## 1. Disability and Well-Being



The relationship between disability and well-being is important both
theoretically and practically. How philosophers, social scientists,
policy makers, and lay people understand that relationship matters for
the theories of welfare and flourishing we construct, the judgments
about our lives we make on a regular basis, and the social and health
policies we adopt.



Assumptions about well-being, tacit as well as explicit, pervade our
thinking about disability. Decisions about abortion after a
"positive" prenatal test result are often based on the
parents' judgment about the child's expected quality of
life. Decisions about life-sustaining treatment for severely disabled
infants and critically ill adults are often made on the same basis,
although what counts now as an acceptable quality of life may differ
from what is considered acceptable when contemplating the futures of
fetuses and newborns. Judgments of well-being also figure in
allocation decisions, where scarce resources may be diverted away from
persons who, because of certain disabilities, are deemed to have poor
prospects for an acceptable quality of life, and toward persons with
"better" prospects. The examples could be multiplied, and
they are not confined to health-related matters.



Disability is often initially encountered as an atypical mental or
physical condition whose impact on well-being is mediated by the
physical and social environments. For example, an individual is
deciding whether to undertake expensive and risky surgery to restore
functioning lost in an accident; a couple is deciding whether to
continue a pregnancy with a fetus diagnosed with a genetically-based
health condition; a legislature is deciding how much money to allocate
to competing injury-prevention programs. All these decision makers
first confront disability as a biological phenomenon--a sudden or
gradual loss of functioning; a genetic condition with various health
effects; a range of vehicular, recreational, household, and workplace
injuries. Their concern is with the effect of disability, encountered
this way, on lives they care about or are charged with protecting:
their own, their future children's, or their
constituents'.



As these examples suggest, the fact that
disability-related disadvantages often reflect contingent features of the
social environment may have different relevance for different decisions
and decision makers. Parents deliberating about whether to have a
child with a severe disability may need to treat as
"given" the adverse effects on well-being of social stigma
or inadequate educational resources. It is far less clear that
legislators would be justified in treating as "given" the
reduction in well-being associated with these social conditions, given
that they are in a position to modify those conditions, by, for
example, prioritizing funding for inclusive education.


### 1.1 Disability and Subjective Theories of Well-Being



We begin by examining the impact that disabilities have, or are
expected to have, on various accounts of well-being. Philosophical
discussions of what makes life go well generally recognize three
distinct types of accounts. T.M. Scanlon distinguishes 



> 
> 
> "experiential theories...which hold that the quality of a
> life for the person who lives it is determined completely
> by...its experiential quality;" 
> 
> 
> 
> "desire theories...which hold that the quality of a
> person's life is a matter of the extent to which that
> person's desires are satisfied;" 
> 
> 
> 



and 



> 
> 
> "substantive-good theories...which hold that there are
> standards for assessing the quality of a life that are not entirely
> dependent on the desires of the person whose life it is".
> (Scanlon 1998:
>  109ff)[1]
> 
> 
> 
> 



The first two accounts are "subjective", in that they
define well-being as relative to the individual's mental states,
whereas the last theory is "objective", assuming a
substantive view about what makes a life go well that is independent
of the individual's mental states (see
 SEP entry on well-being).



These rival accounts of well-being clearly have different implications
for the bearing of disability on individual well-being. If, as hedonic
experiential theories hold, well-being is a matter of having positive
experiences, whether disability reduces well-being depends on whether
and to what extent it reduces the number or intensity of positive
experiences enjoyed by persons with disabilities. On these theories,
the self-reports of persons with disabilities carry considerable
weight in assessments of well-being, at least if we accept the
assumption that people are in a better position, epistemically, to
assess the quality of their own experiences than other people's.
Indeed, most research on the well-being of people with disabilities
relies on self-reports, and those reports do not confirm the grim
views of third parties. Most people with disabilities report a quality
of life similar to people without disabilities (Saigal et al. 1996;
Albrecht and Devlieger 1999; Gill 2000; Goering 2008).



For similar reasons, self-reports ought to carry considerable
evidentiary weight on desire-based accounts of well-being--though
perhaps not as much weight as on the experiential view, if we have
less first-person authority with respect to what our desires and their
fulfillment than t we do with respect to our experiences. Self-reports
have the most limited and contingent relevance on objective accounts,
since individuals will not always be in the best position to know how
well they are doing in various physical, social, and professional
domains.



Some philosophers regard the implication that persons with
disabilities can achieve levels of well-being equal to those of their
able-bodied counterparts as a *reductio* of subjective accounts
(see Sen 1980; Crocker 1995). And some disability scholars have been
drawn to subjective metrics on the basis of their considered judgment
that persons with disabilities can achieve levels of well-being that
are at least comparable to those of their able-bodied counterparts.
Despite this, subjective accounts may offer only thin practical
support for the claim that disabled people are not handicapped in the
pursuit of happiness. Many nondisabled philosophers and laypeople are
inclined to doubt the reliability of disabled persons'
self-reports to the effect that they are doing well. Some suspect that
these ratings are deliberately overstated to take account of their
expected discounting by nondisabled people. Others regard them less as
self-reports than as directives against pity or sympathy. 



Even when self-reports are accepted as sincere, the interpretation of
self-reported well-being is disputed (Menzel et al. 2002; McClimans et
al. 2013; Barnes 2009b). Some psychologists and philosophers see those
reports as distorted by adaptation or response-shift; by habituation
to aversive experiences or a shift to more modest objectives or
comparison classes (Menzel et al. 2002; Murray 1996; McClimans, et
al. 2013). Indeed, the phenomenon of adaptation highlights some of the
differences among rival accounts of well-being. Adaptation refers to
a group of processes, though which newly disabled people change their
habits, activities, and goals to accommodate their disabilities. Among
those processes are developing new skills, changing comparison classes
and goals, and habituating to pleasant or unpleasant experiences
(Menzel et al. 2002). Although the first of these processes--the
acquisition of new skills--might reflect a change in objective
well-being, the latter two would not (unless feelings of satisfaction
and pleasure are included on the "objective" list). But
habituating to unpleasant experiences might improve well-being under a
hedonic account by making the individual feel less pain or more
pleasure. Similarly, insofar as changing one's goals involves
changing one's desires, and insofar as one's new
desire-set is more satisfiable than one's old desire set, the
second process of adaptation would also yield an improvement in
well-being on the desire-satisfaction view. By contrast, on an
objective account of well-being, mere habituation and goal-downsizing
habituation would not necessarily improve well-being.


### 1.2 Disabilities and Objective Lists



Derek Parfit has coined the term "objective list theories"
to refer to accounts that assess well-being in terms of a set of goods
and activities that are objectively good for people (Parfit 1984:
493ff). Some of the more contentious questions about the relationship
between disability and individual well-being concern what objective
goods are indispensable for a good life and at what level of
generality they should be described. Although "objective list
theories" may suggest a simple checklist, they are better seen
as recognizing (i) that there is an irreducible plurality in the goods
of life and (ii) that their contribution to well-being cannot be
expressed in terms of a common metric, like utility. Both (i) and (ii)
distinguish objective list theories as a special case of objective or
substantive-good theories of well-being. Martha Nussbaum, an
influential objective list theorist, includes the following among her
valuable capabilities and functionings: health, nourishment, shelter,
sex, mobility; the ability to use one's senses and to imagine,
think, and reason; family and other relationships, attachments and
love; living a life one has thought about and in some way chosen;
laughter, play, and living in contact with the natural world (Nussbaum
1998: 135-156). It is difficult to see what unifies all these
different categories, but item by item there would probably be
widespread agreement on their value and importance for individual
well-being. 



Given that several of the items on Nussbaum's '98 list
cannot be enjoyed by many people with disabilities, it follows that if
high levels of well-being cannot be attained by someone who cannot
enjoy all of the items on the list, then high levels of well-being are
not attainable by many people with disabilities. If that implication
is false, then the list must be changed. For example, even if it is
necessary to include substantive goods or normative ideals in an
account of individual well-being, it is not clear that *all* of
the categories in Nussbaum's list, for example, are
*necessary* for high levels of well-being. As Jerome Segal
(1998) points out, most of us would agree that a life can go very well
without one or more of the capabilities Nussbaum regards as essential.
Indeed, the most successful of lives of people lacking a single
capability may go as well as the most successful lives of people with
a standard complement of sensory and motor functions. Although a life
could hardly go well without at least some of these capacities, we
have no clear basis for establishing a minimum set.



In understanding how disability may be compatible with high levels of
well-being, understood in objective terms, it is helpful to
distinguish intrinsic from instrumental value. An activity may
valuable for itself, e.g., seeing as a rich sensory experience; or
instrumentally, for what it achieves or contributes to, e.g., seeing
as a means of finding an object. As intuitive as the distinction
seems, it is difficult to make clearly. First, there is deep
disagreement about what is of ultimate value. Second, it is possible
to parse many activities and conditions indefinitely into
instrumentally valuable means and intrinsically valuable ends, e.g.,
making money or friends can be seen as an end in itself, or as a means
to obtaining comfort and security (see
 SEP entry on intrinsic vs. extrinsic value).



The social model of disability encourages us to recognize that many of
the activities precluded by certain disabilities can be seen
instrumentally, as means to valuable ends--ends that can be
achieved by other means that are not precluded by those disabilities.
As Asch contends (2003),



> 
> 
> Those who maintain that disability forecloses opportunity, and that
> any foreclosed opportunity diminishes life, focus too narrowly on the
> activity and do not see it as a means to an end, e.g., ...
> walking instead of mobilizing or exploring; talking instead of
> communicating.
> 
> 
> 



As Asch suggests, much of what we value in seeing, talking, and
walking is instrumental. We value them as ways of achieving
communication with other people, reading, and moving from place to
place, are themselves be bearers of intrinsic value. (Of course, we
also recognize that these activities have instrumental value as well,
e.g., for finding social partners and business opportunities). None of
these valuable activities, however, is precluded by deafness,
blindness, or paraplegia. Each can be achieved in alternative ways, by
signing, reading braille, or operating a wheelchair. If these
considerations are on the right track, they show that the instrumental
value of species-typical functioning is exaggerated, because its ends
can frequently be achieved in multiple ways, many of which are
available to people with fewer, impaired, or atypical functions.



Disability scholars do not deny that typical sensory and motor
functions can have great intrinsic as well as instrumental value, but
they argue that their intrinsic value is often understood too
narrowly. If, for example, we see the intrinsic value in sight not
specifically in visual experience, but in sensory and aesthetic
experience, then that value is not precluded by blindness.



It may be true that someone who cannot see or hear lacks experiences
of great intrinsic value that are available to someone who can see or
hear. However, the broad characterization favored by disability
scholars seems most appropriate for assessing the role of intrinsic
value in how well our lives go. For example, one obvious source of
intrinsic value for standard sensory functions and activities is
aesthetic--the beauty, richness, and complexity of the
experiences they enable. But we do not regard color-blindness,
tone-deafness, or impairments of smell or taste as inimical to
well-being, although they preclude vast ranges of rich aesthetic
experience. There is no reason to doubt that someone who has never
had, or has long lost, those sensory functions (as opposed, say, to an
visual artist or food critic who relies on them for her vocation) can
lead a life as rich and rewarding aesthetically as someone who has
those functions, despite lacking admittedly valuable experiences. This
suggests that we cannot infer from the fact that there is great value
in a function that those who lack it have lives that go significantly
less well. It is only plausible to claim that a good life needs to
contain certain kinds of valuable experiences and activities if those
kinds of experience and activity are characterized very broadly. We
will have more to say about this below, in reviewing the debate over
whether disabilities can be seen as "neutral"
characteristics.



Finally, even granting the significance of objective goods for
well-being, it is not only their possession that makes a life go well.
Also relevant is how a life seems to the person living it, and this
reintroduces subjective elements. Common sense supports the view that
individual well-being must have a subjective as well as an objective
aspect; "two strands", as Jonathan Glover puts it (Glover
2006: Chapter 3). Roughly speaking, well-being consists partly in
having certain substantive goods and partly in being happy with (or
being content with, or enjoying, or taking pleasure in) one's
life. But these strands may not be readily separable: the positive
valuation of objective goods may be necessary for the possession of
those goods to count towards well-being, or for their absence to count
against it. Moreover, any plausible objective list must include
enjoyment or pleasure, either as a free-standing good or as an aspect
of valued states, activities or relationships.


### 1.3 Cognitive Disability and Well-Being



The differences among standard accounts of well-being are particularly
significant in thinking about the well-being of people with severe
cognitive impairments. We believe that a separate discussion of this
topic is warranted, but not because cognitive impairments are in a
class by themselves. As we have noted, there are great differences
among all types of impairments. Cognitive impairments, however, have
until recently received relatively little attention in philosophy, and
we give them special emphasis as a corrective.



Subjective accounts of well-being, hedonic and simple-desire accounts,
appear easier to apply to people with such impairments, for two
reasons. First, joy, pain, satisfaction, and frustration are more
readily conveyed and assessed than the more complex mental states that
informed-desire and objective list theories take into account. Second,
people with cognitive impairments appear less capable of enjoying or
attaining some items on standard objective lists: not merely various
forms of achievement, but also a variety of social relationships and
aesthetic experiences. More broadly, persons with cognitive
impairments may be unable to form and pursue a conception of the good
life. The conviction that persons with severe cognitive impairments
can and often do enjoy relatively high levels of well-being thus seems
to favor a more subjective account of well-being than that adopted for
everyone else.



Even Martha Nussbaum (2006), a strong proponent of an objective
account of well-being and of the capabilities of people with
disabilities, fears that the premium her capabilities account places
on choice may be excessive in assessing the well-being of people with
the most severe cognitive disabilities, who lack the capacity to make
meaningful choices in some or many domains. She favors a greater
emphasis on functionings than capabilities for people with cognitive
disabilities: on what they actually do or experience than on their
capacity to choose among experiences, activities, and life plans. This
suggests a way to modify her account so that more people with such
disabilities reach a threshold of well-being. But it adopts different
standards for people with severe cognitive disabilities as compared to
other people, and raises the question of where and how to draw the
line between those to whom each standard applies.



Some disability scholars may worry that the use of a double-standard
is fraught with elitism and condescension. But it has a stubborn
appeal, insofar as objective accounts seem too demanding when applied
to cognitively disabled people. Jeff McMahan concedes that it seems
"deeply and perniciously inegalitarian" to place people
with severe congential cognitive impairments in a separate comparison
class from cognitively normal people for purposes of assessing their
well-being (2001: 160).
But he argues that it is even less plausible and attractive to view
such individuals as suffering grave misfortune, however well they do
with their limited potential.



Of course, it could simply be the case that all else equal, people
with severe cognitive disabilities do have lower levels of well-being
than people without these disabilities. But all else need not be
equal: it may be that many people with cognitive disabilities can
achieve levels of well-being as high as others if they receive certain
forms of support. For example, recognizing that cognitively disabled
persons may require assistance if they are to develop and carry out
conceptions of the good life, Nussbaum (2006, 2009) and Francis (2009)
have proposed structured ways of assisting them to do so. Nussbaum
suggests that people with even severe cognitive disabilities can have
representatives or surrogates who enable them to participate, at least
vicariously, in most social and political activities (2009; but see
Wasserman and McMahan 2012 for limits on meaningful surrogate agency);
Francis discusses "mental prostheses" that aid in
constructing a personal conception of the good. She offers, as an
example of a mental prosthesis, an actual device that allows people
with Alzheimer's to locate objects in their houses by touching
an icon on their computer screen. The use of that device would not
deny the user agency in locating the device, any more than a
prosthetic foot would deny its bearer agency in running (Francis 2009:
203-204). Such a device could also allow cognitively disabled
persons to communicate their preferences, but it is unclear how it
enables them to form a conception of the good.



These are different approaches to securing the well-being of people
with cognitive impairments, with different purposes. Nussbaum seeks to
facilitate the exercise of, or the capacity for, valuable functionings
such as social affiliation, meaningful work, and political activity.
Francis's goal is broader and less concrete: to promote the
participation of people with cognitive impairments in developing
conceptions of the good that accord with their desires and that offer
reasonable prospects for fulfillment.



Both approaches receive some support from empirical research.
Disability theorists such as Goode 1994 and Ferguson 2001
maintain that people with significant cognitive and communicative
impairments can and do have the capacity to choose among alternatives
if those choices can be formulated in ways they can comprehend, or if
their non-impaired intimates or caregivers can learn to read the ways
in which they actually express their preferences, in order to help
them make their lives go the way they want.


### 1.4 The Claimed Neutrality of Disability



Many plausible accounts of well-being can explain why life can and
often does go comparably well for people with most disabilities
relative to people without disabilities. There are unresolved issues
about how broadly the objective elements of well-being can be framed
without becoming so broad as to lose distinct content. But these
questions may be less about disability and more about objective list
theories generally.



Some philosophers have argued more affirmatively that disabilities are
"neutral" characteristics or "mere
differences", with no average or generally adverse impact on
well-being. They argue that disability should be regarded as a
characteristic like race or sex, which are widely seen as neutral with
respect to well-being, once discrimination and its effects are
factored out--or even if they are not. Disability is grouped with
these characteristics in anti-discrimination law. But it is also
grouped with those characteristics by writers who argue, more
ambitiously, that disability, no less than race or sex, is a neutral
characteristic--one that, in the absence of social exclusion,
does not make lives go any worse on average (Barnes 2009a;
McBryde-Johnson 2003).
These writers do not deny that becoming disabled may make life go
worse for some time, but no more so than other wrenching changes, like
losing a job, home, or loved one. In the former case as well as the
latter, the bad or harm is in the transition--in the loss and
disruption--and not in the end state. Any disadvantage that
persists after the transition is plausibly attributed to social
factors.



There are various ways to distinguish disabilities, on the one hand,
from neutral characteristics like race and sex, on the other. The
distinction can be easily made on a maximalist view of well-being
which holds that life is presumptively better with more valuable
capacities. In contrast to race and sex, disabilities, by definition,
involve fewer valuable capacities, so they presumptively make life go
worse. It is simply better to have more senses, more intelligence, and
a greater range of motion, even if they do not make one happier, have
limited practical value, and do not advance one's specific
projects. This view regards standard disabilities as among the most
salient limitations to which humanity is subject. Less is always
worse, although how much worse will depend on contingent
circumstances. But many philosophers reject maximalism, in part
because they balk at the implication that we should strive to acquire,
and bear children who will possess, the greatest number and range of
possible capacities. 



Jeff McMahan offers a non-maximalist argument against the neutrality
of disabilities, based on a view of how people with single impairments
flourish despite them:



> 
> 
> A single disability may seem neutral because it can be compensated for
> by other abilities that develop to fulfill its functions. Blindness,
> for example, may be compensated for by the enhancement of other
> senses, particularly hearing. But if disabilities were individually
> entirely neutral, they ought also to be neutral in combination; but
> they are not (2005: 96).
> 
> 
> 



Some might dispute McMahan's claim that disabilities cannot be
neutral in combination, but our focus here is his claim that
neutrality for individual disabilities implies neutrality in
combination. In support of this claim, he argues the effects of
disabilities on well-being "are largely additive", because
with each further disability, it becomes harder to compensate for
other disabilities. This argument assumes that the possibility of
living as well without as with any given ability depends on the
possibility of compensating for its absence. This assumption may be
mistaken: the possibility of flourishing with a single disability may
depend not on compensation but on what we could call
"saturation". A blind person can live as well as a sighted
one not because she develops better hearing--she may
not--but just because the senses and abilities she has are more
than adequate to allow her to live as fully and richly as possible. As
Asch and Wasserman argue:



> 
> 
> [H]uman beings enjoy a fortunate redundancy in many of the capacities
> that are instrumental for, or constitutive of, valuable human goods
> and activities, from intimate relationships to rewarding work. Humans
> with a standard complement of senses and motor functions rarely use
> all of these functions in achieving such goods, and humans lacking
> those skills can use only some. But those are usually sufficient (2005: 208
> ).
> 
> 
> 



There may be a limited number of ways to realize important human goods
like rich aesthetic experience, and those with disabilities may have
fewer ways to do so. But the ways they have may be as good as the ways
they lack, and employing the ones they have need not be seen as
compensating for their inability to employ the ones they lack. Having
more ways to realize a good does not mean that you can realize it more
fully.



This response, however, suggests two final sources of difference, both
of which involve what we might call "welfare security".
Even if people with a single major disability can live as well as
people without one, 1) it requires more effort or luck for them to do
so, and 2) they are at greater risk of lacking the means to do so. The
first claim is that the fewer means there are to achieve a particular
good like rich aesthetic experience, the more difficult it may be to
achieve it. An individual who can meet his aesthetic quota, so to
speak, with sunsets or symphonies, doesn't have to work as hard
or need as aesthetically rich an environment as one who can meet his
quota only with symphonies. The second claim is that people with
single disabilities are at greater risk than people without any
disabilities of losing the means to achieve various goods, since they
have a smaller surplus or reserve. The plausibility of these claims
depends on a myriad of unresolved issues: Is there an irreducible
plurality of objective goods and if so, how they are individuated? Are
there a limited number of means for attaining those goods? If it
requires greater effort to attain a particular good with fewer
functions, does that additional effort itself enhance or reduce
well-being?



Another argument for the conclusion that disabilities entail setbacks
to well-being is suggested by the human variation model (Scotch and
Shriner 1997). This treats disabilities not as a distinct category,
but as conditions falling on a continuum of physical or mental
difference. It is not intrinsically disadvantageous to be near the end
of such a continuum but may be disadvantageous in a society in which
only a small proportion of people fall near that end. This is because
many of the physical structures and social practices of that society
will inevitably be designed for its average members. No matter how
just a society, how committed to inclusion, there would still be some
disadvantage in being toward the end of the spectrum. There may be
some truth to this claim, but it is easy to overstate. Universal
design advocates argue that it is, or will become, feasible to build
structures and practices that fully or equally accommodate individuals
across large ranges of human variation. Even if their claims are also
overstated, they suggest a need for caution in concluding that
minority status is intrinsically disadvantageous.



Perhaps the most tenacious source of resistance to the "mere
difference" claim comes from a stubborn asymmetry, which appears to
distinguish disability from race and sex and to challenge its
neutrality. We generally seek to prevent individuals who are not
disabled from becoming disabled, but not vice-versa. We strongly
support measures to prevent disability, if prevention can be
accomplished without coercion, harmful side effects, or the loss or
disruption of personal or narrative identity. Consider a form of
prevention widely seen as unproblematic: taking folic acid during
pregnancy to prevent spina bifida. Some governments mandate that
certain food be enriched with folic acid. These mandates are
controversial, but the controversy concerns the issues of involuntary
medication and possible side-effects rather than the intended
preventative effect. Few, if any, disability advocates object to these
mandates, any more than they object to the myriad safety measures
imposed by the modern state, from requiring seat belts to restricting
teratogenic drugs. Many object to the needlessly grim depiction of
disability in some safety campaigns; few to the campaigns
themselves (Emens 2012).



No such asymmetry exists for other allegedly neutral characteristics.
There would be strong opposition to government measures to prevent
them, alter them, or reduce their incidence. Imagine that a dietary
supplement as safe as folic acid could alter the sex of the fetus, or
lighten its complexion. We suspect that most people would find it
troublesome for pregnant women to take that drug voluntarily, let
alone for the government to put it in the food supply. Or imagine a
fluoride-like substance with a similar effect, which could be safely
added to the water supply. Fluoridation to prevent female sex or dark
skin would strike most people as offensive, even though it would not
prevent the existence of anyone on the basis of a disfavored
characteristic, at least if personal identity survives alteration of
race or sex. The claim that women or people of color lead worse lives
on average due to pervasive discrimination would not be seen as a
justification for changing sex or race. Undertaken by an individual,
it would be seen as complicit with sexism or racism regardless of its
motivation; undertaken by the state, it would be seen as an egregious
expression of racism or sexism. Public health measures to prevent
disability, like dietary supplements, would not provoke similar
objections. In general, measures to alter other significant
characteristics--not only race and sex, but minority cultures,
sexual orientations, and social identities--would be considered
unjustifiable or only justifiable in special circumstances. By
contrast, measures to prevent disabilities are considered
presumptively acceptable.



The contrast between sex and race, on one hand, and disability on the
other, is especially striking in light of the fact that in the former,
measures to alter stigmatized social identities are often regarded as
more objectionable than measures to alter dominant social identities
that are not stigmatized. Just the reverse is true for disability.
Giving deaf children cochlear implants is somewhat controversial;
deafening hearing children would be considered criminal abuse. And
this would be so even if the children were too young to have the
self-conscious experience of hearing, had no other effects from being
deafened, and faced no discrimination on the basis of deafness. These
contrasts raise the question of whether the asymmetry with respect to
disability-prevention is compatible with the view that disabilities
are neutral characteristics--that they do not make life go worse
overall.



Recently, Elizabeth Barnes has sought to challenge this perceived
asymmetry between measures to prevent or correct disabilities and
other significant characteristics. She attributes much of the
objection to changing sex or gender to moral considerations equally
applicable to "correcting" disability: 1) they would
violate the individual's right to control her own body unless
consented to; if consented to, they would be permissible elective
procedures (as would, Barnes maintains, procedures to create
disabilities); and 2) such procedures generally involve considerable
loss and transition costs--but so do procedures to correct
disabilities, as many "cure" narratives attest. For
preventative measures not involving bodily modification, loss, or
transition costs, Barnes argues that the claimed difference between
preventing disabilities and preventing less favored races or sexual
orientations is simply question-begging--no good reason has been
given to accept the former and reject the latter, merely the
"negative-difference" view the intuition is supposed to
support. 



Barnes' argument, not surprisingly, has proven controversial.
Several commentators sympathetic with mere-difference claims for some
disabilities have questioned Barnes categorical claim for all
disabilities; others have questioned whether she is too quick to
accuse those claiming an asymmetry in the case of preventative
measures of begging the question (see Dougherty 2014).



Yet even if disability could be regarded as neutral if other features
contingently associated with it, such as social exclusion, physical
pain, and the loss of valued functions, are factored out, that
conclusion might have limited practical significance for decision
makers who cannot factor out those features. As noted earlier, the
question of whether it is disadvantageous may have a different answer
for those who can significantly modify the physical and social
environment and those who cannot. Many decision makers, from
prospective parents to healthcare policy makers, will fall in the
latter category.



Before discussing specific decision making contexts, then, we need to
consider arguments that significant disabilities can be neutral, in
the sense of not reducing overall well-being, even if various
contingent harmful features are not excluded. We will examine two
grounds for claiming that disabilities, including painful, disruptive,
and stigmatized ones, need not reduce overall well-being, although
they may still be conditions worth preventing: 1) if disabilities deny
some valuable experiences and achievements, they provide others, which
may not be accessible, or may be less accessible, to nondisabled
people; and 2) there is a non-additive relationship between parts or
aspects of a life and life as a whole.



Barnes (2009a) argues that having a disability can make an
individual's life more difficult and challenging at some points
without making it go worse overall, or even making it more probable
that it will. The challenges of disability are like those of other
minority characteristics such as homosexuality; facing those
challenges can give a life greater depth or direction. For example,
some individuals who are disabled in adolescence or adulthood find
that their previously shallow or aimless lives gained focus and
purpose from the challenges they faced, and some individuals find that
they acquired new skills or interests more rewarding than those
precluded by their impairments. Because such enriching responses are
so common, there is no basis for concluding that people with
disabilities have a lower quality of life overall. But because
disabilities 



> 
> 
> are, in general, the kinds of things that make life harder--they
> impose limitations, they cause pain, they subject their bearers to
> stigmas and discrimination (2009a: 339) 
> 
> 
> 



--they are associated with with harms and should be prevented in
some circumstances. They should not, however, be regarded as
"negative difference-makers"--conditions that
necessarily make lives worse overall.



In blocking the inference from disability as a harm to disability as a
negative difference-maker, Barnes adduces instances of the positive
consequences that disabilities have had for specific individuals,
despite or sometimes because of the "local" hardships they
cause. It may be, however, that no positive consequences are needed to
"neutralize" the hardships associated with a disability.
Those hardships may simply get absorbed in the immense complex of
factors that make a life go better or worse. It is only on a simple
additive view of the relationship of parts to whole that a local harm
would necessarily make a life go worse unless compensated for. It is
difficult to be more precise about the impact of disability on whole
lives, however, because it is not clear how the goodness or badness of
parts of a life contribute to the goodness of the whole, on either
objective or subjective accounts of well-being (Feldman 2008). David Velleman has argued
that whatever one's particular theory of individual well-being,
the parts of a life do not contribute to the goodness of a life
additively. That is, the goodness of a whole life is not the sum of
the goodness of its parts. Instead, the goodness of a whole life is to
be understood in terms of the narrative relations between its various
parts. From this perspective, successes or failures at particular
times in one's life can retrospectively alter the meaning or
significance of earlier ones (Velleman 1991).



Recent accounts of noncomparative harm (Harman 2009; Shiffrin 2012,
1999) provide additional reasons to challenge the inference from
disability as harm to disability as negative difference-maker. These
accounts reject the prevailing, counterfactual analysis of harm as a
setback to an individual's interests with reference to some
baseline--her past, her expectations, or the average of her group
or society. Instead, they understand harms as fundamentally bad states
or events, like pain, disability, and death; states or events that
(proponents of these accounts claim) can be regarded as bad without
reference to any baseline. On these views, an individual is harmed
merely by suffering pain or injury, regardless of whether that pain or
injury leaves her worse off overall. She is harmed by painful
life-saving surgery, although that averts a greater harm, or
life-transforming disability, although her life may go much better as
a result.



Obviously a critical question for these accounts is what makes
something a noncomparative harm (Bradley 2012). Harman (2009) offers
no general characterization of noncomparative harms; Shiffrin
characterizes such harms in terms of a significant chasm, conflict, or
other form of significant disconnect between one's will and
one's circumstances (2012: 388). Disabilities, injuries, and
illnesses and typically regarded as harms in these terms because they
"often significantly impede one's capacity to achieve
substantial congruity between one's will and one's life
(2012: 384). Shiffrin recognizes both that one's circumstances
may narrow that chasm considerably, and she considers it a strength of
her account "that it can recognize quotidian conditions such as
ordinary conditions as harms" (2012: 387, n. 46). Although
Shiffrin does not take this additional step, it would seem that if
ordinary conditions can be harmful in damaging one's agency,
extraordinary ones can be harmless, if they were congenital,
predictable, or successfully adapted to, such that congruity between
one's will and one's life is never lost, or is quickly
restored. Further, although Harman and Shiffrin, like Barnes, regard
the onset of most disabilities as harms, they also, like Barnes, hold
that such harms need not make life go worse overall.



Another factor associated with disability--reduced
lifespan--arguably has an adverse impact on well-being. Many
disabilities, or their associated disease processes, result in
lower-than-average life expectancy, though it is worth emphasizing
that the relationship between disability and reduced lifespan is
contingent, and so even if reduced lifespan necessarily reduces
well-being, it would not follow that disability necessarily reduces
well-being. Moreover, it is not clear that reduced lifespan
necessarily reduces well-being. It is at least arguable that living to
80, with the last 5 years of one's life in severe pain, does not
yield more well-being than a life of 75 relatively painless years. And
it is at least arguable that longer lives correlate with greater
well-being because they enable one to pass through all of life's
stages--childhood, adolescence, young adulthood, middle age, and
gradual aging--but that having passed through all of life's
stages, additional years yield small increases in well-being. Clearly,
these are complicated issues that deserve more attention. We simply
note that there is no straightforward inference to be drawn from
disability's correlation with reduced lifespan to
disability's having an adverse effect on well-being. 


### 1.5 The Impact of Disability on Well-Being: What is at Stake?



This subsection will examine how assumptions about the relationship
between disability and well-being that have been challenged in
academic debate continue to play a significant role in reproductive
and health-care decision making. We discuss four contexts in which
these assumptions have been relied upon in policies and personal
decisions about creating or sustaining lives: reproductive testing for
disability, neonatal care, "end-of-life" decision making,
and the use of "quality-adjustment" measures to assess the
cost-effectiveness of health-care and other interventions.



In all of these cases, objections have been raised besides those
concerning the assumption that lives with serious disabilities must be
substantially worse than lives without them. For example, in the case
of life-termination, the debate also concerns the decisional capacity
of newly disabled individuals; in the case of quality-adjustment, the
debate also concerns the assumption that the quality of a life should
affect its priority in allocating scarce resources. We will, however,
focus on the objections that concern well-being.


#### 1.5.1 Reproductive testing



Some prospective parents see life with some disabilities as worse than
no life at all. This claim is often made with respect to such
conditions as Tay-Sachs, Lesch-Nyan, and trisomies 13 and 18. Even for
those conditions, however, that view is not universally held
(Wilkinson 2011). The notion of a life so bad that it is a harm to the
individual living it came to popular and philosophical attention in
the 1980s, when a number of lawsuits in the U.S claimed that
physicians or parents had wronged the child by failing to diagnose its
condition in utero and/or prevent its birth. These lawsuits appeared
to require a comparison of existence and non-existence, which most
courts and some philosophers rejected. A majority of philosophers,
however, starting with Joel Feinberg (1986), have concluded that the
notion can be useful in theory if not necessarily in practice.



In cases involving less severe disabilities, some prospective parents
think that they are protecting the welfare of "their
child" by preventing the existence of a child who would have a
disability. This attitude involves seeing the future child not as a
particular individual who can only exist with a disability, but as a
role that prospective parents do not want to fill with a disabled
child. Philosophers have debated the appropriateness of regarding
future children in this way (Malek 2008; Hare 2007; Velleman 2008;
Wasserman 2008; Heyd 2009). Even if this view were appropriate, its
moral force would depend on the extent to which the diagnosed
condition could reasonably be expected to reduce the child's
welfare, as well as the existence and strength of a moral reason not
to bring into existence persons with such welfare deficits.



In the context of prenatal testing, as with assessments of adult
functioning, the extent to which a disabling condition reduces
well-being depends on the conception of well-being that is adopted.
With prenatal testing, however, there is an additional complication:
there is massive uncertainty about how the detected variants will be
expressed in the developing child. That depends on their their
interplay with other genes and interaction with a variety of
environments. The formidable challenges of predicting phenotype may be
more readily acknowledged by health professionals than the even more
daunting challenges in the non-medical assessment of how life with a
given phenotype could go for the person living it.


#### 1.5.2 Withdrawal of Life Support from Disabled Newborns



The debate over the withdrawal of life support for very premature and
severely disabled newborns surfaced in the 1980s with the 1982
Bloomington, Indiana *Baby Doe* case and the adoption of
federal guidelines for support of newborns and termination of
life-sustaining treatment. The debate continues as medical technology
permits an increasing number of severely disabled newborns to survive.
Some of the debate appears fairly abstract, concerning whether there
should be a "grey area" around "a life (just barely)
worth living", in which parents and physicians would be
permitted to decide for themselves whether to continue or withdraw
life-support (Wilkinson 2011). Disability scholars, however, have the
more practical concern that decisions about life-support, whether made
by parents or caretakers, too often rely on inaccurate or misleading
medical indicators of expected well-being, resulting in significant
discrimination against newborns with disabilities (Silvers and Francis
2011). Although the
accuracy of medical prediction may improve after birth, it remains
difficult to assess the potential of a neonate to develop higher
cognitive functions. And although the prediction of the course of
physical impairments has improved, that improvement offers only a
partial safeguard against the tendency of many parents and health
professionals to exaggerate the hardships of life with an
impairment--a tendency driven as much by stigma as by medical
error and uncertainty.


#### 1.5.3 "End-of-Life" Decision Making



Assumptions about disability and well-being play an important if
somewhat less salient role in this context. They figure most
prominently when the individual is no longer capable of deciding for
herself whether to receive, continue or refuse life-sustaining
treatment. For adults once capable of making such decisions, two
standards apply to surrogate decision making: *substituted
judgment* and *best interest.* The first involves judging
what the individual would have wanted or chosen if she could want or
choose for her current situation; the second involves judging the
person's interests by a standard other than her own. In cases
where the adult never had decisional capacity and there is no basis
for making a judgment about what the patient would have chosen, the
best interest standard applies. But those who judge the best interests
of such an adult are prone to the same errors of projection as
nondisabled people judging the well-being of disabled people. A
nondisabled surrogate might be devastated at losing capacities the
cognitively impaired individual never had, or assume that the
inability to understand the source of, or reason for, physical pain
must be even more traumatic for that individual than it would be for
the surrogate. Such judgments are not clearly wrong, but rather
speculative; the primary error is in overconfidence.



Assumptions about disability and well-being also play a significant
role in judging the reasonableness of requests by competent adults to
end, or not receive, life sustaining treatment. Many jurisdictions
recognize the right of such individuals to make this decision for
themselves, but disability advocates remain concerned that their
decisions are more likely to be considered reasonable, and respected,
if they are made in response to severe, permanent disabilities. Thus,
in the influential case of Elizabeth Bouvia, the court allowed a fully
competent, severely disabled, women to refuse the medical support that
could have prolonged her life indefinitely. Critics of the decision
maintained that both Bouvia and the court were unduly swayed by the
perceived indignity of her physical dependence, and by their
difficulty in seeing how life could go very well with a severe
disability (Asch 2005; Gill 1992; Longmore 1987).


#### 1.5.4 Health Related Quality-of-Life Measures



Perhaps the setting in which the relationship of disability to
well-being has received most attention is the assessment of
"quality of life" (see, generally, Wasserman, et al.
2005a). For judging the cost-effectiveness of medical interventions,
it is useful to have measures of well-being that facilitate
quantitative comparison. Quality-of-life measures in medicine and
health care offer benchmarks for assessing the well-being of groups of
people, focusing on the aspects of well-being most amenable to
reliable assessment. There is no guarantee that individuals who are
doing well by such measures are actually living good lives according
to more robust philosophical criteria of well-being. Any uniform
metric for quality of life will provide an oversimplified assessment
of an individual's well-being, and to some extent this is
unavoidable from a policy perspective. But the worry when these
judgments are applied to people with disabilities is not
oversimplification so much as systematic bias.



Assumptions about the adverse effect of disability on well-being
pervade the measurement of "health-related quality of
life" (HRQL). In particular, two features of many standard
approaches to measuring HRQL treat disability as inimical to
well-being: 1) assuming that an individual's adaptation to a
disability is a source of distortion or a measurement artifact in
assessing how well he or she is doing; 2) expanding the definition of
health outcomes to include not only the physiological and
sensory-motor effects of disease and injury, but their
"sequelae"--their effect on daily living and social
participation. The first feature ignores the extent to which
adaptation involves changes that would count as improvements in
well-being on most objective as well as subjective accounts (Menzel
et al. 2002; Barnes 2009a). The second fails to distinguish the
contribution of medical and social/environmental factors to the
restriction or loss of objectively valuable activities (Wasserman, et
al. 2005a). These features not only exaggerate the adverse impact of
disabilities, but in some contexts, threaten adverse consequences for
people with disabilities.



The inclusion of functional and activity limitations as health
outcomes is in tension with the social model of disability, which
treats many of those limitations as due to an exclusionary
environment. It also conflicts with the view, discussed below, that an
individual can be disabled but healthy. The assumption that adaptation
to disability cannot be an accurate measure of well-being has
motivated a reliance on health professionals to assess the quality of
life with specific disabilities, rather than on people with those
disabilities (Murray 1996). The refusal to treat people with
disabilities as reliable witnesses to, or authorities on, their
well-being is particularly striking, given that nondisabled people
also adapt to the vicissitudes of their lives (Brickman and Campbell
1971). As Wasserman, et al. note:



> 
> 
> The lives of people with disabilities are assumed to be of low
> quality, whatever environmental factors mediate the impact of their
> impairments, and their own testimony to the contrary is seen as
> inherently unreliable. Their adaptations to their impairments appear
> not as instances of the universal processes of adjustment to changed
> circumstances, but as disability-specific strategies for recovering
> the ground that has been lost, or for covering up its loss through
> benign self-deception (2005a: 11).
> 
> 
> 



This view of disability is not merely inaccurate. Its use to assess
the effectiveness of health care interventions has disturbing
implications for the lives of people with disabilities. Effectiveness
measures typically treat a disability as equivalent for assessment
purposes to a shorter life-span. Health outcomes are measured by
life-years saved or gained; life-years are "adjusted" by
their quality, and their rated quality is substantially reduced if the
intervention fails to correct, risks causing, or causes a disability.
As a result, people who have, or will be left with, disabilities also
have their future life-years adjusted downward in light of the
presumed lower quality of those life-years. As a result, the priority
of persons with disabilities for life-saving interventions is
substantially reduced. Because it employed such discounting, the 1990
Oregon Health Care Plan to set priorities for Medicaid-funded
procedures was found to discriminate against people with disabilities
(Bodenheimer 1997). Several years later, the most comprehensive
international effort to develop summary measures of population health
proposed a more explicit and very sharp discounting of lives with
disabilities in assessing the "Global Burden of Disease"
and in setting priorities for its reduction (Murray 1996). Although
some objectionable features of the discounting methodology have been
modified (Saloman and Murray 2002), the Global Burden of Disease
frameworks continue to adopt procedures that result in strikingly low
quality-of-life estimates for many disabilities.



Many mainstream philosophers and bioethicists question the use of
summary health measures in priority setting (Harris 1987; Brock 1995).
They argue that their proposed use is based either on a questionable
utilitarian assessment of lives as more valuable if they
"contain" more utility, or on the controversial
distributive principle that society should give scarce goods to those
who will benefit most from them. But many still defend the general
assumptions about disability and quality of life that informed those
measures (Brock 2005). Other philosophers and disability scholars have
challenged these assumptions (Bickenbach 2005). Some have gone even
further, questioning whether quality-of-life assessments place an
exaggerated premium on the prevention or correction of impairments
that do not, in hospitable environments, preclude rich and rewarding
lives (Barnes 2009a; Asch and Wasserman 2010).


## 2. Disability and Health



People appear to regard health as one of the most important goods,
more important than wealth, status, or professional success. Health is
seen as special in part for instrumental reasons, because it is
thought to be a prerequisite for many or most other goods. So the
relationship of health to disability is an issue of central concern
for those who seek to replace or supplement a medical model of
disability (Bickenbach 1993; Shakespeare 2006).



The social model of disability, which informs the Americans with
Disabilities Act and kindred legislation, may appear to move
disability away from health policy and toward civil rights. Yet
movement in one direction does not preclude movement in the other.
People with disabilities have significant health care needs, and their
needs may depend to some extent upon their disabilities. For
philosophers as well as policy makers, the challenge posed by the
social model is to acknowledge the importance of health and health
care for people with disabilities without assuming that all people
with disabilities are unhealthy just because they are disabled, and
without overemphasizing the correction or mitigation of impairments.
This requires a careful examination of the relationship between health
and disability. Do all disabilities result from, or in, a loss of
health? Can a person with a disability be in good or even
"perfect" health? To answer such questions, we need a
serviceable theory, concept, or definition of health.



There are a variety of competing philosophical accounts of health (see
 SEP entry on concepts of health and disease).
 They can be distinguished in several ways: 1) some regard health as
the mere absence of disease (e.g., Hofman 2005); others regard health
as a form of well-being or flourishing, and treat the absence of
disease as at most a necessary condition of health (e.g., Carel 2007
and WHO 1948); 2) some regard the concept of health as value-laden, or
normative, in the sense that the good of health enters into its very
concept (e.g., Engelhardt 1986; DeVito 2000); others regard health as
value-neutral, or non-normative, defined by bio-statistical or other
biological criteria (e.g., Boorse 1987 and Wachbroit 1998); 3) some
see the value of health as instrumental, in the capacity of the agent
or organism to achieve certain goals (e.g., Nordenfeldt 1995); others
see its value as intrinsic as well, as good in itself (e.g., Becker
2005).



These distinctions are not independent of each other. Non-normative
accounts of health tend to treat health as the absence of disease,
dysfunction, or deformity. These accounts also tend to be
instrumental: they define health as normal or species-typical
biological functioning, which is itself defined in such goal-oriented
terms as survival and reproduction. On the other hand, instrumental
accounts that define health in terms of the pursuit of an
individually, culturally, or other variable range of goals will tend
to weaken the connection of health to bodily, cognitive, or affective
functioning.



If health is defined simply as the absence of disease, then a person
can be disabled but healthy if and only if he can be disabled but not
diseased. If, however, health is a state of psychophysical flourishing
or vitality, then an individual can be healthy, although perhaps not
perfectly healthy, even if disabled or diseased, and unhealthy even if
free of disability or disease.



Many philosophers and bioethicists take it that "health",
"disease", and "disability" are value-laden,
that it is part of their meaning that the conditions to which they
refer are (inherently) desirable or undesirable (e.g., Engelhardt 1986
and DeVito 2000). Two notable exceptions are Christopher Boorse and
Robert Wachbroit, who offer biomedical definitions that are
value-neutral, or as Boorse claims, as value-neutral as biology itself
(Boorse 1987: 359-93; Wachbroit 1998: 533-38). They define
health in terms of normal or species-typical physical and mental
functioning, so that disabilities are by definition unhealthy. But
such value-neutral accounts do not assume that disabilities are
therefore bad or undesirable, merely
 atypical.[2]



Since they deny that the goodness of health is part of its definition,
value-neutral accounts stress the enormous, but contingent,
instrumental value of health. The leading attempt to explain the
importance of health in these terms is Daniels' account of
health-care as maintaining or restoring fair equality of opportunity
(Daniels 1985). Daniels' account gives a priority to the
maintenance of typical functioning and the correction of disabilities
that many critics find excessive (Wasserman 1998: 152-58).
Still, the core intuition, concerning the enormous practical value of
species-typical functioning, can be accepted without accepting medical
normalization as the preferred or default response to atypicality;
indeed, without accepting the claim that species have functions with
species- typical levels defined in biological terms (see Amundson
2000). Further, the claim that species-typical functioning is
instrumentally valuable leaves open the question of *why*
departures from species-typical functioning are instrumentally
*disvaluable*: is it because they render one vulnerable to
discrimination, subject one to an unaccommodating environment, cause
medical problems, or all of the above?



Yet most people have a strong conviction that practical advantages do
not exhaust the value of health, nor practical disadvantages its
disvalue. To accommodate this conviction, those accepting a narrow
definition of health as the absence of disease may want to acknowledge
that disease, or its usual symptoms or consequences, has inherent
disvalue, while distinguishing disability from the other symptoms or
consequences of disease, particularly pain and death. Those adopting a
broader definition of health as an aspect of well-being or flourishing
may also want to claim that being unhealthy has inherent disvalue,
while distinguishing disability from a lack of health.


### 2.1 The First Approach: Distinguishing Disability from Disease



The distinction between disease and disability has received
surprisingly little attention in the philosophical literature. Most
statutory and other official definitions either treat serious diseases
as disabilities or make "impairment", "loss of
function", or "structural/functional abnormality" an
element of disability, leaving the relationship of disease to
disability unclear (e.g., Americans with Disabilities Act, 1990 or
Disability Discrimination Act, 1995). One of the few detailed analyses
of the relationship between disease and disability was offered by Ron
Amundson, who proposed that disability should be understood as one of
the three general consequences of disease, along with pain and death
(Amundson 1992: 105-119). Amundson adopted Boorse's
value-neutral account of health, but argued that Boorse defined
"disease" too broadly, as a "deviation from the
functional organization of typical members of a species"--a
definition which would encompass most disabilities. Amundson contended
that it was both clearer and closer to common usage to treat disease
as an atypical process that tended to result in disability, pain, or
 death.[3]



Amundson defined disability as the loss or deviation from a particular
kind of species-typical function: action at the personal level, e.g.,
the inability to move one's arm, as opposed to the inability to
metabolize sugar. Disabilities that are not products of a process that
leads to pain, death, or further impairment are not symptomatic of
disease in Amundson's sense. They are consistent with health
narrowly defined. Yet some philosophers (Hausman 2001: 254) find the
notion that individuals can be in excellent health if they are blind,
deaf, or paraplegic sufficiently implausible to count against analyses
of health with that implication.



The disagreement between Amundson and Boorse on the distinction
between disease and disability is not just a matter of semantics. The
critical point in Amundson's analysis is a practical one.
Medical interventions are the presumptive response to disease; they
seek to slow, arrest, or reverse processes that cause pain and may
lead to physiological dysfunction, (further) disability (in
Amundson's terms), or death. But on Amundson's view, which
makes disability consistent with health, the presumptive response to
disability need not be medical as opposed to environmental or social.
Furthermore, the loss of opportunity associated with disabilities can
often be prevented or mitigated more effectively and (in the long run)
more economically by modifying the physical and social environment
than by medical intervention. This is true even though environmental
measures are likely to fare poorly against medical interventions in
the competition for scarce resources, because of the prestige and
perceived importance of medical treatment. The failure to distinguish
disease and disability, and the tendency to favor a medical response
for both, reflects the sway of the medical model, and offers a clear
illustration of how it differs from the social model (see
 SEP entry on disability: definitions, models, experience).



Recently, Peter Hucklenbroich has proposed a harm-oriented account of
health as the absence of a "disease" process. Such a
process is *pathological* in the sense that:


1. it is immediately lethal or definitely life-shortening, [or]
2. it is a condition of pain, suffering, or other specific
complaints, [or]
3. it is a condition of infertility (incapability of biological
reproduction), [or]
4. it is a condition of inability or impairment for living together
in human symbiotic communities, [or]
5. it is a non-universal disposition of the organism to develop a
condition that is pathological according to one or more of these
criteria.
 (12)[4]



Hucklenbroich's account defines health in terms of a list of
reasonably health-specific harms and it restricts health to the
absence of biological conditions that either (a) directly
*involve* harm or (b) *dispose* one to suffer harm.



An account along these lines may have the potential to distinguish
disease from disability so as to make the former immediately relevant
to well-being in a way the latter is not. Unlike purely non-normative
accounts, it only finds a health-decrement where something bad comes
from the state of the body. Unlike capaciously normative accounts, it
defines these "bads" in terms of a general and
health-specific harm; not just any body-based limitation on the
pursuit of our (potentially idiosyncratic) goals makes us unhealthy.
And finally, defining health in terms of bodily *dispositions*
could help to explain why extrinsic factors, like those cited by
social models of disability, are irrelevant to health. It could
distinguish between harms that come from social responses to the body
from harms that come from the body itself; thereby distinguishing
between harms that generate claims on health care and harms that
generate claims against discrimination or the denial of fair equality
of opportunity.



Despite the importance of distinguishing disease from disability,
there are at least three reasons why it is difficult to do so. First,
as noted above, many or most diseases are defined as disabilities by
disability discrimination laws or their judicial and administrative
interpretations; they are subject to the same legal protections and
requirements of reasonable accommodation as "Amundsonian"
disabilities. This legal treatment may, however, be justifiable,
because some diseases, such as AIDS, are stigmatized as severely as
many or most disabilities. Second, many disabilities, such as the
inability to walk, may be associated with diseases, such as MS, which
have a progressive character, causing pain and further impairment, and
sometimes increasing the risk of death (Wendell 2001).[5]
 Third, a society such as our own, where atypical functionings are
often not well accommodated, accords a higher priority to the
prevention or treatment of some non-fatal diseases than would a
society that better accommodated them.


### 2.2 The Second Approach: Health as More or Other than the Absence of Disease



An alternative approach to the relationship between health and
disability involves a broad or positive conception of health as more
than, or distinct from, the absence of disease *or* disability.
This approach has more and less instrumental versions. The former is
represented by Nordenfelt's account of health as the ability of
an individual to reach her "vital goals"--those whose
achievement is independently necessary and jointly sufficient for
minimal happiness (Nordenfeldt 1995). On such an instrumental account,
the relationship of disability to health depends on the goals that are
considered vital or central and on the role of typical functions in
achieving them. Some impairments will hinder the pursuit of some goals
(goal-based accounts of health vary in whether or how they specify the
relevant environment(s) affecting their pursuit), other impairments
will have no effect, and some will *enhance* the pursuit of
some goals. Any generalizations about the impact of impairments on
health will depend on the assessment of their net effect on the
pursuit of the specified goals.



The breadth of an instrumental approach is apparent in Sridhar
Venkatapuram's variation on Nordenfeldt, which replaces the
latter's mix of universal and personal "vital goals"
with the "basic capabilities for minimal happiness", as
enumerated by Martha Nussbaum. "What is important",
Venkatapuram maintains, is "the idea of health as the capability
to achieve a cluster of basic capabilities and functionings"
(277). Far from denying
that this conception resembles the much-ridiculed 1948 WHO definition
of health as "a state of complete physical, mental, and social
well-being", Venkatapuram just alters that definition to refer
to a *capability* for *minimal* well-being. Nor does he
shirk from the practical implications of this conception: 



> 
> 
> "Health policy and expertise will have to encompass all the
> determinants of the core human capabilities that constitute a
> minimally decent life" (278). 
> 
> 
> 



At the same time, he recognizes a narrower conception of health,
treating it as one of the more specific capabilities that health in
his broader conception encompasses. Health in this narrow sense is
just the capacity to avoid disease and impairment. But it is unclear
why even health in this narrow sense should be a constituent of
well-being, given the fact of human mortality and vulnerability. 



Lawrence Becker has proposed a broad but less instrumental conception
of health, examining positive conceptions of health in other
disciplines, specifically models of positive mental health in
psychology, which incorporate notions such as resilience, robustness,
developmental maturity, character strength, and subjective well-being
(Becker 2005). Such conceptions go beyond the absence of disease in
two ways: they are positive, requiring psychophysical
vitality--robustness, vigor, and resilience--and they are
broad, concerned not merely with biomedical functioning but with more
comprehensive well-being.



More recently, Becker (2012) argues for "basic good
health" as the metric for "basic justice". For
Becker, basic good health is defined in interactive terms, as
"reliably competent physical and psychological functioning in a
given environment" (2012: 45). As David Crocker (2013) observes,
this notion 



> 
> 
> has both negative and positive elements. The negative dimension
> includes absence of disease, illness, disability, and other
> impairments. The positive aspect is ... "robustly active
> agency. To be healthy is to have a kind of agency appropriate to the
> stages on life's way--from infancy to mature adulthood to
> old age. 
> 
> 
> 



This positive aspect of basic good health, if not the notion as a
whole, gives support and structure to the claim that one can be
disabled but healthy. It could also promote the development of health
interventions for people with disabilities that are not directed at
the normalization of their atypical or impaired functions. One
challenge for this approach is to limit the scope of positive health,
so that it does not encompass all aspects of well-being, but remains
anchored in biomedical functioning. A second challenge for this
approach is to explain how cognitive and affective conditions bear on
health, and how any adverse effects of such conditions can be
mitigated or eliminated without medical normalization.


## 3. Personal Relations, Family, and Disability



Although the connection between disability and interpersonal
relationships is a topic worth exploring in its own right, it also has
important implications for well-being and health. Numerous empirical
studies across a number of behavioral science and medical disciplines
have shown the importance of close interpersonal relationships for
health and well-being (Cohen, Gottlieb, and Underwood 2001; Uchino,
Cacioppo and Kiecolt-Glaser 1996; Cohen and Wills 1985). For example,
more than 130 empirical studies have shown that on a number of
well-being indices, married men and women are generally happier and
less stressed than unmarried people (Coombs 1991). Personal
relationships, including love and friendship, are for most people an
essential ingredient of the life they want for themselves, something
to value for their own sake as well as for the support they provide
during stressful times. However, many people see disability as an
obstacle to friendship, romantic love, and rewarding family life.
Disability scholars and activists reject this widespread belief,
arguing that the obstacles that exist to accessing such relationships
are due primarily to features of the social and physical
environment.



In this section, we discuss the perceived barriers to such
relationships. Clearly, one's view about the effect of
disability on interpersonal relationships depends on one's
conception of disability and on one's conception of the relevant
interpersonal relationships, such as friendship and love. As is
evident from the discussions in the "Friendship" and
"Love" entries in this encyclopedia, there is lively
debate among philosophers concerning the nature and value of love and
friendship.


### 3.1 The Nature of Personal Relationships



The term "personal relationship" encompasses relationships
of widely varying sorts. We will focus on relationships typically
understood as enduring and in some way intimate: between parents and
children, siblings, friends, and committed partners. In that respect,
our conception of personal relationships is narrower than the broad
conception of a relationship that figures in some of the literature on
relational egalitarian theories of justice (see, for example, Anderson
2010; though for a principle of relational egalitarianism that is
derived from consideration of what spouses owe one another, see
Scheffler 2014). The close relationships we have in mind--whether
of friendship, partnership, or family--involve some degree of
mutual regard, personal disclosure, and particularized knowledge. They
also involve material and emotional mutuality, but need not involve
equal exchanges between the parties. 



Philosophers have often treated equality of some kind as a
prerequisite of friendship (see
 SEP entry on friendship).
 In the *Nicomachean Ethics*, Aristotle distinguished among
three kinds of friendship: friendships of pleasure, of utility, and of
virtue. The last, the highest or truest form, required similarity of
character. Philosophers since Aristotle have rejected some of his
prerequisites for friendship, such as equality of social or economic
status, but they have shared his view that friendship must be a
relationship among equals. The debate has largely focused on the kind
of equality that is required. Thus, Aristotle denied that parents and
their children could ever be true friends, since the inequality
between them could never be overcome no matter how much the child does
for his parents. This position is rejected by English (1979) and
Kristjansson (2006). Generally, contemporary accounts of friendship
place less emphasis on equality or similarity of specific traits and
more on equality of respect, investment, and commitment. Given the
vast range of differences among close friends in talents, interests,
and tangible contributions, it would not seem that disabilities pose
any general barrier to intimacy. 



Nevertheless, philosophers and bioethicists have tended to look
skeptically on the possibility that a person with a disability could
offer the mutuality and equality required for a satisfying
relationship with a nondisabled friend, romantic partner, or family
member. Even in those relationships where unequal contributions and
asymmetric dependence are the norm, as with parents and their
children, a child's disability has been seen as an obstacle to a
desirable and rewarding relationship. The disability is perceived as
creating an uncomfortable degree of inequality and dissimilarity;
parents have difficulty picturing the child growing into a productive
adult and parent, fulfilling some of the goals people have for
undertaking childrearing (Ruddick 1998). Additionally, the
child's disability has been viewed as imposing burdens on
parents that differ from and greatly exceed those posed by raising
children who do not have disabilities (Botkin 1995). Moreover, the
child's disability is presumed to extend the duration of
parental care (Botkin 1995; Kittay 1999; Lindemann and Nelson 2008).
Similarly, when the bioethics literature considers people with
disabilities as parents, it is largely to assess whether it will be
harmful for children to be raised by disabled parents (Coleman 2002;
Robertson 2004); or whether adult children will have to give up their
other life projects to care for their newly-disabled parents (Callahan
1988). 



In this literature, relationships involving disabled people are
chiefly viewed from the perspective of those without disabilities.
Whether the topic is end-of-life decision making (Hardwig 2000),
treatment decisions for low birth weight, premature or otherwise
disabled newborns (Stack 1987), the rehabilitation of persons after
traumatic brain injury (Nelson and Frader 2004), or selection for or
against disabling traits in embryos or fetuses (Botkin 1995; Ruddick
2000; Green 2008), the focus is on how nondisabled people are affected
by a (potential) relationship with someone who has a disability. What
is largely missing from these accounts is serious consideration of the
perspective of the person with a disability; of how her life will be
affected, for good or ill, by the family or friendship relationships
in which she is embedded. In addition, little attention is paid to
relationships in which all involved parties have disabilities. As
Chappell (1994) has noted, writers assume that it is in the interest
of people with disabilities to aspire to relationships with
nondisabled people, even if it is not is the interest of the latter.
It seems clear that if the consequences of personal relationships for
the flourishing of persons with disabilities were given the same
weight as the consequences for nondisabled persons, it would encourage
a deeper and fuller appreciation of the goods of personal
relationships. 


### 3.2 Peer Relationships: Friendship and Love



At the heart of the negative portrayal of disability's impact on
interpersonal relationships is the presumed inequality imposed on the
relationship when one participant has a disability but others do not.
The type of inequality and its explanation are not always made
explicit. Does it result from the (perceived) inability of people with
disabilities to participate in activities that are important to some,
most, or all friendships? Or does it arise from the (perceived) need
on the part of the person with a disability for technological or human
assistance to manage typical life tasks? Does it stem from a belief
that the person with a disability does not possess the social or
psychological resources to prove a stimulating and rewarding friend?




The influence of a dichotomous conception of disability, that is, of a
conception of disability as a personal attribute one either has or
lacks, is evident even in the way questions about disability and
personal relationships are framed. In asking questions like "Are
relationships between disabled and nondisabled people necessarily
unequal?" we tend to assume that disability is a categorical
characteristic: that there is a distinct subset of the population that
is disabled and everyone else is nondisabled. If, instead, we adopted
the human variation model of disability (see
 SEP entry on disability: definitions, models, experience),
 we could reframe such questions. That model conceives of an
impairment as an arbitrary range on the continuum of variation for a
human attribute. Moreover, the model sees disability as an interaction
between atypical functioning or embodiment and an unaccommodating
environment. Consequently, it emphasizes that most people are
"disabled" in some particular physical or social context,
insofar as they have some atypical characteristic which fits poorly in
that context. The model also suggests that a disability, like an
impairment, ought to be considered as a graduated characteristic: just
as there are degrees of functioning, there are degrees of fit between
functioning-embodiment and social environment. 



On this view, the question "Are relationships between disabled
and nondisabled people problematically unequal?" would be better
reformulated as 



Is there a positive correlation between the degree to which the
parties to a relationship differ in overall level of disability, on
the one hand, and the degree of problematic interpersonal inequality,
on the other? 



Although this is largely an empirical question and cannot be answered
by philosophical reflection alone, philosophy can clarify the concepts
that figure in the question: what is it to have a disability, what
sorts of equality matter in valuable interpersonal relationships, and
is there a reason, given what disability is and what sorts of equality
matter, to think *ex ante* that such a correlation would
exist?



One reason having or acquiring a physical, intellectual, or emotional
disability lessens the chances that relationships will move beyond
acquaintanceship is that the disability looms so large in the minds of
the nondisabled person (and perhaps the disabled person as well) that
it obscures or eclipses other features on which an intimate
relationship can be solidly grounded. Most people do not yet see
disability as one among many characteristics with respect to which
humans can vary. In this way, one aspect of a person comes to dominate
the whole, an aspect of stigmatization that elsewhere we have
described as "synecdoche" (Asch and Wasserman 2005).


### 3.3 Romantic Love and Sexual Intimacy



These points apply as well to the relationship between disability and
romantic and sexual intimacy. This aspect of romantic leave can
amplify the concerns of people already skeptical about the ability of
persons with disabilities to contribute to thriving friendships. Many
nondisabled people may doubt that people with disabilities can be
fulfilling partners in any loving adult relationship. Prominent
explanations of love, again based in Aristotle, hold that having
loving relationships promotes self-knowledge, insofar as one's
beloved acts as a kind of mirror, reflecting back one's
character (see SEP entries on
 love
 and
 friendship).
 Many nondisabled people may find it hard to imagine seeing their
reflection in a disabled partner. According to LaFollette (1996),
love, at least ideally, brings out the best in the participants. For
nondisabled people, it may be hard to see past the impairment to
imagine that a partner with a disability can bring out their best, be
similar enough to understand them, enhance their self-worth, or meet
their deepest needs. 



Disability creates a number of challenges to forging intimate physical
and emotional relationships. People with sensory-motor impairments who
were disabled beginning in early life often report that they were
socially segregated from other children, either directly because they
were tracked into different classes or different schools, or
indirectly because other students avoided them. Consequently, many
disabled children have not been socialized about sex in the way other
children have been: even playground misinformation can play a role in
developing and affirming a sense of nascent sexual identity in
able-bodied children, yet disabled children are often excluded from
this process. To make matters worse, many disabled children do not
receive sex education until a much later age than their able-bodied
peers (if at all), a reflection of the pervasive stereotype that
disabled people are infantile and asexual (Shakespeare 1996). 



These challenges persist into adulthood. When disabled people form
intimate relationships with other adults, cultural stereotypes and
prejudices continue to exact a high cost. Disabled people are often
expected to be "with their own kind", and if they do form
intimate relationships with unimpaired people, they must confront
patronizing assumptions about the "real" reasons for the
relationship: dependency, pity, etc.. When disabled people form
intimate relationships with one another, they must overcome
psychological barriers to intimacy that result from society's
views about what an appropriate partner would be or what acceptable
sexual activity is. Or they must battle family opposition to being
with a partner whose similar or different disability prevents that
partner from assuming the role of "caregiver" or personal
assistant. Emens (2009) shows how institutional practices, along with
physical and communication barriers, perpetuate and reinforce
prevailing views that people with disabilities will be incapable of
participating in sexual and partner relationships. 



For various reasons, people with intellectual disabilities have been
thought incapable of understanding and appreciating the value of
romantic, sexual, or partner relationships. But as first-person
narratives attest, disabled people have grown quite adept at
navigating and even overcoming these challenges (Shakespeare 1996).
Narratives and research demonstrate that even people with
developmental disabilities or dementia can and often do consent to
mutual, sustained sexual relations (Kaeser 1992). This is not to deny,
obviously, that some disabled people lack the cognitive abilities
necessary to genuinely consent to sex.


### 3.4 Parenting and Disability



The assumption that people with disabilities will not be able to enter
into intimate relationships, or will impose onerous burdens on their
intimates, may play a significant role in the routinization of
prenatal testing and abortion for disability. The reluctance of many
parents to have a disabled child often rests on an exaggerated view of
the physical and emotional demands of raising such children, or on a
failure to appreciate the capacities of such children to form
rewarding parent-child relationships. The latter is likely to play a
major role in the strength of the desire to avoid having a child with
a serious cognitive impairment. Indeed, surveys show that prospective
parents are far more reluctant to have a child with a cognitive or
affective impairment than a sensory or motor impairment (Wertz 1998).



 This reluctance may also rest to a great extent on the
overwhelming salience of the impairment in a setting where little else
can be known about the future child. That salience reinforces the
already-powerful tendency to see only the stigmatized trait. Botkin
may express the dominant view among prospective parents in arguing
that the burden of raising a child with a disability should be treated
as equivalent to the burden of raising an unwanted child (Botkin 1995:
32-39). Ferguson argues that the findings from research and
from parent narratives in the past thirty years contradict such
assertions and demonstrate that families with a child who has a
disability look much like other families in terms of satisfaction,
stress, and system functioning (Ferguson 2001: 373-95). Other
research suggests that raising children with severe cognitive and
other disabilities has greater stresses but similar rewards
(Aschbrenner, et al. 2010; Blacher and Baker 2007; Gerstein et
al. 2009).



Prospective parents with disabilities are less likely to be encumbered
by these stereotypes about disabled children, but they may believe
that their disabilities have been sufficiently difficult for them that
they do not want to pass them on to their children. Moreover, even if
their impairment is not genetic and they are likely to become the
biological parent of a child without a disability, they must struggle
with deeply-rooted skepticism about their own ability to parent
disabled or nondisabled children. If one of the most pervasive
assumptions about disability is its association with a need for help
or "care" from others, the person with a disability may
think herself incapable of doing so for others.



The prospect of parenting by people with disabilities provides an
opportunity to consider the question of which components of customary
parent-child relationships are essential to good parenting (Blustein
1982; Ruddick 1998; O'Neill 2002). Parents with disabilities,
particularly cognitive disabilities, are often regarded as unfit to
meet the "special needs" of disabled children, and
incapable of serving as mentors and role models for nondisabled
children. Although some judicial decisions, empirical reports, and
personal narratives recognize that many people with physical, sensory,
affective, and cognitive impairments can effectively raise children
alone or with some assistance, daily life, social service agencies,
and attitudes of professionals and the public still thwart people with
disabilities in their parenting goals (Collings and Llewellyn
2012; Picciuto 2015). However, social attitudes
are gradually changing as examples of successful parenting by people
with disabilities proliferate (Mutcherson 2008).


### 3.5 Personal relationships and third-party assistance



Disability theorists and activists reject the assumption that
disabilities pose unique difficulties for personal relationships on
the grounds that this assumption reflects an overly narrow view of the
mutuality required in an intimate relationship. That said, not all
persons with and without disabilities have the same views about
possibility of combining intimacy with disability-specific personal
assistance. To accommodate these differences, some theorists and
activists have argued for options that separate instrumental
assistance from close relationships. These options involve providing
by paid staff for personal assistance in cases where this helps to
preserve the mutuality, sharing, and interdependence of friendships,
partner relations, and family life (Litvak et al. 1987; Asch 1993;
Ratzka 2004). There is much to be said in favor of making third-party
assistance available. The lack of education and training of family
members in meeting a person's disability-related needs, the
societal treatment of these needs as different from and more shameful
than other needs, and the scarcity and inaccessibility of other
supportive services for meeting these needs, can indeed place enormous
strain on intimate relationships between nondisabled and disabled
persons. Further, the constant reliance upon intimates for assistance
with travel, communication, or preparation for work or school may
thwart the desires of persons with disabilities to select what they
wear, when they come and go, or with whom they associate in their free
time. The idea of an entitlement to state-subsidized personal
assistance has been developed on a policy level by Litvak, Heumann,
and Zukas (1987), Adolf Ratzka (2004), and Americans Disabled For
Attendant Programs Today (ADAPT). 



It might be thought that the argument for state-subsidized personal
assistance undermines the claim that disability does not pose any
general barriers to intimacy. Those arguing that the state should
subsidize personal assistance for people with disabilities might seem
to share the assumption of Callahan (1988) and Wertz and Fletcher
(1993) that disability-related needs differ in kind as well as in
degree from other material and emotional needs for which
state-subsidized assistance is not defended.



Disability advocates would reject this conclusion for at least two
reasons. First, it is the stigmatization of disability-related needs,
more than the actual cost of meeting them, which serves as a barrier
to intimacy. The stigmatization of disability-related needs creates an
aversion to meeting those needs and a tendency to exaggerate the costs
of doing so. There is an inclination to see meeting those needs as
falling outside the scope of an intimate relationship, when meeting
relevantly similar needs of a nondisabled relative are seen as part
and parcel of intimate relating. By subsidizing personal assistance,
the state helps to overcome the exclusionary effects of deeply
entrenched social attitudes that pose a barrier to intimacy. If these
attitudes change so that the dominant culture does not find it
shameful to have disability-specific needs and distasteful to meet
them, there might well be less need for personal assistance programs.
The remaining need for personal assistance would not sharply
distinguish persons with disabilities from friends and intimates who
also call upon each other for various forms of assistance.



Second, the fact that some people with disabilities require more
assistance than most nondisabled people to achieve their life goals
does not mean that disabilities must pose a barrier to intimacy.
Intimate relationships often impose special demands on participants
unrelated to disability. An individual with expensive projects or
commitments may cost significantly more to befriend or marry, but
unless those projects and commitments are extravagant or
all-consuming, we would not see them as a general barrier to intimacy.
Likewise, even in an Internet age, it may be more costly to maintain
friendships with people who live in remote areas. Yet we tend to see
those costs as incidental to the relationships we form, even if they
limit them in ways we may regret (Amundson 2005).



A state-subsidized personal assistance response to disability-related
needs is not welcomed by all disability theorists and activists.
Wendell (1989, 1996) sees people with disabilities, in their
dependence, as having lessons to teach nondisabled people about human
interdependence. Similarly, Eva Kittay has argued for the importance
of kinship caregiving. Kittay stresses the importance of a loving and
"sustaining" relationship between the caregiver and the
care-recipient, which may be absent when care is professionally
outsourced. Moreover, family caregivers are more likely to maintain
trusting and long-lasting relationships, as opposed to professional
caregivers, who may come and go. Furthermore, Kittay stresses the
significance of including disabled people in familial and cultural
activities rather than relegating them to paid caregivers, although it
is not clear why having a paid assistant is inimical to participating
in familial and communal activities (Kittay 2003). (See also Longmore
1995 and Levine 2004.).



These arguments about the value of kinship caregiving do not undermine
the case for making professional caregiving relationships a dignified
and economically viable option. There are many families ill-equipped
or poorly disposed to adopt that option. But there are also many
circumstances in which the differentiation of personal assistant from
parent, spouse, or friend will give the person with a disability the
freedom and privacy that nondisabled people take for granted. In
circumstances where kinship assistance would strain rather than
enhance intimate relationships between family members, it seems clear
that third-party assistance should at least be made available as an
option, even if it is not encouraged across-the-board. 



Subsidizing third-party assistance is a means by which the state can
help to create the conditions for the flourishing of positive
relationships. The provision of paid third-party assistance is not
intended to force the separation of instrumental help from close
relationships, but to give friends and family members the freedom to
decide how much of such assistance they want to incorporate into their
relationships. Friends and family members may be entirely comfortable
meeting someone's disability-specific needs, just as they are
prepared to meet other needs of the people with whom they have
intimate relationships (Asch 1993). In other cases, and with respect
to other needs, they may not. Close relationships are not all of a
piece, and persons with disabilities, their friends, family members,
and lovers should be able to determine for themselves what kind of
relationship they will have and what role there is in it for
third-party assistance.


## 4. Conclusion



Having separately discussed well-being, health, and personal
relationship, the Entry concludes by considering the links among these
three domains, as they pertain to disability.



On most plausible accounts of well-being, health and personal
relationships are either instrumentally conducive to well-being or
partially constitutive of it. An account of well-being which entailed
that health and personal relationships were not important means to or
constituents of well-being would be *prima facie* implausible.
Consequently, an account of health entailing that persons with
disabilities are necessarily unhealthy, or an account of personal
relationships entailing that persons with disabilities cannot enjoy
many of the goods of those relationships, will also have the
implication that persons with disabilities cannot attain the same
level of well-being as able-bodied persons *absent*
compensating capacities or achievements in other domains.



Many laypersons, policymakers, and philosophers implicitly or
explicitly adopt theories of health and personal relationships with
this implication. But there are plausible accounts of health and
personal relationships which do not entail that disability is inimical
to well-being. And on most plausible accounts of well-being,
disability need not present a formidable barrier to living a good
life. This is so on appropriately pluralistic, flexible and
broadly-framed objective-list accounts as well as on subjective
accounts. A blind or deaf person cannot exercise all five senses. But
there are plausible arguments for the conclusion that they can have
lives with rich aesthetic experience, pleasure, and joy.



We suggest that the difficulty in appreciating that people with
disabilities may have lives as good as those of people without
disabilities, objectively as well as subjectively, may arise in part
from a failure of imagination by nondisabled people. A body of
empirical research indicates that people without disabilities rate the
subjective well-being of people with disabilities far lower than they
rate it themselves. (Albrecht and Devlieger 1999; Gill 2000; Goering
2008). If all persons enjoy a defeasible presumption of epistemic
authority with respect to the quality of their experiences, this
divergence suggests that the widely shared assumption that
disabilities reduce quality of life should be regarded as
controversial, not self-evident. Although we have no empirical
research to support us, we suspect the same is true for the divergent
assessments of the prospects for objective well-being of people with
disabilities. Non-disabled people may have greater difficulty
imagining how people with disabilities can enjoy or develop the
capabilities for the various constituents of objective well-being,
particularly those concerning health and personal relationships.



This highlights a broader point connecting all three domains, as well
as the relationship between philosophy and disability more generally.
Most philosophical discussions of disability have implicitly assumed
the perspective of persons who do not have a disability. They have
asked whether *other* people, the people with disabilities,
have lower levels of well-being; whether other people, the people with
disabilities, are less healthy; whether other people, the people with
disabilities, will pose a comparatively higher burden as friends or
intimates. In much recent work in political philosophy, disability has
figured most prominently as a paradigm example of bad luck, and the
question is whether and to what extent we the able-bodied should
compensate disabled others for their misfortune (see
 SEP entry on disability and justice).
 By implicitly adopting the perspective of nondisabled persons, from
which persons with disabilities appear only in the third-person, much
mainstream work in philosophy has failed to take seriously the
perspectives of persons with disabilities--even when those
perspectives are directly relevant to the conceptual question under
discussion: what is the nature of well-being, or friendship, or
health? We hope that this entry can be a point of departure for a
discussion of these concepts that takes into account a wider range of
relevant considered judgments, intuitions, and perspectives.