There are three items in the EQ-5D with disjunctive answer options: Item 2, 4, and 5. We focus on item 4 to report the results of our analysis. Rather than the wording from the English version of the questionnaire, we provide our translation of the Danish version to best capture the features of the Danish EQ-5D. The translations are presented in brackets surrounded by double quotation marks.
Lexical meanings
The Danish EQ-5D begins with the general instruction “Under hver overskrift bedes du sætte kryds i DEN kasse, der bedst beskriver dit helbred I DAG” (“Under every headline, you are requested to check THE box that best describes your health TODAY”). In item 4, the headline is “SMERTER /UBEHAG” (“PAIN/DISCOMFORT”). The answer options are “Jeg har ingen smerter eller ubehag” (“I have no pain or discomfort”), “Jeg har lidt smerter eller ubehag” (“I have little pain or discomfort”), “Jeg har moderate smerter eller ubehag” ( “I have moderate pain or discomfort”), “Jeg har stærke smerter eller ubehag ( “I have strong pain or discomfort”), and “Jeg har ekstreme smerter eller ubehag” ( “I have extreme pain or discomfort”). We examine how conversational norms should be expected to affect the interpretation of these answer options.
If levels of pain and discomfort were always perfectly aligned, the analysis of compatibilities and omissions in item 4 would be relatively simple. On this assumption, a lexical analysis can ignore the disjunctive form of the answer options, and treat them exclusively as questions about pain, because a respondent’s true answer about the disjunct concerning pain would correspond to her true answer about the disjunction. Given the assumption that pain, and discomfort are aligned, our analysis concludes that the first answer option is incompatible with all the rest. In the second option, “Lidt smerter” (“Little pain”) has a semantic link to a scale ordering pains by their littleness, with the degree of littleness closest to zero as the maximum value. This semantic relation gives “Jeg har lidt smerter” the same meaning as “I have pain (at least as small as) little pains”. “Moderat” (English “Moderate”) has a similar link to a scale, which gives “Jeg har moderate smerter” the same meaning as “I have pains (at least as small as) moderate pains”. Hence, because the threshold degree of littleness for qualifying as moderate is lower than the threshold degree of littleness for qualifying as little, a true answer to the second option entails a true answer to the third. The lexical meaning of “Stærke smerter” (“Strong pains”) relates the fourth answer option to a scale ranking pains by order of their degree with the most extreme pain possible as the maximal value. The expression “Stærke smerter” means the same as “(pains as least as strong as) strong pains”. Accordingly, since the fifth answer option “Jeg har ekstreme smerter” has the meaning of “I have (pain at least as great as) extreme pain” and “Jeg har stærke smerter” means the same as “I have (pain at least as great as) strong pain”, the fifth answer option entails the fourth because extreme pain is at least as strong as strong pain.
In addition, because a respondent’s level of pain and discomfort could simultaneously be stronger than moderate but less than strong, the item also has an omission, on the assumption that a respondent’s pain and discomfort are at identical levels.
Things are considerably more complicated regarding situations where a respondent’s levels of pain and discomfort come apart. Whereas any degree of pain may be assumed to entail the same degree of discomfort, there is no entailment in the opposite direction. Nausea or dizziness, for example, may involve extreme discomfort with little or no related pain. Thus, every answer option that reports a non-zero level of discomfort is compatible with every answer option that reports a lower degree of pain. The truth of “Jeg har ekstreme smerter eller ubehag” is compatible with all other answer options under the second item because the truth of its second disjunct “Jeg har ekstremt ubehag” (“I have extreme discomfort”) is compatible with the truth of the first disjunct in all answer options. Put differently, the truth of the fifth answer option permits the truth of all the remaining disjunctive answer options because one might suffer extreme discomfort together with strong pains that are not extreme, moderate pains, little pain, and absence of pain, and a disjunction is true whenever one of its disjuncts is true (21). Analogously, the truth of the fourth answer option permits the truth of the third, second, and first answer options because a respondent may experience strong discomfort in combination with any of the following: moderate pain, little pain, or absence of pain. For similar reasons, the truth of the item’s third answer option permits the truth of the second and first options, and the truth of the second option permits the truth of the first. None of these compatibilities are due to entailments because facts about pain levels do not follow from facts about discomfort.
Conversational norms and pragmatic effects
With respect to the effects of pragmatic norms on answer choices in item 2, the respondent’s judgments about his/her levels of pain and discomfort are crucial. The key difference is between cases where the respondent judges that his/her level of pain is the same as his/her level of discomfort (relative to the categories of the questionnaire) and where he/she does not. Table 1 shows which answer options may be true when the levels of discomfort and pain are identical.
Table 1
True answer options in item 2 when the level of discomfort equals the level of pain
Combination
|
Level of
discomfort
|
Level of pain
|
Answer option 5
|
Answer option 4
|
Answer option 3
|
Answer option 2
|
Answer option 1
|
1
|
Extreme
|
Extreme
|
True
|
True
|
|
|
|
2
|
Strong
|
Strong
|
|
True
|
|
|
|
3
|
Moderate
|
Moderate
|
|
|
True
|
|
|
4
|
Little
|
Little
|
|
|
True
|
True
|
|
5
|
0
|
0
|
|
|
|
|
True
|
In the situations represented in Table 1, pragmatic dynamics are likely to affect how a respondent decides between compatible answer options. In these cases, the second option “Lidt smerte eller ubehag” (“Little pain or discomfort”) is compatible with the third option “Moderat smerte eller ubehag” (“Moderate pain or discomfort”) but also entails that the third option is true. Accordingly, because confirmation of the third option does not entail that the second option is true, the second option is more informative than the third. Hence, if both the third and second options are true of a respondent, the first maxim of quantity enjoins the respondent to opt for the second option to comply with the co-operative principle. Consequently, if the third answer option is true, pragmatic norms imply that selecting this option is only pragmatically permissible for a respondent when they are not in a position to affirm the second option. Assuming that ordinary pragmatic norms remain in place, scalar implicatures related to informativity (7-9), therefore, determine what the respective answer choices communicate.
Things are different regarding respondents who judge that their level of discomfort exceeds their level of pain. Table 2 provides a schematic overview of the answer options that may be true simultaneously for such respondents.
Table 2
True answer options in item 2 when the level of discomfort exceeds the level of pain
Combination
|
Level of discomfort
|
Level of pain
|
Answer option 5
|
Answer
option 4
|
Answer option 3
|
Answer option 2
|
Answer option 1
|
1
|
Extreme
|
Strong
|
True
|
True
|
|
|
|
2
|
Extreme
|
Moderate
|
True
|
True
|
True
|
|
|
3
|
Extreme
|
Little
|
True
|
True
|
True
|
True
|
|
4
|
Extreme
|
0
|
True
|
True
|
|
|
True
|
5
|
Strong
|
Moderate
|
|
True
|
True
|
|
|
6
|
Strong
|
Little
|
|
True
|
True
|
True
|
|
7
|
Strong
|
0
|
|
True
|
|
|
True
|
8
|
Moderate
|
Little
|
|
|
True
|
True
|
|
9
|
Moderate
|
0
|
|
|
True
|
|
True
|
10
|
Little
|
0
|
|
|
True
|
True
|
True
|
In several of these situations, there are true answer options that are not entailed by another true option. These situations are represented by combination 2, 3, 4, 5, 6, 7, 9, and 10. The absence of an entailment relation implies that the Quantity maxim does not suffice to resolve which answer a respondent should opt for. Consider, for example, the situation represented by row 3 where a respondent judges his/her discomfort to be extreme but considers his/her pain to be little. In such a case, option 5 is more informative than option 4 because the former entails the latter, and option 2 is more informative than option 3 because the truth of option 2 entails the truth of option 3. But there is no entailment from option 5 to option 2 or vice versa. Hence, the respondent is confronted with a problem that neither Quality nor Quantity resolves.
The only Gricean maxim that may be helpful in this predicament is Relevance. A respondent’s decision about the appropriate answer may be aided by his/her assessment as to which information is most relevant to the addressee. Which option Relevance recommends, however, depends on the respondent’s construal of the questionnaire item’s communicative purpose. Although we can speculate about a respondent’s likely assessment of the item’s primary communicative purpose, it hence remains an open question what a respondent with extreme discomfort and little pain would answer to item 2 when guided by pragmatic norms. The same kind of problem arises for respondents in the situations represented by rows 2, 3, 4, 5, 6, 7, 9, and 10 in Table 2.
Depending on how the respondent construes the purpose of the questionnaire, the Relevance maxim may conflict with the Quantity maxim. Consider a respondent who assumes that the questionnaire is primarily intended to capture the maximum extent to which a person is affected by either discomfort or pain. Given this understanding of the purpose of the questionnaire, Relevance should lead him/her to choose option 5 in the situation represented by row 3. But if the same assumption is upheld with respect to a respondent regarding the situations represented by row 8, there is a conflict between the recommendations of the Relevance and Quantity maxims. Relevance would suggest that the respondent should choose option 3 to avoid signaling that both pain and discomfort are minor. In contrast, because the truth of option 2 entails the truth of option 3, Quantity would suggest that the respondent should choose option 2 to avoid indicating that he/she is not in a position to affirm option 2. Accordingly, answering item 2 of the EQ-5D may require a respondent to resolve a tension between conflicting recommendations from different pragmatic norms. With other conceptions of the questionnaire’s purpose, conflicts between Relevance and other maxims may arise in situations represented by other rows in Table 2.
There are also situations in which a respondent’s level of discomfort is greater than the level of pain while either discomfort or pain is at a level below strong but above moderate. These situations are represented in Table 3.
Table 3
True answers in item 2 when the level of discomfort exceeds the level of pain, and discomfort or pain is at a level below strong but above moderate
Combination
|
Level of discomfort
|
Level of pain
|
Answer option 5
|
Answer option 4
|
Answer option 3
|
Answer option 2
|
Answer option 1
|
1
|
Extreme
|
Between strong and moderate
|
True
|
True
|
|
|
|
2
|
Strong
|
Between strong and moderate
|
|
True
|
|
|
|
3
|
Between strong and moderate
|
Moderate
|
|
|
True
|
|
|
4
|
Between strong and moderate
|
Little
|
|
|
True
|
True
|
|
5
|
Between strong and moderate
|
0
|
|
|
|
|
True
|
Some of these situations may also involve conflicts between Relevance and other maxims. In the situation represented by row 4, both answer options 2 and 3 will be true, whereas option 2 will be more informative than option 3. Option 3, however, would be closer to a true representation of the respondent’s level of discomfort. If the respondent does not experience any pain, this tension will be even higher because there will be an even more significant difference between the only true answer, option 1, and the answer option that best represents the respondent’s level of discomfort, either options 3 or 4. Furthermore, if a respondent in either of these situations assumes that it is important for the addressee that reported answers do not underestimate the degree of either discomfort or pain that is highest for the respondent, Relevance might encourage him/her to answer “Stærk smerte eller ubehag” (“Strong pain or discomfort”), although this option is false, and whether available answer options are true. In the situation represented by row 1 in Table 3, the potential conflict confronting the respondent is between selecting option 5 to ensure truthfulness or abandoning truthfulness to somehow take into account that the level of pain is noticeably lower than the degree of discomfort.
It is possible, however, that the complexity of choosing an answer in the situations represented by Table 3 will be mitigated somewhat by contextual adjustment of the meanings of “Moderat” and “Stærk” (“Moderate” and “Strong”). If such modulation adjusts the extension of either “Stærk smerte eller ubehag “ or “Moderat smerte eller ubehag” to eliminate the gap between the two categories, the subsequent interpretative circumstances will be akin to those represented by row 2 or 3 in Table 1, or row 1, 2, 5, 6, 7, 8, or 9 in Table 2. But although this dynamic might reduce interpretative complexity, the issues related to compatibilities would leave considerable obstacles for some respondents to navigate.
Omissions and context-sensitivity
In addition to the many compatibilities, there is also an omission in the fourth item. It is possible for a respondent to simultaneously have pain that is worse than moderate pain but less severe than strong pain while experiencing discomfort, which is worse than moderate discomfort but less severe than strong discomfort. Hence, there may be cases where none of the item’s five answer options is true about the respondent.
None of the Gricean maxims determine how a respondent in such a predicament should respond. Considering the central significance of truthfulness in communication (22, 23), a likely course of action would be for the respondent to decide his/her answer by choosing the option that he/she considers closest to the truth. In that case, he/she would be observing the first maxim of Quality to the highest extent possible, given their circumstances. The other maxim most likely to affect a respondent’s decision is relevance because of how close the relevance maxim is to the overarching co-operative principal (CP). How this maxim might affect a respondent’s choice of answer cannot be determined based on basic pragmatic principles because its influence on a respondent depends on how the respondent construes the purpose of the information exchange mediated by the questionnaire.
It is also possible that the semantic context sensitivity of “Stærk” and “Moderat” (“Strong”) and (“Moderate”) is more significant than pragmatic norms to how the omission in item 4 affects a respondent’s answer. Because the meaning of a context-sensitive term is determined by its context of use, the questionnaire may shift the meanings of “Stærk” and “Moderat” to close the logical gap between answer options 4 and 3. Thus, although the linguistically encoded meanings of the questionnaire’s terms do not generally exclude the possibility of a level of impairment between the categories “Stærk” and “Moderat”, the contextually determined meanings of the terms in the EQ-5D might preclude this possibility. This situation might occur either by lowering the level of impairment that qualifies as “Stærk” or raising the level of impairment that would still be regarded as low enough to qualify as “Moderat”.
Scope of analysis
Whether this analysis of item 4 can be extended to the other items with disjunctive questions (i.e., items 2 and 5) depends on the relations between the disjuncts in their answer options. Item 2 asks about the degree to which the respondent can wash themselves or get themselves dressed, “Vaske mig” (“Wash myself”) or “Klæde mig selv på” (“Get myself dressed”), whereas item 5 enquires about the degree to which the respondent experiences “Ængstelighed” (“Anxiety”) or “Depression” (“Depression”). If a respondent’s difficulty with getting washed and getting dressed are always on the same level, and depression and anxiety are always parallel to each other in severity, then the situations a respondent might be in when answering either item correspond to those in Table 1. If, on the other hand, the degree of depression is compatible with any degree of anxiety as long as the level of anxiety does not exceed the degree of depression, or vice versa, then the possible communicative circumstances of a respondent will be analogous to those in Tables 1, 2, and 3. Finally, if a person’s degree of depression and anxiety do not restrict each other at all, the analog of Table 1, as well as two analogs of Table 2 and two analogs of Table 3 will be required to represent the situations that a respondent might be in when deciding how to answer item 5 of the EQ-5D.