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On Norman Daniels’ interpretation of the moral significance of healthcare
  1. T Schramme
  1. Dr T Schramme, Swansea University, Department of Philosophy, History and Law, School of Health Science, Singleton Park, Swansea SA2 8PP, UK; t.schramme{at}swansea.ac.uk

Abstract

According to Norman Daniels, the moral significance of health needs stem from their impact on the normal opportunity range: pathological conditions involve comparative disadvantage. In this paper I defend an alternative reading of the moral importance of healthcare, which focuses on non-comparative aspects of disease. In the first section I distinguish two contrasting perspectives on pathological conditions, viz a comparative versus a non-comparative. By using this distinction I introduce a related disparity regarding the moral importance of personal responsibility for disease. I claim that people are usually prepared to disregard individual responsibility for disease, if it involves non-comparative harm, but not if it entails mere disadvantage. Since disadvantage means to have less than equal opportunities, Daniels’ conception of opportunity is vital for his theory. It is therefore scrutinised more closely. I try to show that he wavers between two interpretations of the notion of opportunity, which are again linked to the distinction between a comparative and a non-comparative point of view. Finally, I criticise Daniels’ supposition that persons have an interest in the normal opportunity range.

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Most people find healthcare morally important for either of two reasons: because it prevents and ends suffering and harm, or because it reduces and compensates for disadvantage. This might not be an exhaustive list and, furthermore, healthcare need not only be valued for moral reasons, but I want to focus only on these two moral foundations of healthcare. I wish to propose that there are important differences between these rationales, especially when it comes to assessing the significance of responsibility for health. I believe it is worthwhile to take a closer look at Norman Daniels’ explanation of the moral importance of health and healthcare, since he wavers between the two mentioned rationales. Or so I claim.

Daniels explicitly identifies the moral significance of pathological conditions in the resulting disadvantage (pp13, 58).1 The first section addresses Daniels’ theory of health and his normative claims concerning health needs as well as their relation to disadvantage. In the second section, I use the distinction between two perspectives on pathological conditions, that is, non-comparative—or absolute—harm versus comparative disadvantage, to establish a disproportion in the moral weight people usually attach to personal responsibility for disease and disability. Disadvantage implies reduced individual opportunities. I will therefore scrutinise Daniels conception of opportunity a bit more closely in the third section. Again, I will stress the difference between a comparative and a non-comparative perspective. At least on some occasions, Daniels seems to subscribe to a non-comparative interpretation of opportunity: he describes opportunities as abilities to pursue life plans. In contrast, the notion of disadvantage is linked to a reading of the notion of opportunity in terms of a relation to other persons’ situations. In this context, opportunity is interpreted as chance or probability to get or achieve something, usually in a competition. I suggest that Daniels employs the “normal opportunity range” to combine the non-comparative and the comparative aspect of opportunity. In the final section I criticise Daniels’ descriptive supposition as well as his normative endorsement of an interest of persons in this normal opportunity range.

DISEASE AND DISADVANTAGE

Daniels draws on Christopher Boorse’s theory of health and disease to found his normative theory of just health. According to Boorse, “a disease is a type of internal state which impairs health, ie reduces one or more functional abilities below typical efficiency”.2 This is a theory about which conditions are diseases (or pathological); it is not a theory about the moral importance of treating diseases. In fact, Boorse is at pains to establish that his account of health and disease is value-free and does not determine whether a condition ought to be treated. For Daniels, the moral importance of health needs stems from their impact on individual opportunity. Healthcare and other socially controllable factors protect opportunity by meeting health needs. In his earlier work he was mainly concerned with healthcare as a factor affecting individual opportunity; in his recent book he includes social determinants of health as well: health needs are protected by income, education, political participation and so on, not merely by healthcare, and should therefore be included in a system of just health. This is the lesson Daniels has learned from findings in social epidemiology (p4).1

Daniels is morally concerned with disease because it has an impact on opportunities. But he does not maintain that every single pathological condition ought to be treated. Although he is not very specific on what grounds diseases might not be worthy of treatment (p37),1 it seems a fair bet to assume that he would maintain this to be the case if and when they are not disadvantageous. Disease, for Daniels, only seems to raise a moral claim in virtue of its disadvantageousness.

The notion of disadvantage introduces a relational context.3 If someone suffers a disadvantage, for example, because of a disease, he is worse off than others in a certain respect. But consider the case of culturally valued pathological conditions, which boost the status of the affected person. They are not disadvantageous. Peter Sedgwick4 mentions the example of dyschromic spirochetosis, a condition that causes coloured spots on the skin. According to the Boorsian framework it is a pathological condition because it involves biological dysfunction. However, this disease used to be so common in a South American Indian tribe that it was necessary to be allowed to marry, hence it was advantageous. Still, diseases like these might nevertheless be disvalued by the affected person and should therefore, I maintain, be accepted as worthy of treatment. But Daniels does not seem to have the argumentative resources to ground health needs merely on individual disvaluation of a disease.

Another problem of Daniels’ account concerns disadvantageous conditions which are not pathological on Boorse’s account. If Daniels cares about disadvantages, why does he not include disadvantages that are due to non-pathological bodily or mental conditions? Why restrict health needs to pathological conditions and correlated circumstances like poor education? Daniels himself discusses the case of short stature, which is usually disadvantageous—at least in most Western societies. He only wants to accept shortness due to pathology, for example, growth hormone deficit, as a health need.5 But that seems half-hearted if securing individual opportunity is the point of healthcare. So why not give up Boorse’s theory of disease? On the other hand, if Daniels wants to keep this framework, why should not all pathological conditions—not just disadvantageous ones—support a prima facie claim on the use of healthcare resources?i

In this section I raised some concerns regarding Daniels’ general strategy to found normative claims on disadvantages. In the next section I want to show some implications in terms of individual responsibility for disease. Daniels’ reluctance to take individual responsibility into account does not sit well with his approach.

RESPONSIBILITY FOR DISADVANTAGE AND FOR NON-COMPARATIVE HARM

I assume that people in Western societies are usually hesitant to resolve disadvantages which are due to persons’ own choices. For instance, if someone chooses a risky route in a contest and in consequence ruins his competitive abilities we usually hold him responsible and accept that he will have less chance to succeed. However, if people end up in a situation which itself causes or involves suffering, we are normally prepared to help anyway (if they cannot help themselves)—even when the person is accountable for her plight. I therefore take it that the principle of individual responsibility plays a major role in competitive contexts, that is, where we deal with comparative disadvantages, but that it is less important in situations of non-comparative harm, at least in severe circumstances. To let people suffer is too hard to accept for most people, even in clear-cut cases where patients are exclusively held responsible for their suffering (cf7 8).

Disease obviously involves suffering and harm in most cases. Hence to claim that if a person is causally responsible for her ill health she has forfeited her entitlement to (publicly funded) treatment is difficult to endorse. I believe that this is the main principled reason why people object to using individual responsibility as a criterion for restricting eligibility to the use of healthcare resources (p76).1 However, there are pathological conditions that do not necessarily involve absolute harm, though they might be disadvantageous. And in these cases, I want to claim, we indeed have different beliefs about taking responsibility into account. Admittedly, disadvantage is usually seen as harm too, albeit as harm that is based on a comparative aspect (being worse off than others or than before). When I use the concept of harm in my discussion, I want to use it to refer to non-comparative harm (being badly off) which is due to intrinsic features of the condition.

Consider a split tongue. Does it necessarily involve harm? Of course, I do not want to deny that the process of splitting one’s tongue is likely to be painful, but I am interested in the physical condition of having your tongue split—say a couple of weeks after the wound has healed. According to Boorse’s theory, a split tongue is certainly a pathological condition as it involves a reduction of functional ability below typical efficiency. For instance, speech is impaired by the condition. Now for someone whose tongue was split in an accident, this condition can involve continuing psychological suffering, although it does not have to. However, someone who had his tongue split voluntarily for aesthetic reasons does not suffer from this condition though it is pathological (cf9). If he would nevertheless claim compensation for the disadvantage of having a speech impediment (ie, he is not claiming treatment for the condition itself), for example, by requesting special speech training, I suppose most people would be disinclined to grant it. To be sure, there might be other reasons why people would allow socially funded treatment or compensation anyway, for example, because they themselves have an interest in communicating with the other person in the best possible fashion, or because they feel sorry for him. But neither reason for treating the disadvantage is based on considerations of justice.

I doubt that our hesitation to compensate for the disadvantages of a split tongue is only due to the clear-cut situation regarding causality, that is, that we know the person alone is responsible for her condition. Practical considerations regarding the causes of the pathological condition and the related question of responsibility are not the main issue here. Someone who breaks his leg in a test of courage might still be treated, though he is also clearly causally responsible. We would treat him, I submit, not because a broken leg is disadvantageous, but because it is non-comparatively harmful. So I believe that when we assess responsibility for health we distinguish between pathological conditions that involve harm and pathological conditions that merely cause disadvantage. The former will usually be treated (as far as possible) even where people are responsible for the condition, while the latter will not be treated or compensated.

I believe there is another lesson to be learned from these examples: the moral significance of disease and disability, and the moral point of healthcare, are not only found in their relation to disadvantage but also, and probably more importantly, in their relation to suffering and absolute harm. It is true, of course, that we often compensate for disadvantages that are due to pathological conditions, but this may be qualified by individual responsibility. In contrast, in cases where people suffer non-comparative harm, we do not normally assess their causal contribution to the onset of disease; we just help them without further ado. Hence harm seems to be a more basic moral reason in favour of healthcare than disadvantage.

Since Daniels sees the moral significance of pathological conditions in their impact on opportunity, that is, in disadvantage, we would expect him to be more inclined to take responsibility into account than he in fact is. In fairness, he is not against considering responsibility for disease. My point, however, is that he should be more decided on this issue, when he is stressing the moral importance of disadvantage. Nevertheless, maybe Daniels does not, contrary to what can be found in his explicit statements, see the significance of healthcare solely in treating or compensating for disadvantages, but also in non-comparatively harmful aspects of pathological conditions. In the next section, I want to show that this twist stems from an ambiguity in the notion of opportunity and Daniels’ use of the term.

COMPARATIVE VERSUS NON-COMPARATIVE OPPORTUNITIES

The notion of opportunity is often used to refer to a chance someone has to do something, like buying a house or getting a job. Obviously, an opportunity in this sense does not imply that the person actually gets what she has the chance to get. There might be reasons for her to forgo, there might be competitors who are better suited or, more interesting for our discussion, there might be ailments, which inhibit or impair the person’s ability to compete. The ideal of equal opportunity is invoked in this context of competition. Opportunities are equal when people can compete on fair terms, that is, when there are no (undeserved) advantages or disadvantages. It is important to note that in competitive scenarios each competitor’s opportunity, or chance, to succeed is dependent on the other competitors’ situation. How likely it is that someone wins a prize, for example, depends on the presence, motivation, skill, endowment and fitness of other participants. In these scenarios pathological conditions do not necessarily impair a person’s competitive opportunity, either because other contestants might be even sicker than him or because the disease might work to his advantage; so his chance of winning might actually be better than the others’ despite his illness. Since individual competitive opportunity is only assessable in contrast to other people, this notion of opportunity is comparative.

Now when Daniels uses the notion of opportunity he sometimes seems to have something different in mind. For example, he states: “impairments of normal species functioning reduce the range of exercisable opportunities open to individuals from which they may construct their ‘plans of life’ or ‘conceptions of the good’” (p35).1 This can be read in a non-comparative way. Opportunities in this sense are closer to positive freedom or capabilities than to comparative chance (pp66, 203).1 So Daniels is concerned here with abilities a person has or does not have. Whether, and to what degree, a person’s opportunities in this sense are diminished by a pathological condition is not always dependent on other people’s skills, fitness or endowments. Person A’s abilities are not dependent on person B’s situation, but only on A’s own endowments, skills, bodily and psychological fitness etc.

Daniels’ conception of opportunity (at this point) is not comparative, but it might still lead into a comparative scenario. We might think of the opportunity a person has to pursue her plan of life relative to other people. This comparative notion is not concerned with a range of opportunities (plural), interpreted as abilities, but with the opportunity (singular) or chance of individuals to achieve a particular goal—successfully pursuing a life plan. If A is healthy and B sick, then (other things being equal) A has a better chance to succeed in her plan of life than B.

I think it is this comparative interpretation which directs Daniels to the idea of a normal opportunity range. The latter notion combines the absolute, non-comparative aspect of having abilities or positive freedom and the comparative aspect of preventing disadvantages. It is concerned with opportunities as abilities but it is also comparative, because the reference to a normal range calls for a comparison—not directly with other persons but with a standard of normality.ii In order to throw some more light on the question why healthcare is important I believe we should therefore have a closer look at Daniels’ claim that we have a fundamental interest in maintaining a normal opportunity range.

OUR INTEREST IN THE NORMAL OPPORTUNITY RANGE

Why should we assume that people have a fundamental interest in a normal opportunity range (p35)?1 iii Do they really bother if they do not have the normal opportunity range due to a pathological condition as long as they have the opportunities they cherish?,iv For instance, a vegetarian might not care at all if she has a beef allergy, though the allergy is certainly pathological. Daniels’ answer is that we worry about the normal opportunity range, not just about individually valued opportunities, because we might change our life plans, hence our values, in the future (p35).1 So in the example mentioned, the vegetarian might change her preferences regarding food, but would not have the opportunity to eat beef without suffering symptoms. Hence she does have an interest in the normal opportunity range, though she might not be interested in it now.

Daniels’ point of view seems to be based on the rule that the more options you have the better—or, more accurately, that it is bad for you if you have less options than possible, given your natural talents and skills. In this regard he is following the lead of Rawls, who interprets opportunities as a social primary good and social primary goods as things we would prefer to have more of rather than less.10 In one word, we want to have as many opportunities as possible. Therefore, ignoring enhancements for the purpose of this paper, we should have an interest in maintaining at least the normal opportunity range.

This account does not seem to be entirely convincing to me, because some opportunities, which are part of the normal opportunity range, might simply be unthinkable to pursue for some people. Of course Daniels might reply that there is a difference between being entitled to the use of healthcare resources and actually using them. If the vegetarian does not care about her allergy, she will not seek treatment—and that is fine, since she is not acting irrationally by waiving her claim. Ignoring issues of scarcity for the sake of the argument, she would nevertheless be entitled if she wanted to be treated. But be that as it may, even if we appreciate the difference between an entitlement to, and the use of, healthcare resources, there still seems to be a problem to explain why we should care about the normal opportunity range in the first place. The answer cannot be that we could always waive the claim to make use of healthcare resources. Why should we have an interest in something we will certainly forgo because we do not cherish it? Normality as such does not seem to be of any value.

I suppose there must be another reason for caring about the normal opportunity range. I see two possible reasons: firstly, we might say that since people differ in what they cherish, we should offer treatment (and prevention) to secure the normal range of opportunities. Although a person might not be bothered about her allergy, others with the same condition might, and they should be entitled to get treatment. Note, however, that this is not a statement regarding a person’s interest in maintaining a normal range of opportunities for her. It is a moral claim that endorses wide-ranging entitlements to the use of healthcare resources of persons generally. But it does not work as a rationale to assume that people should have a self-regarding interest in maintaining their normal opportunity range.

The other reason why we might have an interest in normal opportunities is related to the Rawlsian strategy, which I have alluded to before. Pathological conditions should not only be seen in terms of what they mean for the affected person in her life, but in terms of their impact on the comparative standing of the person in contrast to other persons. Although a disease or disability might not be intrinsically bad for a person, it might nevertheless cause a disadvantage in virtue of reducing a person’s opportunity range. A disadvantage, according to this argument, conflicts with our interest in the best comparative standing we can achieve. We therefore have an interest in maintaining the normal opportunity range.v

In conclusion, I believe that Daniels indeed wavers between two strategies. Firstly, we find the postulation of an “egocentric” interest in the normal opportunity range, based on the interest in revising life plans. However, I have tried to show that not all impairments of abilities need to bother people. Secondly, Daniels proposes an (more implicit) argument about a “comparative” interest in preventing competitive disadvantages due to pathological conditions. This strategy might succeed (though I would raise some doubts regarding the maximising assumption which seems to underlie it), but it would, firstly, restrict healthcare to the business of dealing with disadvantages and, secondly, call for a stronger emphasis on individual responsibility for disease than Daniels wants to put on it.

Acknowledgments

An earlier version of this article was presented at the University of Zurich on the occasion of a workshop “Meeting the author” with Professor Norman Daniels. I am grateful to A Schulz-Baldes and N Biller-Andorno, who organised the meeting. I should also like to thank the participants, especially N Daniels, and my colleagues M McNamee, H Upton, and S Edwards for helpful suggestions and comments.

REFERENCES

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Footnotes

  • Competing interests: None.

  • i The claim would only be prima facie, because we would need to consider shortage of resources, hence potential rationing (cf6).

  • ii The competitive aspect is more explicit in another book, which Daniels co-authored: “(…) by keeping people close to normal functioning, healthcare preserves for people the ability to participate in political, social and economic life. It sustains them as fully participating citizens, as ‘normal competitors’ in all spheres of social life.” (Buchanan et al 2000, p122)5

  • iii Daniels interprets his claim as “a finding in moral anthropology” (p46),1 so he would not, at this point, use the phrase “people should have an interest in maintaining a normal opportunity range.”

  • iv Note that the opportunities we value are different from what Daniels calls effective opportunities. The latter are opportunities we have in reality. But certainly we can cherish opportunities we don’t have and the other way round.

  • v The difference between a comparative and a non-comparative perspective is even noticeable in the two different versions of phrasing the (alleged) object of our fundamental interest: (a) an interest in a normal opportunity range. This implies an interest in a non-impaired chance to succeed in various competitive scenarios; (b) an interest in a normal range of opportunities. This suggests an interest in standard abilities.

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