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Open Access 01-03-2020 | Scientific Contribution

Health and capabilities: a conceptual clarification

Author: Per-Anders Tengland

Published in: Medicine, Health Care and Philosophy | Issue 1/2020

Abstract

There are great health disparities in the world today, both between countries and within them. This problem might be seen as related to the access to various kinds of capabilities. It is not fully clear, however, what the exact relation is between health and capabilities. Neither Amartya Sen nor Martha Nussbaum has explicitly formulated a theory of health to go with their theories of capabilities. This paper attempts to present a clarification of the conceptual relation between health and capabilities. Health, it is argued, should be seen as a holistic multi-dimensional phenomenon, made up of basic abilities and subjective well-being, and of fundamental states and processes. Using this theory, the paper shows how health is related to Nussbaum’s ten capabilities. It is argued that health, in the senses described, is a necessary part of all ten capabilities. Moreover, some of the capabilities on Nussbaum’s list, such as thinking and imagining, and practical reasoning, refer to health. Finally, it is shown that even though health is part of all capabilities, health cannot itself primarily be seen as a capability. An acceptable degree of health is required as a functioning for any theory of human flourishing to be reasonable.

This addition was suggested to me by Bengt Brülde. Personal communication 2017.

The term “practical possibilities” is used by Lennart Nordenfelt (2000, p. 65).

Note, however, that some functionings are binary, e.g., being married or not, or require mutually exclusive choices, as exemplified above.

Other capabilities have been suggested. See, for example, Wolff and De-Shalit 2013.

Neither does Jennifer Prah Ruger, who has written extensively about health and social justice (in a capabilities context), provide a definition, other than making vague references to health functioning (2010a), which is neither “well-being” nor “quality of life” (2010b, p. 42). Iain Law and Heather Widdows (2008) have also written about health and capabilities, but they have not yet provided (as far as I can see) their promised alternative theory concerning the relation between capabilities and health (p. 311, footnote 3). Sridhar Venkatapuram has, however, developed a theory of health, in relation to the capabilities theory. For a discussion of his theory, see Tengland 2016, where I initially introduced some of the ideas developed here.

I will, however, stick to writing “capability”, since all capabilities have to be combined ones, that is, every being and doing (and feeling) requires both (internal) ability and (external) opportunity (see Nussbaum 2011, p. 20).

Meaning that a fair (sometimes a considerable) degree of some of these factors is required for the capability to exist.

As one reviewer noticed, it is not always possible to make a clear distinction between basic abilities (health) and competences, since the former can become quite advanced over time (without needing “education or special training”).

Motivation, here, is about being able to form intentions and (want to) act on them (Nordenfelt 2006, p. 1463). Some might prefer to call this energy, drive, or will.

In reality, the total absence of some of these internal features will compromise a capability, for example, when severe pain (suffering) makes any kind of action impossible, or when lack of self-knowledge makes a person choose poorly.

“Unacceptable” weather and climate conditions can usually be compensated for in affluent societies.

Note, however, that the environment is important for a theory of health in another way. The environment makes actions possible (and sometimes impossible), and is a “platform” for action. Thus, to be healthy is to be able to act (or pursue one’s goals) given that the environment is acceptable, which means that in it people are expected to be able to act (or pursue their goals). See Nordenfelt 1995 (pp. 47–49), for an explication of this idea. For a detailed conceptual discussion of the boundary between what is external (environment) and internal (in relation to health), see Tengland 2015.

For a thorough analysis of the concept, we need more criteria, but these, I believe, will suffice for the present purposes.

Note that the individual should not only have acquired the abilities (etc.) in question, but also be able to use them here and now (given that the environment is acceptable), in order to be considered healthy.

Briefly, health-related, subjective well-being (and suffering) is those kinds of sensations and moods that have their immediate cause within the person (Tengland 2007, 2016), for example, feeling fit, or experiencing pain. Much more will not be said about subjective well-being, since this aspect of health is less important for the capabilities than abilities.

This claim might have to be qualified. See Tengland 2012, for a discussion of morality and health.

It is unclear why mental health is not included here. My use of the concept of “health” in discussing this capability, later in the text, will cover both physical and mental aspects. However, some of Nussbaum’s other capabilities include aspects of mental health, as I will argue.

Thus, Nussbaum uses the term health in two different ways in her theory, as a capability and as part of an internal capability, and it is unclear how they are related.

Note that in the Ottawa Charter for Health Promotion (WHO 1986), and later WHO charters, health is seen as a “resource for everyday life” (p. 1). This resource is “personal and social”, and includes “physical capacities” (p. 1). This is something quite different from (total) well-being. This idea is, however, still partly unclear, but one reasonable interpretation of it is that what the WHO calls resources are what some theoreticians call abilities (or capacities).

Nussbaum’s second capability, health, could also be interpreted to mean being able to stay free from disease, as Venkatapuram at one point suggests (2011). As such it is an obvious capability. However, we can still require (morally and politically) that the person who has this capability also be free from disease (a functioning), insofar as it is possible.

And it is probably not the view intended by Nussbaum, even though my discussion of it (Tengland 2016) in relation to Sridhar Venkatapuram’s theory (2011) made it appear a second-order one. Note, however, that for some kinds of capabilities the second-order ability might suffice. A person might, for example, want to work as a teacher, but not be able to because she has not got the appropriate education (and, thus, no first-order ability to do so, even if all other conditions needed are present). Nevertheless, the person can still have the second-order ability to acquire the education that permits her to work as a teacher. In such a case the second-order ability to work seems to suffice for us to be able to say that the capability (to work as a teacher) is present (assuming that all other conditions for it are satisfied).

Ruger makes a similar claim when she notes (in passing) that “certain aspects of health are prerequisites for other types of functioning” (2010a, p. 3). She does not, however, specify in what respect. Sen made the same observation in 2004 (p. 23).

This, as Nussbaum recognizes (in relation to children; 2011, p. 26), also goes for other skills and competences, including those learnt in primary and secondary school, for example, (generic skills such as) to write, read, count, cooperate, plan ahead, solve problems, and communicate.

This assumes that the individual has an internal potential to be fully healthy, and is not, for example, born with a dysfunction of some kind.

This means that, if people live (“freely chosen”) lives that reduce their health, many of their capabilities are likely to be reduced over time as well. Therefore, no (liberal) government can guarantee a minimal degree of capabilities for all (adults), over time.

And a certain degree of (health-related) subjective well-being (or at least absence of suffering) will contribute to the capabilities, that is, subjective well-being makes actions and goal attainment easier, whereas suffering makes things more difficult.

Assuming, once again, that the individual has the required inborn potential to develop these abilities and dispositions, and experience (health-related) subjective well-being.

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Title: Health and capabilities: a conceptual clarification
Author: Per-Anders Tengland
Publication date: 01-03-2020
Publisher: Springer Netherlands
Published in: Medicine, Health Care and Philosophy / Issue 1/2020
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-019-09902-w

At a glance: The STEP trials

Springer Medicine

Health and capabilities: a conceptual clarification

Abstract

At a glance: The STEP trials

Springer Medicine

Abstract

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