E Book Quality of Life _University of Chicago_knyga

8/14/2019 E Book Quality of Life _University of Chicago_knyga

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THEQUALITYOFLIFE

Nussbaum, Martha (Editor), Professor of Law and Ethics, University ofChicago

Sen, martya (Editor), Master of !rinity Co""ege, Cambridge

Pub"ication date #$$% (this edition)Print &S'N#* #$++-$-.Print &S'N#%* $-+#$++-$-#doi*#/#$%0#$++-$-./#/#

bstract* !his vo"ume gathers the thoughts of re1uted academics in economics, socia" 1o"icy,1hi"oso1hy, and the socia" sciences as they scrutini2e contentions regarding 3ua"ity of "ife and theway in which it is, it can be, and ought to be measured/ Such debates rough"y boi" down to themerits and shortcomings of measuring the 3ua"ity of human "ife in terms of uti"ity, as we"" as to theadvantages and 1itfa""s of a"ternatives to the uti"itarian a11roach/ Phi"oso1hica" in3uiries concerningwhat constitutes thriving human "ife, engage with concrete 1o"icyma4ing and economicconsiderations in this wor4, bridging the customary schism between theory and 1ractice/ !his boo4is catered not on"y to 1rofessiona" academics but a"so to 1o"icyma4ers and the genera" 1ub"ic whoare interested in the 3uestion of the 3ua"ity of "ife/

5eywords* ca1abi"ity, economics,ega"itarianism,1hi"oso1hy,3ua"ity of "ife measurement, socia"1o"icy, standard of "iving, uti"itarianism, we"fare
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ContentsList of contributors i6&ntroduction

Martha Nussbaum and Amartya Sen#

P7! & L&8ES N9 CP'&L&!&ESE3ua"ity of :hat; Commentator*$ames Griffin#%%

P7! && !79&!&+


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List of contributors i6&aul Seabright 2>2

Commentator+ "erek &arfit 5-

'ifeStyle and the Standard of 'i3ing

Christo0her Bliss 56Commentator+ Amartya Sen 526

9nde/ 55
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List of ContributorsE7&5 LL79!, President of innish cademy, Professor of Socio"ogyUniversity of @e"sin4i@e"sin4i

in"andBUL& NNS, Professor of Phi"oso1hy9e1artment of Phi"oso1hyCo"umbia University

New or4 CityUSC@7&S!


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BMES =7&&N, 7eader in Phi"oso1hy at the University of


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7U!@ NN PU!NM, Professor of Phi"oso1hy9e1artment of Phi"oso1hyUSPUL SE'7&=@!

e""ow of Churchi"" Co""egeCambridgeEng"andM7! SEN, Lamont University Professor and Professor of Economics and of Phi"oso1hy@arvard UniversityCambridge MUSC@7LES !L


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&ntroduction

Martha Nussbaum

Amartya Sen

nd he said, Now, this schoo"room is a Nation/ nd in this nation, there are fifty mi""ions ofmoney/ &snJt this a 1ros1erous nation; =ir" number twenty, isnJt this a 1ros1erous nation, and aJnJtyou in a thriving state;:hat did you say; as4ed Louisa/Miss Louisa, & said & didnJt 4now/ & thought & cou"dnJt 4now whether it was a 1ros1erous nation ornot, and whether & was in a thriving state or not, un"ess & 4new who had got the money, and whetherany of it was mine/ 'ut that had nothing to do with it/ &t was not in the figures at a"", said Sissy,wi1ing her eyes/!hat was a great mista4e of yours, observed Louisa/(Char"es 9ic4ens,%ard *imes):hen we in3uire about the 1ros1erity of a nation or a region of the wor"d, and about the 3ua"ity of

"ife of its inhabitants, Sissy Bu1eJs 1rob"em sti"" arises* @ow do we determine this; :hatinformation do we re3uire; :hich criteria are tru"y re"evant to human thriving; =ir" numbertwenty 3uic4"y discerns that Dust 4nowing how much money is avai"ab"e for a given number of

1eo1"e (the ana"ogue of =NP 1er ca1ita, sti"" wide"y used as a measure of 3ua"ity of "ife) wi"" notta4e us very far/ or we a"so need, at the very "east, to as4 about the distribution of these resources,and what they do to 1eo1"eJs "ives/!he 1rob"em is actua""y more com1"e6 sti""/ or if we are rea""y to 4now much about the thrivingof Sissy Bu1e and her fe""ow citi2ens, we need to 4now not on"y about the money they do or do nothave, but a great dea" about how they are ab"e to conduct their "ives/ :e need sure"y to 4now abouttheir "ife e61ectancy (thin4 of the miners of Co4etown in 9ic4ensJs nove", who 4ee1 their fami"iesfrom want and hunger, but go to a 1remature death)/ :e need to 4now about their hea"th care andtheir medica" services/ :e need to 4now about educationOand not on"y about its avai"abi"ity, butabout its nature and its 3ua"ity (it seems "i4e"y that Mr =radgrindJs schoo" may actua""y diminish thethriving of its 1u1i"s)/ :e need to 4now about "abourOwhether it is rewarding or grinding"ymonotonous, whether the wor4ers enDoy any measure of dignity and contro", whether re"ations

between em1"oyers and hands are human or debased/ :e need to 4now what 1o"itica" and "ega"1rivi"eges the citi2ens enDoy, what freedoms they have in the conduct of socia" and 1ersona"re"ations/ :e need to 4now how fami"y re"ations and re"ations between the se6es are structured, andhow these structures foster or im1ede other as1ects of human activity/ :e need, 1erha1s above a"",to 4now how 1eo1"e are enab"ed by the society in 3uestion to imagine, to wonder, to fee" emotionssuch as "ove and gratitude, that 1resu11ose that "ife is more than a set of commercia" re"ations, and

that the human beingOun"i4e the steam engines of Co4etownOis an unfathomab"e mystery,end 1/#P7&N!E9 7


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human "ife, and with a desire to admit, at "east initia""y, the widest 1ossib"e range of accounts ofhow one might go about this, of what indicators one might trust/


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in common with that of focusing on functionings and ca1abi"ities, and the actua" measurementtechni3ues used have obvious re"evance for the use of the ca1abi"ity a11roach/ !he 1hi"oso1hica"under1innings of the ca1abi"ity a11roach, on the other hand, 1rovide some defence of theScandinavian 1ractices and a"so some suggestions for e6tension/ :hi"e the Swedish and innish

a11roaches differ in some significant res1ects, they agree in focusing neither on o1u"ence nor onuti"ity, but on the ways in which 1eo1"e are actua""y ab"e to function, in a variety of areas/ nd theyinsist that any ade3uate measure of 3ua"ity of "ife must be a 1"ura" measure, recogni2ing a numberof distinct com1onents that are irreducib"e to one another/'roc4Js com1rehensive study of measures of 3ua"ity of "ife in the area of hea"th care shows, amongother things, sti"" another convergence, as doctors and 1hi"oso1hers, "oo4ing for the best way toassess the 3ua"ity of 1atientsJ "ives, have increasing"y turned to a "ist of functiona" ca1abi"ities, notun"i4e those 1ro1osed in the ca1abi"ity "iterature and in the theory and 1ractice of Scandinaviansocia" scientists/ !he fie"d of hea"th care 1rovides a rich ground for com1aring, contrasting, andassessing different a11roaches/end 1/%

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criticism and discontent that may arise within a society/ @owever inarticu"ate these dissentingvoices may be, they are, he argues, to be ta4en as im1ortantend 1/?data in understanding what a good "ife wou"d be for the society as a who"e/

Scan"onJs 1a1er, c"ose"y re"ated to the debate about uti"ity in Part &, 3uestions the ade3uacy of desireas a measure of 3ua"ity of "ife, arguing instead for e61"oring an a11roach based on a critica" scrutinyof a substantive "ist of e"ements that ma4e human "ife va"uab"e/ !ay"or e6amines the forms ofreasoning that 1eo1"e use when they argue that one way of "ife is better for human beings thananother/ "though such arguments a"ways ta4e 1"ace in a 1articu"ar historica" conte6t and do nothave the deductive structure that we have come to associate with good scientific argument, they cannone the "ess, he c"aims, be 1erfect"y reasonab"e, and can succeed in showing that some ways ofdoing things are indeed better than others/

Nussbaum e6amines one maDor account of the 3ua"ity of "ife in terms of a "ist of basic humanfunctionsOristot"eJsOthat does c"aim to have va"idity for a"" human beings/ She argues thata"though ristot"e himse"f did not confront the subt"e arguments cu"tura" re"ativists today might use

against his accountOfor e6am1"e, the argument that even such basic human e61eriences as reasoningand desiring are constructed and e61erienced different"y in different societiesOhis account can sti""

be made to re1"y convincing"y to such obDections/ (!he ristote"ian "ist of functions convergessur1rising"y, once again, with the 1ro1osa"s of Sen, Eri4son, ""ardt, and 'roc4 in Part &, a"thoughthey emanate from different inte""ectua" traditions/):omenJs Lives and =ender Bustice&n no area are there greater 1rob"ems about measuring 3ua"ity of "ife than in the area of womenJs"ives and ca1abi"ities/ !he 3uestion of whether uti"ity is an ade3uate measure and the 3uestion ofcu"tura" re"ativism ta4e on a s1ecia" urgency here/ or in most 1arts of the wor"d women do nothave the same o11ortunities as men/ !hese ine3ua"itiesOand the deficiencies in education ande61erience often associated with themOtend to affect womenJs e61ectations and desires, since it isdifficu"t to desire what one cannot imagine as a 1ossibi"ity/ 9esirebased a11roaches to measuring3ua"ity of "ife fre3uent"y end u1, for this reason, affirming the status 3uo, informing us, fore6am1"e, that the women of country ;have no need of "iteracy because, when investigated by theauthorities of ;, they do not e61ress an unsatisfied desire for "iteracy/ n a11roach based on asubstantive account of human ca1abi"ities wou"d as4 different 3uestions here, and wou"d 1robab"yarrive at a different recommendation/ gain, our so"ution to the 1rob"em of cu"tura" re"ativism wi""have es1ecia""y c"ear im1"ications where womenJs "ives are concerned, for most "oca" traditionso11ress women/ universa" account of human functioning seems to have greater critica" 1otentia"here/ (Current wor4 in 1rogress at :&9E7 wi"" 1ress these issues further, attem1ting to construct anonre"ative account of human ca1abi"ities in the conte6t of 3uestions about women/)

end 1/>P7&N!E9 7


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1ractice is unDust to women/ She "in4s the 3uestion of gender Dustice to re"ated 3uestions aboutDustice across internationa" boundaries/Po"icy ssessment and :e"fare EconomicsPart &8e61"ores a number of ways in which 3uestions about 3ua"ity of "ife arise in we"fare

economics (broad"y defined) and the formation of 1ub"ic 1o"icy/ 7oemer studies the criteria ofresource a""ocation used by the :or"d @ea"th


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Part & Lives and Ca1abi"ities

1E3ua"ity of :hat; on :e"fare, =oods, and Caabi!ities

=/ / Cohen# &ntroduction&n his !anner Lecture of #$-$ ca""ed E3ua"ity of :hat; martya Sen as4ed what metricega"itarians shou"d use to estab"ish the e6tent to which their idea" is rea"i2ed in a given society/:hat as1ect(s) of a 1ersonJs condition shou"d count in afundamentalway for ega"itarians, and notmere"y as cause of or evidence of or 1ro6y for what they regard as fundamenta";&n this study & comment on answers to SenJs 3uestion in recent 1hi"oso1hica" "iterature/ & ta4e forgranted that there is something which Dustice re3uires 1eo1"e to have e3ua" amounts of, not nomatter what, but to whatever e6tent is a""owed by va"ues which com1ete with distributive e3ua"ityRand & describe and critici2e what a number of authors who share that ega"itarian view have saidabout the dimension(s) or res1ect(s) in which 1eo1"e shou"d be made more e3ua", when the cost in

other va"ues of moving towards greater e3ua"ity is not into"erab"e/1!he 1ub"ication of Bohn 7aw"sJsA *heory of $usti#ein#$-#was a watershed in discussion bearingon the 3uestion, derived from Sen, which forms my tit"e/ 'eforeA *heory of $usti#ea11eared,

1o"itica" 1hi"oso1hy was dominated by uti"itarianism, the theory that sound socia" 1o"icy aims at thema6imi2ation of we"fare/ 7aw"s found two features of uti"itarianism re1ugnant/ @e obDected, first,to its aggregative character, its unconcern about the 1attern of distribution of we"fare, which meansthat ine3ua"ity in its distribution ca""s for no Dustification/ 'ut, more 1ertinent"y to the 1resente6ercise, 7aw"s a"so obDected to the uti"itarian assum1tion that we"fare is the as1ect of a 1ersonJscondition which commands normative attention/ 7aw"s re1"aced aggregation by e3ua"ity andwe"fare by 1rimary goods/ @e recommended normative eva"uation with new arguments (goodsinstead of we"fare 3uanta) and a new function (e3ua"ity"instead of aggregation) from thosearguments to va"ues/7aw"sJs criti3ue of the we"fare metric was undoubted"y 1owerfu", but, as &

sha"" argue, his motivation for re1"acing it by attention to 1rimary goods was not corres1onding"ycogent/ @e did not consider, as an a"ternative to e3ua"ity of we"fare, the c"aims of e3ua"ity ofo11ortunity for we"fare, which his criticisms of e3ua"ity of we"fare do not touch/ :hat is more,those criticisms 1ositive"y favour e3ua"ity of o11ortunity for we"fare as a remedy for the defects inthe reDected doctrine/'ut whi"e e3ua"ity of o11ortunity for we"fare survives 7aw"sJs criticisms of e3ua"ity of we"fare,arguments against the we"fare metric which were "ater advanced by Sen a"so a11"y against its

o11ortunitydefined cousin/ Sen ca""ed for attention to something "i4e o11ortunity (under the tit"eca1abi"ity#), but it was not we"fare, or not, at any rate, we"fare a"one, which Sen thought 1eo1"eshou"d have the o11ortunity to achieve/ &nstead, he drew attention to the condition of a 1erson (e/g/his "eve" of nutrition) in a centra" sense ca1tured neither by his stoc4 of goods (e/g/ his food su11"y)nor by his we"fare "eve" (e/g/ the 1"easure or desire satisfaction he obtains from consuming food)/ &nadvancing beyond 7aw"s, Sen therefore 1ro1osed two "arge changes of view* from actua" state too11ortunity, and from goods (and we"fare) to what he sometimes ca""ed functionings/&n my view, SenJs answer to his own 3uestion was a great "ea1 forward in contem1orary ref"ectionon the subDect/ 'ut often a thin4er who achieves a revo"ution misdescribes his own achievement,and & sha"" argue, at some "ength, that SenJs wor4 is a case in 1oint/ @e moved away from 7aw"sianand other views in two directions which were orthogona" to each other/ &f 7aw"s and we"farists

fi6ed on what a 1erson gets in we"fare or goods, Sen fi6ed on what he gets in a s1ace betweenwe"fare and goods (nutrition is de"ivered by goods su11"y and it generates we"fare), but he a"soem1hasi2ed what a 1erson #anget, as o11osed to (Dust) what he does/ SenJs misdescri1tion of his
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achievement "ay in his a11ro1riation of the word ca1abi"ity to describe both of his moves, so thathis 1osition, as he 1resented it, is disfigured by ambiguity/ & sha"" here e61ose the ambiguity inSenJs use of ca1abi"ity (and cognate terms), and & sha"" a"so 1ro1ose an answer to his (my tit"e)3uestion which de1arts from his own in a modest way/

7aw"sian Criticism of E3ua"ity of :e"fare'efore e6amining 7aw"sJs criti3ue of e3ua"ity of we"fare, a word about what wi"" here be meant bywe"fare/


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!he criticism does not seem to necessitate abandoning e3ua"ity of we"fare in a more fundamenta"way/(!he e61ensive tastes criticism isthought to necessitate such an abandonment/ &t occurs in theconte6t of 7aw"sJs advocacy of 1rimary goods as the a11ro1riate thing to e3ua"i2e/ Now the 1hrase

1rimary goods covers a set of different things in 7aw"s,)

but for our 1ur1oses, we can, as 7aw"sdoes in the te6ts & sha"" 3uote, ta4e it narrow"y, as referring to goods in the economistJs sense, or the1ower to 1urchase them/Prosecuting his case against we"fare and for 1rimary goods, 7aw"s as4s us to imagine two 1ersons,one satisfied with a diet of mi"4, bread and beans, whi"e the other is distraught without e61ensivewines and e6otic dishes/ &n short one has e61ensive tastes, the other does not/ we"fare ega"itarianmust, #eteris 0aribus, 1rovide the e1icure with a higher income than the 1erson of modest tastes,since otherwise the "atter might be satisfied whi"e the former is distraught/ 'ut 7aw"s argues

1owerfu""y against this im1"ication of the we"fare ega"itarian 1rinci1"e*as mora" 1ersons citi2ens have some 1art in forming and cu"tivating their fina" ends and 1references/&t is not by itse"f an obDection to the use of 1rimary goods that it does not accommodate those with

e61ensive tastes/


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!he 1rob"em, as it a11ears in 7aw"s, is that the 1icture of the individua" asend 1/#%P7&N!E9 7


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choice, in which case "ibera"s shou"d ta4e the 1ur1"e out of the 1assages in which they set forth theirconce1tion of humanity, and we can add socia"ists shou"d sto1 1ainting ins1iring 1ictures ofthe human future (un"ess they be"ieve that 1eo1"e "ac4 free wi"" under ca1ita"ism but wi"" get it afterthe revo"ution)/


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rainbow in the s4y/1)So whi"e both hedonic and 1referencesatisfaction we"farists are free of thegoods theoristJs fetishistic neg"ect of what goods do to human beings, Sen critici2ed them for theirtoonarrow view of what 1eo1"e get from goods, for focusing not on the 1ersonJs ca1abi"ities but onhis menta" reaction, not, for e6am1"e, on how much nourishment a 1erson gets from food, but on

how muchend 1/#.P7&N!E9 7


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do thingsOor that that is the uni3ue"y im1ortant thing they do for them, or that that is the one thingthey do for them that matters from an ega"itarian 1oint of view/ &n naming his view 'asicCa1abi"ity E3ua"ity Sen fai"ed to de"ineate the true sha1e and si2e of one of the dimensions he haduncovered, and which & sha"" now try to describe/

&t is indeed fa"se that the who"e re"evant effect on a 1erson of his bund"e of 1rimary goods is on, orin virtue of, his menta" reaction to what they do for him/ !here is a"so what we"farists ignore* whatthey do for him, what he gets out of them, a1art from his menta" reaction to or 1ersona" eva"uationof that service/ & sha"" ca"" that nonuti"ity effect of goods midfare, because it is in a certain sensemidway between goods and uti"ity/ Midfare is constituted of states of the 1erson 1roduced bygoods, states in virtue of which uti"ity "eve"s ta4e the va"ues they do/ &t is 1osterior to havinggoods and 1rior to having uti"ity/"%Midfare is a heterogeneous co""ocation, because goods do categoria""y various things for 1eo1"e* (#)they endow them with ca1abi"ities 1ro1er"y so ca""ed, which they may or may not useR () through

1eo1"eJs e6ercise of those ca1abi"ities, goods contribute to the 1erformance of va"uab"e activitiesandthe achievement of desirab"e statesR and (%) goods cause further desirab"e states direct"y,

without any e6ercise of ca1abi"ity on the 1art of their beneficiary* an e6am1"e wou"d be the goodswhich destroy the insects that cause ma"aria/ Ca1abi"ity (1ro1er"y so ca""ed) is, then, a 1art ofmidfare, for it certain"y cannot be e6c"uded from the range of things that goods confer on 1eo1"e,yet, e3ua""y certain"y, it does not e6haust that range/Each terminus of the goodsOmidfareOuti"ity se3uence has seemed to some the right focus forassessment of a 1ersonJs situation from an ega"itarian 1oint of view/ 7aw"sians "oo4 at the

beginning of the se3uence and we"farists "oo4 atend 1/#+P7&N!E9 7


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1erson from what he does


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out of goods in both senses of the 1hrase, but whi"e on"y the first sense re"ates to ca1abi"ity, thesecond denotes something at "east as im1ortant/#/ &n SenJs discourse, to have a ca1abi"ity is to be ca1ab"e of achieving a range of what he ca""sfunctionings/ 'ut Sen characteri2es functionings different"y at different times, and thereby adds

further im1recision to the 1resentation of his view/Sometimes, in 4ee1ing with the ordinary meaning of functioning, and in "ine with SenJs origina"g"oss on ca1abi"ity as being ab"e to docertain basic things,##a functioning is by definition anactivity, something that a 1erson does/#$!he 3uestions Can they read and write; Can they ta4e 1artin the "ife of the community;#%in3uire into 1eo1"eJs functionings in this fami"iar sense of the term/'ut at other times, functionings are not by definition activities but a"" (desirab"e) states of 1ersons,and being we"" nourished, being free from ma"aria, and being free from avoidab"e morbidity#&are conse3uent"y entered as e6am1"es of functionings, a"though, not being activities, they are notfunctionings in the ordinary sense of the term/ (Even though & am free from ma"aria now can be

1art of the answer to the 3uestion @ow are you doing; in its co""o3uia" use/):hen Sen writes that unctionings are / / / 1ersona" featuresR they te"" us what a 1erson is doing,#'

he 1"aces his incom1atib"e broad and narrow definitions of functioning on either side of the semico"on/ or not a"" 1ersona" features, and not a"" of the 1ersona" features that Sen wishes toencom1ass, are things that a 1erson is doing/ Un"i4e reading and writing, being free from ma"aria isnot something that one does/ E"sewhere, a broader definition of functioningsend 1/#P7&N!E9 7


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end 1/P7&N!E9 7


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t 1/ > of his #$++ ty1escri1t, Sen says that ca1abi"ity ref"ects a 1ersonJs freedom to choosebetween different ways of "iving/ !hat formu"ation more or "ess identifies ca1abi"ity with freedomof choice (how much it does so de1ends on what ref"ects means here* it might mean is)/ &n "inewith that characteri2ation of ca1abi"ity is SenJs descri1tion of the rich faster, who has the ca1abi"ity

to be we"" nourished, but chooses not to VbeW/%#

E"sewhere, however, something very different from the freedom to choose whether or not to eat,name"y, freedomfromhunger, is denominated a ca1abi"ity/%$&n fact, though, freedom from hungeris beingwe"" nourished/ &t is not the abi"ity to choose which the rich faster has* it is what he choosesnot to have/ reedom from hunger is a desirab"e absence or 1rivation, the sort of freedom whicheven beings that are not agents can have/ @ea"thy 1"ants have freedom from greenf"y, and soundhouses are free from dry rot/ (Note that a 1erson might even be described, in a s1ecia" conte6t, asfree from nourishment, for e6am1"e, when he wants to fast, or by ca1tors who want him to starve/)Un"i4e the freedom to choose whether or not to eat, freedom from hunger is not constitutive"yfreedom to doanything/ Sen s1ea4s of e/er#isingsuch ca1abi"ities as freedom from hunger andfreedom from ma"aria/%%'ut they are not freedoms that are e/er#ised/ SenJs a11"ication of the term

ca1abi"ity bothto the freedom to a3oidmorbidity%&andto freedomfrommorbidity%'shows that, inthe attem1t to bring the very different issues with which he is concerned under the sing"e rubric ofca1abi"ity, he is "ed to ma4e e3uivoca" use of the term freedom/%(:hen Sen introduced ca1abi"ity e3ua"ity in E3ua"ity of :hat;, he was modest about its c"aims/ &twas a 1artia" guide to the 1art of mora" goodness that is associated with the idea of e3ua"ity/%)iveyears "ater, his c"aim for the new 1ers1ective was much stronger/ or, in the 9ewey Lectures, Sensaid that the0rimaryfeature of we""being can be seen in terms of how a 1erson can Tfunction,ta4ing that term in a very broad sense, and that the accounting of functioning vectors 1rovides amore 1"ausib"e view of we""being than com1eting conce1tions do/&*E"sewhere, we are advisedthat, in assessing we""being and advantage, we shou"d focus on the ca1abi"ity to function, i/e/what a 1erson can door be/ @is uti"ity is on"y e3iden#eof a 1ersonJs advantage in that centra"sense,&1and the goods at his dis1osa" (here ca""ed his o1u"ence) are on"y #ausesof thatadvantage/&"!he 1osition of midfare between 1rimary goods and uti"ity, thus construed, is given asa reason for treating it as the centra" dimension of va"ue/!hese are strong c"aims, but they are easier to acce1t in that functionings are now e61"icit"ydescribed as doings andbeings so that both activities and states of e6istence or being comeunder the functioning rubric/:hat & cannot acce1t is the associated ath"eticism, which comeswhen Sen adds that the centra" feature of we""being is the abi"ity to achieve va"uab"efunctionings/&$!hat overestimates the 1"ace of freedom and activity in we""being/ s Senend 1/>P7&N!E9 7


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we"fare a"one, but more broad"y conceived good states of the 1erson/ &n this reconstruction, theerror of forcing the conce1t of ca1abi"ity to denote both the e"ement of o11ortunity and the move toa broader conce1tion of advantage is e"iminated/:hen Sen first invo4ed ca1abi"ity, it was in the conte6t of a 1ro1osa" that we attend to basi#

ca1abi"ity e3ua"ity/&&

!he re"evant ca1abi"ity was of a fundamenta" sort, ca1abi"ity whose absencedisab"es the 1erson from satisfying his basic needs/ Such need satisfaction is, whi"e c"ear"y re"atedto the achievement of we"fare, a"so irreducib"e to the "atter* one may need something for which onehas no desire and one may desire something which does not constitute a need/ t the basic "eve", wecan, with some confidence, ran4 ca1abi"ities in im1ortance without 1aying attention to 1eo1"eJstastes/ 'ut, as Sen 1oints out, ca1abi"ity ran4ings are more moot once we 1ass beyond the basicdesiderata of a norma" human "ife*when there is diversity of taste, it becomes harder to surmise about ca1abi"ity by sim1"y observingachievement/ or e6treme 1overty this 1rob"em is "ess serious/ 8a"uing better nourishment, "essi""ness and "ong "ife tend to be fair"y universa", and a"so "arge"y consistent with each other des1ite

being distinct obDectives/ 'ut in other cases of greater re"evance to the richer countriesOthe

informationa" 1rob"ems with the ca1abi"ity a11roach can be 3uite serious/&'or ca1abi"ities which go beyond need satisfaction, it is hard to see how ran4ings are 1ossib"ewithout recourse to uti"ity va"uations of the re"evant states/ &n a critica" comment on Sen, 7ichardrneson tries to e61"oit the de1endence on 1reference of the va"ue of higher ca1abi"ities*end 1/.P7&N!E9 7


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f/ &n the "ast sentence of subsection e, & reintroduced the e3uivocation between ca1abi"ity andmidfare/ @ere & sha"" e61"ain why & did so, and why, moreend 1/-P7&N!E9 7


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(#$+)/ Socia" Unity and Primary =oods, in / 5/ Sen and '/ :i""iams, (eds/),:tilitarianism and Beyond/ Cambridge* Cambridge University Press/

(#$+>)/ Bustice as airness, Po"itica" not Meta1hysica",&hiloso0hy and &ubli# Affairs, #?/ (#$+.)/ Citi2ensJ Needs and Primary =oods, un1ub"ished/

Scan"on, !/ M/ (#$->)/ Preference and Urgency,$ournal of &hiloso0hy, -/Sen, / 5/ (#$+)/ E3ua"ity of :hat;, in S/ McMurrin (ed/), *anner 'e#tures on %uman 4alues, i/Cambridge* Cambridge University Press/

(#$+#)/ Ethica" &ssues in &ncome 9istribution* Nationa" and &nternationa", in S/ =rassmanand E/ Lundberg (eds/), *he World E#onomi# 7rder+ &ast and &ros0e#ts/ London* Macmi""an/7e1r/ in Sen (#$+?a)/

(#$+)/ Choi#e@ Welfare and Measurement/ '"ac4we"", #)/ :e""'eing, gency and reedom* !he 9ewey Lectures #$+?,$ournal of&hiloso0hy, +/ (#$+-)/ :e""'eing and gency, un1ub"ished/ et al.(#$+-)/ *he Standard of 'i3ing/ Cambridge* Cambridge University Press/ (#$++)/ Ca1abi"ity and :e""being, un1ub"ished draft of the 1a1er that fo""ows in thisvo"ume/


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Ca1abi"ity and -e!! +ein, martya Sen# &ntroductionCa1abi"ity is not an awfu""y attractive word/ &t has a technocratic sound, and to some it might evensuggest the image of nuc"ear war strategists rubbing their hands in 1"easure over some contingent

1"an of heroic barbarity/ !he term is not much redeemed by the historica" Ca1abi"ity 'rown 1raising1articu"ar 1ieces of landOnot human beingsOon the so"id rea"estate ground that they hadca1abi"ities/ Perha1s a nicer word cou"d have been chosen when some years ago & tried to e61"ore a

1articu"ar a11roach to we""being and advantage in terms of a 1ersonJs abi"ity to do va"uab"e acts orreach va"uab"e states of being/1!he e61ression was 1ic4ed to re1resent the a"ternative combinationsof things a 1erson is ab"e to do or beOthe various functionings he or she can achieve/"!he ca1abi"ity a11roach to a 1ersonJs advantage is concerned with eva"uating it in terms of his orher actua" abi"ity to achieve various va"uab"e functionings as a 1art of "iving/ !he corres1ondinga11roach to socia" advantageOfor aggregative a11raisa" as we"" as for the choice of institutions and

1o"icyOta4es the sets of individua" ca1abi"ities as constituting an indis1ensab"e and centra" 1art ofthe re"evant informationa" base of such eva"uation/ &t differs from other a11roaches using other

informationa" focuses, for e6am1"e, 1ersona" uti"ity (focusing on 1"easures, ha11iness, or desirefu"fi"ment), abso"ute or re"ative o1u"ence (focusing on commodity bund"es, rea" income, or rea"wea"th), assessments of negative freedoms (focusing on 1rocedura" fu"fi"ment of "ibertarian rightsand ru"es of noninterference), com1arisons of means of freedom (e/g/ focusing on the ho"dings of1rimary goods, as in the 7aw"sian theory of Dustice), and com1arisons of resource ho"dings as a

basis of Dust e3ua"ity (e/g/ as in 9wor4inJs criterion of e3ua"ity of resources)/end 1/%P7&N!E9 7


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arrangements/ fu"" accounting of individua" freedom must, of course, go beyond the ca1abi"itiesof 1ersona" "iving and 1ay attention to the 1ersonJs other obDectives (e/g/ socia" goa"s not direct"yre"ated to oneJs own "ife), but human ca1abi"ities constitute an im1ortant 1art of individua" freedom/reedom, of course, is not an un1rob"ematic conce1t/ or e6am1"e, if we do not have the courage to

choose to "ive in a 1articu"ar way, even though we #ould"ive that way if we so chose, can it be saidthat we do have the freedom to "ive that way, i/e/ the corres1onding ca1abi"ity; &t is not my 1ur1osehere to brush under the car1et difficu"t 3uestions of thisOand otherOty1es/ &n so far as there aregenuine ambiguities in the conce1t of freedom, that shou"d be ref"ected in corres1ondingambiguities in the characteri2ation of ca1abi"ity/ !his re"ates to a methodo"ogica" 1oint, which &have tried to defend e"sewhere, that if an under"ying idea has an essentia" ambiguity, a 1reciseformu"ation of that ideaend 1/%%P7&N!E9 7


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goa"s that a 1erson has reasons to ado1t, which can inter aliainc"ude goa"s other than theadvancement of his or her own we""being/ &t can thus generate orderings different from that ofwe""being/ !he second distinction is between (/#) a#hie3ement, and (/) thefreedom to a#hie3e/!his contrast can be a11"ied both to the 1ers1ective of we""being and to that of agency/ !he two

distinctions together yie"d four different conce1ts of advantage, re"ated to a 1erson* (#) we""beingachievement, () agency achievement, (%) we""being freedom, and (?) agency freedom/ !hesedifferent notions, which & have tried to discuss more e6tensive"y e"sewhere, are not, of course,unre"ated to each other, but nor are they necessari"y identica"/1'end 1/%>P7&N!E9 7


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inc"ude other ty1es of obDective (going we"" beyond the 1ersonJs own state of being)/ "so, thedifference between agency achievement and we""being achievement is not on"y a matter ofs0a#e(the former ta4ing us beyond the 1ersonJs own "ife and functionings), but a"so one of differentia"


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ca1abi"ity set for the va"ue1ur1ose of assessing we""being achievement, we wou"d sim1"y have toidentify the va"ue of the ca1abi"ity set with the va"ue of the achieved functioning ntu1"e in it/ !he

1rocedure of e3uating the va"ue of the ca1abi"ity set to the va"ue of oneof the e"ements of that sethas been ca""ed e"ementary eva"uation/""

end 1/%+P7&N!E9 7


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amount of agreement on the e6treme urgency of a c"ass of needs/ Particu"ar mora" and 1o"itica"im1ortance may we"" be attached to fu"fi""ing we""recogni2ed, urgent c"aims/#1&t is 1ossib"e to argue that e3ua"ity in the fu"fi"ment of certain basic ca1abi"ities 1rovides anes1ecia""y 1"ausib"e a11roach to ega"itarianism in the

end 1/?P7&N!E9 7


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&n this 1a1er, & have so far been 1rimari"y concerned with c"arifying and integrating the basicfeatures of the ca1abi"ity a11roach, though & have ta4en the o11ortunity to address, in 1assing, somecriticisms that have been made of this a11roach/ &n this section and in the ne6t, & discuss twodifferent "ines of criticism 1resented res1ective"y by =// Cohen and Martha Nussbaum

arguing for different ways of ana"ysing and assessing the 1rob"ems of we""being and 3ua"ity of "ife/&n his 1a1er in this vo"ume, and e"sewhere (Cohen, #$+$, #$$), =/ Cohen has 1rovided a critica"assessment of my writings on ca1abi"ity (and a"so of the theories of othersuti"itarians, Bohn7aw"s, 7ona"d 9wor4in, !homas Scan"on, et al.), at the same time 1resenting his own answer to the3uestion e3ua"ity of what;/ Cohen is generous in giving credit where he reasonab"y can, and hisassessment is 1ositive in many ways, but the criticisms he ma4es, if sustained, wou"d indicate amaDor motivationa" confusion as we"" as a conce1tua" inade3uacy under"ying the ca1abi"itya11roach as & have tried to 1resent it/CohenJs main thesis is that in my 1a1er E3ua"ity of :hat; (Sen, #$+), & brought two distinctas1ects of a 1ersonJs condition under that sing"e name Vca1abi"ityW and that this unnoticed dua"ityhas 1ersisted in VmyW subse3uent writings/ 'oth as1ects, or dimensions of assessment, shou"d

attract ega"itarian interest, but one of them is not fe"icitous"y described as Tca1abi"ity (1/ #-)/


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set)/ !his 1oint is obscured in CohenJs ana"ysis by his conviction that the e6ercise of ca1abi"itymust be a rather active o1eration, and Cohen is mis"ed by this diagnosis when he argues that hecannot acce1t / / / the associated ath"eticism, which comes when Sen adds that Tthe centra" featureof we""being is the abi"ity to achieve va"uab"e functionings (1/ >)/ Cohen gives e6am1"es (e/g/

sma"" babies being we"" nourished and warm as a resu"t of the activities of their 1arents) that c"ear"yshow that having midfare (or enDoying functionings) need not be a 1articu"ar"y ath"etic activity/ & seeno reason to obDect to this, since ath"eticism was never intended, des1ite the fact that Cohen hasobvious"y beenend 1/?%P7&N!E9 7


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the same midfare, but they differ in their ca1abi"ities/ Ca1abi"ity does have im1ortance in 1o"itica"and socia" ana"ysis/Motivationa""y, the focus on ca1abi"ity (in addition to achieved functionings) is, in fact, nota"together different from the concern that Cohen shows e"sewhere for access to advantage/ Cohen

notes that in his 1ro1osa"advantage is "i4e SenJs functioning in its wider construa", a heterogenous co""ection of desirab"estates of the 1erson reducib"e neither to his resources bund"e nor to his we"fare "eve"/ nd whi"eaccess inc"udes what the term norma""y covers, & e6tend its meaning under a 1roviso that anythingwhich a 1erson actua""y has counts as something to which he has access, no matter how he came tohave it, and, hence, even if his coming to have it invo"ved no e61"oitation of access in the ordinarysense (nor, therefore, any e6ercise of ca1abi"ity)/ &f, for e6am1"e, one enDoys freedom from ma"aria

because others have destroyed the ma"ariacausing insects, then, in my s1ecia" sense, such freedomfrom ma"aria is something to which one has access (Cohen, 1/ +),& do not see any great difficu"ty in e6tending the meaning of access in this way/ n access &enDoy may not have been created by me/ 'ut e6act"y the same a11"ies to freedom and ca1abi"ity as

we""/ !he fact that a 1erson has the freedom to enDoy a ma"ariafree "ife (or, to 1ut it s"ight"ydifferent"y, that his choice of a ma"ariafree "ife is feasib"e) may be entire"y due to the actions ofothers (e/g/, medica" researchers, e1idemio"ogists, 1ub"ic hea"th wor4ers), but that does notcom1romise the fact that he can indeed have a ma"ariafree "ife and has the ca1abi"ity (than4s"arge"y to others) to achieve such a "ife/$*& donJt even see that much e6tension of ordinary usage is invo"ved in such use of the termsfreedom and ca1abi"ity (even though this is not the centra" issue in any case)/$1&ndeed, even thee61ression freedom from ma"aria, used a"so by Cohen, is a 1ointer to the fact that ordinary"anguage ta4es a "ess narrow view of the use of the term freedom/ Simi"ar"y, there is no under"ying

1resum1tion that we have the ca1abi"ity to "ead a ma"ariafree "ife on"y if we haveend 1/?>P7&N!E9 7


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ethics and 1o"itics, it is 1ossib"e to note some ambiguity and indeed to find some tension betweendifferent 1ro1ositions 1resented by him, but his recognition of the crucia" im1ortance of a 1ersonJsfunctionings and ca1abi"ities seems to emerge c"ear"y enough, es1ecia""y in the 1o"itica" conte6t ofdistributive arrangements/

:hi"e the ristote"ian "in4 is undoubted"y im1ortant, it shou"d a"so be noted that there are somesubstantia" differences between the way functionings and ca1abi"ities are used in what & have beenca""ing the ca1abi"ity a11roach and the way they are dea"t with in ristot"eJs own ana"ysis/ ristot"e

be"ieves, as Nussbaum (#$++) notes, that there is Dust one "ist of functionings (at "east at a certain"eve" of genera"ity) that do in fact constitute human good "iving (1/ #>)/end 1/?.P7&N!E9 7


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), even the genera" rationa"e for using such an a11roach may be consistent with some ranges ofanswers to foundationa" 3uestions/# Conc"uding 7emar4&n this 1a1er & have tried to discuss the main features of the ca1abi"ity a11roach to eva"uation* its

c"aims, its uses, its rationa"e, its 1rob"ems/ & have a"so addressed some criticisms that have beenmade of the a11roach/ & sha"" not try to summari2e the main contentions of the 1a1er, but beforeconc"uding, & wou"d "i4e to em1hasi2e the 1"ura"ity of 1ur1oses for which the ca1abi"ity a11roachcan have re"evance/!here are different eva"uative 1rob"ems, re"ated to dis1arate va"ue1ur1oses/ mong the distinctionsthat are im1ortant is that between we""being and agency, and that between achievement andfreedom/ !he four categories of intra1ersona" assessment and inter1ersona" com1arison that fo""owfrom these two distinctions (name"y, we""being achievement, we""being freedom, agencyachievement, and agency freedom) are re"ated to each other, but are not identica"/ !he ca1abi"itya11roach can be used for each of these different ty1es of eva"uation, though not with e3ua" reach/ &tis 1articu"ar"y re"evant for the assessment of we""being in the form of both achievement and

freedom and for the re"ated 1rob"em of Dudging "iving standards/s far as socia" Dudgements are concerned, the individua" eva"uations feed direct"y into socia"assessment/ Even though the origina" motivation for using the ca1abi"ity a11roach was 1rovided byan e6amination of the 3uestion e3ua"ity of what; (Sen, #$+), the use of the a11roach, ifsuccessfu" for e3ua"ity, need not

be confined to e3ua"ity on"y/%#!he usabi"ity of the a11roach in ega"itarian ca"cu"us de1ends on the1"ausibi"ity of seeing individua" advantages in terms of ca1abi"ities, and if that 1"ausibi"ity isacce1ted, then the same genera" 1ers1ective can be seen to be re"evant for other ty1es of socia"eva"uation and aggregation/!he 1otentia""y wide re"evance of the ca1abi"ity 1ers1ective shou"d not come as a sur1rise, since theca1abi"ity a11roach is concerned with showing the cogency of a 1articu"ars0a#efor the eva"uationof individua" o11ortunities and successes/ &n any socia" ca"cu"us in which individua" advantages areconstitutive"y im1ortant, that s1ace is of 1otentia" significance/+ib!io,rahyristot"e (?th c/ bc )/ *he Ni#oma#hean Ethi#s* see 7oss (#$+)/rneson, 7/ (#$+-)/ E3ua"ity and E3ua"ity of ./Cu"yer, / B/ (#$+>)/ !he Sco1e and Limits of @ea"th Economics, 7konomie desGesundheits


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dJs1remont, C/, and =evers, L/ (#$--)/ E3uity and the &nformationa" 'asis of Co""ective Choice,Re3ie< of E#onomi# Studies, ?./de'eus, Bos (#$+.)/ SenJs !heory of Liberty and &nstitutiona" 8acuum, University of msterdam/de8os, 5/, and @agenaars, "di B/ M/ (#$++)/ Com1arison between the Poverty Conce1ts of Sen

and !ownsend, mimeogra1hed, University of Leiden/end 1/>P7&N!E9 7


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Lidde"", @/ =/, and Scott, 7/ (#$--)/A GreekEnglish 'e/i#on, e6tended by @/ S/ Bones and 7/Mc5en2ie/


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(#$+%b)/ 9eve"o1ment* :hich :ay Now;,E#onomi# $ournal, $%R re1r/ in Sen (#$+?)/ (#$+%#)/ Poor, 7e"ative"y S1ea4ing, 7/ford E#onomi# &a0ers, %>R re1r/ in Sen (#$+?)/end 1/>P7&N!E9 7/ (#$$)/9neDuality Ree/amined/ )/Ethi#s and the 'imits of &hiloso0hy/ London* ontana, and Cambridge, M*@arvard University Press/

(#$+-)/ !he Standard of Living* &nterests and Ca1abi"ities, in Sen (#$+-b)/:i"son, =/ (#$+-)/Money in the amily/ "dershot* vebury/

Gamagni, S/ (#$+.)/ &ntrodu2ione, in / Sen, S#elta@ Benessere@ EDuita/ 'o"ogna* &" Mu"ino/end 1/>%


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=// Cohen* E3ua"ity of :hat; on :e"fare, =oods and Ca1abi"ities martya Sen* Ca1abi"ity and:e""'eing

show cha1ter abstract and 4eywordshide cha1ter abstract and 4eywords

Christine M/ 5orsgaard!hese two 1a1ers 1ro1ose ways to understand and measure certain im1ortant as1ects of the 3ua"ityof "ife/ =era"d Cohen is concerned s1ecifica""y with e3ua"ity* what it is 1eo1"e must have an e3ua"amount of, in order for them to be e3ua" in the sense ega"itarians ought to care about/ @is 1a1ercritici2es the views of 7aw"s and Sen, and offers his own answer, which is that 1eo1"e shou"d bee3ua" in their a##ess to ad3antage/1'oth terms in this formu"a are meant to be ec"ectic/ dvantageinc"udes both we"fare and resources, and whatever e"se we might decide is a desirab"e state of the

1erson/"ou have access to things you have or can get or are given to you/ !o say that 1eo1"eshou"d be e3ua" in their access to advantage, according to Cohen, is to say that any invo"untarydisadvantageOany disadvantage which either was not chosen or cannot be vo"untari"y overcomeOought to be e"iminated or com1ensated/

martya SenJs view is that the 3ua"ity of a 1ersonJs "ife shou"d be assessed in terms of the 1ersonJsca1abi"ities/ ca1abi"ity is the abi"ity or 1otentia" to do or be somethingOmore technica""y, toachieve a certain functioning/ unctionings are divided into four over"a11ing categories, which Senca""s we""being freedom, we""being achievement, agency freedom, and agency achievement/


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maDority/#Even in a democratic society, we must 1"ace "imits on what may be achieved through1o"itica" means/ Po"itica" obDectives must ref"ect the reasons 1eo1"e have for submitting to thecoercive authority of the state in the first 1"ace/!he "egitimacy of a 1o"itica" obDective obvious"y de1ends on what sort of 1o"itica" 1hi"oso1hy one

es1ouses, what one thin4s the state is for/ So & wi"" begin by discussing the 4inds of 1o"itica"obDectives that have been thought "egitimate, and s4etching a view that & find 1"ausib"e/ & wi"" thenassess SenJs and CohenJs 1ro1osa"s in the "ight of that view/ o""owing 7aw"s, & begin with thedistinction between "ibera" and non"ibera" 1o"itica" theories/$&n a "ibera" theory, the 1ur1ose of thestate is to a""ow each citi2en to 1ursue his or her own conce1tion of the good/ &n a non"ibera"theory, some conce1tion of the good is ta4en as 1hi"oso1hica""y estab"ished, and the goa" of the stateis to rea"i2e that conce1tion/ &f a non"ibera" theory is acce1ted, my first two forms of assessmentare not after a"" se1arate* to show that something is a "egitimate 1o"itica" obDective, a"" we need do isshow that it is indeed an estab"ished good/ ccording to such theories, the state is in the business of

bringing about the good/ s 7aw"s 1oints out, c"assica" uti"itarianism is strict"y s1ea4ing a non"ibera" theory, since it ta4es the goodness of the ma6imi2ation of 1"easure as both 1hi"oso1hica""y

estab"ished and ca1ab"e of Dustifying 1o"itica" 1o"icy/%n ristote"ian theory that ta4es the 1ur1oseof the state to be to educate the citi2ens for a virtuous "ife, or a Mar6ist theory aimedend 1/>>P7&N!E9 7


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!here is another, o"der way to be a "ibera" which is a "itt"e different/ ccording to Loc4e and 5ant,the business of the state is to 1reserve and 1rotect rights and freedom, notto faci"itate the 1ursuit ofa good "ife/ !hese 1hi"oso1hers be"ieved that it is of the nature of rights and freedom that their

1reservation Dustifies the use of coercion/ Loc4e be"ieved that you have natura" rights which you are

entit"ed to enforce* first, and innate"y, a right to your own "abour, andend 1/>.P7&N!E9 7


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wi"" regard as a dreary form of "ibertarianism/ &f the on"y thing that the state can guarantee isfreedom, and not a good "ife, there wi"" be no grounds for guaranteeing things that seem c"ear"y to

be 1art of the good and not of freedom food, medica" care, an economic minimum, and so forth/!his 4ind of theory ma4es it hard to be a we"fare "ibera"/

!here is a"so a way to overcome this obDection/ &t is to insist both on the necessity of em1"oying arich 1ositive conce1tion of freedom, and on the idea that certain we"fare conditions must be met inorder to achieve what 7aw"s ca""s the worth of "iberty, the rea" 1ossibi"ity of ta4ing advantage ofoneJs rights and o11ortunities/117aw"s himse"f dec"ines to treat the conditions of the worth of "ibertyas 1art of, or essentia" to, being free/ 'ut in fact it does not matter much whether we ta"4 of theworth of "iberty or its rea"ity/ :e cannot effective"y guarantee "iberty without guaranteeing itsworth/ !he genera" idea behind this view, then, is that un"ess certain basic we"fare conditions aremet and resources and o11ortunities 1rovided, we cannot serious"y c"aim that society is 1reservingand 1rotecting everyoneJs freedom/ !he 1oor, the Dob"ess, the medica""y neg"ected, the unhoused,and the uneducated are not free no matter what rights they have been guaranteed by the constitution/!here are two reasons for this/ !he first is their im1aired ca1acity for formu"ating and 1ursuing a

conce1tion of the good/ !he second is Dust as im1ortant/ 1erson who "ac4s these basic goods issubDect to intimidation by the rich and 1owerfu", es1ecia""y if others de1end on her/ s uns4i""edwoman "abourer who 1uts u1 with a "ower income, 1oor conditions, or even se6ua" harassment onthe Dob because her on"y a"ternative is to "et her chi"dren starve is not free/ !o fai" to satisfy 1eo1"eJs

basic needs and 1rovideend 1/>+P7&N!E9 7


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Sen seems to say that the 1oint of 1roviding someone with, say, food is that they mayfeedthemsel3esrather than Dust that they mayget fed, whoever is the agent in the case/ Cohen argues thatit is im1ortant that 1eo1"e get fed, not Dust that they feed themse"ves, and su11oses that Sen missesthis 1oint because he is focused too much on freedom and activity/ 'ut a 1ersonJs getting fed may

be Dustified 1o"itica""y by the contribution to his freedom that being we"" nourished ma4es/ :e donot have to choose between giving nourishment a 1o"itica" weight which is unre"ated to freedomand the ath"eticism of which Cohen accuses Sen/ eeding yourse"f is not the on"y free activity forwhich the 1rovision of an ade3uate diet is essentia"/CohenJs own 1ro1osa" gives a different ro"e to freedom from those of Sen and 7aw"s/ Cohen

be"ieves that it is unDust that 1eo1"e shou"d be disadvantaged in ways they do not free"y choose/ @ethin4s that this idea is what gives intuitive force to the e61ensive tastes criticism of we"farism

1ro1ounded by 7aw"s and others/ Cohen accuses 7aw"s of switching bac4 and forth between adeterministic and a "ibertarian view of human nature/ :hen he attac4s the 1o"itica" use of the notionof desert, 7aw"s uses deterministic arguments, saying that if someone is more di"igent or ambitiousthan others, these virtues are most "i4e"y the 1roduct of a favourab"e u1bringing/


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!his is not Dust for the 1ragmatic reason that meta1hysica" Dudgements about free wi"" are hard toma4e in 1articu"ar cases/ &n the conce1tions of 7aw"s and Sen, freedom is regarded as somethingsociety shou"d bring about, not Dust as the occasion for Dudgements about what 1eo1"e deserve/ ndthis "eads me to a fina" 1oint, which is that there is a"so a mora" reason for wor4ing through the

basic structure, and so avoiding 1articu"ar Dudgements of the sort Cohen has in mind/ Budgementsabout whether others have free"y chosen their conce1tions of the good are not on"y ones we cannotvery easi"y ma4e, they are ones we ought not to ma4e/ Such Dudgements are disres1ectfu"/ &f one ofour goa"s is to ma4e it 1ossib"e for the members of society to have decent moralre"ations with oneanother, this is an additiona" reason for ma4ing freedom a11ear instead as a #onseDuen#eof DusticeRsomething that resu"ts, that is, from a Dust basic structure of society/+ib!io,rahy5ant, &mmanue" (#-$-)/ *he Meta0hysi#al Elements of $usti#e, trans/ Bohn Ladd (#$.>)/&ndiana1o"is* 'obbsMerri"" Library of Libera" rts/Loc4e, Bohn (#.$)/ Se#ond *reatise of Go3ernment/ &ndiana1o"is* @ac4ett Pub"ishing/Mi"", Bohn Stuart (#+>$)/ 7n 'iberty/ &ndiana1o"is* @ac4ett Pub"ishing/

7aw"s, Bohn (#$-#)/A *heory of $usti#e/ Cambridge, Mass/* @arvard University Press/ (#$+)/ 5antian Constructivism in Mora" !heory* !he 9ewey Lectures #$+,$ournal of&hiloso0hy, -- (Se1t/ #$+)/ (#$+a)/ !he 'asic Liberties and !heir Priority, in *anner 'e#tures on %uman 4alues, iii/Sa"t La4e City* University of Utah Press/

(#$+b)/ Socia" Unity and Primary =oods, in :tilitarianism and Beyond, ed/ martya Senand 'ernard :i""iams/ Cambridge* Cambridge University Press/end 1/.#P7&N!E9 7


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!hese basic ca1abi"ities are certain"y of great im1ortance in an ana"ysis of 1overty/ !hey are no"onger of much interest in a com1arison of high"y deve"o1ed countries, for the sim1"e reason thatmost of the tru"y e"ementary functionings are achieved to a very high degree in those economies/ &tseems to me, however, that another set of basic functionings is more and more coming to the fore in

high"y industria"i2ed countries, functionings we have forgotten to thin4 about since everyone hadaccom1"ished them former"y/ Some of these basic functionings are in danger of becomingunachievab"e (or on"y 1artia""y achievab"e), others a11ear to be out of reach for the time being/ Letme Dust name a few* to drin4 ta1water, to ta4e a swim in rivers or in the sea, to eat fish from thesea, to breathe c"ean air in a metro1o"itan area, to wa"4 around at night without fear, to "ive withoutthe danger of an accident in a nuc"ear 1ower 1"ant/end 1/.P7&N!E9 7


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!he foregoing argumentation shows how difficu"t it is to assess we""being freedom/ "arger set ofntu1"es of functionings is not necessari"y tantamount to a 1referab"e set (sometimes a sma""er setcou"d even be a better set when information gathering and 1rocessing become too cost"y)/ !heeva"uative 1rob"em may be "ess com1"icated when the rights as1ect in we""being freedom is

considered/ &t seems to me that there is a direct re"ationshi1 between we""being freedom and a1articu"ar societyJs bi"" of rights or, formu"ated more cautious"y, a societyJs "ist of guaranteedthatis, actua""y 1rotectedfundamenta" human rights/ reedom of thought means freedom ofe61ression, freedom of the 1ress is tantamount to access to a huge amount of information, freedomto choose oneJs 1"ace of wor4 increases oneJs f"e6ibi"ity, and so forth/ &n other words, civi" and

1o"itica" "iberties increase an individua"Js ca1abi"ity set and therefore his or her we""being freedom/!he situation again becomes more com1"icated when interde1endencies are brought into the 1icture/My range of freedom, for e6am1"e, is "imited by your range of freedom, and vice versa/ "so,ca1abi"ity sets do not seem to be given once and for a"", that is, to be abso"ute and invariant/ P7&N!E9 7


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:i""iams, '/ (#$+-)/ !he Standard of Living* &nterests and Ca1abi"ities, in Sen (#$+-)/end 1/..P7&N!E9 7 the Swedish government set u1 a commission with the tas4 of describing the conditions and

1rob"ems of "ow income earners/ !he commission 1"anned its tas4 in three ste1s* (#) a study of thedistribution of factor income, () a study of the distribution of dis1osab"e income, and (%) a study oftheend 1/.-P7&N!E9 7


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%/ Economic resources&ncome and wea"th, 1ro1erty, abi"ity to cover unforeseen e61enses ofu1 to Y#, within a wee4

?/ Education and s4i""s ears of education, "eve" of education reached>/ ami"y and socia"

integrationMarita" status, contacts with friends and re"atives

./ @ousing Number of 1ersons 1er room, amenities-/ Security of "ife and

1ro1ertyE61osure to vio"ence and thefts

+/ 7ecreation and cu"ture Leisuretime 1ursuits, vacation tri1s

$/ Po"itica" resources8oting in e"ections, membershi1 of unions and 1o"itica" 1arties, abi"ityto fi"e com1"aints

Z &n the first survey in #$.+ no 3uestions were as4ed about security of "ife and 1ro1erty, whereas3uestions were inc"uded about diet and nutrition/end 1/.+P7&N!E9 7 1er cent confidence interva"s/


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igure # 7egression 9iagram


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igure 7egression 9iagram #. #? #. #$ Private technica" and c"erica" .>/ +/$ $/-+- $? ## %# - ?Pub"ic sa"aried .+/> -$/% +?/?$ $ $? % #$ #-Meta" wor4ers >$/? -#/- -/#-+ + -+ > #. #>>/$ .-/% .+/+-> -- -- > Construction wor4ers .%/+ -%/$ -$/-+. +? +$ %- #> #+:or4ers in "oca" government >$/# -?/ -./#-$ +? +> . #$ #:or4ers in state government .%/$ -?/- -+/+. +> +- #+ #% $end 1/-#

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igure % 7egression Mode" or Pro1ortions :ith !hree


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obDective or im1artia" way e6ists by which it wou"d be 1ossib"e to decide which of two men is betteroff if one of them has, for e6am1"e, worse hea"th but better economic conditions than the other/:e"fare or "eve" of "iving seems, at "east in the Euro1ean tradition, to be based either on 1eo1"eJsneeds or on their resources/11&f needs are made centra", then the concern is with the degree of

needsatisfaction/1"

&f resources are made centra" then the concern is rather with manJs #a0a#itytosatisfy those needs or, more genera""y, to contro" and conscious"y direct his "iving conditionsR theindividua"Js "eve" of "iving wi"" thus be an e61ression of his sco1e of action/1#7esources, asunderstood here, seem to be very c"ose to SenJs conce1t of ca1abi"ities/ nd, as Sen 1oints out,we""being freedom, that is, a ca1abi"ity to achieve satisfaction in many res1ectsor, as termedhere, a "arge sco1e of actionis not on"y a means to achieve a high "eve" of satisfaction, it is ofva"ue in itse"f/1$!o base the conce1t of "eve" of "iving on resources rather than on needs has some advantages/ :ethen "oo4 u1on man as an active being who uses his resources to 1ursue and satisfy his basicinterests and needs/ :e do not necessari"y have to decide what these needs are, the individua" isassumed to use his resources in his best interests/


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and which are of such im1ortance that there are co""ective"y organi2ed attem1ts to co1e with themin a"" societies/1(


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how 1eo1"eJs resources inf"uence their "eve" of satisfaction and, of course, how this in turninf"uences their resources and conditions/ 'ut & suggest that we"fareor "eve" of "ivingshou"d bedefined in terms of resources and conditions and is best measured by the use of descri1tiveindicators/ nd to the e6tent that we"fare research is cou1"ed to societa" 1"anningwhich, in

Scandinavia, is 1art of its historica"end 1/--P7&N!E9 7


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1ertinent to the 1o"itica" discussion/ Moreover, it is a way to try to get round 1art of the 1rob"em of1referentia" choices in com1arisons between individua"s/ &f we com1are two 1eo1"e and find thatone goes on to higher education whi"e the other does not, this cou"d we"" be because the first one

1refers a higher "eve" of consum1tion "ater in "ife whi"e the other is more interested in earning

money immediate"y/ Simi"ar"y, if we find that one 1erson is unem1"oyed whi"e another, with thesame education, etc/, is not, the first may we"" 1refer to wor4 as "itt"e as 1ossib"e and conse3uent"yto consume "ess whi"e the other has different 1references/ @owever, it is more difficu"t to ma4e suchan e61"anation 1"ausib"e if we find that 1eo1"e of the same inte""ectua" abi"ities but of differentsocia" origins systematica""y ma4e different educationa" choices, or if we find systematicdifferences in unem1"oyment between 1ersons with simi"ar human ca1ita" "iving in differentregions/ :e cannot, of course, ru"e out the 1ossibi"ity that the differences in these cases are sti"" dueto different distributions of 1references, but those who c"aim so wou"d have to ma4e 1"ausib"e theircontention that such 1references vary with for e6am1"e, socia" c"ass and region/"&!he study of ine3ua"ity in nondistributab"e conditionssuch as hea"th or 4now"edge and s4i""s, ofwhich it is not 1ossib"e to transfer units between 1ersonsa"so becomes more meaningfu" when we

study ine3ua"ity between grou1s rather than between individua"s/ !o study the distribution ofhandica1 over the 1o1u"ation at "arge is, for e6am1"e, of rather "imited interestR it cou"d be su11osedon"y to show some natura" variation in hea"th/ &f, on the other hand, as in igure #,we show that

1hysica" mobi"ity on average and net of age differences varies between socia" c"asses, more socia"e61"anations must be sought, e61"anations which in one way or another re"ate hea"th to theconditions, e61eriences, and ways of "ife of 1eo1"e in different c"asses/> Poverty versus &ne3ua"itySo far & have not discussed 1overty/ !his is no oversight/ s im1"ied by the discussion above,ine3ua"ity rather than 1overty has been the im1ortant conce1t in Swedish we"fare research/ !hisfo""ows 1art"y from the em1hasis on nonmonetary as1ects of we"fare, given that 1overty refers toeconomic resources/"''ut it is a"so 1art"y the conse3uence of an interest in variation over the who"erange of a condition and not on"y over a 1overty "ine/


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these services shou"d in 1rinci1"e be such that no demand for 1rivate hos1ita"s or schoo"s a11earsand it shou"d be 1ossib"e to have a good standard of housing regard"ess of income and fami"y si2e/end 1/+P7&N!E9 7


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Cam1be"", ngus, Converse, Phi"i1 E/, and 7odgers, :i""ard L/ (#$-.)/ *he ;uality of Ameri#an'ife/ New or4* 7usse" Sage/Co"eman, Bames (#$-#)/Resour#es for So#ial Change/ New or4* :i"ey/9rewnows4i, Ban (#$-?)/ 7n Measuring and &lanning the ;uality of 'ife/ !he @ague* Mouton/

Easter"in, 7ichard / (#$-?)/ 9oes Economic =rowth &m1rove the @uman Lot; Some Em1irica"Evidence, in Pau" / 9avid and Me"vin :/ 7eder (eds/),Nations and %ouseholds in E#onomi#Gro)/ Mu"tidimensiona" 9escri1tions of Socia" &ndicators, So#ial 9ndi#ators

Resear#h, #-/ (#$+-)/ 7egression as a !oo" for 9escribing Leve" of Living, in Eri4son and [berg (#$+-)/Sen, martya (#$+)/ 9escri1tion as Choice, 7/ford E#onomi# &a0ers, %/

(#$+>a)/ :e""'eing, gency and reedom/ !he 9ewey Lectures #$+?,$ournal of&hiloso0hy, +/ (#$+>b)/ Commodities and Ca0abilities/ msterdam* North@o""and/S2u"4in, 7ys2ard (#$+-)/ Po"itica" 7esources, in Eri4son and [berg (#$+-)/

!\h"in, Michae" (#$$)/ Po"itics, 9ynamics and &ndividua"ism* !he Swedish 11roach to Leve" ofLiving 7esearch, So#ial 9ndi#ators Resear#h, /!itmuss, 7ichard M/ (#$>+)/Essays on the Welfare State/ London* Unwin University 'oo4s/

(#$-?)/ So#ial &oli#y/ London* =eorge ""en and Unwin/United Nations (#$>?)/9nternational "efinition and Measurement of Standards and 'e3els of

'i3ing/ New or4* United Nations Pub"ications/ (#$..)/ *he 'e3el of 'i3ing 9nde// New or4* United Nations 7esearch &nstitute for Socia"9eve"o1ment/:i"ens4i, @aro"d, and Lebau6, C"aude (#$>+)/9ndustrial So#iety and So#ial Welfare/ New or4*7usse" Sage oundation/end 1/+%

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show cha1ter abstract and 4eywordshide cha1ter abstract and 4eywords

'engtChrister sanderEri4sonJs 1a1er 1resents both a survey method for measuring "eve" of "iving and some em1irica"

resu"ts from using the method on Swedish househo"ds/ 'oth are interesting, but what & 1ersona""yfind most intriguing is what "ies in betweenthe 1rob"ems cro11ing u1 in im1"ementing thetheoretica" conce1ts/& wi"" try to e6em1"ify this by commenting on three broad im1"ementation decisions, as they a11earin the Swedish survey/ !hey dea" res1ective"y with the choice of indicators, the choice ofdistribution s1ace, and fina""y the choice of measure of distributiona" change/Let me start with the choice of we"fare indicators/ s Eri4son right"y stresses, this choicea"wayssomewhat arbitrarywi"" ref"ect the concerns and interests of the investigator/ !his is certain"y truein this case, where the Swedish government commissioned the survey/ :hat the governmentwanted was not sim1"y to 4now how to 4ee1 various voter grou1s ha11y in order to retain 1ower,

but a detai"ed descri1tion of "iving conditions, both as a bac4ground to 1"anning distributive 1o"icies

and to mobi"i2e su11ort for these 1o"icies/ @ence the choice of detai"ed descri1tive indicatorsinstead of more genera" eva"uative 3uestions/&t is interesting to note that in searching for suitab"e indicators, the designer, Sten Bohansson, had anidea" in mind, seeming"y very c"ose to SenJs conce1t of ca1abi"ity/ &t is, of course, hard to be 3uitesure about what ca1abi"ity right"y means/ 'ut it is here enough if we thin4 of it as an o11ortunityset of actions, achievements, or functioningsa set which may of course foresta"" any 3uestion ofchoice by having Dust one member/ Ca1abi"ity thus sim1"y becomes a measure of o1tions/:hat is even more interesting is the fact that in an overwhe"ming number of cases, the investigatorsfai"ed to observe and measure anything which cou"d, with the best wi"" in the wor"d, be ca""ed aca1abi"ity/ !hey had to ma4e do with 1articu"ar individua" achievements, from which they cou"d tryto construct or estimate ca1abi"ities/ !his cou"d, of course be due to "ac4 of imagination and0orana"ytica" f"e6ibi"ity on the 1art of the investigators/ & rather sus1ect, however, that it a"so showsthat ca1abi"ities are often rather e"usive things to catch, that it is difficu"t to measure direct"y thecounterfactua" 1art which has to do with what a 1erson might be or door might have been or havedone/ Economists may be confused here because they are used to dea"ing with one of the fewas1ects of "ife where the o11ortunity set can be reasonab"y we"" defined and measured/&f you try to "oo4 more c"ose"y at how ca1abi"ities are dea"t with in the survey, you find that theyusua""y seem to be im1"icit"y defined in terms of some a 1riori behavioura" mode" which s1e""s outwhat the 1robabi"ity is that a certain ca1abi"ity or set of o1tions wi"" manifest itse"f in certainobservab"e achievements/ certain degree of 1o"itica" ca1abi"ity, for e6am1"e, means a certain 1robabi"ity that you wi"" get

1o"itica""y organi2ed, ma4e s1eeches, and write to the news1a1ers/ &f you then observe theachievements of a s1ecific individua", you can try a 1osteriori to estimate his ca1abi"ity/ !here"iabi"ity of the resu"ts wi"" de1end on how good or genera""y acce1tab"e your a 1riori mode" is/ &tcan be a ris4y business/ &f you are fond of marching in demonstrations or 1estering your MP with

1hone ca""s, is this a sign of 1o"itica" ca1abi"ity or the re2erse


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income/ !he 4ind of a 1riori mode" you need shou"d thus be formu"ated in terms of Doint1robabi"itiesOa rather forbidding tas4/ second difficu"ty arises when you try to use the indicators to measure differences in ca1abi"ities

between different countries or different times/ :hat o1tions are im1"ied by actua" behaviour wi""

a"ways de1end on the current socia" and institutiona" setting/ 9is1osab"e income, for e6am1"e, is arather em1ty we"fare conce1t if there is nothing to buy/ !he o1tions indicated by observed actionscan shrin4 drastica""y in the face of 1o"itica" regu"ations or socia" sanctions/ ou thus need a "ot ofcom1"ementary information on the institutiona" framewor4 and the division of rights to draw anyconc"usions as to fundamenta" ca1abi"ities from the indicators used/ Even within the com1arative"ystab"e and homogeneous Swedish society, Eri4son runs into difficu"ties in ma4ing com1arisons overa thirteenyear 1eriod/ chievements "i4e having a secondary education or having seen a doctormean different things in terms of Dob o11ortunities or 1hysica" ca1abi"ity after the big e61ansion inhigher education and out1atient care during the #$-s/nother connected conce1tua" 1rob"em has to do with socia" security/ high income, for e6am1"e,has 3uite different we"fare im1"ications when it is reasonab"y secure from when it is 1art of a socia"

"ottery and can disa11ear at any time/ ou rea""y need to measure not Dust 1resent o1tions butcontingent future o1tions/ @ow we"" are your 1resent o1tions insured against ris4s of various4inds; Even in the Swedish conte6t, changes in the coverage of socia" insurance, etc/, have beenconsiderab"e, and if you e6tend the method to cover internationa" com1arisons the ris4 scenariowou"d certain"y have to be ta4en into account as a maDor com1onent of we"fare/!hese various 1rob"ems may raise some doubts about the 1ossibi"ity of ma4ing the ca1abi"ityconce1t o1erationa" for so1histicated we"fare measurement/ !heyend 1/+>P7&N!E9 7


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:hat is done in the Swedish survey is sim1"y to com1are the distribution at different times/ & wou"d"i4e to argue that this is se"dom enough/ &n order to eva"uate the change, understand it, and 1"an new

1o"icies, you must go a ste1 further and study the change for the individua"s ma4ing u1 thedistribution/

:e cannot rea""y eva"uate a distributiona" change without 4nowing, for e6am1"e, if the former"yunder1rivi"eged have 4e1t their 1"ace or if they have e6changed 1"aces with the 1rivi"eged/ :ecannot ho1e to understand why a change occurs if we cannot trace how one 1osition, or set ofca1abi"ities or "ac4 of them, conditions the ne6t/ nd this is what we need to 4now if we are todesign a distributive strategy/

Now the survey materia" offers an unusua" chance of "oo4ing into individua" change, since for eachsubse3uent observation year some +> 1er cent of the res1ondents be"ong to a 1ane" "eft over fromthe ear"ier survey/ &t does seem a 1ity to 1ass u1 this chance/Prob"ems do arise, however, when you try to a11"y conce1ts "i4e ca1abi"ity or e3ua"ity to the "ifecareers of individua"s/ !hese conce1ts are usua""y definedend 1/+.

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!he second "argesca"e Scandinavian we"fare study was a com1arative one, conducted in #$- bythe 7esearch =rou1 for Com1arative Socio"ogy at the University of @e"sin4i, and su11orted byresearch counci"s in the Scandinavian countries/ &t was based on interviews of nationa" 1robabi"itysam1"es of a11ro6imate"y #, 1ersons in each of 9enmar4, in"and, Norway, and Sweden

(""ardt, #$->R ""ardt, #$-.* -O?)/ !he nationa" sam1"es in the com1arative study were sma""erthan in the nationa" studies focusing on one country on"y/ !he com1arative a11roach containedmany 1rob"ems of measurement, and its measures did not, as a ru"e, have the same high degree ofre"iabi"ity as the Swedish Leve" of Living Survey/ &n retros1ect the im1ortance of the Com1arativeScandinavian :e"fare Study was that it offered a more com1rehensive system of indicators fordescribing the "eve" of "iving and the 3ua"ity of "ife than the Swedish mode"/ &t is a"so a more o1ensystem, a""owing for the introduction of new indicators and measures when society changes/


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e#onomi# resour#es* income and wea"thR

)/
http://www.oxfordscholarship.com/oso/private/content/economicsfinance/0198287976/p030.html#acprof-0198287976-bibItem-175http://www.oxfordscholarship.com/oso/private/content/economicsfinance/0198287976/p030.html#acprof-0198287976-bibItem-170http://www.oxfordscholarship.com/oso/private/content/economicsfinance/0198287976/p030.html#acprof-0198287976-bibItem-175http://www.oxfordscholarship.com/oso/private/content/economicsfinance/0198287976/p030.html#acprof-0198287976-bibItem-170


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Such measures are intended to describe 1redicaments in the bio"ogica" and 1hysica" environments ofindividua" citi2ens/ &t is to be noted that the research design for we"fare surviva" im1oses somerestrictions on what environmenta" conditions can be inc"uded/ !he intention is to e61"ain variationsin human we"fare among individua" citi2ens, and the measures have therefore to ref"ect variations in

the environment of individua"s/ Measures ref"ecting 1redicaments common to a"" human4ind and toa"" citi2ens of a country wou"d be of "itt"e use in this ty1e of we"fare survey/Unfortunate"y a great dea" of socia" science we"fare research has continued in its traditiona" 1athwithout considering measures of the 3ua"ity of the bio"ogica" and 1hysica" environment/ &n a recentotherwise very we""edited and we""written boo4 about the Scandinavian we"fare mode", we"fareresearch is defined as research which in a systematic and e61"icit fashion conce1tua"i2es good and

bad conditions of manJs "ife, and which aims at a com1rehensive conce1tion of his situation byinc"uding a"" crucia" as1ects of "ife (Eri4son et al., #$+-* #-+)/ Neverthe"ess, measures of the3ua"ity of manJs bio"ogica" and 1hysica" environment are absent from the boo4/end 1/$P7&N!E9 7


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to what e6tent a 1erson can 1artici1ate in decisions and activities inf"uencing his "ifeR

wa"4ing, gardening, and fishing/ !he Use of 'oth


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end 1/$P7&N!E9 7)/Att ha@ alska@ att 3ara. 7m 3alfard i Norden(@aving, Loving, 'eing/


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Eri4son, 7obert, et al.(eds/) (#$+-)/ *he S#andina3ian Model. Welfare States and WelfareResear#h/ London* M/ E/ Shar1e/=a"tung, Bohan (#$->)/ Measuring :or"d 9eve"o1ment &,Alternati3es, #, #%#O>+/

(#$+)/ !he 'asic Needs 11roach, in 5atrin Lederer (ed/),%uman Needs. A Contribution

to the Current "ebate/ Cambridge, Mass/*


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Aua"ity of Life Measures in @ea"th Care and Medica" Ethics9an 'roc4# &ntroduction!here has been considerab"e 1hi"oso1hica" wor4 during the "ast two decades, es1ecia""y in the

United States but not "imited to there, in a re"ative"y new fie"d ca""ed medica" ethics/ My aim in this1a1er is to e61"ore what i""umination that body of wor4 might offer to our understanding of the3ua"ity of "ife/ &f one "oo4s on"y to the medica" ethics "iterature e61"icit"y addressing the notion ofthe 3ua"ity of "ife, there are few sustained ana"yses of it and of its ro"e in various medica" and hea"thcare conte6ts/ Conse3uent"y, it is necessary to "oo4 more broad"y to issues and areas of research thatoften do not e61"icit"y address the 3ua"ity of "ife, but that neverthe"ess have an im1ortant bearing onit/ & be"ieve there are two main areas of wor4 in medica" ethics that fit this criterion/ !he first iswor4 on ethica" framewor4s for medica" treatment decisionma4ing in a c"inica" conte6t, inc"udingaccounts of informed consent and "ifesustaining treatment decisions/ !he second is thedeve"o1ment of va"uationa" measures of outcomes of hea"th care treatments and 1rogrammesR theseoutcome measures are designed to guide hea"th 1o"icy and so must be ab"e to be a11"ied to

substantia" numbers of 1eo1"e, inc"uding across or even between who"e societies/ !he two main1arts of this 1a1er wi"" address these two main bodies of wor4/ 'efore doing so, however, severa"1re"iminary issues need to be brief"y addressed/& have mentioned that the "iterature that & wi"" be summari2ing and drawing on often does note61"icit"y address the conce1t of the 3ua"ity of "ife, but instead uses other notions that are eitherc"ose"y re"ated or rough"y e3uiva"ent in the conte6t/ Sometimes a notion of hea"th is em1"oyed,

1articu"ar"y in its broader inter1retations, as e6em1"ified in the :or"d @ea"th P7&N!E9 7


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wor4 on these theories has been in the service of deve"o1ing an account of uti"ity, broad"yconstrued for em1"oyment in conse3uentia"ist mora" theories/$:hat is common to hedonisttheories, as & wi"" understand them here, is that they ta4e the u"timate good for 1ersons to be theundergoing of certain 4inds of conscious e61erience/ !he 1articu"ar 4inds of conscious e61erience

are various"y characteri2ed as 1"easure, ha11iness, or the satisfaction or enDoyment that ty1ica""yaccom1anies the successfu" 1ursuit of our desires/ Particu"ar states of the 1erson that do not ma4ereference to conscious e61erience, such as having diseased or hea"thy "ungs, and 1articu"aractivities, such as studying 1hi"oso1hy or 1"aying tennis, are 1art of a good "ife on this view on"y tothe e6tent that they 1roduce the va"uab"e conscious e61erience/Preference satisfaction theories ta4e a good "ife to consist in the satisfaction of 1eo1"eJs desires or

1references/ & here understand desires or 1references as ta4ing states of affairs as their obDects* fore6am1"e, my desire to be in 'oston on !uesday is satisfied Dust when the state of affairs of my beingin 'oston on !uesday obtains/ !his is to be distinguished from any fee"ings of satisfaction,understood as a conscious e61erience of mine, that & may e61erience if & am in 'oston on !uesday/!he difference is c"earest in cases in which my desire is satisfied, but & either do not or cou"d not

4now that it is and so receive no satisfaction from getting what & desire* for e6am1"e, my desire thatmy chi"dren shou"d have "ong and fu"fi""ing "ives, a state of affairs that wi"" on"y fu""y obtainend 1/$.P7&N!E9 7


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end 1/$-P7&N!E9 7


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a number of inde1endent vectors/ irst, it a""ows us to acce1t 1art of what 1ro1onents of each of thethree traditiona" theories of a good "ife have wanted to insist on, name"y the theoretica"inde1endence of those com1onents/ !he three com1onents of ha11iness, 1reference satisfaction, andidea"s of a good "ife can each be re1resented by their individua" vectors, or subdivided further into

distinct vectors within each com1onent, having inde1endent weight within an overa"" account of agood "ife/ Second, the vector a11roach 3uite natura""y yie"ds the 1ossibi"ity of two senses of 1artia"com1arabi"ity of the 3ua"ity of different "ives/ or a sing"e individua", a"ternative 1ossib"e "ives may

be on"y 1artia""y commensurab"e if one a"ternative "ife 1rovides a greater va"ue on one vector, but a"esser va"ue on another vector, than another 1ossib"e "ife/ 'ut for two different 1ersons it isim1ortant that at "east 1artia" com1arabi"ity between their "ives may be 1ossib"e, contrary to thedogma about the im1ossibi"ity of inter1ersona" com1arisons of uti"ity, by com1aring commonvectors or by com1aring different changes in common vectors ma4ing u1 a good "ife for each/Medicine and hea"th care 1rovide strong grounds for insisting on these inde1endent vectors and,

1erha1s more im1ortant, a"so suggest a content and structure to the idea"s a"ong the "ines 1ro1osedby Sen in his wor4 on agency and ca1abi"ities, which drew on setting "arge"y outside of hea"th care/

:e a"so need to distinguish between the re"ative im1ortance of a 1articu"ar feature or condition, sayas re1resented by a s1ecific vector, in its contribution to a 1erson having a good "ife, com1ared withwhat & sha"" ca"" its broader mora" im1ortance/ sim1"e e6am1"e wi"" suffice/ 1er cent be"ow and > 1er cent above the norm, such that the effect on a 1ersonJs3ua"ity of "ife in movingfrom > 1er cent be"ow the norm u1 to the norm is 3uantitative"y rough"y the same as moving fromthe norm to > 1er cent above it/ :hi"e the degree or im1ortance of the two changes in a 1ersonJs3ua"ity of "ife or good "ife may be rough"y the same, it can none the "ess be consistent"y he"d thatthese two com1arab"e effects on the 1ersonJs 3ua"ity of "ife have different moralim1ortance or

1riority/ &t might be he"d, for e6am1"e, that on grounds of e3ua"ity of o11ortunity bringing a1ersonJs mobi"ity from > 1er cent be"ow the norm u1 to the norm has greater mora" 1riority thanincreasing his mobi"ity from the norm to > 1er cent above it/ !he genera" 1oint is that as1ects of a

1ersonJs 3ua"ity of "ife may 1"ay a ro"e not on"y in Dudgements about his 3ua"ity of "ife or about howgood a "ife he has, but a"so in other distinct mora" and 1o"itica" Dudgements, or in the a11"ication ofinde1endent mora" 1rinci1"es such as a 1rinci1"e of e3ua" o11ortunity/ !his is, of course, athorough"y fami"iar 1oint in mora" and 1o"itica" 1hi"oso1hy genera""y, and concerningconse3uentia"ist mora"ities in 1articu"ar, against which it is often obDected that they ignore the mora"im1ortance of whether the good is fair"y or Dust"y distributed/ &n the 1resent conte6t its im1ortance

is in reminding us to distinguish Dudgements concerning the im1rovement or reduction of 1eo1"eJs3ua"ity of "ife from other inde1endent mora" eva"uations of those same changes so as not to confuseneed"ess"y the nature of 3ua"ity of "ife Dudgements in hea"th care/ Ethica" ramewor4s for @ea"th Care !reatment 9ecisionMa4ing!he first broad area of wor4 within medica" ethics bearing on the conce1t of the 3ua"ity of "ifeconcerns the aims of medicine and the account of medica" treatment decisionma4ing a11ro1riate tothose aims/ &t may be he"1fu" to begin with a natura" obDection to thin4ing that these issues inmedica" ethics wi"" i""uminate any broad notion of the good "ife/


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at a biochemica" "eve", every mo"ecu"e can be characteri2ed in terms of its function/ !he 1arts, bothmacrosco1ic and microsco1ic, contribute to the maintenance and functioning of the other 1arts, andma4e 1ossib"e the maintenance and functioning of the who"e/11:hat constitutes we""functioning varies with the 1articu"ar bio"ogica" s1ecies in 3uestion, but 5ass

is at 1ains to argue that hea"th is a natura" standard orend 1/#P7&N!E9 7


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treatment, and a recommendation regarding treatment/ !he 1atient brings the 4now"edge of his orher aims, ends, and va"ues that are "i4e"y to be affected by different courses of treatment, and thisenab"es a com1arative eva"uation of different 1ossib"e outcomes to be made/ s a"ternativetreatments have mu"ti1"ied and become 1ossib"e in circumstances 1romising increasing"y margina"

or 3uestionab"e benefits, both 1hysicians and 1atients are ca""ed u1on to ma4e increasing"y difficu"tDudgements about the effects of treatment on 1atientsJ 3ua"ity of "ife/ &t is worth noting that1ro1onents of shared decisionma4ing need not reDect the functiona" account of hea"th as abio"ogica" norm defended by 5ass and others/ :hat they can reDect is the c"aim that the on"y 1ro1ergoa" of medicine is hea"th/ &nstead, medicineJs goa" shou"d be to 1rovide treatment that best enab"es

1atients to 1ursue successfu""y their overa"" aims and ends, or "ife 1"ans/ &t is the re"ative va"ue ofhea"th, and of different as1ects of hea"th, as com1ared with other ends, that varies for different

1ersons and circumstances/Most 1atientsJ decisions about "ifesustaining treatment wi"" be based on their Dudgement of the

benefits and burdens of the 1ro1osed treatment and the "ife it sustains, though in some instances1atients may give significant weight t

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E Book Quality of Life _University of Chicago_knyga