 2011) and multi-item, multidimensional scales and composed
Experience sampling is decidedly hedonistic: it records ‘mood
of the moment’, the balance of positive and negative affects at
random moments. But just like a chair is something else than a bunch
of pieces of wood and an article is more than a collection of words,
there clearly is an emergent dimension to life beyond the integral of
all its moments, if only because experiences interact and blend into
an emergent ‘total experience’.
As for multidimensional instruments to measure QOL (‘profile’
instruments), it is uncontroversial that the physical, mental and social
domains, each containing many dimensions and items, all play a role
in overall QOL. What is controversial, is the selection of the items
and the weight of the different dimensions in overall QOL. QOL dimensions
have been shown to have very different importances e.g. between different
patient populations or (sub)cultures, and giving the selected items
equal or arbitrary weights creates biases (Rose et al. 1999, Rojas 2006).
Moreover, in human individuals, assuredly complex systems, the many
dimensions and items of QOL observably interact, probably sometimes
also in chaotic or unpredictable ways. For example, one’s health
state may affect one’s appraisal of one’s finances and a
person in love may lose interest in social relations. In conditions
of complexity, the weights of isolated items in individuals become for
all practical purposes meaningless. Therefore, the much-used multi-item
questionnaires at best describe, but do not evaluate QOL, neither in
individuals, nor in populations.
For example, suppose in randomised populations of patients with end-stage
metastatic cancer, one would compare last-line chemotherapy (which provides
some hope but only a small chance of remission, and has nasty side effects)
with only palliative care, and one would, as can be expected, find no
significant differences in average survival (the few remissions on chemotherapy
being balanced by earlier deaths), and chemotherapy superior for the
mental domain, but inferior for the physical comfort domain: we would
not know which treatment, on aggregate, would be the better.
The problem is that QOL is an individual and emergent construct, the
end result of a great many interactions between components, some of
which are not practically measurable. Overall QOL is therefore of a
different order than its contributing components. It can best be captured
as a global self-assessment. Just as people in everyday life, while
acting under uncertainty, make global assessments all the time, so they
can seriously answer the serious question: 'How have you been?' (Veenhoven
A vast body of useful data has been generated with the conventional
global uniscale question (Veenhoven 2011). E.g. it allowed by comparing
QOL in a great many countries to validate the Universal Declaration
of Human Rights (Heylighen & Bernheim (2000). Unfortunately, some
perplexing results, such as Nigerians coming out the happiest people
in the world (Inglehart 2004), undermine its reliability. Indeed, the
global uniscale question on QOL has its own problems. One is banalisation
or mood-of-the day bias: it is a more serious question than the everyday
‘How are you?’. A second problem is peer-relativity: respondents
comparing themselves to others rather than using their own criteria.
Yet another is cultural relativity: Chinese, for example, tend to rather
uniformly report intermediate levels of QOL, probably in conformity
with Confucian virtues of moderation (Ouweneel & Veenhoven 1991,
Diener 2000, Lau & Cummins 2004).
An attempt to remediate some problems with the conventional question
on global wellbeing is Anamnestic Comparative Self Assessment (ACSA).
It aims to be a solemn, practical, non peer-relativistic, non-cultural,
experiential, self-anchored and well tolerated way to obtain global
QOL responses. The respondents are invited to define their individual
scale of QOL using their memories of the best and the worst times in
their life experience as the scale anchors. ACSA is thus both exquisitely
idiosyncratic, and yet can in a universalist humanistic perspective
be considered generic if one –reasonably- assumes that all individuals
have had excellent and terrible times (Shmotkin et al. 2006).
Originally, ACSA was developed in a clinical setting where cancer patients,
faced with their life-threatening illness, volunteered that they spontaneously
recalled the best and the worst periods in their lives, i.e. had gone
through a life-review process. In effect, they had thus defined a highly
personal scale of global subjective wellbeing. In ACSA interviews (or
in paper or electronic formats) respondents are asked to rate the quality
of their life during a preceding period of e.g. two weeks in comparison
with their personal best (+5 on the rating scale) and worst (-5 on the
scale) periods in life (Bernheim 1983). In e.g. the patient-physician
relation ACSA promotes empathetic communication (Singer & Bluck
2003). ACSA ratings were shown very sensitive to inter- respondent differences
(Bernheim 1983; Bernheim and Buyse 1984, Bernheim et al. 2006, Möller
et al 2008, Bruno et al. 2011). When ACSA was used in consecutive consultations,
ACSA ratings were found to be quite sensitive to changes in disease
state, with major fluctuations over the evolution of disease (Bernheim
1983; Bernheim and Buyse 1984).
In research conducted in several European sites the best periods of
life typically concerned experiences of love, the birth of a child,
career milestones or other personal achievements. The worst periods
in life were typically bereavements, divorce, abuse, imprisonment, bankruptcy,
experiences of war or a serious disease. In partial contrast, in a South-African
formerly disadvantaged population, the anchors were much more often
related to income (Möller et al. 2008). This finding is in agreement
with a Maslowian view of human needs (Maslow 1970). Research in clinical
settings found that ACSA differentiated better than the conventional
question on global subjective well-being, was more responsive to objective
changes in the lives of respondents, and less sensitive to trait-like
variables. ACSA was found particularly suited for use in longitudinal
or intervention studies, as it appeared to be more responsive than the
conventional single-question on global QOL (Bernheim et al. 2006).
In sum, the main distinguishing features of the ACSA measure are as
follows. The frame of reference against which subjective well-being
is assessed, by being biographical, is made concrete, explicit and personal.
This discourages peer- or culture-relative and superficial or socially
desirable responses. ACSA is less sensitive to trait-like socio-demographic
variables and therefore probably to personality traits and cultural
differences (Bernheim et al. 2006). Philosophically, its invitation
to life review at least gives the respondents the option to choose a
eudaimonic perspective on their QOL or to use their own blend of hedonistic
and eudaimonic perspectives.
Therefore, ACSA is proposed as a refinement of the well-established
conventional single-question on global QOL. It is an alternative to
composite indices and a complement rather than an alternative to multi-dimensional
questionnaires. Using ACSA together with such QOL profile instruments
allows to by logistic regression better determine the respective contributions
of dimensions and items to overall QOL in populations and thus to identify
those whose improvement have the greatest probability to enhance the
QOL of the greatest number.
Bernheim J.L.. (1983), L’auto-évaluation anamnestique
comparative (ACSA). Description d’une méthode de mesure
de la qualité subjective de la vie des malades cancéreux.
Psychologie médicale, 15: 1625 – 1626.
Bernheim J.L.. (1999), ‘How to get serious answers to the serious
question: ‘How have you been?’: subjective quality of life
(QOL) as an individual experiential emergent construct’, Bioethics,
Bemheim, J. L., Buyse, M. (1984). The anamnestic comparative self-assessment
for measuring the subjective quality of life of cancer patients. Journal
of Psychosocial Oncology, 1, 25-38.
Bernheim J L., Theuns, P., Mazaheri, M., Hofmans, J., Fliege, H., &
Rose, M. (2006). The potential of Anamnestic Comparative Self Assessment
(ACSA) to reduce bias in the measurement of Subjective Well-Being. Journal
of Happiness Studies 7(2): 227-250.
Bok S.. (2010) Exploring Happiness: from Aristotle to Brain Science.
Yale University Press.
Bruno M.-A., Bernheim J.L., Ledoux D., Pellas .F, Demertzi A, Laureys
S.. (2011). A survey on self-assessed well-being in a cohort of chronic
locked-in syndrome: patients: happy majority, miserable minority. British
Medical Journal Open doi:10.1136/bmjopen-2010-000039
Diener E., Suh E.M. (eds.) (2000), Culture and subjective well-being,
The Massachusetts Institute of Technology (MIT) Press, Cambridge MA.
Heylighen F. & Bernheim J. (2000). ‘Global progress l: Empirical
evidence for ongoing increase in quality-of-life’, Journal of
Happiness Studies, 1: 323-349.
Inglehart R. (2004), World Values Survey, www.worldvaluessurvey.org/news/index.html
Kahneman D., Deaton A. (2010) High Income improves Evaluation of Life
but not Emotional Wellbeing. Proceedings National Academy of Sciences,
Lau A., Cummins R. (2004), ‘The subjective well-being of Asian
Chinese and Western populations : a cross-cultural perspective’,
Quality of Life Research, 13: 1496
Maslow A.H. (1970), Motivation and personality (2nd edition), Harper
and Row, New York.
Mazaheri M., Theuns, P. (2009). Effects of Varying Response Formats
on Self-ratings of Life-Satisfaction. Social Indicators Research 90:381-395.
Möller V., Theuns P., Erstad I., Bernheim J.L.. (2008) The Best
and Worst Times of Life: Narratives and Assessments of Subjective Well-Being
by Anamnestic Comparative Assessment (ACSA) in the Eastern Cape, South
Africa. Social Indicators Research 89:1-22.
Nussbaum M. & Sen A. (eds) (1993), The quality of life, Oxford University
Press Inc., New York
Ouweneel P. & Veenhoven R. (1991), ‘Cross-national differences
in happiness: Cultural bias or societal quality?’ in Bleichrodt
N. & Drenth P.J. (eds), Contemporary Issues in Cross-Cultural Psychology,
Swets & Zeitlinger, Amsterdam. , 168-184.
Rojas M. (2006), ‘Life satisfaction and satisfaction in domains
of life: is it a simple relationship?’, Journal of Happiness Studies,
Rose M., Fliege H., Hildebrandt M., Bronner E., Scholler G. & Klapp
B.F. (2000), ‘Gesundheidtsbezogene Lebensqualität –
ein Teil der allgemeinen Lebensqualität? in BULLINGER M. &
Ravens-Sieberer U., Jahrbuch Medizinische Psychologie, 206 – 221.
Singer J. & Bluck S. (2003). ‘New perspectives on autobiographical
memory: The integration of narrative processing and autobiographical
reasoning, Review of General Psychology, 5, 2: 91-99.
Shmotkin D., Berkovich M., Cohen K. (2006), ‘Combining happiness
and suffering in a
retrospective view of anchor periods in life: A differential approach’,
Social Indicators Research, 77: 139–169
Veenhoven R. (2011), World Database of Happiness, www.eur.nl/fsw/research/happiness