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In Habilitation, Health and Agency, Lawrence Becker aims to provide a new framework for normative theories of distributive justice. Early in the book, he describes the argument as providing three overarching proposals for these theories: first, that they should “accept a particular conception of habilitation as a framing device for their inquiries”; second, that basic good health should be used as the representative good for basic justice; and third, that these theories should take as their aim “robustly healthy agency” (p. 4). A large part of the book is devoted to working out the concepts underlying these proposals. Part 1 focuses on the idea of basic justice and its relationship to habilitation, which Becker describes as “the process of equipping a person or thing with capacities and/or functional abilities, usually as relevant to a given environment” (pp. 6 -7). Part 2 develops Becker’s theory of health and the related concept of healthy agency, then proposes a metric for health. It then argues that healthy agency should be regarded as the representative good for basic justice, as opposed to considerations of wealth or income, or to an irreducibly pluralistic account of such goods. In part 3, Becker considers the overlap and the mapping between his account of healthy agency and a variety of norms for basic justice. It is important to note that, rather than endorsing any single normative theory of justice, he wants to supply a framework within which the success of these theories can be measured. Therefore, he focuses on areas of agreement between normative theories, so that the norms that he considers are largely uncontroversial. The final section of the book summarizes Becker’s theory and considers some potential objections.
This review will focus primarily on Becker’s accounts of health and of healthy agency, which are central to his framework. Becker argues that health ought to be understood as including not just physical, but also psychological functioning, and also that a complete account of health requires not just a negative account (relating health to disease), but also a positive account of health as well-being. Robustly healthy agency is described in terms of reliable, competent functioning in a given environment.
At the beginning of his discussion, Becker acknowledges the similarities between his approach and both the capabilities approach associated primarily with Sen and Nussbaum, and the various theories (including feminist care ethics) that stress the importance of human dependency and community. He argues, though, that his habilitation approach is more inclusive than these related theories. With regard to the capabilities approach, he also claims that habilitation is less pluralistic, while with regard to the latter, he suggests that habilitation can cover both close relationships and relationships among mutually disinterested individuals.
As noted above, habilitation is related to providing individuals with the skills and competencies required to allow them to function in a given environment. One strength of this account, Becker points out, is that it avoids the pitfalls faced by the many theories that begin with healthy, fully functioning adults and then expect to be able to extend the theory to account for “those who are disadvantaged by gender roles, caring for children, disabilities, or caring for the elderly and disabled” (p. 45). Instead of taking health as a given, Becker focused on what is required to provide people with (as far as it is possible) robustly healthy agency.
Another strength of Becker’s work is that it uses a very broad conception of health. Because he wants to ensure that health is understood as a positive concept, and not just as the absence of disease, Becker provides an extensive discussion of his understanding of the term. He relies in part on ancient philosophy, describing his account of health as “eudaimonistic”, and linking it to the broader question of what is required to lead a good, virtuous life and to the idea that health must be understood in a way that takes account of our inherent sociality. He also draws heavily on recent work in positive psychology, arguing that neither public health nor clinical medicine has offered a reasonable account of health in terms of well-being. He notes that physical and psychological health are closely related and that we need, in addition to being free of disease or injury, to have positive strengths and resilience that allow us to resist the descent into ill health. Finally, Becker cashes out the notion of health in terms of reliably competent functioning in a given range of environments. He acknowledges that what counts as health thus becomes, to an extent, dependent on the kinds of environment and agent finds herself in – and also that competent functioning will differ across the life cycle.
Curiously absent from Becker’s work is a discussion of the relationship between his account of health and the debates in the philosophy of medicine on the nature of health and disease. Christopher Boorse’s work is mentioned in a footnote, but there is no discussion at all of Lennart Nordenfelt’s account of health as the ability to reach vital goals (e.g. Nordenfelt 1995, 2001). Given the extent to which Nordenfelt’s work has influenced debate over the nature of health, and the similarities between his and Becker’s positions, it would have been helpful had Becker used this theory to situate his own account of health.
Moreover, there is an extensive literature on the just distribution of health care and it would have been nice to see Becker engage with this literature. Like Boorse, Norman Daniels has been relegated to a footnote. While Daniels works within an explicitly Rawlsian framework (see, e.g. Daniels 1985, 2007) and Becker deliberately refrains from developing a normative theory of distributive justice, some discussion of Daniels’s work might have helped to clarify the relationship between health and basic justice (Chapter 6).
Finally, while Becker argues convincingly that his account of healthy agency is able to cover the goals that we want to see met by a theory of basic justice, and that it is at least plausible that it does a better job of this than using wealth or income, it should be noted that health and wealth are related in ways that are relevant to justice. Work in epidemiology, such as that by Kate Pickett and Richard Wilkinson, suggests that inequality in a society may have important effects on exactly the kinds of characteristics that Becker includes in his theory of healthy agency (Pickett and Wilkinson, 2009). While this does not mean that health cannot be a reliable indicator for basic justice, it does suggest that it Becker’s framework is not as neutral as he hopes; it is likely to favor theories that minimize inequality.
Daniels, N. (1985) Just Health Care. Cambridge: Cambridge University Press.
Daniels, N. (2007) Just Health: Meeting Health Needs Fairly. Cambridge: Cambridge University Press.
Nordenfelt, L. (1995)On the Nature of Health: An Action-Theoretic Account 2nd Edition. Dordrecht ; Boston : Kluwer Academic.
Nordenfelt, L. (2001) On the goals of medicine, health enhancement and social welfare. Health Care Analysis 9 (1):15-23.
Pickett, K. and R. Wilkinson. (2009) The Spirit Level: Why More Equal Societies Always Do Better. New York: Allen Lane.
© 2013 Robyn Bluhm
Robyn Bl Robyn Bluhm uhm (PhD),Department of Philosophy and Religious Studies, Old Dominion University.