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تاريخ التسجيل : 26/10/2009
وســــــــــام النشــــــــــــــاط : 6
 | |  The Second Approach: Health as More or Other than the Absence of Disease | |
An alternative approach to the relationship between health and disability involves a broad or positive conception of health as more than, or distinct from, the absence of disease or disability. This approach has more and less instrumental versions. The former is represented by Nordenfelt’s account of health as the ability of an individual to reach her “vital goals”—those whose achievement is independently necessary and jointly sufficient for minimal happiness (Nordenfeldt 1995). On such an instrumental account, the relationship of disability to health depends on the goals that are considered vital or central and on the role of typical functions in achieving them. Some impairments will hinder the pursuit of some goals (goal-based accounts of health vary in whether or how they specify the relevant environment(s) affecting their pursuit), other impairments will have no effect, and some will enhance the pursuit of some goals. Any generalizations about the impact of impairments on health will depend on the assessment of their net effect on the pursuit of the specified goals.The breadth of an instrumental approach is apparent in Sridhar Venkatapuram’s variation on Nordenfeldt, which replaces the latter’s mix of universal and personal “vital goals” with the “basic capabilities for minimal happiness”, as enumerated by Martha Nussbaum. “What is important”, Venkatapuram maintains, is “the idea of health as the capability to achieve a cluster of basic capabilities and functionings” (277). Far from denying that this conception resembles the much-ridiculed 1948 WHO definition of health as “a state of complete physical, mental, and social well-being”, Venkatapuram just alters that definition to refer to a capability for minimal well-being. Nor does he shirk from the practical implications of this conception: - اقتباس :
- “Health policy and expertise will have to encompass all the determinants of the core human capabilities that constitute a minimally decent life” (278).
At the same time, he recognizes a narrower conception of health, treating it as one of the more specific capabilities that health in his broader conception encompasses. Health in this narrow sense is just the capacity to avoid disease and impairment. But it is unclear why even health in this narrow sense should be a constituent of well-being, given the fact of human mortality and vulnerability.Lawrence Becker has proposed a broad but less instrumental conception of health, examining positive conceptions of health in other disciplines, specifically models of positive mental health in psychology, which incorporate notions such as resilience, robustness, developmental maturity, character strength, and subjective well-being (Becker 2005). Such conceptions go beyond the absence of disease in two ways: they are positive, requiring psychophysical vitality—robustness, vigor, and resilience—and they are broad, concerned not merely with biomedical functioning but with more comprehensive well-being.More recently, Becker (2012) argues for “basic good health” as the metric for “basic justice”. For Becker, basic good health is defined in interactive terms, as “reliably competent physical and psychological functioning in a given environment” (2012: 45). As David Crocker (2013) observes, this notion - اقتباس :
- has both negative and positive elements. The negative dimension includes absence of disease, illness, disability, and other impairments. The positive aspect is … ”robustly active agency. To be healthy is to have a kind of agency appropriate to the stages on life’s way—from infancy to mature adulthood to old age.
This positive aspect of basic good health, if not the notion as a whole, gives support and structure to the claim that one can be disabled but healthy. It could also promote the development of health interventions for people with disabilities that are not directed at the normalization of their atypical or impaired functions. One challenge for this approach is to limit the scope of positive health, so that it does not encompass all aspects of well-being, but remains anchored in biomedical functioning. A second challenge for this approach is to explain how cognitive and affective conditions bear on health, and how any adverse effects of such conditions can be mitigated or eliminated without medical normalization.3. Personal Relations, Family, and DisabilityAlthough the connection between disability and interpersonal relationships is a topic worth exploring in its own right, it also has important implications for well-being and health. Numerous empirical studies across a number of behavioral science and medical disciplines have shown the importance of close interpersonal relationships for health and well-being (Cohen, Gottlieb, and Underwood 2001; Uchino, Cacioppo and Kiecolt-Glaser 1996; Cohen and Wills 1985). For example, more than 130 empirical studies have shown that on a number of well-being indices, married men and women are generally happier and less stressed than unmarried people (Coombs 1991). Personal relationships, including love and friendship, are for most people an essential ingredient of the life they want for themselves, something to value for their own sake as well as for the support they provide during stressful times. However, many people see disability as an obstacle to friendship, romantic love, and rewarding family life. Disability scholars and activists reject this widespread belief, arguing that the obstacles that exist to accessing such relationships are due primarily to features of the social and physical environment.In this section, we discuss the perceived barriers to such relationships. Clearly, one’s view about the effect of disability on interpersonal relationships depends on one’s conception of disability and on one’s conception of the relevant interpersonal relationships, such as friendship and love. As is evident from the discussions in the “Friendship” and “Love” entries in this encyclopedia, there is lively debate among philosophers concerning the nature and value of love and friendship. 3.1 The Nature of Personal RelationshipsThe term “personal relationship” encompasses relationships of widely varying sorts. We will focus on relationships typically understood as enduring and in some way intimate: between parents and children, siblings, friends, and committed partners. In that respect, our conception of personal relationships is narrower than the broad conception of a relationship that figures in some of the literature on relational egalitarian theories of justice (see, for example, Anderson 2010; though for a principle of relational egalitarianism that is derived from consideration of what spouses owe one another, see Scheffler 2014). The close relationships we have in mind—whether of friendship, partnership, or family—involve some degree of mutual regard, personal disclosure, and particularized knowledge. They also involve material and emotional mutuality, but need not involve equal exchanges between the parties.Philosophers have often treated equality of some kind as a prerequisite of friendship (see SEP entry on friendship). In the Nicomachean Ethics, Aristotle distinguished among three kinds of friendship: friendships of pleasure, of utility, and of virtue. The last, the highest or truest form, required similarity of character. Philosophers since Aristotle have rejected some of his prerequisites for friendship, such as equality of social or economic status, but they have shared his view that friendship must be a relationship among equals. The debate has largely focused on the kind of equality that is required. Thus, Aristotle denied that parents and their children could ever be true friends, since the inequality between them could never be overcome no matter how much the child does for his parents. This position is rejected by English (1979) and Kristjansson (2006). Generally, contemporary accounts of friendship place less emphasis on equality or similarity of specific traits and more on equality of respect, investment, and commitment. Given the vast range of differences among close friends in talents, interests, and tangible contributions, it would not seem that disabilities pose any general barrier to intimacy.Nevertheless, philosophers and bioethicists have tended to look skeptically on the possibility that a person with a disability could offer the mutuality and equality required for a satisfying relationship with a nondisabled friend, romantic partner, or family member. Even in those relationships where unequal contributions and asymmetric dependence are the norm, as with parents and their children, a child’s disability has been seen as an obstacle to a desirable and rewarding relationship. The disability is perceived as creating an uncomfortable degree of inequality and dissimilarity; parents have difficulty picturing the child growing into a productive adult and parent, fulfilling some of the goals people have for undertaking childrearing (Ruddick 1998). Additionally, the child’s disability has been viewed as imposing burdens on parents that differ from and greatly exceed those posed by raising children who do not have disabilities (Botkin 1995). Moreover, the child’s disability is presumed to extend the duration of parental care (Botkin 1995; Kittay 1999; Lindemann and Nelson 2008). Similarly, when the bioethics literature considers people with disabilities as parents, it is largely to assess whether it will be harmful for children to be raised by disabled parents (Coleman 2002; Robertson 2004); or whether adult children will have to give up their other life projects to care for their newly-disabled parents (Callahan 1988).In this literature, relationships involving disabled people are chiefly viewed from the perspective of those without disabilities. Whether the topic is end-of-life decision making (Hardwig 2000), treatment decisions for low birth weight, premature or otherwise disabled newborns (Stack 1987), the rehabilitation of persons after traumatic brain injury (Nelson and Frader 2004), or selection for or against disabling traits in embryos or fetuses (Botkin 1995; Ruddick 2000; Green 2008), the focus is on how nondisabled people are affected by a (potential) relationship with someone who has a disability. What is largely missing from these accounts is serious consideration of the perspective of the person with a disability; of how her life will be affected, for good or ill, by the family or friendship relationships in which she is embedded. In addition, little attention is paid to relationships in which all involved parties have disabilities. As Chappell (1994) has noted, writers assume that it is in the interest of people with disabilities to aspire to relationships with nondisabled people, even if it is not is the interest of the latter. It seems clear that if the consequences of personal relationships for the flourishing of persons with disabilities were given the same weight as the consequences for nondisabled persons, it would encourage a deeper and fuller appreciation of the goods of personal relationships. | |
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