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The Quality of Life$

Martha Nussbaum and Amartya Sen

Print publication date: 1993

Print ISBN-13: 9780198287971

Published to Oxford Scholarship Online: November 2003

DOI: 10.1093/0198287976.001.0001

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(p.1) Introduction
The Quality of Life
Martha Nussbaum, Amartya Sen
Oxford University Press

Abstract and Keywords

‘And he said, Now, this schoolroom is a Nation. And in this nation, there are fifty millions of money. Isn't this a prosperous nation? Girl number twenty, isn't this a prosperous nation, and a'n't you in a thriving state?’

‘What did you say?’ asked Louisa....

‘And he said, Now, this schoolroom is a Nation. And in this nation, there are fifty millions of money. Isn't this a prosperous nation? Girl number twenty, isn't this a prosperous nation, and a'n't you in a thriving state?’

‘What did you say?’ asked Louisa.

‘Miss Louisa, I said I didn't know. I thought I couldn't know whether it was a prosperous nation or not, and whether I was in a thriving state or not, unless I knew who had got the money, and whether any of it was mine. But that had nothing to do with it. It was not in the figures at all,’ said Sissy, wiping her eyes.

‘That was a great mistake of yours,’ observed Louisa.

(Charles Dickens, Hard Times)

When we inquire about the prosperity of a nation or a region of the world, and about the quality of life of its inhabitants, Sissy Jupe's problem still arises: How do we determine this? What information do we require? Which criteria are truly relevant to human ‘thriving’? Girl number twenty quickly discerns that just knowing how much money is available for a given number of people (the analogue of GNP per capita, still widely used as a measure of quality of life) will not take us very far. For we also need, at the very least, to ask about the distribution of these resources, and what they do to people's lives.

The problem is actually more complex still. For if we are really to know much about the ‘thriving’ of Sissy Jupe and her fellow citizens, we need to know not only about the money they do or do not have, but a great deal about how they are able to conduct their lives. We need surely to know about their life expectancy (think of the miners of Coketown in Dickens's novel, who keep their families from ‘want and hunger’, but go to a premature death). We need to know about their health care and their medical services. We need to know about education–and not only about its availability, but about its nature and its quality (it seems likely that Mr Gradgrind's school may actually diminish the ‘thriving’ of its pupils). We need to know about labour–whether it is rewarding or grindingly monotonous, whether the workers enjoy any measure of dignity and control, whether relations between employers and ‘hands’ are human or debased. We need to know what political and legal privileges the citizens enjoy, what freedoms they have in the conduct of social and personal relations. We need to know how family relations and relations between the sexes are structured, and how these structures foster or impede other aspects of human activity. We need, perhaps above all, to know how people are enabled by the society in question to imagine, to wonder, to feel emotions such as love and gratitude, that presuppose that life is more than a set of commercial relations, and that the human being–unlike the steam engines of Coketown–is an ‘unfathomable mystery’, (p.2) not to be completely ‘set forth in tabular form’. In short, to think well about Sissy's problem, we seem to need a kind of rich and complex description of what people are able to do and to be–a description that may be more readily available to the reader of Dickens's novel than to those who confine their reading to the narrowly technical and financial documents favoured by Sissy's teachers.

Economists, policy‐makers, social scientists, and philosophers are still faced with this problem of measurement and assessment. They need to know how people are doing in many different parts of the world, and they need to know what is really involved in asking that question. When they face the problem well, they face it, so to speak, with wonder (to use, deliberately, the word least tolerated in Mr Gradgrind's school); with a sense, that is, of the profound complexity of assessing a human life, and with a desire to admit, at least initially, the widest possible range of accounts of how one might go about this, of what indicators one might trust.

Of course, it is possible to wonder not at all–to stick to a mechanical formula that is easy to use and which has been used before. The unasked question does not have to be answered. This volume is an attempt to ask questions and to propose and examine some possible answers. By examining the arguments for and against a variety of different accounts of how to measure quality of life, it aims to generate a more complex understanding of alternative positions and their respective merits. The original motivation for this project lay in our perception that these issues were being debated in several different fields whose communication with one another was unfortunately slight. Most social scientists and economists would agree with Sissy Jupe that GNP per capita is a crude and incomplete measure of quality of life; and yet such measures continue to be widely used when public policy is made. Again, philosophers have for some time been debating the merits of measuring the quality of human life in terms of utility (whether understood as happiness or as the satisfaction of desires or preferences). Some philosophers continue to defend this general approach–though usually with considerable qualification, producing utilitarianisms with complex and subtle restrictions on the nature of the preferences that may be taken into account. Others have concluded that the whole utilitarian approach should be rejected–to be replaced, perhaps, by an account of the many different kinds of activity that actually make up a ‘thriving’ human life. (Such a programme can take various forms and some of these are explored in the papers by Cohen, Sen, Brock, Scanlon, and Nussbaum.) The philosophical debates have not had much impact on the making of public policy in much of the world; nor have they been particularly noticed in the standard works in economics. Our hope was that by getting the participants in these debates together and encouraging further debate among them, we might advance the state of the question, encourage further co‐operative inquiries, and present the debate in a form accessible not only to professionals in these academic disciplines but also to policy‐makers and the general public.

(p.3) Lives and Capabilities

The papers in Part I address the general questions we have already described, examining how we may try to find adequate criteria for assessing the quality of life. Cohen's and Sen's papers both discuss the ‘capability approach’ presented by Sen, but Cohen also examines a number of other approaches, including, among others, utilitarian calculations, the Rawlsian focus on primary goods, and Dworkin's use of resources. After criticizing these approaches, Cohen argues for concentrating on what he calls ‘midfare’, which is fairly close to the idea of functionings used in the ‘capability’ literature.

The life that a person leads can be seen as a combination of various doings and beings, which can be generically called functionings. These functionings vary from such elementary matters as being well nourished and disease‐free to more complex doings or beings, such as having self‐respect, preserving human dignity, taking part in the life of the community, and so on. The capability of a person refers to the various alternative combinations of functionings, any one of which (any combination, that is) the person can choose to have. In this sense, the capability of a person corresponds to the freedom that a person has to lead one kind of life or another. Cohen's paper discusses why one has to go in this direction (rather than staying with the traditional concerns: incomes, utilities, resources, primary goods), but he ends by questioning whether the freedom‐type idea of capability is the precisely correct alternative. Sen presents the capability approach and its rationale, and also attempts to answer Cohen's critique (along with a few other criticisms presented elsewhere).

The papers by Erikson and Allardt discuss some methods and strategies for measuring the quality of life that have been used by Scandinavian social scientists for a long time. Their approach has much in common with that of focusing on functionings and capabilities, and the actual measurement techniques used have obvious relevance for the use of the capability approach. The philosophical underpinnings of the capability approach, on the other hand, provide some defence of the Scandinavian practices and also some suggestions for extension. While the Swedish and Finnish approaches differ in some significant respects, they agree in focusing neither on opulence nor on utility, but on the ways in which people are actually able to function, in a variety of areas. And they insist that any adequate measure of quality of life must be a plural measure, recognizing a number of distinct components that are irreducible to one another.

Brock's comprehensive study of measures of quality of life in the area of health care shows, among other things, still another convergence, as doctors and philosophers, looking for the best way to assess the quality of patients' lives, have increasingly turned to a list of functional capabilities, not unlike those proposed in the capability literature and in the theory and practice of Scandinavian social scientists. The field of health care provides a rich ground for comparing, contrasting, and assessing different approaches.

(p.4) Traditions, Relativism, and Objectivity

When standards are chosen to assess the quality of life of people in different parts of the world, one has to ask whose views as to the criteria should be decisive. Should we, for example, look to the local traditions of the country or region with which we are concerned, asking what these traditions have regarded as most essential to thriving, or should we, instead, seek some more universal account of good human living, assessing the various local traditions against it? This question needs to be approached with considerable sensitivity, and there appear to be serious problems whichever route we take. If we stick to local traditions, this seems to have the advantage of giving us something definite to point to and a clear way of knowing what we want to know (though the plurality and complexity of traditions should not be underestimated, as frequently happens in cultural‐relativist accounts). It seems, as well, to promise the advantage of respect for difference: instead of telling people in distant parts of the world what they ought to do and to be, the choice is left to them. On the other hand, most traditions contain elements of injustice and oppression, often deeply rooted; and it is frequently hard to find a basis for criticism of these inequities without thinking about human functioning in a more critical and universal way. (For example, Dickens's criticism of British materialism and class injustice relies centrally on some extended reflections about what a human being is—reflections that, in their socially radical character, would not have been easy to extract from the traditions of English class relations.)

The search for a universally applicable account of the quality of human life has, on its side, the promise of a greater power to stand up for the lives of those whom tradition has oppressed or marginalized. But it faces the epistemological difficulty of grounding such an account in an adequate way, saying where the norms come from and how they can be known to be the best. It faces, too, the ethical danger of paternalism, for it is obvious that all too often such accounts have been insensitive to much that is of worth and value in the lives of people in other parts of the world and have served as an excuse for not looking very deeply into these lives.

The papers in Part II confront this difficult set of questions, exploring arguments about cultural relativism from a variety of viewpoints and showing the bearing of these arguments on questions about the quality of life. Putnam's paper attacks the widely accepted idea that questions of science are matters of fact, and ethical questions, by contrast, are questions in resolving which we can appeal to nothing beyond subjective preferences. He argues that ‘fact’ in science is a more anthropocentric and ‘internal’ matter than is frequently realized, and that the very same sort of truth and objectivity that is available in science is available in ethics as well. Walzer, by contrast, defends a qualified form of relativism, in which, however, much attention is paid to the various forms of criticism and discontent that may arise within a society. However inarticulate these dissenting voices may be, they are, he argues, to be taken as important (p.5) data in understanding what a good life would be for the society as a whole.

Scanlon's paper, closely related to the debate about utility in Part I, questions the adequacy of desire as a measure of quality of life, arguing instead for exploring an approach based on a critical scrutiny of a ‘substantive list’ of elements that make human life valuable. Taylor examines the forms of reasoning that people use when they argue that one way of life is better for human beings than another. Although such arguments always take place in a particular historical context and do not have the deductive structure that we have come to associate with good scientific argument, they can none the less, he claims, be perfectly reasonable, and can succeed in showing that some ways of doing things are indeed better than others.

Nussbaum examines one major account of the quality of life in terms of a list of basic human functions–Aristotle's–that does claim to have validity for all human beings. She argues that although Aristotle himself did not confront the subtle arguments cultural relativists today might use against his account–for example, the argument that even such basic human experiences as reasoning and desiring are constructed and experienced differently in different societies–his account can still be made to reply convincingly to such objections. (The Aristotelian list of functions converges surprisingly, once again, with the proposals of Sen, Erikson, Allardt, and Brock in Part I, although they emanate from different intellectual traditions.)

Women's Lives and Gender Justice

In no area are there greater problems about measuring quality of life than in the area of women's lives and capabilities. The question of whether utility is an adequate measure and the question of cultural relativism take on a special urgency here. For in most parts of the world women do not have the same opportunities as men. These inequalities–and the deficiencies in education and experience often associated with them–tend to affect women's expectations and desires, since it is difficult to desire what one cannot imagine as a possibility. Desire‐based approaches to measuring quality of life frequently end up, for this reason, affirming the status quo, informing us, for example, that the women of country Q have no need of literacy because, when investigated by the authorities of Q, they do not express an unsatisfied desire for literacy. An approach based on a substantive account of human capabilities would ask different questions here, and would probably arrive at a different recommendation. Again, our solution to the problem of cultural relativism will have especially clear implications where women's lives are concerned, for most local traditions oppress women. A universal account of human functioning seems to have greater critical potential here. (Current work in progress at WIDER will press these issues further, attempting to construct a non‐relative account of human capabilities in the context of questions about women.)

(p.6) But as we try to answer such questions, we also need to decide whether the quality of a female life has the same constituents as the quality of a male life. Some respected philosophical answers to this question (for example, that of Jean‐Jacques Rousseau), while universalist rather than relativist about the good, have divided humanity into two distinct ‘natures’, with different norms and goals for each. If Rousseau's Emile were found leading the life that is judged best for his consort Sophie, tending the house and caring for children, Rousseau would judge his quality of life to be low indeed; so too for Sophie, were she to be discovered (per impossible, as Rousseau would have it) exercising the virtues of citizen autonomy. Some contemporary feminist writing tends in a similar direction. In Part III, Annas's paper examines this question, defending a single account of human functioning. O'Neill partly concurs, and describes a strategy we might use to judge that a particular practice is unjust to women. She links the question of gender justice to related questions about justice across international boundaries.

Policy Assessment and Welfare Economics

Part IV explores a number of ways in which questions about quality of life arise in welfare economics (broadly defined) and the formation of public policy. Roemer studies the criteria of resource allocation used by the World Health Organization, comparing them with some criteria proposed by economists and philosophers. The axioms implicit in practical policies can be made explicit and then illuminatingly contrasted with rival demands. Van Praag analyses the results of some empirical studies of how people perceive their well‐being. He shows that perceptions are highly relative to surrounding social issues.

Seabright examines the problem of living standards in terms of the plural influences that call for accommodation. He explores the connection between contractarian justifications of social theories and pluralist conceptions of the social good.

Finally, Bliss discusses the measurement of the standard of living, arguing (against Sen) that this question should be separated from the broader question of quality of life. He presents, partly by implication, a partial defence of more orthodox measures of living standards, in particular real income, but develops his own line of departure in terms of the concept of ‘life‐style’, the contents and implications of which he investigates extensively.

The contributions of the commentators at the original WIDER conference were, in general, of such a high order that it was decided to publish them along with the papers. Although this introduction has not commented on their contents, they are an integral part of the philosophical and practical debate of which this volume is the outcome.