In the past 50 years, there has been burgeoning philosophical interest in well-being, health, and personal relationships. There has also been increasing philosophical writing on disability, particularly in relation to justice and equality. Until recently, however, there has been little philosophical discussion of disability's relevance to well-being, health, or personal relationships—in contrast to the growing scholarship on these topics in the social sciences. Until the past decade, most philosophical discussions of well-being simply treated disabilities as conditions that reduced it. Philosophical accounts of health and disease have mentioned disability, but mainly to treat it as a form of disease or ill-health; they have had little to say about the complex, contested relationship between disease and disability. And with the notable exception of parental attitudes toward one’s actual or possible disabled children, the role of disability in personal relationships has provoked scant philosophical interest.
This Entry will proceed as follows. Part 1 will discuss disability and well-being. It will begin by reviewing debates on the application of three standard accounts of well-being to disability. It will note the divergence between first- and third-person assessments of the impact of disability on well-being under all these accounts and suggest some reasons for this divergence. We will then examine what we regard as the most difficult challenge to the claim that many or most disabilities do not necessarily reduce well-being: the widely-held view that it is desirable to prevent, correct, or mitigate disabilities, and generally undesirable to acquire one. The concluding section of Part 1 will examine how assumptions about disability and well-being inform a number of contemporary debates in medicine and health care.
Part 2 will examine philosophical writing on health and disease. It will review different definitions of health and their implications for the question of whether it is necessarily unhealthy to be disabled. It will consider the few attempts that have been made to distinguish disability from disease. It will also note a tension for disability scholars in making the distinction between disease and disability: although that distinction provides a basis for separating the medical from the socially constructed aspects of disability, it can also oversimplify the experience of people with disabilities.
Part 3 will discuss disability and personal relationships. It will examine widely shared assumptions concerning the impact of disabilities on a variety of relationships, in particular the doubts expressed by many laypeople about the capacity of adults with disabilities to become friends, lovers, and parents. This Part will also consider how historical and contemporary accounts of friendship and love apply to persons with disabilities.
After exploring the relevance of disability to well-being, health, and personal relationships, this Entry will conclude by examining common features of the philosophical treatment of disability in the three domains. Philosophical scrutiny is particularly needed in these areas, because of the strength and persistence of popular assumptions about the adverse impact of disability on all three.
The impact that disability has on each domain is largely a function of the view or model of disability one accepts. Disability scholars and philosophers of disability now refer to two models of disability, the medical and the social (see SEP entry on disability: definitions, models, experience). For present purposes, we understand the social model of disability as holding that the physical and social environment are the primary source of the limitations and disadvantages faced by people with almost all impairments. This model has obvious relevance for the accounts of well-being, health, and personal relationships we will examine. It suggests that if people with disabilities appear to be unhappy, unhealthy, or socially isolated, it is primarily due to contingent features of their physical and social environments, not to any intrinsic features of their impaired functions. In some cases, this recognition will require a reassessment of their present well-being, health, or social relationships. In other cases, it will not challenge that assessment, but will alter the prescription for improving their well-being, health, or relationships, or the expectation of success in doing so.2. Disability and Health
2.1 The First Approach: Distinguishing Disability from Disease
2.2 The Second Approach: Health as More or Other than the Absence of Disease
3. Personal Relations, Family, and Disability
3.1 The Nature of Personal Relationships
3.2 Peer Relationships: Friendship and Love
3.3 Romantic Love and Sexual Intimacy
3.4 Parenting and Disability
3.5 Personal relationships and third-party assistance
4. Conclusion
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[size=30]1. Disability and Well-Being
The relationship between disability and well-being is important both theoretically and practically. How philosophers, social scientists, policy makers, and lay people understand that relationship matters for the theories of welfare and flourishing we construct, the judgments about our lives we make on a regular basis, and the social and health policies we adopt.
Assumptions about well-being, tacit as well as explicit, pervade our thinking about disability. Decisions about abortion after a “positive” prenatal test result are often based on the parents’ judgment about the child’s expected quality of life. Decisions about life-sustaining treatment for severely disabled infants and critically ill adults are often made on the same basis, although what counts now as an acceptable quality of life may differ from what is considered acceptable when contemplating the futures of fetuses and newborns. Judgments of well-being also figure in allocation decisions, where scarce resources may be diverted away from persons who, because of certain disabilities, are deemed to have poor prospects for an acceptable quality of life, and toward persons with “better” prospects. The examples could be multiplied, and they are not confined to health-related matters.
Disability is often initially encountered as an atypical mental or physical condition whose impact on well-being is mediated by the physical and social environments. For example, an individual is deciding whether to undertake expensive and risky surgery to restore functioning lost in an accident; a couple is deciding whether to continue a pregnancy with a fetus diagnosed with a genetically-based health condition; a legislature is deciding how much money to allocate to competing injury-prevention programs. All these decision makers first confront disability as a biological phenomenon—a sudden or gradual loss of functioning; a genetic condition with various health effects; a range of vehicular, recreational, household, and workplace injuries. Their concern is with the effect of disability, encountered this way, on lives they care about or are charged with protecting: their own, their future children’s, or their constituents’.
As these examples suggest, the fact that disability-related disadvantages often reflect contingent features of the social environment may have different relevance for different decisions and decision makers. Parents deliberating about whether to have a child with a severe disability may need to treat as “given” the adverse effects on well-being of social stigma or inadequate educational resources. It is far less clear that legislators would be justified in treating as “given” the reduction in well-being associated with these social conditions, given that they are in a position to modify those conditions, by, for example, prioritizing funding for inclusive education.
1.1 Disability and Subjective Theories of Well-Being
We begin by examining the impact that disabilities have, or are expected to have, on various accounts of well-being. Philosophical discussions of what makes life go well generally recognize three distinct types of accounts. T.M. Scanlon distinguishes
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- اقتباس :
- “experiential theories…which hold that the quality of a life for the person who lives it is determined completely by…its experiential quality;”
“desire theories…which hold that the quality of a person’s life is a matter of the extent to which that person’s desires are satisfied;”
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and
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- اقتباس :
- “substantive-good theories…which hold that there are standards for assessing the quality of a life that are not entirely dependent on the desires of the person whose life it is”. (Scanlon 1998: 109ff)[1]
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The first two accounts are “subjective”, in that they define well-being as relative to the individual’s mental states, whereas the last theory is “objective”, assuming a substantive view about what makes a life go well that is independent of the individual’s mental states (see
SEP entry on well-being).
These rival accounts of well-being clearly have different implications for the bearing of disability on individual well-being. If, as hedonic experiential theories hold, well-being is a matter of having positive experiences, whether disability reduces well-being depends on whether and to what extent it reduces the number or intensity of positive experiences enjoyed by persons with disabilities. On these theories, the self-reports of persons with disabilities carry considerable weight in assessments of well-being, at least if we accept the assumption that people are in a better position, epistemically, to assess the quality of their own experiences than other people’s. Indeed, most research on the well-being of people with disabilities relies on self-reports, and those reports do not confirm the grim views of third parties. Most people with disabilities report a quality of life similar to people without disabilities (Saigal et al. 1996; Albrecht and Devlieger 1999; Gill 2000; Goering 2008).
For similar reasons, self-reports ought to carry considerable evidentiary weight on desire-based accounts of well-being—though perhaps not as much weight as on the experiential view, if we have less first-person authority with respect to what our desires and their fulfillment than t we do with respect to our experiences. Self-reports have the most limited and contingent relevance on objective accounts, since individuals will not always be in the best position to know how well they are doing in various physical, social, and professional domains.
Some philosophers regard the implication that persons with disabilities can achieve levels of well-being equal to those of their able-bodied counterparts as a
reductio of subjective accounts (see Sen 1980; Crocker 1995). And some disability scholars have been drawn to subjective metrics on the basis of their considered judgment that persons with disabilities can achieve levels of well-being that are at least comparable to those of their able-bodied counterparts. Despite this, subjective accounts may offer only thin practical support for the claim that disabled people are not handicapped in the pursuit of happiness. Many nondisabled philosophers and laypeople are inclined to doubt the reliability of disabled persons’ self-reports to the effect that they are doing well. Some suspect that these ratings are deliberately overstated to take account of their expected discounting by nondisabled people. Others regard them less as self-reports than as directives against pity or sympathy.
Even when self-reports are accepted as sincere, the interpretation of self-reported well-being is disputed (Menzel et al. 2002; McClimans et al. 2013; Barnes 2009b). Some psychologists and philosophers see those reports as distorted by adaptation or response-shift; by habituation to aversive experiences or a shift to more modest objectives or comparison classes (Menzel et al. 2002; Murray 1996; McClimans, et al. 2013). Indeed, the phenomenon of adaptation highlights some of the differences among rival accounts of well-being. Adaptation refers to a group of processes, though which newly disabled people change their habits, activities, and goals to accommodate their disabilities. Among those processes are developing new skills, changing comparison classes and goals, and habituating to pleasant or unpleasant experiences (Menzel et al. 2002). Although the first of these processes—the acquisition of new skills—might reflect a change in objective well-being, the latter two would not (unless feelings of satisfaction and pleasure are included on the “objective” list). But habituating to unpleasant experiences might improve well-being under a hedonic account by making the individual feel less pain or more pleasure. Similarly, insofar as changing one’s goals involves changing one’s desires, and insofar as one’s new desire-set is more satisfiable than one’s old desire set, the second process of adaptation would also yield an improvement in well-being on the desire-satisfaction view. By contrast, on an objective account of well-being, mere habituation and goal-downsizing habituation would not necessarily improve well-being.[/size]
Disability: Health, Well-Being, and Personal Relationships
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