Health and capabilities: a conceptual clarification

Before discussing health, and then health in relation to the capabilities, it might be a good starting point to present, on a fairly abstract level, what can be part of a capability, or rather, what Nussbaum calls combined capability.⁶ As we have already seen, a capability consists of all those internal and external factors that are necessary for a specific case of doing or being (or feeling) something. Lacking a capability is lacking a sufficient degree of at least one factor that is necessary for actualizing the functioning in question.

Here are some suggestions as to what a capability might include as constitutive parts.⁷ First, the internal factors:

Foundational for most of those internal conditions are:

There are, furthermore, internal factors that contribute to the realization of capabilities but that do not seem to be all that necessary for them.¹⁰ Some causally contributing factors might, for instance, be:

Note that most of those abilities and competences, etc., come in degrees. In general, the more one has of them, the better (one’s capabilities). However, certain capabilities might only require a limited number of them, and a minimal degree of (some of) them. For example, the capability to “take a walk in the park” requires certain basic abilities (such as the abilities to walk and perceive), those abilities’ physiological, anatomical, and psychological foundations, some motivation, knowledge about where the park is located (and how to get there), and, of course, the (external) opportunity to take a walk in the park (for example, a safe and accessible park to walk in, and some free time).

As to the external aspects of a capability (that is, opportunity), I will be briefer, since they are not (in general) regarded as belonging to health. We have:

The physical environment:

The social environment:

Some of the factors listed (at least partly) cover Sen’s lists of five instrumental (social) freedoms: political freedoms, economic facilities, social opportunities, transparency guarantees, and protective security (1999, p. 10).

All those factors (internal or external) are, of course, not equally supportive of (or necessary for) all capabilities. An investigation into the person’s aspirations and situation will tell us more about what is, in the specific case, necessary for doing or becoming (or feeling) something.

Where should we draw the boundaries of health? Within the individual, say some (Whitbeck 1981; Fulford 1989; Nordenfelt 1995, 2016; Brülde 2000a, b; Tengland 2007). So that it includes parts of the environment as well, say others (Pörn 1984; Seedhouse 2001; Venkatapuram 2011). The former idea seems more plausible. A major drawback of including the environment in the concept is that it becomes impossible to differentiate between health and its determinants. Let us say that drinking water, part of our environment, is also part of a person’s health. But drinking water is also a determinant of health (and survival). Drinking water is thus, on this view, both part of health and its determinant, which appears contradictory. We can conclude, then, that none of the factors listed above that are external to the individual should be part of an individual’s health.¹²

There is still the difficulty of deciding exactly what within the individual belongs to health, since everything internal is not part of an individual’s health either. Before trying to answer this question, we first have to ask what we need a theory (and a definition) of health for. This is mainly of practical importance (Brülde 2000a, b; Brülde and Tengland 2003). In society we need to establish professional boundaries and governmental responsibilities. Health is one responsibility, education is another, and creating work opportunities a third. Cutting the cake (conceptualization) can be done in various ways, but one way might still be superior to another (given our practical needs). So one important question is what view of health makes most sense given the division of labor that we have in our societies, where professional and institutional areas, such as medicine, health care, and public health, have certain responsibilities (for example, to treat, cure, and prevent ill health, and promote positive health).

One criterion for a successful theory (and definition) of health is, then, that it has practical relevance. To this we can add that the theory (and definition) produced should be in reasonable accordance with ordinary language use (descriptive adequacy), that is, how people speak about health and ill health. There should, of course, be a rather high agreement between this criterion and the professional division of labor, even if they might not match perfectly. Two prominent aspects found in common parlance regarding health (and ill health) are, suggests Lennart Nordenfelt (1995, 2016), ability and (subjective) well-being (and its opposites disability and suffering). This is in agreement with what central parts of medicine and health care deal with (for example, the restoration of ability and the alleviation of suffering) and health promotion tries to achieve. Not all kinds of ability and well-being are, however, health related, so some qualifications have to be made in order to make the definition more precise. There is, then, a stipulative element in choosing these as key components of health, but the stipulations can be, and have been, defended (see Nordenfelt 1995, 2016; Brülde and Tengland 2003; Tengland 2007).

Finally, it is of moral importance how we define politically significant concepts.¹³ It is thus an advantage if the suggested theory of health increases our ability to make ethical judgments, for example, in (a Western context) deciding whom to help and when: helping someone with a health need in general seems more morally pertinent than helping someone with financial problems (assuming that the financial problems are not the immediate cause of the ill health). In relation to this we might add that even if capabilities, and indirectly quality of life, might be the ultimate political value, and society therefore should see to it that the population acquires a high degree of them (and that they are fairly distributed), it seems that understanding what health is, is politically crucial. The reason is not necessarily that health has final value, which it only partly has, but rather that health, as I will argue, is such an important part of the capabilities.

Let us return to the list suggesting internal conditions for capabilities (on page xx). Based on the above reasoning (and similar reasoning elsewhere; see Tengland 2007), that is, combining our linguistic intuitions and the importance of drawing professional boundaries, with the ethical aspects, health should consist in (at least) an individual’s basic (intentional and innate) abilities and dispositions,¹⁴ a certain kind of subjective well-being,¹⁵ which will be referred to as manifest (or holistic) health, and those more fundamental internal states and processes that are required for upholding manifest health, which will be referred to as fundamental health (Tengland 2010, 2015; see also Brülde 2000a, b). Moreover, some kind of basic motivation seems to be part of health, since without it no action would take place at all. These are precisely the kinds of internal features of people that health promotion and public health want and ought to promote and protect, and the kinds of states and processes that medicine and health care treat and take care of when they have been reduced.

Those internal features of a person (listed above) that are not part of her health are, then, her knowledge (including her self-knowledge), skills and competences, her virtues, her morality, and her personality and temperament.¹⁶ Those aspects of a person can, of course, be reduced because of ill health, as when a person cannot ride a bike (a competence) because she cannot grip the handlebars (basic ability), due to a fractured wrist (an injury). More could be said here, but this is hopefully sufficient for the rest of the discussion.

Let us now turn to Nussbaum’s list of capabilities (2000, 2011). It is well known, so I will be brief. The capabilities (here abbreviated) are: “[b]eing able to” (2011, pp. 33–34)

However, Nussbaum also presents the idea of “internal capabilities” (Nussbaum 2011, p. 21). They consist of a variety of “fluid and dynamic” states, such as personality traits, skills, knowledge, capacities, and health (Ibid., p. 21).¹⁸ She goes on to add what she calls “basic capabilities” (Ibid., p. 23), those innate physiological, anatomical, and (deep) psychological factors that “make later training and development [of the internal capabilities] possible” (Ibid., p. 24). Whereas the internal capabilities have to be trained (Ibid., p. 21), as when a skill is exercised, the basic capabilities need to be “nurtured” (Ibid., p. 23), for example, through a regular intake of nutrition.

Note that Nussbaum’s mentioning of health, as part of a person’s internal dynamic states, fits well with this paper’s suggestion that (manifest) health consists in a person’s basic abilities (and dispositions) and subjective well-being (both clearly internal dynamic states). She is also careful to differentiate health from a person’s other internal states, such as skills and knowledge, as is also done in this paper. The difference, then, compared to the theory proposed here, is that Nussbaum does not specify which of an individual’s internal states belong to health and how they are differentiated from the other dynamic states.

Having decided on a theory of (manifest and fundamental) health, I will now examine what the relation is between the items on Nussbaum’s list and health.

Health is the second item on her list. In a footnote, Nussbaum (2000), when discussing reproductive health, seems to adopt the WHO idea that health is “complete physical, mental and social well-being” (p. 78, footnote 83). This idea has been widely criticized, however, both for being too broad, for example, by including states of happiness, or quality of life, in the definition of health, and for being vague regarding what “well-being” stands for (Callahan 1973; Brülde and Tengland 2003, pp. 237–238). It also excludes an important aspect of health, namely, ability (Nordenfelt 1995).¹⁹ So, the capabilities theory requires something better.²⁰

Before we get to the discussion about some of the capabilities and their relation to health, a theoretical issue has to be dealt with. When Nussbaum presents her ten capabilities, she consistently writes “[b]eing able to…” (2011, pp. 33–34). Ability in this context, it should be clear, encompasses opportunity, since we are talking about “combined capabilities”, which consist of both internal and external conditions (Nussbaum 2011, pp. 20–21). Now, there are two ways of interpreting this way of formulating the capabilities, that is, as “being able to”. One is that people should be able (and have the opportunity) to acquire the capability in question. The other is that the person should be able (and have the opportunity) to exercise (or actualize) it (here and now). The difference is between, for example, being able to learn to read (here and now), and being able to read (here and now), or between being able to acquire an education (for a specific profession), and work in (exercise) the chosen profession. In Nordenfelt’s terms, the first would be a “second-order ability”, and the second one a “first-order ability” (1995, pp. 49–53).

Concerning health, the first interpretation (second-order) would be that the person should be able to acquire health (here and now), and the other (first-order) one that she should be able to “exercise” her already acquired health (or sustain it, as I will later suggest). The second-order view of ability seems less attractive, especially concerning health.²¹ It does not seem reasonable only to require that people should be able to become healthy (if they so wish). Rather, people should have acquired health (at least when they come of age).

Besides explicitly placing health on her list of capabilities, Nussbaum also includes several other “abilities” (the internal parts of) which, I would argue, belong to health, since they belong to the person’s basic abilities and dispositions that I have suggested are part of manifest health. Sense, imagination, and thought, the internal parts of capability four, are all basic mental abilities, the reduction of which should be the concern of psychiatry, medicine, and health care. For example, a reduced ability to think clearly, something that might be the effect of dementia, appears to be such a responsibility. Capability five also seems to include health-related aspects. Being able to experience emotions, and being able to form emotional attachments, are typical basic dispositions and abilities that people acquire in most societies, and the absence or reduction of either of them seems to be a sign of reduced mental health. The state of alexithymia (Taylor 2000), that is, not being able to describe, or identify, emotions, for example, is considered a case for psychiatry, or neurology. Practical reason, the sixth capability, (the internal part of) which, I take it, is (more or less) synonymous with the ability for autonomy, also, I would argue, belongs to the basic abilities. Having a reduced ability for self-determination, a possible effect of, for example, substance abuse, is having reduced mental health, and such a condition is arguably a responsibility for health care. It is probable that the capabilities mentioned in this section should also be interpreted in the first-order sense, that is, what matters is being able to “exercise”, not being able to acquire, them.

Finally, the first capability on Nussbaum’s list, that is, live a normal life span, is also clearly related to health. Living a normal life span presupposes that the individual is, at least, minimally healthy, but health is also instrumental in staying healthy over time (more on this later).

Both Sen and Nussbaum focus on the provision and distribution of capabilities. They should be “the currency of egalitarian [social] justice” (Cohen 2011, p. 3; Sen 1995, 2009). However, whether or not these capabilities are turned into functionings is a matter for each individual. The important thing, politically and morally, is that (at least a minimal degree of) any one of the ten capabilities can be actualized at any time (assuming that a functioning does not exclude others from being exercised at the same time). Nussbaum claims that “it is capabilities, not actual functionings, that should be in [sic] the legislator’s goal” (1990, p. 224). The relative lack of (theoretical) interest in what functionings people do in fact acquire, has, as we have already seen, to do with Nussbaum’s (and Sen’s) liberal political orientation. No one else should have the right to determine how people should live their lives, that is, what to be or do (or feel).

This focus on capabilities might sound more convincing (to a liberally oriented person) than it is. I want to argue that some functionings, not only capabilities, should also be regarded as “the legislator’s goal”, and that health is one such functioning. First, it seems clear that certain functionings, and especially health (in the above-mentioned senses), are presupposed by, and are, therefore, part of all capabilities.²² Some degree of health, especially mental health, is required for all functionings (and is, thus, part of all capabilities), such as to freely move around (which requires the abilities to stand, walk, and hold one’s balance), to play (which often requires the basic abilities to move and imagine), establish affiliations (which requires the disposition to experience emotions), make reproductive choices (which requires the ability to think and deliberate), live with other species (which requires basic perceptual abilities), control the environment (which requires critical reflexivity), seek employment (which requires basic psychological motivation), and make political choices (which requires basic reasoning capacity). Thus, (some degree of) health, as an actuality (functioning), is necessary for any kind of activity and, thus, for living a “normal” life.

Second, this also means that the list of capabilities needs some clarifications and amendments. Health, the second item on Nussbaum’s list, should not itself be seen as a capability (except, as was just claimed, as a constitutive part of all capabilities). It is not a second-order ability that can be acquired, if so chosen, nor an “ability” waiting to be exercised, as when a person who has learnt to read chooses to read, or as when a person has an education (and, thus, a competence waiting to be exercised) and then applies for a job, gets it, and starts working. It is not as if the (health-related) abilities to deliberate, move around, perceive, and think await a decision for them to be realized. The health-related abilities and dispositions are present and constantly realized, that is, they are functionings.

Thus, every individual, at least when she comes of age, has to be equipped with a decent degree of health, in order for us to be able to say that she is well prepared for (a good) life.²³ Health, then, is a functioning that people should have acquired and “use” (when they come of age) in order for a society to be considered decent, and not a capability that can be actualized (or exercised), if the individual so chooses.²⁴

Having secured this necessary functioning, we need to make sure that people have the capability to maintain it. This, it seems, is (at least for a liberal) where freedom, or choice, enters, that is, choosing to, or not to, sustain the functioning.²⁵ Thus, including (general) health (as a specific item) on any list of capabilities should probably only mean that the (hopefully already healthy) individual has a real possibility to remain healthy.

Furthermore, some of the other capabilities (or parts of them) mentioned in the list, are, as we have seen, part of (general) health. As they are part of health, they, of course, also have to be functionings. In order to “exercise one’s practical reasoning” and to “critically reflect” (given the opportunity) the person should already have acquired a high degree of the ability for autonomy (as a functioning). The capability being able to “use one’s senses, imagination, and think” is, as we saw, also health related, since sensing, imagining, and thinking are all basic abilities. But they obviously also go beyond health, since these basic health-related abilities can be developed in various ways (that is, be developed into competences), which shows that health in this sense (basic cognitive abilities) is presupposed for the more advanced capability to think. The generic ability to imagine (health) can be used for writing a novel (a skill), and thinking (health) can be trained to encompass advanced logical reasoning (a skill). Thus, having the real possibility to think advanced thoughts, and to imagine creatively, already requires several basic (health-related) abilities and dispositions as functionings. My point is that these specific (health-related) examples from Nussbaum’s list should all be considered necessary functionings, and the related capabilities are (as for general health) about sustaining those health-related functionings. To be upheld or sustained, they also, among other things, require that the individual is (minimally) healthy, for example, is able to exercise, is able to understand health information, and is able to make informed and rational decisions concerning health. In brief, the capability (suggested in this paper) to stay healthy (sustain health) and Nussbaum’s first capability to live a normal life span require (some degree of) health.

What has been said about (manifest) health, namely, that (some degree of) it is required for all capabilities, also (and even more so) pertains to what Nussbaum has called “basic capabilities”, that is, those internal factors that make training and development possible and that, as I have suggested, constitute the person’s fundamental health (Tengland 2010, 2015). Basic capabilities (that is, fundamental health) should obviously not be called capabilities at all, but basic functionings, since they are necessary (to a high degree) for all of the health-related abilities and dispositions, for (health-related) subjective well-being, and for most competences, as well as for living a normal life span. Thus, if the internal states and processes do not function as they are supposed to do (at least to some minimal degree) we cannot act, and will not survive for long.

In contrast to manifest health and fundamental health, which should be seen as necessary functionings, there is nothing necessary about capabilities such as being able to express concern for other species, enjoy recreational activities, or participate effectively in political choices. They can be actualized (exercised), or not, and nobody would be (really) alarmed if they were not (even though we might think that the individual would be better off acting on them). Furthermore, they are not part of, or required for, actualizing (exercising) the other capabilities. A person could go through life indifferent to politics (at least if she lives in a decent society, where others are politically active) or to other species, and still actualize (exercise) most other capabilities, that is, turn them into functionings.