Hard Trade Offs: Disability, Dignity and Capability

As ominous as it sounds, the world is ageing. According to a United Nations projection, the number of individuals over 60 is expected to double by 2050 and is one of the fastest growing age brackets. This growing population means countries are going to need to provide more nursing homes in the next few decades. A study published by the Lien Foundation estimated that 50,000 seniors will require a form of residential care facilities by 2030, a significant increase compared to the 12,000 beds currently available.

There are implications to these trends. In an aging population, the caretakers are no longer sons and daughters but strangers with medical degrees. In an age of access and efficiency, the unable and slow get left behind. Concern about welfare is a valid one, but I argue a more pertinent question is this: how do we insure that the elderly live fulfilled lives given their limited capacities?

The political philosopher Martha Nussbaum argues that political institutions should work to insure a social minimum of ten basic human capabilities. Her simple argument is that certain capabilities are necessary to live a life that is “fully human”. For Nussbaum, to live as a “dignified free human being” is to have the opportunity to actively shape one’s life path. Furthermore, Nussbaum stresses that “the ultimate political goal is always the promotion of the capabilities of each person.”

Nussbaum acknowledges, however, that these ten basic capabilities are not enough. She recognizes that there are certain internal capabilities within the individual that are required to exercise these basic capabilities. More often than not, this requires the support of a suitable external environment. Examples like learning to share or speaking in front of an audience come to mind. Her response to critiques that full external capability cannot be reasonably granted by the state is this: society should guarantee a social minimum of these capabilities. As a result, these capabilities are not fixed and are realized in different ways according to taste, culture, and tradition.

Nussbaum argues that these capabilities are universal and acknowledges that such a universal framework should be “sufficiently flexible to enable us to do justice to the human variety we find.” Nussbaum’s argument for these capabilities considers the dignity and worth of the individual, but her argument fails to address the inevitable hard tradeoffs in the disability case.

I should note that Nussbaum does acknowledge disability briefly: “we may judge that the absence of capability for a central function is so acute that the person is not really a human being at all, or any longer – as in the case of certain very severe forms of mental disability, or senile dementia.” Nussbaum states that she is not concerned with this extreme case, but what of the less extreme case? What of the bedridden or the amputated or the elderly and disabled?

Nussbaum fails to acknowledge that there is a limit to the restoration of certain capabilities. Her argument focuses on women, particularly women living under the caste system in India. The situations of Vasanti and Jayamma are due to social constraints and systematic oppression. Given access to certain combined capabilities and a fostering external environment, such capabilities can be restored. However, in the case of the old folks home, the restoration of bodily health is limited due to a lack in medical advancement. Some bodily integrity is compromised due to limited mobility. Furthermore, affiliation with loved ones is restricted as a result of the sequestered home. The limitation of one capability affects the others.

During my time as a volunteer at a nursing home in Singapore, I had a conversation with a resident who refused to participate in the home’s activities. He resisted everything from physical therapy appointments to movie screenings. Due to his resistance and passivity, his mobility got worse over time and he spent his days voluntarily confined to the bed. “My family can’t take care of me, so I’m just waiting to die,” he said. When asked if he wanted to go home, he nodded wistfully. It was a strange phenomenon, but not an unusual one. In fact, the physiotherapists liked to joke that the more assistance a patient needed, then the more they wanted to go home and the more likely they were to resist treatment. This raises an interesting question: should the residents be allowed to choose the external conditions they want to live in?

It is important to note that if residents are allowed to choose their external conditions, this could infringe on the capabilities of the individuals within the family. The strain on the primary caregivers would be tremendous, particularly if the resident is unable to control bodily functions. Families may not have the medical expertise to look after the resident and residential in-home care can be costly. The infringement on other’s capabilities is an important consideration when answering this question.

What would a potential response be to this scenario? One could argue that Singaporean society has guaranteed a social minimum for these capabilities. The external conditions in the home are sufficient. Residents can participate in physiotherapy and improve their bodily integrity and the home has extensive visiting hours for families. The resident who refuses treatment is refusing an opportunity, but that does not mean his basic capabilities aren’t being met. Since the nursing home has met the Singaporean social minimum, it is not the responsibility of the state to compensate for a resident’s desire to move back home.

There is something morally problematic about this response, particularly in regards to Nussbaum’s argument. On the one hand, Nussbaum believes that a dignified human is one who has the ability to shape their own life path. On the other hand, society should guarantee a social minimum of these capabilities. Yet, under this potential response, the dignity of the resident who wishes return home is undermined. Furthermore, the capabilities of the family caregiver take precedence over the capabilities of the resident. One could venture to argue that certain capabilities have to be insured before others can be realized. For example, an individual needs to have full bodily health in order to have bodily integrity. This does not seem like a just social minimum at all and we are faced with the problem of hard trade offs: whose and which capabilities are the the most important?

Societies that are considered with welfare should be aware the implications of welfare decisions on their citizens. In the anecdotal case of the nursing home, some residents felt a loss of multiple capabilities due to a change in external surroundings. Yet, the imposition on their families was too great to bear.  Providing 38,000 more beds in the next decade is perhaps the easier solution, but it does not necessarily equate to a good life for its future occupants. If the goal of welfare is to assist individuals in living a meaningful life, the implementation of an opt-in elderly bonus scheme would allow individuals to have autonomy over their external environment. Although this is a happy medium solution, implementation is costly. The disability example sheds light on the potential hard trade-offs in Nussbaum’s argument and the tension between dignity and capabilities.

ACKNOWLEDGEMENTS: This article would not have been possible without the opportunity granted to me by the nursing home. Thank you for your service to this community. I would also like to express thanks to Professor Sandra Field for her commentary throughout the brainstorming and editing process.

 

WORKS CITED

(2017). World Population Prospects: The 2017 Revision, Key Findings and Advance Tables. United Nations Department of Economic and Social Affairs, Population Division. Working Paper No. ESA/P/WP/248: 13.

Basu, R. (2016). Safe but Soulless: Nursing Homes Need a New Narrative. Lien Foundation and Khoo Chwee Neo Foundation. ISBN 978-981-11-0818-1.

Nussbaum, M. (2001). “In Defense of Universal Values” in Women and Human Development: The Capabilities Approach. Cambridge: Cambridge University Press. 77-80.

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At Yale-NUS College, we are thinking about ideals of equality and democracy, and how they relate to practice, in Singapore and in the wider world.

This website showcases our reflections.

Articles were originally submitted as course papers for Professor Sandra Field’s classes Contemporary Egalitarianism and Democratic Theory.

The Equality&Democracy project has been made possible through the support of a Teaching Innovation Grant from the Yale-NUS Centre for Teaching and Learning: ‘Applying Political Philosophy to Real World Cases’.

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