A Philosophy of Nursing Forum
Saturday, June 27, 2009
This list is in danger of suffering from disuse atrophy, which is a bad
thing, as I have reason to know. So I decided to post something.

I just received an announcement that Martha Nussbaum will be coming to the
southern part of heaven (otherwise known as UNC-Chapel Hill) next spring to
make a presentation (title TBA) to the philosophy department. I can't pass
up a chance to meet another philosophical rock star. So, in anticipation of
the coming event, I sat down and read Nussbaum's "Sex and Social Justice,"
one of several of her books that relies on what she calls the "capabilities
approach" to ethical and political theorizing.

Nussbaum writes beautifully, with the goal of engaging not just
philosophers, but all thoughtful people. Commendably, she doesn't just
theorize in a philosopher's study, but often descends in to the messy world
of day to day life as ordinary people around the world must live it, and, as
one Jesuit reviewer put it, "if you are looking for wisdom, her books are
full of the stuff."

Much of the "wisdom" is derived from her encyclopedic knowledge of the
ancient world, particularly Aristotle and the stoics. Of course, not
everyone agrees that she "gets them right." I am not competent to
adjudicate, so I just think of it as a case of "Aristotle and Aurelius as
She Understands Them", or AASUT for short (sounds sort of like the "AHH
S..T!" that working nurses exclaim when the vein they are trying to puncture
for a blood sample blows up).

In any event, informed by AASUT, and the work of the economist Amartya Sen,
Nussbaum offers us the notion of "capabilities." The goal here is to
specify "a life in which fully human functioning, of a kind of basic human
flourishing, will be available." She attempts, in other words, to meet a
big challenge for eudamonian based ethical theories, that of specifying what
counts as a "good life." Problems rush in here, for doesn't the very idea
of "basic human flourishing" smack of dreaded "essentialism"? "Good life"
for me might be a whole different kettle of fish from "good life" for
Hitler. In fact, I am pretty sure I would mean something different by the
term than he would.

What counts as a good life ought to matter to nursing if anything does,
especially in light of the love affair nursing has had with virtue ethics
over the years. But, you don't have to be in nursing very long to discover
that there are differing conceptions of the "good life" amongst the patient
population. Some nursing scholars are lead to conclude, by the diversity of
views on the subject, locally and globally, that there is simply no such
thing as THE "good life," and any attempt by some
old-fat-white-man-ex-lawyer-now-a-nurse (like, say, me) to define the term
would be an exercise in "colonialism"; a LITTLE better than yelling "bash
the WOGs and Fuzzies, let's have another gin" - but not MUCH better.
Attempting to define "good life" for other folks turns me, apparently, into
a sort of intellectual neo-Clive let loose upon the world once more,
opressing everyone from Dublin to the Ganges (well, not Dublin - I love
Dublin. Let's abuse them last). Bob the nabob, minus the opium and dancing
girls (damn it, I was born too late!).

Nussbaum is not unaware of these difficulties, and gamely tackles them. Her
efforts are impressive, and even the likes of Simon Blackburn (who does not
suffer fools lightly) admires them. The approach is supposed to be (mostly)
culture neutral because it addresses capabilities as opposed to practices,
and so at some level or another supposedly doesn't involve telling other
people what to do. Consider the list:

life; bodily health and integrity; senses, imagination and thought;
emotional expression; practical reason; affiliation; play; other species;
and, control over political and material environments.

The idea has initial plausibility - take, say, control over the political
environment. It doesn't rule out of court an Islamic republic, for example,
provided the folks living there want to live in one and have some say in
choosing that form of life. But not every "post-colonialist" is likely to
be persuaded. For instance, some cultures are not too ginned up about
giving women even certain "capabilities." There are societies which deny
women substantial capabilities viz. affiliation, bodily integrity, thought
and environment. The capabilities approach would declare them illegitimate,
and therefore is, arguably, "colonialist".

To this criticism from the left flank, there are at least three replies.
First reply: who speaks for the culture in question - the girls who want to
go to school, or keep their clitoris, but who are not allowed to, or the
(male) mullahs, elders and/or warlords who won't let them? Maybe what the
culture "really" wants IS compatible with the "capabilities" approach.

Second reply: maybe these silly savages are just ignorant. Maybe they don't
know that women are actually smarter than men, on average, and so OUGHT to
go to school if anyone does, or they've misunderstood their own scripture,
or they don't understand enough about human physiology to comprehend that
eumenorrhea is normal and healthy and occurs for homeostatic reasons, or
that it is a bad idea to mutilate female genitalia with or without antsepsis
and anesthesia for any number of reasons, or ... I could go on for while,
but you get the general idea. Sort of a Millian style argument, like the
one he gave against Bentham's "equality of pleasures" position.

Third reply: this provides a repugnant conclusion/reductio ad absurdum
refutation of post-colonialist arguments. Simply put, IF post-colonial
theory countenances, in any shape, form or fashion, stuff like female
circumcision, obligatory suicide of widows, "honor" killing of women, etc.,
then so much the worse for post-colonial theory. What's wrong with the idea
that cultures, like individuals, make mistakes?

Assaults could be mounted from the right flank as well. While emphasizing
"capabilities" is not AS blatantly egalitarian/redistributionist as say, a
Rawlsian program of equal distribution of all social "goods", it is still
going to involve some "taking from the rich" and "giving to the poor".
Noziak-style libertarians will, therefore, still object. First reply: a
capabilities approach is consistent with unequal distributions of wealth so
beloved by libertarians - it just assures equality of opportunity to the
fullest extent possible, not equality of achievement. You get to keep, in
other words, what you fairly earn; capabilities approaches are simply trying
to give everyone, to the extent possible, the same chance you have. It
can't give everyone a great voice and a lucrative concert career, for
example, but it can make it possible for everyone who has a great voice to
have music lessons. After the lessons it's up to you. How could even Mrs.
Thatcher or Ronald Regan object to that?

Second reply: All the "capabilities approach" is doing is assuring some sort
of compliance with the "Lockean proviso", which says that you, or Bill
Gates, or Madonna can take as much of the world's riches as you want, so
long as you do so fairly and leave "enough and as good" for everyone else.
Most libertarians accept the Lockean proviso. It is hard to know exactly
what that proviso comes to, in today's world, but maybe some sort of
"capabilities approach" captures the spirit of what Locke had in mind.

Interesting stuff. But what, one asks, has this got to do with Nursing?
Nothing, if Nursing affords no valuable and unique perspective on questions
such as how should healthcare resources be distributed, o what constitutes
"disease" or "disability". But, if it does have such a perspective, this
might be one way to articulate it that is in some meaningful sense

Also, it seems to me that this sort of analysis of social justice and human
flourishing mirrors, in some interesting ways, the ways in which various
nursing processes analyze the individual's health. The parallels with
Orem's theory are especially striking. Perhaps Plato was on to something in
suggesting that the healthy person and the healthy society are structurally

One VERY bright young Don in the UK, Lorella Terzi at Roehampton University,
is doing some interesting work on this approach in the context of education
and learning disability. See, for example, her ‘Beyond the Dilemma of
Difference: the capability approach on disability and special educational
needs’ in Journal of Philosophy of Education , 39 (3), pp.443-459.

I don't think it is absurd to think that there may be parallels between
questions surrounding the delivery of educational services to the learning
disabled and the delivery of nursing services to the physically disabled, or
to the care of the sick in general.

Thoughts, anyone?


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