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7ИССЛЕДОВАНИЯ КУЛЬТУРЫ
Теория возможностей и максимизирование здоровья: вызовы пандемии
А. А. Даровских
Во время пандемий вопросы распределения медицинских ресурсов становятся особенно острыми. В данной статье автор проводит этический анализ одного из подходов к распределению медицинских ресурсов - теории возможностей. Показывается, в какой степени подход, основанный на теории возможностей, может предоставить новые пути решения проблемы в области распределения медицинских ресурсов. Приводятся аргументы в пользу эффективности подхода, основанного на теории возможностей, в условиях нынешнего кризиса системы здравоохранения, связанного с пандемией 2020-2021 годов. Автор подчёркивает преимущество подхода, основанного на теории возможностей, перед теориями благосостояния (например, ОАЬУ), и настаивает на неприемлемости «эй-джизма». Данный аспект представляется особенно важным, учитывая, что пожилое население находится в большей зоне риска, и учитывая природу вируса. В заключительной части статьи показаны некоторые слабые места в теории возможностей: показано, что проблема агрегирования возможностей представляет собой серьёзную практическую сложность.
Ключевые слова: Медицинская этика, распределение ресурсов, пандемия, теория возможностей, утилитаризм, годы жизни с поправкой на качество (ОАЬУ)
The capabilities approach and health maximization: the challenges of the pandemic2
Andrey A. Darovskikh
Pandemics is the time when the questions of medical resource allocation become especially acute. This paper focuses on one of the approaches to health care distribution - the capabilities approach. It examines the extent to which the capabilities approach can provide new solutions to the decision making in health care and medical resource allocation. The author argues for the efficiency of the capabilities approach in the current health care crisis of the 2020-2021 pandemic. Secondly, it focuses on one specific advantage of the capabilities approach over the welfare theories (QALY), namely the avoidance of ageism. This aspect seems crucial because the elderly population suffers disproportionally due to the nature of the virus. Lastly, the paper shows some limitations of the capabilities approach: it is argued that the problem of capabilities aggregation presents a serious practical challenge.
Keywords: Medical ethics, resource allocation, pandemic, the Capabilities approach, utilitarianism, Quality adjusted life years (QALY)
Introduction
What is pandemic, apart from medical and societal definitions? One can formulate it as a raging of an infection with serious clinical manifestations, most importantly including high death rate which reaches several countries and territories. Although the ultimate course of a disease and its impact are uncertain, it is not merely possible but likely that it will produce enough severe illness to overwhelm health care infrastructure. An outburst of pandemics usually places tremendous pressure on the existing health system. It ultimately requires rationing medical resources and interventions. Furthermore, the individual relations to the state of health
2 This study is a part of a research project "Social order in conditions of epidemic: socio-philosophical analysis" supported by the Russian Foundation for Basic Research (project № 20-011-00314).
condition the social relationship regarding health care distribution. Everyone has some understanding about a norm of their health, based on that people have expectations about the available treatment. One of the approaches to health care distribution which allows to talk about the flexibility of the norm is the capabilities approach. The capabilities approach was first developed by an economist and philosopher Amartia Sen, later it was furthered in collaboration with Martha Nussbaum and some others.3 Coming from the field of economics, the capabilities approach has made a great deal of impact on a number of academic disciplines and policy making; it also forayed into the territory of health care and medicine.4 This paper focuses on examining the extent to which the capabilities approach can help provide new solutions to the decision making in health care and medical resource allocation.
The capabilities approach is neither an egalitarian theory nor it is a theory of distributive justice. This approach conceives physical capabilities as providing opportunity to be someone, and to do something, what is at discretion of the individual. Capabilities are not something formally (nominally) available, it is some type of real physical opportunity, which is "effectively available to the agent". The main direction of the study about capabilities approach aims to work out a full theory of justice, but I see my interest in this paper in outlining a move toward more applied, non-ideal theory. So, it should be rather an applied theory of health available for some real circumstances, such as our current circumstance of the 20202021 pandemic.
This paper is not specifically about COVID-19, but I take some implications of it as a case study in order to show the advantages of the capabilities approach. As a second focus of this study, I argue that the capabilities approach provides more robust justification of age-related access to health care than the QALY (quality adjusted life years) approach. It is a well-known fact that on top of other co-morbidities the severity of outcome of coronavirus disease disproportionally de-
3 See: [6; 17; 22; 23; 31]. For more recent studies on capabilities approach see: [4; 11].
4 See: [2; 3; 8; 10; 16; 26].
pends on the age of patients. Statistically 80% of hospitalizations fall on adults over 65 years old, and they have a 24-fold greater risk of a fatal outcome compare to those who are under 65. It is a matter of fact that as people age, they tend to have more of underlying conditions and for instance cardiovascular disease, diabetes and obesity significantly increase the chances of a fatal scenario. Nevertheless, different studies show that this "mild" illness in case of young and life-threatening one in case of elderly can be explained by the molecular difference between young, middle aged and older people [15]. Thus, it looks like age in itself is an independent risk factor in the case of COVID. In the paper I will argue that even though the capabilities approach is not committed to age related rationing it does better job in avoiding the alleged ageism normally attributed to utilitarian strategies of health care maximizations.
Finally, I will conclude with some limitations of the capabilities approach and focus on the problem of aggregation which poses a practical challenge to the maximization of health in case if we put the capabilities approach into practice.
Capabilities and Freedom
The core of the theory of capabilities is the idea of what people can do vs what they actually do. Consequently, the capabilities approach in its essence relates to the state of human freedom: the freedom to achieve some sort of well-being. For in order to achieve the state of well-being people are often in need of some physiological capabilities, i.e., freedom to achieve well-being can be understood in terms of people's functionality (capabilities). Functionality in itself, can either be good or bad or even neutral, and often times the goodness or badness of functionality depends on the context. As a conceptual category functioning is neutral and refers to the state of being someone or to the activity of doing something. Conceivably it can be good or bad depending on the concept. For example, it is bad to be undernourished if you are poor and you really want to eat, however, it is not bad to be undernour-
ished if you are fasting as a part of your diet, physical therapy, or religious practice.5
Capabilities - is potentiality, while functioning - is a realization of that potentiality, i.e., it is perfection of capabilities. Thus, equality of capability is different from equality of functioning in the same way as equality of opportunity is different from the equality of outcome. Normally when people talk about the "capabilities approach" they talk about any of the three main aspects:
1) Assessment of individual well-being. How do we measure well-being, and what we consider as a necessary attribute of that well-being?
2) The evaluation and assessment of social arrangements.
3) The design of policies and proposals about social change in the society.
The assessment of individual well-being is supposed to tell us which types of beings and doings matter (are desirable) and for who. Is it possible to have one overall assessment of well-being by means of capabilities? How can we put together all capabilities into one unified assessment of well-being? The functionings as realizations of capabilities are constitutive component of person's being. When we say that functionings are constituents we want to say that they literally constitute the being of a human. Every human being has at least some list of functionings. At this point we can either talk about normal species functioning which make lives of humans both lives and also human. On top of that one can argue for capabilities which warrant proper fuctionings that define particular individuals. Thus, in order to evaluate a state of well-being we need to assess the constituent elements of the well-being, i.e. we need to evaluate capabilities.
Basic capabilities
Discussions about national (or universal) health care often try to look for some minimum threshold of health below which no one should be pushed. The capabilities approach al-
5 This is a famous example repeated by many in different studies. For example, see: [4, p. 299].
so formulates this threshold as inherent gear of individuals that is necessary for expanding the more enhanced capabilities [17, p. 84]. This innate equipment in the form of basic capabilities allows to satisfy some crucially important function-ings. In other words basic capabilities refer to the freedom to do some essential things considered that are necessary for survival and consequently to escape poverty or other serious deprivations [24, p. 19]. The relevance of basic capabilities stems from the fact that they help to figure out not just the standards of living but rather the cut-off points that help delimit poverty and deprivation [23, p. 109]. The point about basic capabilities, can be either formulated as a part of a theory of justice, because it is something what we want all people to provide with; or if we talk about health care distribution, then basic capabilities is something below what we cannot go, unless people do choose that.
With that being said, the task of a state/society in providing basic capabilities seems to be necessary. It can be something like a real opportunity to avoid misery, poverty, and meeting the lower threshold of physical functionality. However, in the affluent fraction of the population, by contrast, well-being assessment will focus on capabilities that are less necessary for survival and not basic. In this respect the capabilities approach seems to be better than functionality/normal species functioning approach because the appreciation of capabilities does not pick a "particular account of good life", instead it admits variability of opportunities among which a person can choose a way to live.
Selecting capabilities
One of the frequently mentioned critiques the capabilities approach appeals to the difficulty in measuring capabilities. No doubt, to measure functioning seems easier, because they are not just opportunities and they are at least observable. But even if we come up with criteria how to measures capabilities, one may further question: which capabilities we select as relevant, and most importantly who will decide it? Clearly, in some ideal world - all capabilities are important and should count. When we talk about ideal world, we not only imply some ideal financial circumstances but also some
ideal technological capabilities, and even some ideal interest to all capabilities. Obviously, there might be some human capabilities which are if no interest to all people, or at least to majority.
Let us look at this problem from a different perspective: do we need to differentiate between some more relevant capabilities and some less relevant? Who does decide which capabilities are relevant and which are irrelevant? Even a cursory reading of the literature advices that authors normally say that we need to demarcate relevant capabilities from irrele-vant.6
When we differentiate between capabilities, we can start with outlining a possible lower threshold of capabilities, beyond which no one wants to go, and therefore society cannot force anyone to go beyond that threshold. There are many proposals about the selecting process; some of them are substantive proposals with a developed theoretical framework some are rather "a theoretical practices" which imply data collection and subsequent decision based on certain statistical techniques. Here are some of them:
1. The only relevant basic capabilities are those which are needed for participation in societal life as a citizen, i.e. they aim to help avoid any time of oppressive social relationships [5].
2. Nussbaum's list of ten capabilities which are moral entitlements of every human being: life; bodily health; bodily integrity; senses, imagination, and thought; emotions; practical reason; affiliation; other species; play; and control over one's environment [18]. Nussbaum argues that each of these capabilities is needed in order for a human life to be "not so impoverished that it is not worthy of the dignity of a human being" [17, p. 72].
3. Sen has been reticent on the question of how to select and weight capabilities. Overall, he draws on his ideal of agency and argues that each group should select capabilities independently.
4. Sabina Alkire offers practical reasoning approach -"Why do I do what I do"? The basic reasons for acting are the
6 See: [19; 20; 21].
following capabilities: life, knowledge, play, aesthetic experience, sociability (friendship), practical reasonableness, and religion [1].
5. Lastly, David Croker proposes an agency-sensitive capability approach [9].
When we select capabilities, we can work in ideal and non-deal circumstances. If it is a theory of justice within and ideal world it is one thing, but if we move to non-ideal circumstances then the selection becomes even more difficult, because of feasibility constrains, availability of resources, technological possibilities, practical relevance. It is true that those lists are often formulated at a very abstract level. This is because the capability theory contrary to some other theories of justice is concerned not with the means to well-being, but with well-being itself, which can be achieved differently. A more precise version can be done on a local level, while all the differences are considered. The reason, why the lists of capabilities is so vague is partly because not always people want to put forward one list of predetermined capabilities.
The welfarist maximization of health.
Quality adjusted life years
Before I proceed with application of capabilities approach to the questions of resource allocation, I would like to present a contrasting argument of welfarism, which I think only illuminates the advantages of capabilities system. The traditional approach to health maximization on a macro level can be viewed as an attempt to employ utilitarianism when outcomes matter more than principles. QALY is a welfarist approach which falls into the broader scope of utilitarianism; however it relies on the assessment of the quality of outcomes. Thus, QALY or quality adjusted life years, is a system of balancing the quality and quantity of a patient's expected life years following a specific treatment. The quantity can be measured by the number of years a patient is expected to live after treatment and quality can be measured by the feelings of the average representative patient after having that treatment. The invention of QALY attributed to several works which suggested an idea that for maximization of health care we
need to adjust length of life by numerous indices of functionality.7 The first appearance of the term is credited to Zeckhauser and Shepard [32]. QALY is a measure of the value of health outcomes, where a year of life in perfect health is given a value of 1 and a year of unhealthy life is given a value of <1 (e.g. 0.5). A negative QALY would be an outcome that is worse than death (which is 0 QALY), that would be a type of life which is not worth living. The effectiveness of QALY can be considered through the example of Laryngial Carcinoma and its different treatments. In the case of such a diagnosis a surgery brings a 60 % five-year survival rate, but it is incompatible with normal speech, while radiotherapy yields only 30-40 % five-year survival rate however it preserves normal speech. In such a case QALY should investigate the cost effectiveness of each procedure and if they are roughly equal it will favor the radiotherapy. Overall QALY is a system that looks at what would benefit a big population, thus a health care system which maximizes QALYs is the one which proves the most benefit. It not only promotes health, but the quality and quantity of patients' lives.
Some of the common arguments against QALY include claims that it discriminates against those with expensive healthcare problems. Thus a 60-year-old burn patient may require prolonged stay on intensive care, repeated surgery etc. In such a case the total cost of care can enter hundreds of thousands euro /dollars and the patient may only live another 10 years. Thus, the cost of QALY would be too high and it will bring too little benefit for the society. In contrast with that QALY would be in favor of providing financial resources for smoking cessation therapy to thousands of people, where the costs will be minimal with a maximum benefit for the society.
Another argument against QALY points out that it normally favors those who are already better off. For instance, we have 2 patients both requiring treatment for community acquired pneumonia. Patient A is fit and well, while patient B has COPD, CCF and IHD. Certainly, in such circumstance QALY would favor the treatment of patient A. Lastly, QALY is often criticized for being "ageist". Older patients normally have
7 See: [12; 14; 28].
increasing likelihood of co-morbidities, thus limiting quality of life years gained subsequent upon treatment. Therefore, treatment would generally favor younger healthier patients.8 To do justice, I would argue that QALY does not specifically discriminate based on age. For instance, a 10-year-old with condition resulting short life expectancy would not be favored by QALY, while a 70 year old, marathon runner with no medical concerns may go on to live another 10-20 years and will certainly be ranked with a greater potential for QALY gain. It is just the way things naturally work so that age comes with co-morbidities, and therefore QALY favors younger, even though it is not specifically focusing on age, and does not discriminates based on age solely. Nevertheless, there is a tendency to argue that even indirect age relatedness of health care distribution is a sign of ageism.9
Capabilities and health maximization
Often, the capabilities approach is presented as an alternative to welfare economics for the resolution of public health problems and resource allocation. There is a conventional agreement about four points difference between the capabilities approach and welfare economics, and all these points are relevant for the medical resource allocation.
1. Contrary to welfare economics, which underlines the activities people take, the capabilities approach focuses on the options people have.
2. The capabilities approach facilitates the multivariable approach to well-being.
3. The capabilities approach allows to make interpersonal comparisons, which are normally difficult to make because interpersonal utility is rather elusive.
4. Contrary to economic welfare the capabilities approach does not focus on preferences for measuring personal interests.
I am picking on the study of Anand who argues that the QALY / welfarist "defense of health maximization is flawed, not as justification of age-related rationing, but rather as defense
8 For the ageist critique of welfare approaches see: [29].
9 See: [13; 27; 30].
of health maximization" [4, p. 302]. Contrary to that the capabilities approach seems to do better in providing a justification of health care rationing in the conditions when age is not possible to neglect. In this respect I would like to get back to the question of selecting the capabilities. We need to ask the question: which capabilities would we like to promote? The point is that depending on in which way we would like to succeed it will change the array of capabilities we should promote. The role of age in such a case becomes rather interesting. The thing is that people accept age and all the consequences of it like the lack of mobilities, some normally associated with age diseases, but they are not ready to accept pain or higher chances of fatal results in case of something what normally does not pose a common threat. That reflects in our view on capabilities: when you are 30 you are not happy that you cannot run in order to catch a bus, however when you are 70, your view on this capability changes and you sort of expect it not to happen and do not even try. As Anand puts it "... there is a tendency to be objective with respect to the dimensions of capabilities and functionings..." [4, p. 302]. Since we all age slightly differently and have different interests as a result our tradeoffs of those dimensions of capabilities are usually subjective; i.e. some people cannot tolerate that they are no longer capable of playing tennis, others are not happy that their hearing can no longer allow them enjoy their famous opera performance. Nevertheless, if we can conventionally agree on some level of capabilities and functionings with regard to the age - that will have impact on the system of health care distribution. It is important to note, that such policy might look as discriminatory with respect to age, but for the reasons which connect to a (conventionally) socially desirable outcomes. It will be an example of discrimination which is not discriminatory, or at least not self-evidently discriminatory.
Secondly, in case of the capabilities approach the appeal to age is not motivated by the sum maximization of the health system. The relevance of particular capabilities depends on the value assigned to it not by the calculation of maximization but by some conventional agreement done either by experts or broader public, and often times by a collaboration of both.
Therefore, the capabilities theory comes to different than welfarist approach conclusions: "weighed maximization may reflect quite different ethical bases to the utilitarian approach which sum maximization formalizes" [4, p. 303].
Aggregation of capabilities
The last question I would like to address is problem of aggregation on capabilities. If we have a list of capabilities the question is whether capabilities should be aggregated. If yes, then how do we aggregate them. Is there a formula for aggregating? Is the weight of each capability the same or different? Are they then interchangeable? Lastly, are we talking in this respect about trading within the well-being of the individual or within the society?
For example, Nussbaum was arguing that each capability is unique and cannot be traded off, her ten capabilities are incommensurable. They are absolute entitlements and cannot be trumped by a normative consideration. It might sound like an ideal theory almost like a utopian one, however, the point is that if capabilities are commensurable and replaceable, then they become a means to some ends, such as happiness or some other states. Because when we do weighting - the weighting cannot be objective, it is always going to be with respect to some system of coordinates, and this system of coordinates is the way how they contribute to happiness. Another question is how to do aggregation on a collective level. Conceivably it can be done by means of "democratic or some other social choice procedure" [7, p. 246]. The basic idea would be to encourage or prescribe that the relevant group of people decide on the weights, plus it can refer to some participatory techniques.
Weighting is just one of the forms of aggregating, aggregating is not necessarily "adding up". An alternative would be a complementation of capabilities. For example, if you are paralyzed neck down your other possible capabilities will be worth very little. Some capabilities may thus be complementary capabilities, implying that their value to a person depends on the presence (or absence) of other capabilities.
Conclusions
I believe that any discussion about capabilities which ignores the problem of selection or offers some vague criteria for selection renders the worthiness of the whole approach moot. Interestingly enough, by far only very few works on ethical theory formulated clear proposals on selecting and weighting or aggregating of capabilities. Instead, most of the palpable proposals on selecting have been put forward by scholars working in applied ethics, normative political philosophy, or engaged with normative work in the social sciences. That means that either the theoretical grounding of the capabilities selection and aggregation is still to be worked out, or this all suggests that to think about selection in terms of weighting is a wrong way to go, and we have to go in more practical direction when we think about capabilities. The conclusion I make in this regard is that the capabilities approach does demonstrate some usefulness for the resolution of health care distribution problems in the circumstance of pandemic, however the question how to aggregate capabilities leaves big room for further discussion before it comes to a practical application of this theory.
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