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“And how is life going for you?”—an account of subjective welfare in medicine


The dominant account of welfare in medicine is an objective one; welfare consists of certain favoured health states, or in having needs satisfied, or in certain capabilities and functionings. By contrast, I present a subjective account of welfare, suggested initially by LW Sumner and called “authentic happiness”. The adoption of such an account of welfare within medicine offers several advantages over other subjective and objective accounts, and systematises several intuitions about patient-centredness and autonomy. Subjective accounts of welfare are unpopular because of their implications for justice and the autonomy of the healthcare professional. This account of welfare, however, seems to have the resources to resist these criticisms.

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  • i Daniels goes on to suggest that needs are important because they “maintain normal species functioning”.

  • ii Examples are Braybrooke’s theory of needs7, Thomson’s theory of needs and interests8, Sen’s theory of functioning and capabilities,9and teleological theories5 10 To summarise: Braybrooke argued that an individual’s life was going well if his basic needs were being satisfied. These needs include such items as nourishment, exercise, rest, companionship, social acceptance, personal security and so on. Braybrooke tries to justify these items in two ways. First, he sees basic needs as essential to functioning normally. But this begs the question of what it is to function normally. Some individuals would see their lives as going well without reference to many of the items on Braybrooke’s list. The other way in which Braybrooke tries to justify his list of needs is by arguing that they are “indispensable to mind or body in performing the tasks assigned a given person under a combination of basic social roles” (p 48). But this again is circular: why should these social roles matter more than others in determining needs? Garrett Thomson8 tries to make the concept of a need depend on avoidance of harm (p 50). But Thomson then defines a harm as something that frustrates our interests. Interests, however, have a very subjective feel to them and thus it seems that Thomson’s account of needs is fundamentally a subjective one. Sen11 suggests that an individual’s life is going well if it has a certain combination of functionings (achievements) and capabilities (opportunities). But this, too, begs the question. The functionings and capabilities of (say) a professional philosopher and a Masai warrior will be radically different, and it may be impossible to generate a list of functionings that would meaningfully describe the welfare of both individuals. This is even true within one society. Consider the differing functionings of (say) a bricklayer and a brain surgeon. Finally, Taylor10 and Nussbaum5 argue that human beings have certain goals or excellences and that these objectively define what it is for a life to go well. But, whether these excellences are intellectual, artistic or moral, it is still an open questions whether achieving these goals constitutes a life rich in welfare.

  • iii Brink13 believes that accounts of welfare should not be subjective, because a subjective account might imply that repugnant or trivial lifestyles were lives rich in welfare. But even though such a life might score poorly for moral or perfectionist value, it is still arguably good for the liver of the life and, therefore, high in welfare.

  • iv Bykvist14 argues (p 487) that Sumner’s concerns about preference-satisfaction accounts of welfare can be answered. The main thrust of his complex argument is to deny that preferences have to be future oriented, and he argues that many preferences are “for now”. The risk of pushing this viewpoint is to make preferences indistinguishable from pro-attitudes, so that a preference-satisfaction account of welfare begins to look like a hedonistic account of welfare.

  • v Sen first developed this point, though as an objection to preference-satisfaction accounts of welfare.

  • vi See also in this context Dan Brock,15 quoting Leon Kass: “[M]edicine’s proper end is the much narrower one of health, … and other goals such as happiness and gratifying patient desires are false goals for medicine” (p 393).

  • vii Sumner’s account of welfare is also a hybrid account, but in Sumner’s account the objective element (authenticity) qualifies the subjective element and is not independent of it.

  • viii Objective accounts of medical welfare offer some explanation of what makes an item a constituent of welfare (or not)—for example, whether it leads to satisfaction of needs (Braybrooke7) or contributes to functionings and capabilities (Sen9). But it is an open question whether a certain item actually counts as a need or as a functioning. So these types of theory are actually indeterminate about welfare or (worse still for the objectivist) collapse into some form of subjectivism.

  • ix It should be noted that our duties as doctors to promote subjective welfare are limited to the practice of medicine. We do not have a duty qua doctor to lend our patients money, repair their faulty plumbing or teach them Latin—though all of these acts would (arguably) improve their subjective welfare. (We may have a general duty to do some of these things as (say) citizens or members of the same community.)

  • x There is a clear analogy here with the move from direct utilitarianism to indirect utilitariainism.

  • Funding: None

  • Competing interests: None declared

  • The author is a student on the Doctorate in Medical Ethics (DMedEth) course at Keele University, Keele, Staffordshire.

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    BMJ Publishing Group Ltd and Institute of Medical Ethics