Capabilities approaches

Martha Nussbaum’s approach differs from that of Sen in a number of respects (see Robeyns 2005). Nussbaum (2006) offers a normative framework for a ‘partial’ theory of justice. For Nussbaum and Sen a capability is a “substantial freedom he or she enjoys to lead the kind of life he or she has reason to value” (Sen 1999), resources and preferences only give a partial conception of how well off someone is. Sen uses the achievement of capabilities and functionings as an indicator of the justice of social arrangements. Freedom has two aspects. One is a process aspect – “ability to be agents” – to affect the processes at work in their own lives or as general rules in the working of society, and second an opportunity aspect – “ability to achieve” valued functionings. Sen distinguishes agency and wellbeing, freedom and

being freedom. Sen (2005) refers to important process freedoms, which cannot be adequately analysed within the capability framework. These include the extent to which the person is free to choose or whether others intruded or obstructed. He argues that capabilities allow

comparisons of systems, institutions, and the situation of different groups and individuals. Sen is interested in agency and individual freedoms and the achievement of real and effective opportunity. He does not endorse a specific list of capabilities or functionings, and does not consider capabilities to be entitlements. Sen suggests that “the capability approach points to an informational focus in judging and comparing overall individual advantages, and does not, on its own, propose any specific formula about how that information may be used” (Sen 2005, p232). “The capability perspective does point to the central relevance of the inequality of capabilities in the assessment of social disparities, but it does not, on its own, propose any specific formula for policy decisions” (p232). Sen refers to capabilities as “the right kind of information” (p233).

By contrast Nussbaum argues for a specific list of capabilities as (normative) entitlements that are required for a life of human dignity. Nussbaum (2006, p36) suggests that human beings are characterized both by dignity or moral worth (as ends in themselves) and by sociability. Nussbaum (2006, p36) quotes Grotius – “But among the traits characteristic of the human being is an impelling desire for fellowship, that is for common life, not of just any kind, but a peaceful life, and organized according to the measure of his intelligence, with those who are of his kind… Stated as a universal truth, therefore the assertion that every animal is impelled by nature to seek only its own good cannot be conceded”. Entitlements flow from these ideas – “human sociability indicates that advantage is not the only reason for which human beings act justly” (p37). The capabilities describe necessary conditions for a decently just society, in

the form of a set of fundamental entitlements for all citizens (p154). The approach (unlike that of Rawls) does not employ a hypothetical initial situation (p156), and envisages cooperation out a wide range of motives including love of justice and compassion for those who have less than they need to lead decent and dignified lives. There is an assumption human beings are held together by many different ties including altruism (p158). There is an underlying conception of the person out of which basic political principles grow. This is a conception of human beings as needy temporal animal beings who begin as babies and end, often, in other forms of dependency. Rationality and sociability are temporal and relations may be more or less asymmetrical. Dignity and capabilities are intertwined. The right and the good are also intertwined. For Nussbaum capabilities should be the primary focus of concern, except in certain areas for example “self-respect and dignity itself” (p172), and compulsory education for children (p172).

Nussbaum proposes that the list of capabilities (and entitlements) is provisional, and can evolve through a form of reflective equilibrium, akin to the process suggested by John Rawls (1971). We start with a rough list, which is intuitively acceptable and then proceed to reflect on this list, and consider the implications of the choices that we have made. There may be capabilities that should be included but have been left out of the initial choices. Wolff & De Shalit (2007) proposed additional capabilities that might be added to Nussbaum’s list. Once agreed the list applies to all so cannot be described as paternalistic at least in the sense that one or more individuals is making decisions about the interests of others. Interests (and their specification) are pre-defined.

For Nussbaum a sufficiency of capability in all the ten dimensions describes the necessary minimum conditions for individuals to be considered to be living in a decently just society. Health is one of the ten capabilities but the other nine capabilities are considered by

Nussbaum to be of equal importance for a life of human dignity. The list is normative and not just a source of the right kind of information to be used in comparative evaluations.

Nussbaum grounds the list of capabilities in an Aristotelian conception of the requirements of a life of human dignity. Critiques of the approach proposed by Sen do not all apply to

Nussbaum and vice verse. Sen suggests that any selected list requires account to be taken of local context and valuations (preferences) whereas Nussbaum considers that impartial and universal application of a capability approach to evaluation requires a predefined list. The capabilities selected by Nussbaum are not fixed but could be the object for an overlapping consensus amongst citizens – justified by acceptability to all. Nussbaum emphasises skills and traits whereas Sen is criticised for over-emphasising freedoms (as opposed to for example justice) (Gasper & van Staveren 2003). Neither Nussbaum nor Sen are very specific about fair process rather it is the outcomes from different social realizations, which are important in evaluating the underlying institutions and processes. Both emphasise the plural and

incommensurable nature of capability sets, and argue that social states should be evaluated and defined in the space of human capabilities. Valuable states expand human capabilities. Utility maximization is an insufficient objective (for Nussbaum) when it comes to defining just social arrangements.

In discussing the position of a capabilities approach with respect to abortion Dixon & Nussbaum (2011) consider that a focus on dignity is clearly different from a focus on utility, or resources, or preferences. They emphasise a positive obligation to foster capabilities. Each

life is of equal worth and each person is considered as an end. For the foetus survival is contingent on the mother and a life with human dignity is only a potential life, so “The asymmetry between a potential and an actual being suggests that pre-viability, the woman’s claim should in general prevail” (Dixon & Nussbaum 2011, p9). Capabilities require a minimum of agency, sentience, and potential capacity for independent survival. Once the decision has been made to admit an infant to an intensive care unit then the objective to try to foster potential capabilities would seem straightforward, equally if there a sufficient certainty that an acceptable threshold for a given capability cannot (reasonably) be reached then treatment should be withdrawn. Nussbaum describes Basic, Internal and Combined capabilities. Basic capabilities are those held by a healthy infant and are required for the development of internal and combined capabilities, internal capabilities are the conditions required for certain functions such as speech, and combined capabilities are those that exist when the internal and external conditions/institutional arrangements are right. From the perspective of capabilities the key thing for infants would be the securing of thresholds of ‘basic’ capabilities such as seeing, hearing, or reasoning. Other aspects of capabilities are less relevant at this stage of development because without basic capabilities other capabilities cannot develop (such as the necessary conditions for free preference formation, and equal opportunity). Capabilities draw attention to the importance of a range of capabilities such as emotional development in addition to health.

Table 2.1 Ten Capabilities required for a life of human dignity

For Nussbaum the choice is intuitive, can be subject to debate, and can be changed as a result of a form of reflective equilibrium, but once agreed the list applies universally.

Many others have produced similar lists and justified components in different ways (see overview in Alkire 2005, Chapter 2). For example, Alkire bases her list and the justification

Capability Functions

Life a full life (not dying prematurely)

Bodily Health good health and shelter

Bodily integrity freedom of movement and security Senses, Imagination, Thought intellectual and religious freedoms

Emotions emotional development un-blighted by fear

Practical Reason one’s own life plan

Affiliation engagement in social interactions Other species concern for other creatures

Play (and enjoy) recreational activities

of choices on the work of Finnis (1994). Alkire describes the Finnis approach as one that “(i) enables and requires participatory dialogue in application, but also (ii) has objective

foundations and (iii) can coherently engage with and be refined by the large and growing literatures on happiness, subjective well-being, quality of life indicators ….” (p27). Finnis grounds his list of basic human goods (non-moral) through what he describes as a process of practical reasoning on the determinants of human fulfilment. He repeatedly asks why do I do what I do and why do others do what they do? He uses this line of reasoning to develop a discrete and heterogeneous set of the most basic and simple reasons for acting which reflects the complete range of kinds of valuable (moral and non-moral) human states and actions.

Moral ‘goods’ are specified by Finnis by using two principles (1) The principle of non- contradiction, and (2) The principle that good is to be done and pursued. Persons or institutions should undertake to act only so that each action furthers human ends or the dimensions of development. Ethical actions and practices make their way towards human flourishing coherently – in such a way that is consonant with the desire for all people across time to enjoy sustainable human development in any or all dimensions – “in voluntarily acting for human goods and avoiding what is opposed to them, one ought to choose and otherwise will those and only those possibilities whose willing is compatible with a will toward integral human fulfilment” (Finnis 1994, p136). Finnis suggests that these reasons for action require specification and agreement by communities taking account of context (including empirical data) before they can be used to formulate political obligations or individual entitlements.

try to engage patients for example newborn infants or hospital patients in any process of agreement or specification. Also it is not clear (just as with aggregated preferences) how we would select the community with which to dialogue (see the foregoing discussion of valuation of health states). Alkire (2005) describes the ‘Achilles heel’ of her selected approach to reducing poverty (in part by engaging poor people in the process) “is the assumption that poor people can articulate and analyse their poverty and their valued freedoms in multiple

dimensions, and further that if they do so the resulting analysis will be different from a sophisticated but narrower analysis that uses income as a proxy for poverty and freedom” (p199). For me this is more than an Achilles heel when it comes to the interests of substantial numbers of hospital patients such as those who lack competence, and I have chosen not to use this example of a capabilities approach.

For the purposes of this thesis I have accepted the list that Nussbaum proposes as illustrative rather than definitive, in that there is still much debate about the elements that should be included in a capabilities list even when we accept a justification based on requirements for a life with human dignity (see for example Wolff & De-Shalit 2006).