Philosophical Issues in the Definition and Social Response to Disability

David Wasserman. Handbook of Disability Studies. Editor: Gary L Albrecht. Sage Publications. 2001.

Disability should be of interest to philosophers because it raises fundamental issues about the significance of variations in physical and mental functioning for human performance and well-being, for personal and social identity, and for justice in the allocation of resources and the design of the physical and social environment. Recent Anglo-American philosophy, in turn, should be of interest to disability scholars because of its close analysis of concepts critical to the conceptualization and social response to disability, such as health, normality, and disease; human action and well-being; and discrimination, justice, and equality.

Yet there is tension in the relationship between philosophy and disability. To the extent that philosophers turn to disability in addressing more general questions about well-being or justice, they may be inclined to misrepresent or oversimplify disabilities for the sake of argument. The distortion need not be intentional; philosophers are hardly immune to the “myths, fears, and stereotypes” about disabilities that prevail in contemporary society. Disability advocates, for their part, may be inclined to treat philosophy as the handmaiden of policy and may be unduly suspicious of or impatient with any philosophical analysis not in the service of a reform agenda. Despite these cross-purposes, however, philosophers can bring much-needed clarification to many debates about disability classification and policy. Disability advocates, in turn, can help to educate philosophers about the functional and social significance of human variation and to disabuse them of familiar myths and stereotypes about impairment.

In this chapter, I will begin by outlining several areas of philosophy that are relevant to the conceptualization and social response to disability. In some of these areas, the potential contribution of philosophy to disability policy has been widely recognized; in others, it has been largely ignored. I will focus on a subset of issues that highlights the tensions between two aspects of disability: as functional limitation or deficiency and as stigma or social marker. I will examine the meaning and the implications of the impairment classification, the causal role of impairments in personal and social limitations, and the significance of impairments for well-being. I will not attempt to resolve these issues but merely outline the debate over them and suggest that their resolution does not have the implications for social policy that some disability advocates fear.

I will then turn to political philosophy, where the tension between the two aspects of disability has been most explicit and most acute. Distributive-justice approaches to disability focus on deficits in capacity and performance. Antidiscrimination approaches to disability focus on stigmatization and exclusion. I will examine the potential of each approach standing alone to provide an adequate foundation for disability policy and the prospects for integrating the two.

Three terminological matters: I will follow the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) (World Health Organization 1980) in speaking of “impairments” as biomedically defined conditions, but I will depart from it in using “disabilities” to cover both the activity limitations and participation restrictions associated with impairments. I will have little to say about the necessity or utility of drawing a line between activity and participation, except to discuss one way of drawing that line that is not embodied in the ICIDH: between basic and nonbasic actions. I may also depart from the ICIDH on occasion in speaking of the limitations of “basic” actions, such as the inability to raise one’s arm or wiggle one’s ears, as impairments rather then activity limitations, blurring the tripartite classification scheme on the other end as well.

My theoretical commitments are less ambiguous on another matter. I generally use the term people with impairments rather than people with disabilities, which is the term that prevails in the American legal context. While the latter term may be perfectly appropriate in that context, I want to use a term that identifies people with biomedically defined conditions without making any assumptions about their degree of limitation, well-being, or fair treatment. For some who adopt a social or minority group model of disability or who see the impairment classification as form of stigmatization, my usage may seem naive or question begging. On their view, disability is either conceptually prior to or entirely separate from impairment. I disagree and believe that it is analytically appropriate and useful to start with impairments.

Finally, I will frequently contrast “mainstream philosophers” and “disability advocates.” There is a small, growing, and welcomed overlap between the two groups: philosophers trained in the mainstream analytic tradition who also engage in disability research and advocacy, such as Ron Amundsen, Anita Silvers, Susan Wendell, and Jerome Bickenbach. In contrasting mainstream philosophers and disability advocates, then, I will often be contrasting not different individuals but (what I take to be) different perspectives or allegiances of the same individuals. My reason for referring to distinct groups is simply convenience, which I want to make clear from the outset.

Overview: How is Philosophy Relevant to Disability Policy?

Several areas of philosophy have shared interests with and implications for disability studies. The philosophy of science analyzes the concepts of causation and explanation, concepts with broad relevance to claims about the contribution of biological, environmental, and social factors to disability. Philosophical accounts of the distinction between causes and conditions and of the relationship and ordering of different causal factors may be useful in evaluating medical, interactive, and social models of disability, with their apparently conflicting claims about the primary cause, or locus, of disability. Is it ever appropriate to attribute particular activity limitations or participation restrictions exclusively to physical or mental impairment or to the physical or social environment? Is it meaningful to assign proportions of an individual’s limitation or restriction to his or her impairments and environment? Is it meaningful to even compare the contributions of his or her impairments and environment and judge one greater than the other? Within the philosophy of science, the philosophy of biology and medicine examines concepts such as health, disease, normality, fitness, and functioning, addressing issues about the meaning, significance, and normative content of biological classifications and medical diagnoses. Is the underlying notion of normality in terms of which impairments are identified biological, statistical, or normative? Is there a difference in this respect between physical and mental impairments? Are “universal” processes or states such as pain (perception), tooth decay, and aging to be understood as impairments? Is the distinction between normal and abnormal conditions a matter of degree or kind; is it arbitrary or conventionalor grounded in scientific theory?

The philosophy of action is concerned with the relationship between human agents and the external world. It examines the widespread tendency to see human actions as hierarchical, with more complex and contingent interventions in the world resting on a bedrock of “basic actions” that the agent can perform more or less independently of the world. Theories of basic action tend to treat impairments as having a presumptively negative impact on agents’ efficacy and to underwrite a distinction between disability and handicap (or between activities and participation, to use the language of the ICIDH-2 [World Health Organization 1997]). Critics of basic action tend to treat the agents’ efficacy as more contingently related to their physical endowments.

Epistemology, or the philosophy of knowledge and belief, bears on disability in its concern for the importance and reliability of sense perception and the relationship of different sensory modalities. Perennial philosophical questions about the extent to which our understanding of the world must be obtained from sensory experience or from the operation of various senses have obvious and important implications for the assessment of disabilities. For example, do people who can see have access to knowledge and understanding that people who cannot see cannot acquire or can acquire only derivatively? Do the senses of touch and sight necessarily yield consistent information about the world? Could an external world be perceived or constituted solely through sound? The philosophy of language examines the completeness and comparability of different systems of communication, an examination relevant to the appraisal of the sign languages and tactile communication employed by deaf and blind people.

Aesthetic and moral philosophy examine questions of value that bear on the appraisal of differences in function and structure. Can we make meaningful comparisons about the beauty, richness, or complexity of the experience yielded by different senses or combinations of senses? Are various sensory and motor functions or combinations of functions necessary for or only contingently related to well-being? Do limitations in cognitive function have a more direct or less contingent relationship to well-being than differences in sensory and motor function? Is some minimal level of sensory or cognitive function necessary for humanity or personhood, for enjoying moral rights against various harms or for various goods, or for exercising certain moral powers, that is, to make promises?

Finally, recent social and political philosophy has taken two different and potentially conflicting approaches to justice that focus on different aspects of disability. The dominant approach understands justice primarily in distributive terms, in terms of the pattern of individual resources, opportunities, or welfare across society. This approach tends to treat impairments as functional limitations that may generate various distributive claims. A second approach understands justice primarily in terms of social structures and processes, in terms of relationships of power, privilege, and status among social groups. This approach tends to treat impairments as the markers of oppressed social groups and sees justice for impairments in terms of the elimination of oppressive and discriminatory attitudes and practices.

These competing approaches to justice and disability highlight a tension existing in several areas of philosophical inquiry outlined above—between approaching disabilities as functional limitations and as social markers. This difference in orientation yields a familiar but by no means necessary alignment of positions on questions related to disability. Thus, philosophers who approach impairments as functional limitations tend to see the impairment classification as, at least in theory, value neutral and objective. While denying that that classification is based on value judgments, they also tend to regard normal functions as presumptively desirable and many, though not all, impairments as disadvantageous in causing various limitations and in denying or restricting valuable experiences or opportunities. They tend to see these disadvantages as exacerbated, but not created, by neglect and exclusion. They tend to favor medical correction or monetary compensation as the presumptive social response to disability.

In contrast, philosophers who focus on impairment as stigma tend to regard the impairment classification as value laden and subjective. Moreover, they tend to reject the values they see as informing that classification. They deny that the conditions classified as impairments cause disadvantage or limit human flourishing and that people with those conditions have lives that are any less rich, complex, or satisfying than those classified as normal. They tend to regard the appropriate social response to disability as the transformation of the basic cultural, political, and economic structures of society or, more modestly, as the elimination of discriminatory attitudes and practices and their pervasive structural manifestations. They acknowledge that these changes may well affect the distribution of resources and the comparative advantage of individuals with impairments, but they do not have that as their primary purpose.

This alignment of positions, however, is unnecessary. It oversimplifies the complex relationship between the conceptualization of and social response to disability. As I will argue in the following sections, the understanding of impairments as sources of functional limitation is fully compatible with the recognition of impairment as stigma and with the endorsement of environmental reconstruction and social reform as the primary responses to disability. The claim that the impairment classification is value neutral may be adduced to argue that biological normality has only a contingent relationship to human flourishing and that the disadvantages associated with disability arise largely because social practices are tailored to normal human functioning. The claim that certain impairments preclude valuable experiences does not mean that they thereby make life any less rich or valuable overall; it may rather support the conclusion that there is an indefinite variety of ways in which human lives can flourish. A focus on the functional significance of impairments is compatible with understanding disability as a poor fit between the individual and his or her environment, such as an obsolete skill or membership in a very small linguistic or cultural minority. This view lends support to environmental modification over medical correction or monetary compensation as the presumptive response to disability.

What Does It Mean to Classify a Physical or Mental Condition as an Impairment?

It is widely agreed that “physical or mental impairment” is a biomedical classification—one made by doctors or other health professionals. Yet there is considerable disagreement about what that classification means. This disagreement is part of a wider debate about the meaning of health—whether it simply is the absence of disease, injury, or impairment and whether disease, injury, and impairment are distinct categories, appropriately grouped together as adverse health states.1 I will focus on the question of whether the classification of a physical or mental condition as an “impairment” is value free or value laden. Is one claiming or assuming that a condition is at least presumptively undesirable by classifying it, or is one making a scientific judgment that, standing alone, has no normative implications? I will not discuss the questions of how “thick” a notion health is or how to distinguish disease from injury from impairment, although both questions are closely related to the one on which I focus. If the notions of impairment and disease are value neutral, it may be tempting to deny that health consists of nothing but their absence. If health is merely the absence of disease or impairment, it may be tempting to deny that those notions are value neutral.

As I mentioned earlier, some philosophers and disability advocates have tended to assume that the impairment classification is value laden and to question the values they see as underlying it. Their claim is not merely that the actual classification of impairments at any given time and place will reflect the influence of prevailing social norms and values but that those norms and values are integral to the classification, not sources of error or bias. Some who attack the medical model of disability suggest that conditions classified as impairments are mere differences, akin to skin and hair color, stigmatized because they are uncommon or unfamiliar. A more modest and perhaps more widespread claim is that to judge a structure or function “impaired” is to hold it up against some moral or aesthetic ideal. About health and related concepts, Tristram Engelhardt (1986), one of the leading “normativists,” said,

To see a phenomenon as a disease, deformity, or disability is to see something wrong with it. Diseases, illnesses, and disfigurements are experienced as failures to achieve an expected state, a state held to be proper to the person afflicted. (P. 165)

The normativist need not endorse or reject the values underlying the impairment classification; his or her claim is merely that that classification is not a strictly scientific matter and that it involves the fallible and controversial applications of moral and aesthetic ideals to human variation.

The principal alternative to this view maintains that the classification of disease and impairment is descriptive and scientific, that it is not based on, even though it may be distorted by, moral or aesthetic values. Thus, Christopher Boorse (1977), the leading exponent of this view, argues that the diagnosis of disease or impairment is a strictly biological judgment: that some part or system of the organism is not performing its normal or species-typical function with at least statistically typical efficiency. Boorse understands the species-typical function of a part or system to be

its ultimate contribution to certain goals at the apex of the [biological] hierarchy…. The function of the heart is to pump blood rather than produce heart sounds, and the function of the kidney is to eliminate wastes rather than to keep the bladder full. It is the former effects, not the latter, that contribute to the organism’s highest-level goals…. I suggest that those functions are, specifically, contributions to individual survival and reproduction. (P. 556)

Other philosophers of science have disputed Boorse’s assumption that species-typical levels can be identified for most functions. According to Alexander Rosenberg (1986), for example,

Modern biology suggests that variation of many endowment is not a matter of normality and disturbances from it, but of the random distribution of relatively discrete traits … contemporary biological theory does not identify the average as the normal or natural level. There is no such thing. (Pp. 5-6)

Somewhat more cautiously, Ron Amundson (2000) maintains that “it is an open empirical question whether evolution results in the kind of functional uniformity that would license normality definitions” (p. 7). He finds grounds for skepticism in a variety of case studies from developmental biology and disability research, which suggests that

functional adults can develop in an indefinitely large number of ways…. Development yields adults that function, but not adults that function identically. Functional diversity is a product of developmental plasticity. (P. 9)

These case studies certainly illustrate the loose connection between typical and successful functioning. The question is whether they can be generalized to challenge the very notion of biostatistical normality. Even if they can, it is unclear how they are relevant to other value-neutral accounts of biological normality that do not identify with the central tendency of a statistical distribution of functioning (e.g., Wachbroit 1994). I will not attempt to judge the merits of this dispute. My interest is rather in what it means for an account of biological normality to be value neutral and what, if anything, such neutrality implies about the appraisal of and social response to impairments.

Boorse (1987) claims that his definition of disease or impairment, in terms of departures from species-typical functioning, “is value-neutral, or as value-neutral as biology itself” (p. 372).

The determination that a condition is an impairment does not imply that it is undesirable or disadvantageous. As he observes,

At least in some circumstances, a disease state may be preferable to normality: it is advantageous to have cowpox in a smallpox epidemic, rubella prior to pregnancy, myopia or flat feet during a military draft, or oviduct blockage if one wishes no more children…. [Moreover,] some normal conditions are far worse than some pathological conditions. For example, short stature, low intelligence and moderate ugliness are by most standards greater handicaps than athlete’s foot or myopia, even if the latter last a lifetime. (Boorse 1987:369)

In highlighting the extent to which environmental conditions and personal goals mediate the impact of impairment, Boorse’s (1987) account appears fully compatible with an interactive model of disability. The extent to which a departure from species-typical functioning is disadvantageous to an individual depends on her or his environment and goals. Boorse’s account makesno judgment about the moral importance of individual survival and reproduction, as opposed to other goals and projects. Rather, it invites an explicit resolution of the issues of value that, according to normative accounts, are implicitly resolved by the very act of classification.

Thus, for example, a Boorsean would probably uphold the classification of deafness as an impairment simply because the auditory systems of deaf people did not make a statistically average contribution to their individual survival and reproduction. Yet he would not thereby be committed to the proposition that deaf activists emphatically deny that it is undesirable or disadvantageous to lack hearing (see Lane 1992; Wasserman 1996). In places where sign language was widely used (or interpreters plentiful), where Deaf culture flourished, or where cacophonous sounds abounded, it might be desirable or advantageous to lack hearing.

The resistance to value-neutral accounts by disability advocates may have less to do with their actual implications than with a concern that they lend scientific credibility to social bias. Even if doctors and other health professionals believe that they are making a value-neutral judgment in classifying physical and mental conditions as impairments, their aversion to or disapproval of those conditions may often influence their judgments. The sway of social norms is now obvious with respect to some conditions long classified as diseases or impairments, such as masturbation; it may be as great, though less obvious, for many conditions still classified as diseases or impairments. It does not follow, however, that the need to justify that classification in scientific, value-neutral terms serves to protect, rather than expose, those social biases.

A related concern is that doctors are notorious for their embrace of individual survival (if not reproduction) as the overriding goal of medical practice. Even if the priority of that goal is not inherent to the impairment classification, those making the diagnosis often assume it. However, a nonnormative account does not support that assumption. Rather, by treating individual survival as only one goal among many, it requires that that assumption be independently justified.

A final concern, however, closely related to the previous two is more difficult to dismiss. On a value-neutral account, a person correctly classified as impaired does have something objectively wrong, defective, or lacking, even if it is something she or her might be indifferent toward or, in some circumstances, welcome. For some disability advocates, this provides a strong foothold for erroneous attributions of responsibility: Thus, Amundson (2000) argues,

Philosophers and medical practitioners have used the category [biological normality] to conclude that the disadvantages of disabled people result from their own abnormality; they have only themselves (and nature) to blame…. When an inaccessible environment causes the confinement of a wheelchair user, the abnormality of the wheelchair is identified as the cause of the confinement. The doctrine of biological normality … the linkage of normality to opportunity … and hence to quality of life … rationalizes the assessment. The opportunity losses of abnormal people are theorized to be not only natural and obvious, but morally innocuous. (P. 29)

Amundson may be correct that the doctrine of biological normality has been used to rationalize neglectful (or intrusive and demeaning) social responses to disability. But none of the linkages he describes are compelled by the acceptance of a value-neutral account of biological normality. That doctrine does not support the claim that the wheelchair user’s abnormality is the cause of his confinement, let alone that he is responsible for his confinement or that his confinement is “morally innocuous.” In the next section, I will discuss the difficulty of finding a principled basis for designating any factor as the cause of a limitation or disadvantage and suggest that causal attribution is more plausibly seen as grounded in, rather than as grounding, judgments of moral responsibility and political obligation.

What does It Mean to Claim that an Impairment is the Cause or a Cause of the Personal and Social Limitations with Which it is Associated?

There is a broad consensus among scholars writing about disabilities that the limitations associated with impairment are a joint product of biological features, environmental factors, and personal goals. As Amundson (1992) explains in a representative passage,

A person with a disability [impairment] is handicapped only with respect to a particular environment and a particular goal. This is because the structure of the environment determines which goals are accessible to people with certain disabilities. Blind people are handicapped with respect to access to information because so much information in the present social environment is stored only in visually accessible form. Wheelchair users are handicapped with respect to travel because so little public transportation is accessible to wheelchairs. (P. 110)

The recognition that impairment alone does not cause limitations in personal activity and social participation is central to the tripartite classification scheme of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH). The revised version (ICIDH-2) explicitly assigns a causal role to environmental and social factors in producing both disabilities (referred to in the ICIDH-2 as personal activity limitations) and handicaps (referred to in the ICIDH-2 as social participation restrictions). Although there are several competing schemes for classifying the effects associated with impairments of biological function, they all take an interactive approach to disability, recognizing environmental and social as well as biological contributions.

The existence of a plurality of causal factors for any personal or social limitation raises the question of what it means to claim that a particular factor is the cause of an outcome or is a cause rather than a mere condition of its occurrence. As Robert Wachbroit (2001) notes, philosophers have made various proposals for distinguishing causes from mere conditions:

Some have claimed that causes are factors that we can control or manipulate, whereas conditions are factors beyond our control. Thus, the blow from the bat swing caused the baseball to land in the bleachers; gravity was a (background) condition. Others have identified causes as the unusual or salient factors. Thus, the driver being drunk caused the accident last night; that the road was also dark was a (background) condition. Still others have identified causes as those factors that address the interests we may have in the inquiry. Thus, what the road engineer regards as the cause of a car accident (the banking of the turn) might be different from what the automotive engineer regards as the cause of the accident (the way the power is distributed on each of the car wheels). (Pp. 69-70)

Wachbroit (2001) argues that the distinction between causes and conditions can be regarded subjective, “in the sense of [depending] upon what we find salient or what interests motivate the inquiry rather than objective features of the world” (p. 70). Whether the impairment classification is subjective or value laden, the attribution of personal or social limitations to impairments is likely to be.

One reason why impairments are often seen as the causes of the limitations associated with them is their salience. If a wheelchair user cannot get up a flight of stairs, we tend to attribute his or her failure to lack of leg movement rather than to the stairs. If a person with standard limb function cannot get up a sheer concrete wall, we tend to attribute his or her failure to the wall rather than to his or her lack of suction-cupped feet. The absence of standard leg movement is salient; the absence of suction-cupped feet is not, but there is no scientific or neutral basis for making an exclusive causal attribution in either case.

Similarly, the background features of the environment are unlikely to figure in a causal account because they are, as Harlan Hahn (1999) observes, taken for granted. Although gravity contributes to the limitations experienced by would-be stair and wall climbers alike, it would rarely be cited as the cause of their limitations, just because of its pervasiveness. Again, however, there is no scientific warrant for its omission, just a pragmatic or psychological explanation.

In light of the general recognition that disability results from the interaction of a variety of factors and that the selection of a given factor as the cause is subjective or context dependent, why should there be controversy over the causal role of biological and social factors in disability? In part, the controversy reflects conflicting intuitions about how much each type of factor contributes. The claim that disabilities are naturally or socially caused may be taken to express (somewhat hyperbolically) the claim that one kind of factor predominates. If the lack of standard limb function is more likely to be regarded as the cause of a mobility limitation than the lack of suction-cupped feet, it is not only because the former is more salient but also because, in a wider range of environments, the former is believed to be associated with greater mobility limitations. Such intuitions, however, are notoriously difficult to make more precise. This is illustrated by the somewhat analogous attempt to apportion the causal contributions of genetic and environmental factors to various mental and behavioral traits in an analysis of variance (Sober 2001; Wachbroit 2001). Without a generally accepted way of enumerating environments or of measuring the distance between them, assigning causal shares to biological and social causes is virtually meaningless.

Yet the stubborn conviction that biological or social factors predominate in the creation of disability is rarely based on a canvass of all possible environments, even an incomplete or selective one. Rather, the judgment that one type of factor is the real or predominant one reflects the tacit choice of a baseline environment for making causal attributions. For many mainstream political philosophers, that baseline is a “state of nature” in which no one has the advantages of technology or social cooperation; for some disability advocates, it is a state in which people with impairments have unlimited access to existing and emerging technology. Those who adopt the first baseline regard any limitation that would arise in a state of nature as caused (predominantly) by natural or biological factors; those who adopt the second baseline regard any technologically surmountable limitation as caused (predominantly) by social factors.

The selection of either baseline is clearly value laden, and the resulting divergence in causal attributions is more likely to reflect moral than empirical disagreement. Thus, the adoption of the second baseline is likely to reflect the conviction that people with impairments should enjoy unlimited access to adaptive technology, a conviction that singles out limitations in access to such technology as the cause of disability. The adoption of the first, state-of-nature baseline is based on a view of organized society as a contract among self-interested people who bargain or deliberate in light of their default position—how they would fare in the absence of a cooperative scheme. There are a variety of contractarian theories, but almost all share the assumption that a society has a greater obligation to avoid creating or exacerbating differences among its members than to eliminate differences that exist in a precontractual setting. A society’s most stringent obligation is to leave its members no worse off, in comparative or absolute terms, than they would be in a state of nature; its obligation to make them better off is more qualified or contingent.

The moral convictions that underlie these opposing baselines can be criticized on moral grounds—that they demand too much or too little of us and that they embrace a conception of society that is too encompassing or too atomistic. I will turn to these concerns in the final section, on disability and justice. Here, I want to consider a threshold difficulty: that both these baselines provide a shaky foundation for causal attribution because they are ambiguous or indeterminate. I will focus on the state-of-nature baseline because it is adopted more widely and uncritically in making causal attributions.

The interactive nature of disability makes it difficult, if not impossible, to assess how individuals would fare in the absence of a scheme of social cooperation. Human beings are social animals and relentless artificers; a state in which people lived without frequent contact and cooperation, or in which they did not modify their environment to accommodate their needs and limitations, would be a highly unnatural one. An indefinite variety of informal arrangements might exist or develop in the absence of organized civil and political society. People with impairments might fare very differently under those different arrangements, and there is no obvious basis for deciding which to regard as “the state of nature.”

The problem with a state-of-nature baseline is not merely that there is an indefinite number of alternatives to the present society or to any organized society. It is also that many of the disadvantages people experience in a given society must be understood in terms of the framework of advantages that society creates. It may not make sense to ask if they would have experienced those disadvantages outside of that framework, in a state of nature.

The difficulties of abstracting away from a specific social order, or any social order, in making causal attributions are readily apparent in Thomas Pogge’s (1989) attempt to distinguish natural and social disadvantages in the service of a theory of justice that regards society as having stronger obligations to the latter than to the former. Pogge asserts that “human life is exposed to a wide range of natural contingencies, such as genetic handicaps, illnesses, accidents, and other misfortunes not socially induced” (p. 45). He views the distribution of social goods as “superimposed upon [the distribution] of natural goods and ills” (p. 46). Although a person’s genome can, at least until the advent of routine genetic therapy, be reasonably regarded as a natural contingency (although social policies and practices pervasively affect what genetic features get reproduced), the extent to which a given genetic feature is a “handicap” or “misfortune” may be due, to a considerable extent, to environmental factors that are “socially induced.”

Pogge (1989) recognizes that diseases and impairments themselves will sometimes be “socially produced, that is, due to the interactions among participants in the social system.” He includes pollution, crimes, and traffic accidents as conditions whose incidence is affected by political decisions (Pogge 1989:190-91). He appears to regard these cases of social causation as marginal, rather than central, threats to the distinction that he wants to draw. In fact, as recent studies of influenza, hepatitis, and AIDS suggest, virtually all contagious diseases owe their epidemic character, and many owe their particular biological form, to various features of organized social life, especially agriculture and trade. The contribution of organized social life is even more obvious with respect to most types of adventitious injury.

Social arrangements contribute not only to the incidence of various types of biological impairments but, more pervasively and more important for our purposes, to the impact of those impairments on the lives of those who possess them—from the impact of literacyon dyslexia to the impact of the telephone on deafness. If it is difficult to attribute the production of the underlying impairment to a natural or social cause, it will be even more difficult to make such an attribution with respect to the personal and social limitations associated with impairments.

The difficulty with a state-of-nature baseline is not just a matter of uncertainty or indeterminacy about the conditions that would prevail in such a state. Even if we could, for example, extrapolate from the mortality statistics of less developed nations, showing dramatically lower life expectancies for people who are blind or paraplegic in an attempt to conclude that people with those conditions would generally have fared poorly in certain parts of the world in the absence of civil and political society, this gives us a very tenuous basis for attributing their present disadvantages to “nature.” Thus, imagine a technologically sophisticated society built in an inhospi table environment, where precivil life for blind or paraplegic people can be presumed to have been nasty, brutish, and short. Assume that this society made no provision for sightless communication or legless mobility but kept its blind and paraplegic members in physically comfortable institutions. Apart from the obvious injustice of this state of affairs, it would seem odd to attribute the disadvantages of those blind and paraplegic individuals to “nature” or to their natural endowment. What they lacked could only be characterized in terms of the activities and opportunities available to other members of the society and in terms of the social and political decisions that made those activities and opportunities unavailable to them.

This is not to deny that the past can sometimes be a benchmark for making causal attributions. We may not be able to compare our present social arrangements with a hypothetical state of nature, but we can compare them to the state of society before the introduction of a new social practice or a new technology to assess whether those changes have exacerbated or alleviated various types of disadvantage. The introduction of the telephone caused much business and social communication to shift to amedium to which deaf people had no access. In addition, icon-based computer software poses a similar threat to the blind, for whom it is considerably harder to access than the DOS software it replaced. Such ante/post comparisons provide a basis for attributing the increased exclusion of people with impairments to changes in technology and social practice, but not for attributing their disadvantages generally to natural or social causes.

One alternative to the state of nature as a baseline for causal attribution would be a state of “maximum feasible adaptation.” Such a state would allow people with impairments to enjoy the benefit of all technologically possible measures to adapt the environment to their needs and goals. This baseline has not, to my knowledge, been clearly articulated, but it appears to be implied by the claims of some disability advocates to the effect that any barrier that could be removed by human technology, at any cost, is socially constructed rather than natural. Thus, the Union of the Physically Impaired against Segregation (UPIAS) declares that “in our view, it is society which disables physically impaired people” (quoted in Oliver 1996:22). The apparent denial of any causal role to biological factors seems to reflect both a very strong view of entitlement and a very strong technological optimism. Whether it is a morally more appropriate baseline than a “state of nature” is not the issue. In a world of infinite need and limited resources, it is an equally ambiguous or indeterminate one. It is notoriously difficult to assess the limits of technological possibility. Investment in technology yields unpredictable results, and a greater investment at an earlier time might have made possible enhancements in mobility and sensation that now seem fanciful.

It is not clear, however, that the claims of exclusive social causation made by some disability advocates should be taken at face value. Unlike some political philosophers, these advocates appear to recognize the morally and politically contentious character of causal attributions. Thus, the claim that disability is socially caused is seen by some proponents as a reaction against the opposing tendency to treat the disadvantages associated with disability as solely biological. As Tom Shakespeare explains,

The achievement of the disability movement has been to break the link between our bodies and our social situation, and to focus on the real cause of disability, i.e., discrimination and prejudice. To mention biology, to admit pain, to confront our impairments, has been to risk the oppressors’ seizing on evidence that disability is “really” about physical limitation after all. (Quoted in Oliver 1996:39)

This passage suggests that the claim of exclusive social causation is a calculated overstatement, a corrective for the opposing and more damaging misrepresentation, but the analysis of causation also really involves the attribution of moral and political responsibility. These suggestions are made more explicit by Amundson (2000):

Causationis a complicated thing. Wepick out one antecedent event or condition and baptize it as the cause of a phenomenon. Different perspectives, different theoretically orientations, of different prejudices can lead to the baptism of different events as the cause. The Social model of disability never identifies the biomedical condition as the cause of that person’s disadvantages. The causes are always identified in the environment and the social context. A critic might dismiss this approach as politically motivated and therefore not scientifically objective. But consider the alternative…. Philosophers and medical practitioners have used the category [biological normality] to conclude that the disadvantages of disabled people result from their own abnormality. They have only themselves (and nature) to blame. Is this assessment scientifically objective? (P. 29)

The answer to Amundson’s question, of course, is that neither assessment is scientifically objective. Instead of choosing the politically more congenial oversimplification, it would be preferable to reject the false dichotomy between biology and society as the cause of disability and to break the link between causation and responsibility—to hold society responsible for the alleviation of disadvantage, whether it can be said to have caused it or not.

Even if we had some basis for attributing the disadvantages associated with impairments to natural causes, it would hardly mean that the individuals were to blame or that their alleviation was not society’s responsibility. As long as those disadvantages were not voluntarily chosen or risked, their source or locus will have no direct relevance on most plausible accounts of distributive justice. What will matter on those accounts is the cost to others of alleviating those disadvantages and the possible intrusiveness or indignity of particular forms of alleviation. Yet those considerations will have only a tenuous relationship with the attribution of those disadvantages to natural or social causes. There may be good reasons for favoring one kind of intervention over the other, particularly for modifying the environment rather than the individual (although the distinction between the two will not always be clear). It may be more respectful, dignified, or effective. But the fact that a disadvantage can be attributed to natural causes hardly means that it is not amenable to environmental modification.

What, if Anything, is Bad about Impairments? Do Impairments Detract from Well-Being?

Philosophers, as we have seen, disagree about whether the classification of a physical or mental condition as an impairment implies a judgment that it is undesirable and about the extent to which impairments can be said to cause the disadvantages associated with them. In discussing these issues, I have deferred, or sidestepped, the obvious and important issues of what makes a physical or mental feature undesirable and what counts as a disadvantage.

The two sets of issues are connected in the following way: the more general or abstract the description of a desirable state or condition, the more tenuous or limited the causal role of impairment appears to be. Thus, various neuromuscular impairments appear to affect the ability to move one’s limbs more directly than they affect the ability to get around. Yet even the ability to move one’s limbs is environmentally mediated. On Jupiter, none of us could move our legs very well or far without assistive devices; on Earth, a person with a neuromuscular impairment could move his or her legs with the right assistive device. As I argued in the last section, it is difficult to be more precise about the intuition that the causal role of impairments is more direct in the case of some actions or states than in others. Certain impairments may contribute definitionally to the absence of certain activities (e.g., the absence of limbs to voluntary arm or leg movements). But even if the connection is not a matter of definition, there may be no known or achievable environment in which a person with a given anatomical or physiological impairment could engage in particular action. It is certainly worth asking what loss of value he or she would thereby experience. And even when the connection is more contingent than this, it makes sense to ask what, if anything, is desirable or valuable about the various personal and social activities that impairments play some role in limiting.

Philosophers have addressed such questions at length, though rarely under the rubric of disability. They have typically debated the more general questions about what makes a life go well, how or whether we can measure well-being and compare the well-being of different individuals, and whether certain forms of well-being matter more for certain purposes, such as political justice (Pogge 1999). These questions have been of special interest to philosophers who embrace some form of utilitarianism because they base the moral appraisal of actions on the evaluation of their (expected) outcomes. Yet many nonutilitarian philosophers have addressed these questions as well, especially those who adopt what Robert Nozick (1974) has called “end-state” conceptions of justice, in which the justice of a society or cooperative scheme depends to some extent on who ends up with what or in what condition.

Historically, utilitarians understood well-being in terms of pleasure or happiness, without regard to the ways in which individuals achieved those states. Contemporary welfare economists have tended to adopt the less psychological, even more general, metric of preference-satisfaction, without regard to the specific preferences chosen or the ways they are satisfied. Recent utilitarian philosophers have been drawn to constrained preference and desire-satisfaction accounts, which count only the preferences or desires that an individual would have with full or adequate information. Despite considerable differences among them, these accounts of well-being are all subjective in two senses. First, they define well-being in terms of psychological states, such as pleasure and desire, or psychological constructs, such as preferences. Second, they involve no judgment about the objective worth or value of different sources of pleasure or happiness or different objects of (informed) preference or desire. (Preference or desire accounts may be objective in another sense, in treating the satisfaction of preferences as a matter of fact, about which the preference holder can be mistaken. Informed preference and desire accounts may also be objective in imposing a high standard of knowledge or rationality on the preference formation process.)

More objective conceptions understand human well-being in terms of states or activities that are valuable “in themselves,” whether or not anyone values them and whether or not they yield pleasure or happiness (although pleasure or happiness may be among the objectively valuable states, and well-being may require or even consist of taking pleasure in objectively valuable activities). What counts as valuable may be determined by ideals of human perfection; by the telos of humanity, revealed in theology, biology, or history; or by critical generalizations about what people have found valuable across times, places, and cultures. Objective accounts vary in the specificity with which they describe what is valuable for people and in the extent to which they emphasize valuable experiences or activities or the opportunity or capacity for such experiences or activities. Distinguishing subjective and objective accounts can be difficult since the constraints imposed on informed desire and belief accounts may bring them into rough correspondence with some objective ones, while objective accounts may rely heavily on what people actually desire or have desired in determining what is desirable or worthy. Moreover, some metrics of well-being appear to have an irreducibly hybrid character, such as opportunity for welfare (where “opportunity” is not based on the individual’s own unconstrained probability judgments).

On subjective conceptions of well-being, the impact of impairments is largely contingent. With the exception of impairments that are defined in terms of pain, unhappiness, or frustration or that involve limitations in the capacity to form coherent and stable preferences or desires, people with impairments can have as much pleasure, happiness, or satisfaction as people without them, and research on subjective well-being suggests that they often do. Indeed, some philosophers regard this as a reason for rejecting subjective accounts. They see the “happy cripple” as a reductio ad absurdum of any view that regards subjective states as the primary constituents of well-being (see Crocker 1995; Sen 1980). Not surprisingly, some disability scholars have been drawn to subjective metrics out of a concern that more objective accounts of well-being place it beyond the reach of people with impairments. It is not clear, however, that objective accounts must render the adverse judgments about impairments that are often made in specific arguments for those accounts.

In examining how impairments fare on objective accounts of well-being, it will be useful to consider two influential but problematic distinctions: between intrinsic and instrumental value and between basic and nonbasic action. The first distinction is integral to the commonsense explanation of motivation and behavior. An activity may be valued instrumentally because of what it brings about, contributes to, or facilitates, or it may be valued intrinsically in itself. As intuitive as the distinction is, it can be hard to make—in part because there is deep disagreement about what is of ultimate value, in part because it is possible to parse many activities and states almost indefinitely into instrumentally valued means and intrinsically valued ends. For example, making money or friends can be seen as an end in itself or as a means to obtaining comfort and security.

The interactive approach to disability encourages the parsing of activities in this manner. Thus, for example, much of what we value in talking, seeing, and walking is instrumental. We value them as ways of achieving communication with other people, reading, and moving from place to place—activities we regard as valuable in themselves. (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 intrinsically valuable activities is precluded by deafness, blindness, or paraplegia; each can be achieved in alternative ways, by signing, reading Braille, or operating a wheelchair.

This parsing of activities into instrumentally valued means and intrinsically valued ends is often informed by a hierarchical conception of action, in which simpler actions, more fully under our control, generate more complex actions, whose successful completion is more dependant on environmental factors. A general characterization of this hierarchy can be made with reference to a distinction philosophers have debated for decades. This is the distinction between basic actions, which a person does not do by doing anything else but “just does,” and nonbasic or generated actions, which a person does by doing other actions, ultimately—on pain of regress—basic ones. Nonbasic actions can be generated causally. I make a breeze by waving my hand. Or they can be generated conventionally. I say goodbye by waving my hand, but I do not, or need not, do anything else to wave my hand (Danto 1965; Goldman 1970). This is an intuitively appealing notion that seems helpful in clarifying how impairments are associated with the loss or absence of intrinsic value. As I suggested earlier, impairments may preclude basic actions definitionally; that is, whatever distinctive value there is in moving one’s legs and eyes is precluded by impairments that involve the absence of the anatomical structure necessary for walking or seeing. Contingently, a neuromuscular impairment may prevent limb movement in all known environments. In either case, impairments can be said to deny the value that inheres in the basic actions they preclude. Blindness does not preclude reading, but it does preclude seeing; deafness does not preclude communication, but it does preclude hearing; leg paralysis does not preclude mobility, but it does preclude walking and running. Impairments may also be thought to be disadvantageous instrumentally, in limiting the stock of basic actions with which the individual can generate other, more valuable or advantageous actions.

Some philosophers, however, doubt that we can give an adequate account of basic actions (e.g., Candlish 1984); others have argued that the actions, which are truly basic, are mental events such as volitions (e.g., Hornsby 1980), which seem relatively immune from or less directly vulnerable to (physical) impairments. And even those philosophers who accept a notion of basic action, under which many such actions are precluded by particular impairments, differ about the extent to which the precluded actions are a source of instrumental or intrinsic value. Several philosophers have argued that, at least in technologically advanced societies, most of the actions we value intrinsically are nonbasic and can be generated with widely varying sets of basic actions. Thus, Steven Edwards (1997) argues that

basic actions are not interesting in their own right, but only in so far as they have an effect at the level of persons…. [But] a person may still be able to perform an extensive range of types of actions whether or not it is possible to perform a particular range of basic actions. (Pp. 602-3)

Similarly, John Dupre (1998) maintains that

most of the significant capacities of even fully able people are contextually determined…. Indeed, as far as mobility goes, it is surely the case that the financial resources necessary for access to cars, train tickets, or plane fares are far more determinative than are control over one’s limbs. Similar remarks apply to sensory limitations of sight or hearing. In summary, though it is no doubt uncommon to lack the use of one’s legs or the evidence of one’s eyes, and although such deficits are hugely inconvenient to those who suffer from them, such deficits should not be seen as more than some among a range of characteristics that determine the vastly diverse range of capacities of different people in different societies. (Pp. 230-31)

Other philosophers regard these claims as too extreme. They do not deny the availability of alternate means of generating the kinds of activity people value; they merely claim that the instrumental importance of the standard set of basic actions can be underestimated. Even if there are alternative ways of generating less basic activities, they may be less effective, more expensive, or costlier in less tangible ways. Thus, Nordenfelt (1997) argues,

There may be one type of basic action which is the dominant means for realizing a certain end state, and where we cannot see a good replacement. It is, admittedly, rarely the case that the favored basic action is absolutely necessary for achieving the desired end. The action may in practice, however, be necessary, given the way society works; or it may be the only way that can lead to the desired state in an expedient and efficient manner, given the way society works. (P. 617)

Nordenfelt (1997) gives the example of the hand and finger movement involved in signing a wide range of documents. The comparative difficulty of executing a document without manually signing depends, of course, on existing social practices and technology, and a reduction in comparative difficulty may be claimed as a matter of justice. However, in assessing this claim of justice, it is also necessary to weigh the cost to others in modifying existing social practices and technology. It would surely count as instrumentally disadvantageous if those costs were very high “given the way society works.”

There is disagreement about the intrinsic and instrumental value of many standard sensory and motor functions and the actions closely associated with them—seeing, hearing, and walking. One threshold issue is whether the value in such functions and actions inheres in their exercise or performance or in the “internal” experience they yield. If the latter, then the value of those functions and actions themselves would be instrumental, and the loss of value from their impairment would be contingent. Examples such as Nozick’s (1974) “experience machine,” which faithfully simulates the experience of climbing a mountain and reaching its summit, suggest that what matters is not just the experience but attaining it through certain actions. This intuition, however, may be stronger for experiences that are also achievements, such as mountain climbing, for which simulation seems to be a form of cheating. It is not clear that we would find a similar loss of intrinsic value in the simulation of more a passive experience, such as experiencing the programmed arousal of the acoustical centers of the brain to produce the sensations of listening to a symphony versus listening to a digital recording of that symphony—at least if the simulation were shaped by the actual symphony performance to the same extent as the digital recording. Yet it may notbeclear whether asymphony could be simulated or how it could be judged to be successfully simulated for someone who was congenitally deaf. Also, it may not make sense to talk about the simulation of cognitive functions and activities, such as imaging, imagining, and reasoning, since it may be impossible to distinguish their simulation from their occurrence.

Setting aside the issue of simulated experience, it is hard to deny that many standard sensory and motor functions or the activities closely associated with them have intrinsic value. But it is almost as hard to assess how the absence of that value affects overall well-being. One obvious source of intrinsic value for standard sensory functions and activities, for example, is aesthetic-their beauty, richness, and complexity. 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. We generally assume that people who have never had those sensory functions (as opposed to, say, an artist or food critic dependent on his or her daily exercise) can lead perfectly good lives without such admittedly valuable experiences. This suggests that we cannot infer from the fact that there is great intrinsic value in a basic action that those who cannot perform that action have lives with significantly less intrinsic value. As Silvers, Wasserman, and Mahowald (1998) argue,

Things have intrinsic value when we esteem them for themselves or, more precisely, for the character of the direct experience of them. It might seem to follow, then, that the absence of intrinsically valuable experience might be deleterious, injurious, or disadvantageous. But this inference is incorrect. Indeed, missing one kind of experience can enhance the quality of the remaining kinds. (P. 89)

Silvers et al. (1998) claim that once we distinguish the absence from the loss of valuable sensory and motor experiences, there is no reason to believe that the absence of intrinsically good experiences is intrinsically bad. They note that the value of sensory and motor experiences increases with the attention we are able to devote to them and that a smaller range of experience may permit greater concentration. Silvers et al. also observe that we do not make the assumption that unimpaired people who can, but do not, have particular sensory or motor experiences necessarily lead impoverished lives.

It may be that arguments such as Silvers et al.’s (1998) take an overly narrow view of the intrinsic value to be found in certain sensory and motor functions. As Magee and Milligan (1995) argue,

The practical usefulness of seeing plus its power to provide aesthetic pleasure come nowhere near to accounting for the awed value that sighted people place on it. There are several other large ingredients. One, of course, is the sheer avidity of the desire to see…. This has no parallel with the senses of hearing, taste, or smell; we are under no slavish compulsion to be hearing sounds all the time, or tasting tastes, or smelling smells. However, there might be a similarity with the fifth remaining sense, that of touch. (P. 105)

Magee and Milligan (1995) go on to suggest a second “ingredient”—that seeing and touch link us to the world more directly and closely than do the other senses and that their loss involves a profound isolation from physical and social reality (Magee and Milligan 1995:105-6). It is not clear, however, that we need both seeing and touch to avoid such isolation or that any of the other senses has comparable importance.

A more general claim about the relevance of impairment to well-being has been made by several recent philosophers. Martha Nussbaum (1990), for example, maintains that having some form of sense perception and mobility is necessary for humanity and that “being able to move from place to place” and “being able to use the five senses” are essential to human flourishing (Crocker 1995:170-80; Nussbaum 1990:219, 225). Nussbaum, however, does little to justify these claims. She views them as generalizations derived from and supported by “a wide variety of self-understandings of people in many times and places” (Crocker 1995:171; Nussbaum 1992). Our conception of human flourishing, she maintains, has evolved around the standard complement of human functions, and we cannot step outside of our collective experience to demand a free standing justification.

Yet without more specific argument about the role of specific functions in our relationship to the physical world or to other people, we have no way of resolving conflict about the importance of those functions or of addressing the charge that the consensus “of people in many times and places” reflects nothing more than widespread prejudice or error. To respond, for example, to the claim of deaf activists that people’s lives can go as well without hearing as with it,

Nussbaum could not merely assert what no one would deny—that there is great aesthetic value in hearing. Without claiming that hearing is essential for some broader social or intellectual good, a claim that would almost certainly be false, it is unclear what Nussbaum could argue. More broadly, as Jerome Segal (1998) points out, we can hardly deny that some people flourish without many of the capabilities Nussbaum seems to regard as essential. The most successful lives of people lacking those capabilities appear to go as well as the most successful lives of people with a standard complement of sensory and motor functions. While a life could hardly go well without at least some of the capacities Nussbaum enumerates, we have no clear basis for establishing a minimum set.

An alternative to the dogmatic enumeration of essential human goods is suggested by Sen’s (1993, 1980) approach to capabilities as a metric of positive freedom. Instead of insisting that any particular function is necessary for well-being, Sen places a more abstract emphasis on positive freedom as a good in itself. This emphasis suggests that the greater the number of valuable functionings we have the capability to engage in, the better off we are, even if we do and can engage in only a limited number of them. If there is intrinsic value in the opportunity or positive freedom to do as many activities as possible, in as many different ways as possible, then impairments may be intrinsically undesirable in reducing our range of opportunity. But it is unclear why there should be greater intrinsic value in larger “capability sets,” beyond some minimum needed to ensure a meaningful choice among different options. It may be wrong for the government to limit people’s options on the basis of a parochial or contested view of human flourishing, but it is not necessarily bad for a person to face life with a narrower than average but still capacious set of options. An emphasis on positive freedom, like an emphasis on material goods, can become obsessive or fetishistic.

The difficulties in finding an appropriate metric of well-being suggest that no single metric may be appropriate for all purposes. Several philosophers (e.g., Griffin 1993, 1986) have suggested that different conceptions of well-being are appropriate in different contexts. For example, it may be more appropriate to adopt a comprehensive, value-laden conception in assessing how one’s own life is going, or would go, than to allocate resources based on relative disadvantage. Thomas Scanlon (1998) has contended that well-being is not the “master value” it is assumed to be by some philosophers who are primarily, but not exclusively, consequentialists. He argues that from the first-person point of view, “the things that contribute to (one’s own) well-being are obviously important, but the concept of well-being plays very little role in explaining why they are important” (p. 142). It is simply an “inclusive” concept encompassing many or most of the person’s specific aims and concerns. From a third-person point of view, some but not all aspects of well-being matter. For instance, a parent or guardian will be concerned about specific ways in which things go well or badly for his or her charges, while a political society or cooperative scheme may be obliged to promote or equalize some aspects of well-being but not others.

So perhaps we do not need a general answer to the question of how impairments affect well-being. What matters to the individual are his or her aims and special concerns; what matters to the society to which he or she belongs are those aspects of well-being that are a source of political obligation, and that may be quite distinct from what matters to the individual and his or her family or friends. In the next section, I will focus on the question of how impairments affect what we owe each other as a matter of justice.

How are Impairments Relevant to Social and Political Justice?

The question of whether or how much impairments reduce well-being has often been conducted in the shadow of the more general debate about how well-being is relevant to the allocation of resources and to the design of society. In denying that impairments reduce well-being, some disability advocates may be responding to the perceived consequences of conceding that they do reduce well-being. This is seen in the assignment of low priority to the lives of impaired people in choices among lives and the assignment of high priority to the often unwelcomed medical “correction” of impairments. Disagreements about the impact of impairments on various aspects well-being might be more tractable if they were not seen as having such questionable distributive implications.

Nowhere are the implications of impairment for resource allocation starker or more controversial than in utilitarian accounts of health care decision making. In its classical form, utilitarianism assesses the value of lives by the pleasure, happiness, or satisfaction they contain and produce and judges decisions among lives by their impact on the sum of pleasure, happiness, or satisfaction in the world. Individuals matter only as bearers and producers of utility: The more utility they gain or produce from a resource, the stronger their claim to it. To the extent that impairments reduce utility, the preservation of the lives of people with disabilities has lower priority; to the extent that the correction of impairments increases utility, the medical treatment of people with impairments has higher priority.

The classical utilitarian calculus provides apparently straightforward, if often unpalatable, answers to questions about creating and extending lives. If the birth of an impaired child increases overall utility, the child should be born, unless its “replacement” by a child without an impairment would increase utility even more (see, e.g., Kuhse and Singer 1985). If a hospital can save the life of two disabled people or one nondisabled person, but not both, it should save the nondisabled person if his or her life would be sufficiently longer, happier, or more productive (see Brock 1995, 1997; Daniels 1997; Murray 1996).

Some utilitarians attempt to deny these implications by insisting that it is necessary to consider the full range of consequences—not only the length and quality of the lives immediately at stake but also the possibility of mistaken judgments about length and quality, as well as the distrust and demoralization that would result from the use of a utilitarian decision criterion. Other utilitarians, while not denying that all such consequences must be taken into account, are more inclined to challenge than accommodate popular sentiment. Among the latter, by far the most prominent and controversial is Peter Singer (1993), who has proposed that parents be allowed to let severely impaired newborns die. Singer’s (1999) conviction is that “philosophy ought to question the basic as sumptions of age” (p. 466), whether the assumption thatonly humans matter morally or the assumption that all humans matter to the same extent. Singer’s challenge to the former has made him a champion to many in the animal rights movement, while his challenge to the latter has made him a nemesis to many in the disability rights movement. The consistency Singer claims for these positions may be superficial or foolish, but his vigorous advocacy has challenged opponents to articulate their own conceptions of equality more clearly.

Utilitarianism is often thought to demean the lives of people with disabilities. Yet it gives equal weight to the utility of all persons and favors the interests of people with disabilities in any context where their relative disadvantage promises high marginal utility for interventions on their behalf. Unlike some of the egalitarian and “prioritarian” theories of justice I will discuss below, it does not treat people with impairment as special cases. It takes an equally calculating and instrumental view of all lives. Moreover, the interpersonal comparison and aggregation mandated by utilitarianism seem difficult to banish altogether from theories of justice since considerations of aggregate well-being exercise a powerful intuitive constraint on the reduction of inequality and the improvement of the position of the worst off.

For political philosophers committed to equalizing rather than maximizing well-being, people with lower well-being generally have stronger claims to resources. To the extent that impairments reduce well-being, people with impairments have priority for both life-extending and life-enhancing resources. Philosophers with such egalitarian commitments have often assumed that physical impairments such as paraplegia and blindness dramatically reduce well-being because functions such as seeing and walking are critical for a wide variety of life plans. They have proposed a variety of special provisions to compensate for the absence of those functions, from a cash allowance approximating the insurance that people with impairments would have purchased against their deficits in hypothetical circumstances (Dworkin 1981) to an unlimited allowance to restore them to normal functioning (Daniels 1986, 1990).14

Disability advocates have not been much happier with the high priority accorded by egalitarian approaches to people with impairments on the basis of their presumed disadvantage than with the low priority accorded them by utilitarian approaches on the basis of their presumed misery. The inappropriateness of standard egalitarian provisions for disability has led some disability advocates to regard egalitarian justice as part of the problem, not the solution. They have concluded that any theory of political justice that sees its mission as equalizing people or reducing inequality on some metric of well-being or advantage will inevitably demean those it regards as disadvantaged.

In the remainder of this section, I will discuss three responses to these misgivings, suggested by three critiques of egalitarian theories of distributive justice. While these critiques have not, for the most part, been informed by the complaints of disability advocates, they reflect similar concerns. The first, friendliest critique is that egalitarian theories have set about equalizing the wrong thing, either external resources or subjective welfare. An individual’s share of material resources is not the appropriate metric of advantage for purposes of political justice, nor is her or his happiness or satisfaction. People with impairments are poorly served by both metrics: Equality in individual resources takes no account of the disabling effect of the physical and social environment and tends to exaggerate the limitations of people with impairments, while equality in welfare ignores those limitations altogether. What is needed is a metric that takes into account differences in functioning by recognizing claims to environmental adaptation.

The second, most hostile critique calls into question the very idea of justice as principally concerned with the distribution of resources or the well-being of individuals. Some philosophers have argued that distributive accounts make inappropriate provisions for disability because they fail to recognize the locus of injustice for people with impairments. In focusing on the symptoms of material disadvantage, distributive justice ignores the underlying structural causes: oppressive and exploitative economic, social, and political relations among groups. Disparities in material resources across social groups may be important evidence of oppression and exploitation, but they have no independent significance. In addition, heroic efforts to extend distributive justice beyond material resources to intangible, participatory, and collective goods are futile; they merely “reify” concerns that are properly understood as relational and procedural, in terms of oppression and domination, not maldistribution (Young 1990).

In its application to impairments, this approach focuses on their character as stigma rather than as causes of functional limitation. Impairments are of concern to justice not because of any direct or proximate effect they have on the performance or well-being of the impaired but because they are, like skin color or ancestry, the markers of an oppressed and subordinated social group. Justice for people with impairments requires the transformation of these relationships. Any change in the share of resources assigned to people in an oppressed group would be a by-product of that more fundamental change.

A third critique attempts to steer a middle course between justice as equality in resources, welfare, opportunities, or capabilities and justice as the absence of oppression and domination in social structures and relationships. Justice must be understood primarily in social and political terms, as a matter of equal citizenship. On this approach, impairments are relevant to justice only to the extent that people with impairments are not treated as equal citizens, not in the more pervasive way they are to utilitarian and some egalitarian accounts. The philosophers who argue for a distinct notion of political equality claim or assume that such equality imposes a threshold that can be reached or exceeded by almost everyone in modern postindustrial societies. They claim that equality is not an elusive goal whose partial achievement must be balanced against other values and whose pursuit requires intrusive and insulting assessments of individual well-being.

The next three subsections examine the adequacy of these competing approaches for disability policy. They consider

  • Whether distributive justice is broad or flexible enough to encompass environmental adaptation;
  • Whether non distributive approaches to justice have the resources to prescribe appropriate modifications in the physical and social environment, without recourse to distributive considerations; and
  • Whether an account of justice, in terms of political equality, can successfully combine distributive and nondistributive considerations relevant to disability.

Can Distributive Justice Encompass Claims for Environmental Adaptation?

In debates over the appropriate conception of well-being or comparative advantage for distributive justice, impairments are often presented as hard cases. Both the profound misery of the blind and the crippled and their unaccountable euphoria are invoked to criticize various metrics as demanding too much or too little for the disabled or of the able-bodied (Cohen 1989; Dworkin 1981; Sen 1980). The caricatured picture of impairments that informs these debates has led some philosophers and disability advocates to conclude that merely framing the issue of justice for people with impairments in distributive terms is to present them as defective and helpless (e.g., Silvers 1994).

While this conclusion is understandable, it is too sweeping. The treatment of impairments as a problem of deficient natural endowment is not dictated by a distributive conception of justice; it arises in part from a failure to appreciate the interactive character of disability. An awareness of the myriad ways that individuals’ environment and goals mediate the impact of their impairment on their well-being would surely reduce the temptation to assume that their misery was inconsolable, their euphoria unreasonable, or their needs inexhaustible (see, e.g., Albrecht and Devlieger 1999). Thus, the assumption that people with impairments invariably require a significantly larger bundle of resources to pursue their (reasonable) life plans reflects a failure to take into account the disabling effects of what Hahn (1999) has aptly described as the “taken-for-granted” environment and of the enabling effects of environmental adaptations.

The question, however, is whether claims to greater environmental adaptation can be captured by a theory of distributive justice. Typically, such theories have sought to equalize or reduce inequalities in the resources possessed or controlled by individuals or their welfare, that is, their pleasure, happiness, or satisfaction. It is difficult to express claims for environmental reconstruction in terms of either a resource or a welfare metric.

Theories of justice that take resources as the metric of comparative advantage tend to take the environment for granted. The (hypothetical) division of resources into individual bundles takes place either within the present scheme of social cooperation and economic production or else in a state of nature that is assumed to evolve into a scheme such as the present one through transactions among the equally endowed participants. Giving people with impairments equal economic shares in a society constructed as our own, with a physical environment and social practices designed for people with standard endowments, might improve their material circumstances, but it would be likely to leave them at the margins of society.

It is doubtful that any approach to justice based on the partition and allocation of external or material resources could give people with impairments an adequate say in the design of the physical and social environment to bring them into the mainstream of social activity and political decision making. In failing to provide an accommodating environment, a scheme of resource equality might, as disability advocates fear, legitimize the inferior status of people with impairments, as individuals disadvantaged by deficits in natural endowment, not in external resources. A resource metric can only respond to these concerns with more of the same, giving people with impairments larger bundles of goods or special compensation for their inefficiency in converting those goods to their own purposes by a cash allowance or medical correction.

Theories of justice that take welfare as the metric of comparative advantage do not require or encourage such special treatment for people with impairments. They either defer to the individual’s own assessment of how she or he is doing or else base her or his status on some independent measure of her or his pleasure, happiness, or preference satisfaction. However, welfare approaches seem manifestly unsatisfactory as a basis for determining political obligations or what weowe each other as members of the same political community. It seems intuitively unfair that we should owe more to those who, because of extravagance or self-importance, would be miserable with less, or less to those who, because of self-denial or self-denigration, would be happy with very little. While the euphoria of a blind or paraplegic person should hardly be taken as a reductio ad absurdum of a welfare approach (that euphoria may be entirely warranted), it does suggest a stronger, more general objection to welfare metrics. Even if extreme misery or frustration is a concern of justice, what we owe each other is not some level of happiness or satisfaction but a reasonable means to lead a happy and satisfying life. Moreover, the assessment of individual welfare for distributive purposes would seem likely to be a particularly intrusive, demeaning, and unreliable process. An adequate theory of political obligation requires a more objective metric of human flourishing.

Recent political philosophers have been keenly aware of the inadequacy of both resource and welfare metrics. They have proposed a variety of alternative metrics that assess well-being for purposes of distributive justice not, or not only, in terms of what the individual has or feels but also in terms of his or her opportunities, capacities, or activities in terms of opportunity for welfare (Arneson 1989, 1990), access to various kinds of advantage (Cohen 1989), or range of capabilities (Sen 1980; Nussbaum 1990). These “midfare” metrics (Cohen’s 1993 term) are more objective than welfare metrics in looking beyond the individual’s feelings or preferences to assess her or his comparative advantage, but they are more individualized than resource metrics in looking at what a person can do with the resources at his or her disposal. Although they regard impairments as undesirable to the extent that they limit opportunity or access or preclude valuable activities, they also treat the physical and social environment as a source of disadvantage and underwrite claims to environmental modification.

Perhaps the most comprehensive metric for assessing comparative advantage for purposes of political justice is offered by the capabilities approach of Sen and Nussbaum, discussed in the last section. Their approach does treat impairments as inherently undesirable in precluding valuable functions or capacities, such as seeing, hearing, or walking. But most of the capabilities regarded as essential or important bear a highly contingent, environmentally mediated relationship to impairments. Thus, for example, the capabilities approach abstracts from the physical differences between people with limb impairments and normal limb function to find a common claim to the means of moving about from place to place. Those means will often but not always be the same for both; they may be architectural, vehicular, mechanical, or prosthetic, or they may involve making places more accessible or making the individual more mobile. In some circumstances, it may well be more difficult or costly for people with limb impairments to achieve or maintain that capability, but the difference will not be a categorical one. In general, the capabilities approach and other midfare metrics allow the disadvantages of people with impairments to be seen as problems of environmental fit rather than deficient endowment.

A recognition of the critical role played by the environment in creating and alleviating disability is found not only in the development of more flexible or comprehensive metrics of well-being but also in the analysis of social and technological changes that affect the participation of people with impairments. Several philosophers have observed that social decisions and policies about the deployment of new technology and the design of social rules and practices make impairments more or less disabling (Buchanan 1996; see also Silvers and Wasserman 1998; Wikler 1979). The introduction of the telephone and Windows software, the raising and lowering of competence standards for legal responsibilities and social activities, and the modification of requirements for earning a college degree or playing in a golf tournament have all had profound effects on the access and participation of people with various impairments. In each case, there appears to be a conflict between the inclusion of some and the satisfaction of others—a quintessential problem of distributive justice. A society could develop an indefinite number of cooperative schemes and social practices that would be more or less inclusionary, rewarding, and productive. No doubt some of the alleged trade-offs are avoidable, and others are exaggerated. However, there will inevitably be trade-offs, and an adequate theory of distributive justice is needed to resolve them on a principled basis.

To provide such guidance, one must enlarge that subject matter of a theory of distributive justice without losing focus on individual outcomes. Although such a theory must be comparative, concerned with how the members of a society are faring relative to each other, it need not and often cannot be achieved through individual allocations; it may require changes in the structure and organization of society. Such changes are required not only for people with impairments but also for people who belong to minority cultures, for people who possess obsolete skills, and, more broadly, for people who value goods that can be realized only in social institutions and practices. Thus, for example, similar issues of environmental modification arise in deciding how to accommodate atypical functions and minority languages; they arise for users of American Sign Language as well as for speakers of Spanish or Chinese. The fact that Spanish-and Chinese-speaking children learn Standard English more easily than deaf children may be relevant to the way the issues are resolved, but it does not change their fundamental character. Assimilation may be possible for deaf as well as for Spanish and Chinese children through oralism or cochlear implants, and, to the extent that it is possible, it raises similar concerns about cultural survival and intergenerational estrangement. Impairments are merely some of the more significant and conspicuous variations that a just society must accommodate.

The rejection of a distinction between natural/internal and social/external causes of disadvantage will, if anything, sharpen the conflicts over environmental accommodation because the claims of people with impairments cannot be accorded lower priority on the grounds that they concern naturally occurring disadvantages. Yet if such claims cannot be treated as less urgent than those of able-bodied people, they will not necessarily prevail against conflicting claims. Environmental modifications can be very expensive, and modifications that serve people with one type of impairment may be useless or inconvenient for those with other impairments or for non impaired people.

Thus, consider the issue of how to educate and support people with severe cognitive and developmental impairments. It is, of course, important to recognize that the classification of cognitive limitation may be driven by the economic demands of modern industrial and postindustrial societies and that the disadvantages associated with the levels and styles of mental functioning, classified as impairments, are largely due to the failure to accommodate atypical functioning in the design of educational institutions, the provision of caregiving services, and the structuring of jobs. However, we still need to decide how to redesign our educational, caregiving, and employment institutions to fairly accommodate people classified as cognitively and developmentally impaired. It would be naive to assume that the designs that best serve those individuals will best serve individuals with normal or superior cognitive functioning or will have no adverse impact on productivity, safety, wealth, or other values and concerns.

More broadly, it is likely that we will have to choose between cooperative schemes that have higher average or total well-being on any metric, not based exclusively on material goods, and schemes that have smaller disparities in well-being. People with impairments have often been unfairly typecast to illustrate this conundrum, but a less distorted view of impairment would hardly eliminate it. Some philosophers have responded to the obvious difficulty of achieving equality on any adequate metric of well-being by arguing that equality needs to be balanced against other values, such as beneficence. Others have argued for giving priority to the worst off rather than attempting a general reduction in inequality (Parfit 1997). Just as egalitarian accounts must decide how much inequality to tolerate for the sake of other values, “prioritarian” accounts must decide how much priority to accord the worst off at the expense of such values. The moral uncertainty of these trade-offs is as daunting as the individualized assessment of well-being they require.

Can Justice for People with Impairments be Achieved by Eliminating Discrimination against them or, More Broadly, by Eliminating Oppression and Subordination?

The complexities of more comprehensive theories of distributive justice have a moral cost. They appear to diminish the urgency of the pursuit of justice by shifting its focus away from the elimination of great social evils—slavery, caste, political repression, child labor—to the pursuit of an elusive goal with debatable criteria. Much of the appeal of procedural or relational accounts of justice, which focus on such specific evils, is that they seem to capture the moral importance of justice better than the abstract assessment of outcome disparities.

The strengths and limitations of a relational account of justice for disability policy, based on the elimination of oppressive attitudes, practices, and structures, are suggested by the antidiscrimination approach taken by the Americans with Disabilities Act of 1990. While that approach does not embody a complete relational theory of justice for people with impairments, it treats the locus of injustice as the underlying attitudes of contempt and devaluation, as well as their pervasive structural and institutional manifestations. It relies on and extends the broad notion of discrimination that has evolved in American civil rights law over the past generation, treating impairments as the markers of an oppressed social group. The antidiscrimination approach identifies a core evil in the treatment of people with impairments and provides effective means of responding to it. Yet as a social policy for disability, it is, as I will conclude, radically incomplete.

Several philosophers and legal scholars have argued that the core notion of discrimination that informs recent American civil rights law involves contempt or devaluation of individuals based on their membership in a social group (Wasserman 1998). For more than 30 years since the passage of the 1964 Civil Rights Act, this notion has been enlarged by legislation, judicial decisions, and legal commentary to cover not only deliberately unfavorable treatment based on hatred or contempt but also the long-term and institutional effects of intentional discrimination and the “facially neutral” practices that embody or perpetuate it.

The analysis of discrimination, as embedded in ostensibly neutral norms and standards, owes much to the feminist critique of earlier civil rights law, with its narrow focus on the direct and indirect effects of intentional discrimination (see Rebell 1986). Feminists have argued that the design of physical structures and social practices for one group—able-bodied males—constitutes a significant form of discrimination against the rest.

If the structures and practices of our society embody a norm of male functioning, they also embody a norm of healthy functioning. As Susan Wendell (1989) argues,

Life and work have been structured as though no one of any importance in the public world … has to breast feed a baby or look after a sick child…. Much of the world is structured as though everyone is physically strong … as though everyone can walk, hear and see well. (P. 111)

This position was an ticipated a generation ago by Jacobus tenBroek (1966), who argued that the right of the disabled “to live in the world” required comprehensive changes in our physical and social order, not just in the design of buildings and public spaces but also in the duties of care owed by “abled” pedestrians, drivers, common carriers, and property owners to disabled people traveling in public places. The refusal to make these changes denied the disabled their right to live in the world as much as the exclusion of blacks and women from public facilities.

The ADA famously embodies this notion of structural discrimination. It treats the failure to make “reasonable accommodation” for people with disabilities, in the design of buildings and facilities and in the structuring of jobs, as a form of discrimination. It provides exemptions only for undue burdens and for changes that would alter the fundamental nature of the activity.

Some commentators maintain that an antidiscrimination approach is not appropriate for disability because of vast differences in the prevailing attitudes and practices toward different impairments and in the experiences of people with those impairments. Thus, Bickenbach (1996) argues, “Not only are the social responses to different forms of mental and physical difference vastly different, there is almost no commonality of experience, or feelings of solidarity, between people with diverse disabilities” (p. 6).

Because I wish to consider a different question, I will assume, for the sake of argument, that people with impairments face the kind of prejudice necessary to claim discrimination and that many or most of the environmental barriers they face are attributable directly or indirectly to that prejudice. The issue I will address is not whether people with disabilities can be regarded as victims of structural discrimination but whether we can eliminate structural discrimination without the guidance of a substantive theory of justice.

Clearly, the elimination of structural discrimination involves more extensive reconstruction for disabled people than for women. As one judge commented about an early disability discrimination statute,

What must be done to provide handicapped persons with the same right to utilize mass-transportation facilities as other persons? Does each bus have to have special capacity? Must each seat on each bus be removable? Must the bus routes be changed to provide stops at all hospitals, therapy centers, and nursing homes? Is it required that buses be able to accommodate bedridden persons? (Quoted in Wegner 1984:404)

Even tenBroek (1966) conceded that “the policy of integration has its limitations: it cannot be pushed beyond the physical capacity of the disabled” (p. 914). The limitations are not physical so much as technological and economic. The “physical capacity of the disabled” depends on available technology, and that, in turn, depends on the resources invested in research and implementation. For example, opening doors is “beyond the physical capacity” of many disabled people, but that limitation can be overcome by electric door openers. Securing the right of people with disabilities to “live in the world” involves an indefinite commitment of resources.

An injunction against discrimination does not, by itself, tell us the extent to which we must modify our physical and social environment to accommodate people with disabilities. It is one thing to agree that physical structures and social practices have been designed for those who fall within a very narrow range of physical and mental variation, that this results in part from the devaluation of those outside the range, and that this constitutes a powerful, if unwitting, form of discrimination. It is quite another matter to decide how we should redesign those structures and practices to end discrimination against people who fall outside the range. What norm should we adopt? A requirement that structures and practices be designed to strictly equalize burdens or benefits (e.g., the time to get by public transit from point A to point B) for all people in every conceivable mental or physical condition is obviously problematic, as the judge’s comments suggest. A standard based on the structures and practices that we would obtain if we did not devalue people with disabilities would require that we suspend the attitudes we have every reason to regard as entrenched and pervasive.

Even if we could imagine a society in which people with impairments were not devalued, however, that exercise would not yield a determinate standard for structuring the physical and social environment to accommodate the full range of human physical and mental variation. While the members of such a society, free of the prejudices that taint our own judgment, would doubtless condemn many social practices and arrangements to which we are indifferent or inured, they would still need a theory of justice to decide on the practices and arrangements they should adopt for themselves. How would they, for example, design their educational systems and structure their jobs to accommodate people with very limited cognitive functioning? Doubtless, they would find solutions through the rough-and-tumble of their untainted political processes. But it would still make sense to ask if those solutions were just.

This reflects a more general problem with procedural or relational approaches to justice. We can acknowledge that some procedures have criteria for fairness that are independent of the outcomes they produce and that in some contexts, justice may be purely procedural, such that any outcome produced by a fair procedure is ipso facto fair. However, when we are assessing not discrete, context-specific procedures such as lotteries but whole social systems, it is doubtful that we could find procedural or relational criteria—that is, of nondiscrimination, nonoppression, and nonsubordination—adequate to assess the justice of the society and of the outcomes experienced by its members. Even if we could establish and apply such procedural criteria independently of distributive considerations, we could not assume that their satisfaction would always yield just outcomes or that any outcome that seemed intuitively unjust could be traced to an infirmity in social relationships. It is a sociological question whether oppressive and exploitative social relationships must produce great disparities in various kinds of advantage, but it is a conceptual or moral question whether we can judge disparities in advantage as unjust without having traced them to such a relationship. Some philosophers suggest that we cannot. Thus, Richard Norman (1999) argues,

What is unjust is not the bare fact that some are better off than others, but the facts of domination and exploitation. These terms are central to the vocabulary of injustice, and they serve to pick out the facts that power is unequally distributed, and that this enables some members of a community to make use of others and to prosper at their expense. (P. 191)

But this seems mistaken if domination and exploitation mean anything more than participation in a social scheme that gives one unjustified advantages. The use of force or deception to create or maintain such advantages (or even an improper reliance on psychological or physical vulnerability) surely makes them more objectionable. Yet they are objectionable even if they are acquired without force or deception (or exploitation, if it means more than participation in a scheme that produces such advantages). There are circumstances in which better-off people will be guilty of tolerating injustice but not of dominating or exploiting worse-off people.

Thus, consider a society earnestly striving for justice, in which better-off people have relinquished many of their perquisites and their claims to them. There may well be reasonable disagreement within that society about what justice requires on issues ranging from the fairness of academic tracking, the acceptability of significant income disparities between managers and workers, and the appropriate level of investment in geriatric medicine. It should be possible to argue that the society had made the wrong decision in any of these areas and was to that extent unjust, without condemning it for domination and exploitation. To deny this possibility is either to make the implausible empirical claim that domination and exploitation are present whenever unjustifiable disparities in outcome are found or else to strip those terms of their opprobrium by defining them to be present whenever such disparities are found.

Is an Account of Equality as Equal Citizenship Adequate for Disability Policy?

Several recent political theorists have argued that justice is concerned with equality only in a limited social and political sense. While justice imposes constraints on distribution and on disparities in certain forms of advantage, it does not require equality of resources or welfare, let alone equality on some more comprehensive metric of well-being (Anderson 1999; Miller 1997, 1999). This general point, reminiscent of Scanlon’s (1988) suggestion that different conceptions of well-being are appropriate in different contexts, is well made by Richard Norman (1997):

Egalitarian distribution cannot plausibly be comprehensive, and the idea that it should be is an idea which has standardly incurred the derision of anti-egalitarians. Some people are incurably shy and find it difficult to form deep emotional relationships with others. Some people are emotionally volatile, forming relationships only to destroy them and move on. Some people strike a balance between these extremes. The third group are likely to have more satisfying lives than those in the first or second group. Is this inequality “a bad thing”? … The commonsense answer is “That’s life.” The idea that we ought to redistribute emotional sensitivity (by genetic engineering?) so that everyone has an equally fulfilling emotional life would be a caricature of egalitarianism. (P. 246)

A more modest and appropriate egalitarianism would treat disparities in well-being as relevant to justice only to the extent that they undermined equality in basic social or political roles, in status and participation. Proponents of this narrow notion of political equality see its principle virtue as identifying the core injustice in various social and economic disparities—the denial of equal citizenship—and as avoiding the intrusiveness of more comprehensive egalitarian theories.

I will focus on the recent account of “democratic equality” offered by Elizabeth Anderson (1999) because it draws from both the distributive and the procedural or social relationship approaches discussed above and because it is informed by disability scholarship and has explicit implications for disability policy. Her account suggests that equality, in the sense relevant to justice, can be secured for people of varying physical and mental endowments without quixotic and demeaning attempts to achieve a more comprehensive equality.

Democratic equality, as Anderson (1999) presents it, is an interesting hybrid of distributive and procedural approaches. Like many philosophers who reject comprehensive equality as a social or political imperative (Miller 1997, 1999; Norman 1997, 1999; Young 1990), she sees injustice as something quite distinct from and more egregious than mere unjustified disparities in well-being. She identifies as the core of social and political injustice what others have identified as the core evil of discrimination—the treatment of some people or groups of people as moral inferiors:

In egalitarians asserted the justice or necessity of basing social order on a hierarchy of human beings, ranked according to intrinsic worth. Inequality referred not so much to distributions of goods as relations between superior and inferior persons…. Such unequal social relations generate, and were thought to justify, inequalities in the distributions of freedom, resources, and welfare. (Anderson 1999:312)

Anderson recognizes, however, that the elimination of such hierarchy requires a certain kind of equality among the members of a society, and she attempts to offer a positive account of that equality. She builds on Sen’s (1980, 1993) capabilities metric and endorses its emphasis on activity and participation. But she regards only a small set of capabilities as critical for the kind of equality a just society should pursue:

Negatively, people are entitled to whatever capabilities are necessary to enable them to avoid or escape entanglement in oppressive social relationships. Positively, they are entitled to the capabilities necessary for functioning as equal citizens in a democratic society. (Anderson 1999:317)

The set of capabilities Anderson finds necessary for these purposes is fairly extensive, however:

To be capable of functioning as an equal citizen involves not just the ability to effectively exercise specifically political rights, but to participate in the various activities of civil society more broadly…. And functioning in these ways presupposes functioning as a human being…. To be capable of functioning as a human being requires effective access to the means of sustaining one’s biological existence—food, clothing, medical care—and access to the basic conditions of human agency knowledge of one’s circumstances and options, the ability to deliberate about means and ends. (Anderson 1999:317-18)

While this might seem like a tall order, Anderson emphasizes that it does not require equality in many things that people dearly value, such as sensual pleasure, romantic fulfillment, or intellectual stimulation. She argues that her functional democratic orientation to equality avoids the objectionable implications for disability of welfare or resource metrics. It does not seek to compensate people with impairments for their alleged unhappiness or inefficiencies in consumption but to ensure their standing as full citizens:

Democratic equality … demands, for instance, that the disabled have good enough access to public accommodations that they can function as equals in civil society. To be capable as functioning as an equal does not require that access be equally fast, comfortable, or convenient, or that one get equal subjective utility from using public accommodations. There may be no way to achieve this. But the fact that, with current technology, it may take an extra minute or two to get into city hall does not compromise one’s standing as an equal citizen. (Anderson 1999:334)

Anderson appears to be claiming that the important thresholds for democratic equality can be met and that any more precise, exacting, or comprehensive equality is not necessary. Both these claims are questionable. On its face, Anderson’s conception of equal citizenship requires the indefinite expenditure of resources to achieve partial reductions in inequality, while her placement of certain capabilities outside the purview of democratic equality may not satisfy a robust notion of equal concern and respect.

The suggestion that democratic equality imposes thresholds that can be met by all or nearly all citizens is belied by Anderson’s list of relevant capabilities. Thus, for example, “effective access … to medical care” would require indefinite expenditures for citizens with chronic and degenerative health conditions, unless effective is understood to mean only formal or logistical access to perfunctory care. However, such a spare understanding would hardly serve the purposes of democratic equality because it would not secure (to the limited extent that current or emergent medical technology permitted) the freedom from debility and pain necessary to take part in civic life. Such freedom cannot be guaranteed; it can only be achieved to a greater or lesser extent, by a greater or lesser number of people, through the use of scarce resources. There is no universally achievable threshold for the capability of “functioning as a human being,” only a goal that competes with the enhancement of other capabilities.

A similar point could be made about competence in deliberation, which Anderson (1999) regards as an element of “access to the basic conditions of human agency.” We could spend an indefinite amount on education, training, and support for people with cognitive disabilities without achieving such competence (Veatch 1986). As protracted litigation over the requirement of a “free and appropriate education” under the Individuals with Disabilities Education Act has made painfully clear, there are sharp trade-offs involved in even marginally enhancing this capability (Howe 1996). Such trade-offs arise regardless of whether we treat cognitive disability as a problem of internal function or environmental accommodation. Although mental incompetence is socially constructed, in the sense that society determines the cognitive complexity of many tasks and sets the minimum standards for proficiency (Buchanan 1996; Wikler 1979), decreasing the complexity of those tasks or lowering the standard for proficiency may have considerable social costs. Again, there is no universally achievable threshold for the capability of “functioning as a human being,” only a goal that competes with the enhancement of other capabilities.

If Anderson (1999) underestimates the difficulty of achieving “sufficient”—as opposed to equal—levels of functioning, she also underestimates the harshness of excluding a wide range of capabilities from the scope of democratic equality. She offers examples of relatively trivial pursuits, such as playing cards expertly, enjoying luxury vacations, and competing in beauty pageants, as capabilities that democratic equality can safely ignore. However, to extend G. A. Cohen’s (1989) criticism of Sen’s capabilities approach, an impaired individual might be able to function quite well “as a human being, as a participant in a system of cooperative production, and as a citizen of a democratic state” (pp. 918-21) while in constant low-grade pain, bereft of friends, lovers, and family and devoid of aesthetic and cultural stimulation. It seems uncomfortably instrumental to regard a person’s pain, loneliness, and drudgery as matters of collective or public concern only to the extent that they affect his or her capacity to work or vote. The refusal to view the alleviation of severe and protracted pain or loneliness as a general obligation seems inconsistent with an equal concern for those who experience such pain or loneliness. We may have to accept comprehensive measures of well-being and considerable intrusion into our private lives as the price of a robust commitment to equal concern and respect.

In focusing on the weaknesses of Anderson’s (1999) account, I do not want to overlook one of its most significant achievements. It represents one of the first sustained efforts of a mainstream political philosopher to take disability scholarship seriously. Even if Anderson underestimates the extent to which democratic equality requires harsh trade-offs and intrusive interventions, she has made great strides in elevating people with impairments from caricatures and cameo appearances to equal partnership in a challenging intellectual and moral inquiry.

Conclusion: The Prospects for Convergence

There is an intriguing symmetry in the challenges facing distributive and relational accounts of justice as they apply to disability. Distributive accounts must recognize the centrality to justice of equal social and political participation and develop metrics of individual well-being in which the capacity and opportunity for such participation figure prominently. Relational accounts, in turn, must make the notions of nondiscrimination and nonoppression sufficiently determinate to guide the reconstruction of the physical and social environment. Hybrid approaches such as Anderson’s (1999) raise hopes for a convergence between distributive and relational accounts of justice.

Those hopes, however, may be illusory. Justice, as Walzer (1983), Miller (1999), and others argue, may be irreducibly plural. Although both distributive and relational accounts of justice appear to be guided by a principle of equal concern and respect, the former emphasize concern, the latter respect. The two kinds of accounts focus on inequalities that, however closely correlated, may be morally distinct. The failure to take adequate account of atypical functioning in the design of the physical and social environment may be a fundamentally different kind of wrong than the treatment of people with atypical functions as inferior beings. These wrongs may require different remedies: the former, redistribution; the latter, recognition (Fraser 1995). Perhaps, then, a single theory of justice cannot do justice to both aspects of impairments, as sources of functional limitation and as stigmatized differences. We may require both distributive and relational accounts to guide disability policy.

Whether justice for people with impairments is singular or plural, it will be better understood and perhaps more fully realized if philosophers and disability scholars take each other seriously. That requires philosophers to become more attentive to the perspectives and research of disability scholars and disability scholars to become less skeptical and dismissive of philosophical inquiry. The prospects for dialogue are improving, as philosophers become more restless with armchair analysis and disability scholars expand their disciplinary frontiers beyond social science.