by Amartya Sen
281
t h e i d e a o f j u s t i c e something quite peculiar in the insistence that no intrinsic importance at all is given to anything other than utility or happiness in the assessment of alternative states or policies.
The neglect applies strongly to freedoms, including substantive opportunities – what are sometimes called ‘positive’ freedoms (for example, the freedom to have free or affordable school education, or the freedom to have basic healthcare). But the neglect applies also to
‘negative’ freedoms which demand the absence of intrusive interference by others, including the state (e.g. the right to personal liberties).* Welfarism demands a very limited view of normative evaluation and welfare economics. It is one thing to see utility as important, which it must be, but it is quite another to insist that nothing else matters. In particular, we may have much reason to want that substantive note be taken of considerations of freedom in assessing social arrangements.
Second, the informational limitation is made even stronger by the particular utilitarian interpretation of individual welfare, seeing it entirely either in terms of happiness or as the fulfilment of desires and longings. This narrow view of individual well-being can be particularly restrictive when making interpersonal comparisons of deprivation. The issue calls for some discussion here.
h a p p i n e s s , w e l l - b e i n g a n d a d va n t a g e
The utilitarian calculus based on happiness or desire-fulfilment can be deeply unfair to those who are persistently deprived, since our mental make-up and desires tend to adjust to circumstances, particularly to make life bearable in adverse situations. It is through ‘coming to terms’
with one’s hopeless predicament that life is made somewhat bearable
* I should note here that the use of the distinction between ‘positive’ and ‘negative’
freedoms in welfare economics tends to be rather different from the philosophical contrast outlined by Isaiah Berlin in his classic 1969 lecture at Oxford on ‘The Two Concepts of Liberty’, the focus of which was on the difference between internal and external constraints on a person’s ability to do things he or she may have reason to value; see Berlin, Four Essays on Liberty (London: Oxford University Press, 1969).
282
h a p p i n e s s , w e l l - b e i n g a n d c a p a b i l i t i e s
by the traditional underdogs, such as oppressed minorities in intolerant communities, sweated workers in exploitative industrial arrangements, precarious share-croppers living in a world of uncertainty, or subdued housewives in deeply sexist cultures. The hopelessly deprived people may lack the courage to desire any radical change and typically tend to adjust their desires and expectations to what little they see as feasible. They train themselves to take pleasure in small mercies.
The practical merit of such adjustments for people in chronically adverse positions is easy to understand: this is one way of being able to live peacefully with persistent deprivation. But the adjustments also have the consequential effect of distorting the scale of utilities in the form of happiness or desire-fulfilment. In terms of pleasure or desire-fulfilment, the disadvantages of the hopeless underdog may thus appear to be much smaller than what would emerge on the basis of a more objective analysis of the extent of their deprivation and unfreedom. Adaptation of expectations and perceptions tends to play a particularly major part in the perpetuation of social inequalities, including the relative deprivation of women.*
The perspective of happiness has received some strong advocacy recently, and not only from Richard Layard.12 It is important to be clear about the distinct issues involved in this renewed championing of the utilitarian perspective of happiness – the attempted revival of the philosophy of the eighteenth-century Enlightenment, as articulated by Jeremy Bentham.13 We have to examine in particular whether –
and to what extent – these claims can be accepted without having to deny what has just been said about adaptive scales of happiness, related to persistent deprivation.
A particular distinction of great importance in this context is that between interpersonal comparisons of well-being, and interstate comparisons for the same person. The adaptive phenomenon particularly
* I have discussed the far-reaching effects of the adaptive adjustment of utility scales to deprivation in my ‘Equality of What?’ in S. McMurrin (ed.), Tanner Lectures on Human Values, vol. I (Cambridge: Cambridge University Press, 1980); Resources, Values and Development (Cambridge, MA: Harvard University Press, 1984); Commodities and Capabilities (Amsterdam: North-Holland, 1985; Delhi: Oxford University Press, 1987). See also Martha Nussbaum, Women and Human Development: The Capability Approach (Cambridge: Cambridge University Press, 2000).
283
t h e i d e a o f j u s t i c e affects the reliability of interpersonal comparisons of utilities, by tending to downplay the assessment of the hardship of the chronically deprived, because the small breaks in which they try to take pleasure tend to reduce their mental distress without removing – or even substantially reducing – the actual deprivations that characterize their impoverished lives. To overlook the intensity of their disadvantage merely because of their ability to build a little joy in their lives is hardly a good way of achieving an adequate understanding of the demands of social justice.
This is perhaps a less serious problem for making comparisons for the same person. Since happiness is not irrelevant to the quality of life, even though it is not a good guide to all other features that may also have considerable relevance, the building of some joy through adaptive expectations and through making desires more ‘realistic’ may be seen as a clear gain for the persons who achieve that. This can be seen as a point in the direction of attaching some importance to the happiness and desire-fulfilment even when generated by the adaptation to persistent deprivation. There is some obvious sense in that recognition. However, even for the same person, the use of the happiness scale can be quite misleading if it leads to ignoring the significance of other deprivations that may not be at all well judged in the scale of happiness.
Indeed, the relation between social circumstances and perceptions also yields other problems for the mental metric of utilities, since our perceptions may tend to blind us to the deprivations that we do actually have, which a clearer and more informed understanding can bring out. Let me illustrate the issue with an example involving health and happiness.
h e a l t h : p e r c e p t i o n
a n d
m e a s u r e m e n t
One of the complications in evaluating states of health arises from the fact that the person’s own understanding of their health may be limited by lack of medical knowledge and by inadequate familiarity with comparative information. More generally, there is a conceptual con-284
h a p p i n e s s , w e l l - b e i n g a n d c a p a b i l i t i e s
trast between the ‘internal’ views of health based on the patient’s own perception, and ‘external’ views based on observations and examinations by trained doctors or pathologists. While the two perspectives can often be fruitfully combined (a good medical practitioner would be interested in both), there can also be considerable tension between evaluations based on the two different outlooks.14
The external view has come under considerable criticism recently, particularly in powerful anthropological analyses by Arthur Kleinman and others, for taking a distanced and less sensitive view of illness and health.15 These works bring out the importance of seeing suffering as a central feature of illness. No mechanically observed medical statistics can provide an adequate understanding of this dimension of bad health, since pain, as Wittgenstein had noted, is a matter of self-perception. If you feel pain, then you have pain, and if you do not feel pain, then no external observer can sensibly reject the view that you do not have pain. In dealing with this aspect of illness, the empirical material on which health planners, economic allocators – and cost-benefit analysts frequently rely may therefore be fundamentally deficient. There
is a need to draw on the rich discernment provided by anthropological investigation of these matters.
It is in fact sensible to argue that public health decisions are quite often inadequately responsive to the patient’s actual suffering and the experience of healing. On the other hand, in assessing this debate, which has figured in past discussions as well as contemporary ones, the extensive limitations of the internal perspective must also be considered.* Even though for sensory assessment the priority of the internal view can hardly be disputed, medical practice is not concerned only with the sensory dimension of ill-health (important as it undoubtedly is). One problem with relying on the patient’s own view on medical matters lies in the fact that the internal view of the patient may be seriously limited by his or her knowledge and social experience. A person reared in a community with a great many diseases and little
* Self-reported morbidity is in fact already widely used as a part of social statistics, and the scrutiny of these statistics brings out difficulties that can thoroughly mislead public policy on healthcare and medical strategy. I have discussed some of the problems involved in ‘Health: Perception versus Observation’, British Medical Journal, 324
(April 2002).
285
t h e i d e a o f j u s t i c e medical facilities may be inclined to take certain symptoms as ‘normal’
when they are clinically preventable. Like adaptive desires and pleasures, there is also an issue here of adaptation to social circumstances, with rather obscuring consequences. This issue was discussed earlier, in Chapter 7 (‘Position, Relevance and Illusion’).
While the ‘internal’ view is privileged with respect to some information (that of a sensory nature), it can be deeply deficient in others.
There is a strong need for socially situating the statistics of self-perception of illness, taking note of levels of education, availability of health facilities and public information on illness and remedy. While the ‘internal’ view of health deserves attention, relying on it in assessing healthcare or in evaluating medical strategy can be extremely misleading.
That recognition has relevance for health policy, and more generally for policy for good health which is influenced by a great many variables other than narrowly defined ‘health policies’ (such as general education and social inequalities).* However, for the subject of the present discussion, what the lacuna between health perceptions and actual health conditions bring out is the limitations of the perspective of subjective evaluation in assessing the well-being of people. Happiness, pleasure and pain have an importance of their own, but to treat them as general-purpose guides to all aspects of well-being would be, at least partly, a leap in the dark.
w e l l - b e i n g a n d f r e e d o m
I turn now to the third question that was identified earlier: how does capability link with the well-being of a person? Related to that we also must address the question whether an expansion of capability must invariably be a welfare-enhancing change.
* The important contrast between health policies per se and policies that yield health advancement has been extensively investigated by Jennifer Prah Ruger, ‘Aristotelian Justice and Health Policy: Capability and Incompletely Theorized Agreements’, Ph.D.
dissertation, Harvard University, 1998 (to be published by Clarendon Press as Health and Social Justice). See also her ‘Ethics of the Social Determinants of Health’, Lancet, 364 (2004) and ‘Health, Capability and Justice: Toward a New Paradigm of Health 286
h a p p i n e s s , w e l l - b e i n g a n d c a p a b i l i t i e s
Capability, as already discussed, is an aspect of freedom, concentrating in particular on substantive opportunities. Any claim that an assessment of capability must be a good guide to the well-being of a person must be restrained by the understanding of two important distinctions: (1) the contrast between agency and well-being; and (2) the distinction between freedom and achievement. Both these differences have come up, in other contexts, earlier in this work; but there is a case for a more direct discussion of these contrasts to assess the relation between capability and well-being.
The first distinction is between the promotion of the person’s well-being, and the pursuit of the person’s overall agency goals. Agency encompasses all the goals that a person has reasons to adopt, which can inter alia include goals other than the advancement of his or her own well-being. Agency can thus generate orderings different from those of well-being. A person’s agency objectives will standardly include, inter alia, his or her own well-being, and thus agency and well-being will typically have something in common (e.g. an increase in well-being, given other things, would tend to involve a higher agency achievement). Also, a failure to achieve one’s non-well-being objectives may also cause frustration, thereby reducing one’s well-being. These and other connections exist between well-being and agency, but they do not make the two concepts congruent.
The second distinction is between achievement and the freedom to achieve, which was discussed earlier, in Chapter 11 in particular. This contrast can be applied both to the perspective of well-being and that of agency. The two distinctions together yield four different concepts of advantage, related to a person: (1) ‘well-being achievement’; (2)
‘agency achievement’; (3) ‘well-being freedom’; and (4) ‘agency freedom’. We can have a four-fold classification of points of evaluative interest in assessing human advantage, based on these two different distinctions.16
Ethics, Policy and Law’, Cornell Journal of Law and Public Policy, 15 (2006), and the doctoral thesis of Sridhar Venkatapuram, ‘Health and Justice: The Capability to Be Healthy’, Ph.D. dissertation, Cambridge University, 2008. The WHO Commission on Social Determinants of Health, chaired by Michael Marmot, examines the policy implications of a broader understanding of health determination (World Health Organization, Closing the Gap in a Generation: Health Equity through Action on the 287
t h e i d e a o f j u s t i c e The assessment of each of these four types of benefit involves an evaluative exercise, but they are not the same evaluative exercise.
They can also have very disparate bearings on matters for which the evaluation and comparison of individual advantages are relevant. For example, in determining the extent to which a person is deprived in a way that calls for assistance from others or from the state, a person’s well-being may be, arguably, more relevant than his or her agency success (e.g. the state may have better grounds for offering support to a person for overcoming hunger or illness than for helping him to build a monument to the person’s hero, even if the loyal guy were to attach more importance to the monument than to avoiding hunger or illness).
Furthermore, in the making of state policy for adult citizens, well-being freedom may be of greater interest, in this context, than well-being achievement. For example, the state may have reasons to offer the person adequate opportunities to overcome hunger, but not to insist that the person must take up that offer, without fail.* Offering the opportunity to all to lead a minimally decent life need not be combined with an insistence that everyone makes use of all the opportunities that the state offers; for instance, making everyone entitled to an adequate amount of food does not have to be combined with a state ban on fasting.
Taking note of agency achievements or agency freedom shifts the focus away from seeing a person as just a vehicle of well-being, ignoring the importance of the person’s own judgements and priorities, with which the agency concerns are linked. Corresponding to this distinction, the content of capability analysis can also take different forms. A person’s capability can be characterized as well-being freedom (reflecting the freedom to advance one’s own well-being), and Social Determinants of Health (Geneva: WHO, 2008).
* There is a serious complication for social policy when the capability of the family to avoid hunger for all its members is not translated into that achievement, because of the differing priorities of the dominant members of the family (for example, when the male ‘head’ is keener o
n goals other than the interests of each member of his family). The distance between capability and achievement arising from such multi-person decisions tends to strengthen the relevance of the perspective of achievement in assessing the advantage of all the persons involved.
288
h a p p i n e s s , w e l l - b e i n g a n d c a p a b i l i t i e s
agency freedom (concerned with the freedom to advance whatever goals and values a person has reason to advance). While the former may be of more general interest to public policy (such as poverty removal, in the form of eradicating major deprivation in well-being freedom), it is the latter that can, arguably, be seen as being of primary interest to the person’s own sense of values. If a person attaches more importance to some goal, or some rule of behaviour, than to personal well-being, it is a decision that could be seen to be for him or her to make (except for special cases, such as mental dysfunction that may prevent the person from thinking clearly enough about their priorities).
The distinctions discussed here also answer the question about whether a person’s capability can go against his or her well-being.
Indeed, agency freedom – and that particular version of capability –
can, for reasons already discussed, be contrary to the single-minded pursuit of personal well-being, or for that matter, the cultivation of well-being freedom. There is no mystery in that divergence. If agency objectives differ from the maximization of personal well-being, then it follows that capability seen as agency freedom can diverge from both the perspective of well-being achievement and that of well-being freedom. As was discussed in Chapter 9, (‘Plurality of Impartial Reasons’) and also earlier in this chapter, when more capability includes more power in ways that can influence other people’s lives, a person may have good reason to use the enhanced capability – the larger agency freedom – to uplift the lives of others, especially if they are relatively worse off, rather than concentrating only on their own well-being.