Disability and Rehabilitation, December 2006; 28(23): 1461 – 1465

COMMENTARY

On health, ability and activity: Comments on some basic

notions in the ICF

LENNART NORDENFELT

Department of Health and Society, Linköping University, Linköping, Sweden

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Abstract
Purpose. The purpose of this article is to highlight and at the same time criticize the holistic view of health expressed in the
‘‘International Classification of Functioning, Disability and Health (ICF)’’. Particular attention will be paid to the idea
suggested in the ICF that not only the ability to perform a specified action but also its actual performance is included in the
person’s health. My argument intends to show that this is an untenable position.
Method. The theoretical platform of this paper is philosophical action theory. My argument makes particular use of the
distinctions between ability, opportunity, activity and will. My analysis also uses some insights from the contemporary
philosophical discussion of health concepts.
Conclusions. Ability (or capacity) and its opposite disability (or incapacity) are essential ingredients in the implicit
philosophy of health of the ICF. However, the ICF also puts an emphasis on the actual performance of actions. This is
For personal use only.

entailed by the performance qualifier that is included in the ICF. I give some arguments for questioning the relevance of this
qualifier if it is intended to have a place in the concept of health or have a general function for decisions in health care or
rehabilitation. Instead I suggest the introduction of an opportunity qualifier, which could fulfill some of the purposes
intended for the performance qualifier.

Keywords: Health, ability, opportunity, activity, ICIDH, ICF, performance qualifier

has taken us further in the revolution of our outlook

Introduction
on disabilities. The main contribution of this
The World Health Organization has during the last classification is, I would say, that it marks a shift
25 years in several ways transformed the thinking of from the focus on disability to a focus on ability or
healthcare personnel with regard to health and capacity. The manual itself says the following:
disability matters. The first disability classification
of the WHO, the ICIDH, opened up the whole area ICF has moved away from being a ‘consequence of
of such consequences of diseases and injuries as disease’ classification to become a ‘components of
circumscribed people’s lives, i.e., their disabilities health’ classification. ‘Components of health’ identifies
and what were then called handicaps. This classifica- the constituents of health, whereas ‘consequences’
tion made it a concern for healthcare personnel to focuses on the impacts of diseases or other health
deal with people’s disabilities and handicaps. The conditions that may follow as a result [2, p. 5].
ICIDH also made us aware of the intricate relation-
ship between people’s environment and their abil- This statement is quite interesting. It says that
ities. The environment can be, and often is, the the elements classified in ICF (presumably the ones
preventing factor when it comes to a person’s on the positive side) are components of health.
possibility of engaging in an activity. But we also Thus, for instance, the categories of activity and par-
became aware of how difficult it often is to allocate ticipation and their elements are seen as components
the responsibility for a person’s failure to act [1]. of health. The authors of the ICF have thereby
The present manual, the International Classifica- committed themselves to a strong holistic tradition
tion of Functioning, Disability and Health, the ICF, in the philosophy of health. This can be seen as a

Correspondence: Lennart Nordenfelt, Dept of Health and Society, Linköping University 58183 Linköping, Sweden.
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2006 Informa UK Ltd.
DOI: 10.1080/09638280600925886
 1462 L. Nordenfelt

continuation of the commitment made by the WHO typical efficiency (in relation to survival and
itself when it proposed its famous definition of health reproduction).
in 1946. The other main stream in the philosophy of health
In this presentation I will focus on this holistic view and disease takes a completely opposite position
on health. I will do so because it is only indicated and regarding these basic matters. According to these
not much developed in the manual itself. Moreover, if philosophers, who are often called holists, health and
one wishes to reconstruct the holistic health concep- disease are concepts related to the human being as a
tion of the ICF in a systematic way one will encounter whole in his or her environment. The concepts
certain difficulties. It seems as if the ICF includes too cannot be totally defined in biological or even
much in health. The manual and its instructions psychological terms, if these terms refer solely to
encompass an area that, I will argue, lies partly particular functionings. A main group of holists,
outside the proper domain of health. including myself, have settled on ability as the
In order to make my argument come out clearly I fundamental concept when it comes to the definition
will first say a few words about some modern theories of health [4 – 6]. In fact, we argue, in partly different
in the philosophy of health. I will particularly high- ways, that the dimension ability/disability is the core
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light such theories as focus on the basic notion of dimension determining whether health or ill health is
human ability. These theories are in a way quite close the case. A healthy person has the ability to do what
to the intentions of the ICF and are ones which the he or she needs to do, and the unhealthy person is
ICF (as modified) might rely on. To this presentation prevented from performing one or more of these
I will add a brief analysis of the conditions for actions. (I am here using the expression ‘‘needs to
human activity. This will give me the conceptual do’’ in a very general way since there are different
apparatus to raise my critical argument against the specifications.)
ICF as an adequate theory of health but also, The formidable task for these theorists is to
more generally, as a theory of matters relevant to characterize the set of actions that a healthy person
the institution of healthcare. I will first turn to the should be able to perform. Seedhouse [4] refers to
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modern theories of health. the person’s conscious choices, and Fulford [6] to
such actions as could be classified as ‘‘ordinary
doings.’’ I myself [5] have settled for what I call the
Two theories of health
subject’s vital goals.
Two main streams of theories of health and disease My general formulation of the characterization of
have appeared in the arena. One main stream is health [7, p. 9] is the following: A is completely
sometimes called the medical one, or the bio- healthy if, and only if, A is in a bodily and mental
statistical one. Typical of philosophers within this state which is such that A has the second-order
stream is that they claim that the concepts of health ability to realize all his or her vital goals given a set of
and disease are, or could be, treated like any other standard conditions.
biological concepts. ‘‘Health’’ and ‘‘disease’’ are, Observe that in this cautious formulation of the
they say, biological concepts in the same sense as ability theory of health I speak of the subject’s being
‘‘heart’’ and ‘‘lung’’ and ‘‘blood-pressure’’ are in a bodily and mental state that is such that a certain
biological concepts. Health and disease can be ability is the case. The body, the physical basis, is not
defined in completely value-neutral terms. Health is forgotten in the ability theory of health. For further
contrasted in particular with disease, but also with clarifications of my characterization of health I have
injury, defect and disability. The perfectly healthy to refer to my texts on these matters [see, in
person according to this reasoning is the person who particular, 5 and 7].
does not have any diseases or maladies.
The most famous protagonist of this view,
Ability and activity in the ICF
Christopher Boorse [3], defines disease in the
following way: ‘‘A disease is a type of internal state Whatever the exact choices here, we can see that
which is either an impairment of normal functional ability is the concept that is fundamental to a
ability, i.e., a reduction of one or more functional conception of health that is proposed by some
abilities below typical efficiency, or a limitation on contemporary theorists of health. And ability is, of
functional ability caused by environmental agents’’, course, a concept that is closely related to ‘‘capacity’’
[3, p. 7]. The notion of functional ability, in this which is the favoured term in the ICF [2] (There is
theory, is in its turn related to the person’s survival something called a capacity qualifier introduced on
and reproduction, viz. his or her fitness. The same p. 121 of the ICF.) It is also clear that the ability-
idea can be formulated in the following positive disability dimension is the crucial one in the ICF. Let
terms: A person is completely healthy if, and only us remember where everything started. The initial
if, all his or her organs function with at least classification, the ICIDH [1], was a classification
 Comments on some basic notions in the ICF 1463

of disabilities and handicaps. The focus was on the However, the ICF manual seems to suggest that we
things we are not able to perform, mainly, although should also classify people according to what they
not exclusively, as a result of diseases and injuries. actually perform in their current environment. I quote:
The opposite of disability is ability or, if we wish to ‘‘Because the current environment brings in a
use the other term, capacity. societal context, performance as recorded by this
However, the ICF, the modern version of the qualifier can also be understood as ‘involvement in a
classification, also includes what it calls a performance life situation’ or the ‘lived experience’ of people in
qualifier. The question in the ICF often concerns the actual context in which they live’’ (2, p. 121).
whether a particular activity is actually performed. Let me here consider some examples taken from
The focus then is not on the ability but on the actual chapter 9 of the ICF, Community, social and civic
performance. This is interesting: Why should the life. Here under the heading Community life, it is
actual performance of an activity and not only the asked whether the subject engages in charitable
ability, be of interest to the healthcare or rehabilita- organizations, service clubs and professional social
tion personnel? In order to make my question clearer organizations. Under the heading ‘‘Recreation and
I will have to introduce the following notions. leisure’’, it is asked whether the subject engages in
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I introduce first the concept pair: Ability/opportu- any form of play, recreational or leisure activity, such
nity. An ability can be understood as a person’s inner as informal or organized play and sports, pro-
possibility for action. The ability is what a person’s grammes of physical fitness, relaxation, amusement
inner resources permit him or her to do. By inner or diversion, going to art galleries, museums,
resources I mean the biochemical, physiological and cinemas or theatres.
psychological conditions inherent in the person. The So there seems to be a question posed here by the
opportunity, on the other hand, is the person’s outer authors of the classification and which they consider
or external possibility. It includes such factors as to be legitimate: How much of community, social
surround the person: Physical as well as psychoso- and civic life does a specific person take part in?
cial, cultural as well as legal. Consider the following Observe that we are scrutinizing a classification
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example: The inner resources of a Volvo mechanic within the area of healthcare and rehabilitation. It is
permit him to engage in his craft, to use his hands in not a manual for sociologists who are engaged in
the way he wishes. The external arena, the workshop, characterizing the lifestyle or the habits of a certain
gives him the opportunity to use the necessary tools. population. And the question can be asked: Is it the
The rules of the company and the laws of the country task of a medical classifier to investigate whether a
permit him to have the work he has and they specific person regularly goes to museums or
constitute the ultimate opportunities for him with cinemas? Should the medical classifier primarily be
regard to this set of activities. Together the concerned with how people decide to steer their
mechanic’s ability and opportunity for engaging in lives, should they be concerned with people’s
his craft form his whole possibility for action. The interests and inclinations?
amalgamation of a person’s ability and opportunity Above I claimed that ability and opportunity are
is sometimes called the person’s practical possibility not sufficient for the performance of an action. In
for action. order to actually act one must first intend to act or
That there exists a practical possibility on the part want to act. And in this respect people differ very
of an agent for an action F, however, does not much without there necessarily being anything for
necessarily mean that the agent actually performs the the institution of healthcare to consider. Some
action F. I now have, for instance, the practical people are active and want to do a lot of things,
possibility of leaving this room. I have both the inner whereas others want to do little. As a result, there is a
ability and the external opportunity; nothing pre- great difference in their actual performance. But,
vents me from leaving this room. However, I am not normally, there is nothing of medical interest behind
going to leave it at this moment. Why not? The these differences.
answer is simply that I do not want to leave this room A benevolent interpretation of the intention of the
now. There is a lack of will on my part. The will is constructors of the ICF is that they have mainly had
thus a crucial notion in all action theory. But the will in mind such tasks as all or most people need to fulfil
is quite absent in the theory of the ICF. I will shortly in managing their daily life. Thus, it could be
return to this fact. (For an introduction to the action- presupposed that all or most people also want to
theoretic notions mentioned here, see [8].) act in the specified manner. Or, if they, in extreme
cases, do not want to perform these actions, they still
have to perform them in order to survive. We can
Performance qualifier
have in mind such actions as eating, sleeping and
As I have just argued above, it is the notion of ability performing basic hygienic activities. I do not wish to
that is the kernel element in the notion of health. deny that it can be of medical interest to know
 1464 L. Nordenfelt

whether a person actually performs such fundamen- within the standard, as I see it. The healthy person
tal activities as are necessary for his or her survival. should be able to handle situations within a wide
I am also willing to accept that this reasoning can range of circumstances, including moderately harsh
be expanded somewhat outside the basic necessities and demanding circumstances, for instance from the
for mere survival. The manual has a chapter about point of view of climate, professional life and family
Interpersonal interactions and relationships. Here the life. Therefore, if a person is unable to perform a
manual explicitly says that it deals with the carrying particular action in the present situation he or she is
out of actions required for basic and complex for the most part unable to perform it in standard
interactions with people in a contextually and socially circumstances, i.e., he or she is then unhealthy,
appropriate manner [2, p. 150]. The idea here, then, according to my analysis.
is that the performance of certain actions is necessary Whatever our final conclusion on this point it is
for having any deep personal relationships. This in its essential to emphasize the following. If we want to
turn, the argument says, is a prerequisite for a assess the holistic health of a person in a particular
minimally decent life. I can grant this. A person must situation, what should be determined is normally not
not only be able to perform, but must also actually the actual performance of a specific action but the
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perform, certain actions in order to live a decent life ability to perform this action in the situation in
or reach minimal ‘‘well-being’’, the latter being a question. The individual may be perfectly able to
technical term used in the ICF manual. act in the present situation but may simply not
But even if I grant this it will only cover a minor want to act.
part of what people in fact do. There are many There are, however, as I said, several non-standard
activities/participations as classified in the ICF that it situations. There are situations where a person who
is not necessary or even reasonable for everybody to is basically healthy and wants to do something is
perform in a regular manner. Going to art galleries, prevented from doing this by some salient obstacle.
museums or cinemas is indeed rewarding to many The obstacle could be everything from a physical
people, but others are just not interested in these hindrance to a whole societal structure. In many
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activities. They may take an interest in completely cases it seems proper that healthcare personnel are
different things or they may have rather few interests. concerned about such situations. And we should be
But is such a fact a matter for healthcare or able to describe the most typical of such situations.
rehabilitation? In order to do this we need, I argue, instead of a
So far I have agreed that there may be good performance qualifier an opportunity qualifier. Al-
reasons for including the actual performance of certain most all people need and want to run their own
quite basic activities – and not merely the ability to household. A particular person may have difficulty in
perform these activities – in a healthcare manual. doing so, because his or her house is extremely badly
The performance of these activities may be necessary planned. Several corrections may have to be made in
for survival or for a minimally acceptable survival. order to help the person in his or her daily activities.
My concession does not, however, entail that I think Or indeed, most people need and want to move from
that the performance of the activities is an element in one place to another. Assume now that a particular
the health concept itself. person is disabled from doing so, also given
Let me however now also briefly consider an standard circumstances; he or she may not be able
argument prompted by some formulations in the to walk but could be helped to move around with
ICF manual itself. The manual says the following the help of a wheelchair. Thus this person may be
about the capacity qualifier: ‘‘Capacity is measured given an opportunity that he or she did not have
in a uniform or standard environment, and thus before.
reflects the environmentally adjusted ability of the The provision of opportunities not only for people
individual’’ [2, p. 122]. The performance qualifier, with normal capabilities, but also and indeed in
on the other hand, ‘‘describes what an individual particular, for people with subnormal capabilities,
does in his or her current environment.’’ So there has a certain place in the area of public health, health
seems to be an interesting difference here with regard care and rehabilitation. (In a way the same point is
to the environment clause. implicitly made in the ICF under the heading
In my own health analysis I relate the individual’s Environmental factors. The notion of opportunity is
ability to standard circumstances. The ability en- however not mentioned there.) We know how much
tailed in health cannot in general be looked upon the provision of opportunities belongs to the duties
from the point of view of the present environment. of occupational therapists and social workers.
The reason is that the present environment can be We also find it quite reasonable that the removal of
extremely harsh or extremely demanding. In such obstacles preventing certain activities belongs to the
extreme situations also healthy people may fail to act. duties of healthcare professionals. It is, however, a
However, most ‘‘present’’ environments actually fall deep and difficult question to determine the limits
 Comments on some basic notions in the ICF 1465

for this enterprise. Many of us would argue that the have a general function for decisions in healthcare or
removal of obstacles on a more complex social level rehabilitation. Instead I have suggested the introduc-
ought instead to be handled by people in the political tion of an opportunity qualifier, which could fulfill
echelons of society. some of the purposes intended for the performance
However this may be, we should observe that the qualifier.
provision of opportunities to people is not the same
as making people perform certain activities. Whether
they actually act is still depending on their own References
inclinations and wants. Thus, introducing an oppor- 1. World Health Organization. International Classification of
tunity qualifier is not tantamount to introducing a Impairments, Disabilities and Handicaps (ICIDH). Geneva:
performance qualifier. World Health Organization; 1980.
To summarize: In this paper I have attempted to 2. World Health Organization. International Classification of
Functioning, Disability and Health (ICF). Geneva: World
make an assessment of one crucial aspect of the Health Organization; 2001.
health concept embedded in the ICF. This assess- 3. Boorse C. A rebuttal on health. In: Humber J, Almeder R,
ment has involved a brief presentation of some
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editors. What is disease? Biomedical Ethics Reviews. Totowa,

modern holistic theories of health. In these theories N.J.: Humana Press; 1997.
the concept of ability has a central place. Ability (or 4. Seedhouse D. Health: The foundations for achievement.
Chichester: John Wiley & Sons; 1986.
capacity) and its opposite disability (or incapacity) 5. Nordenfelt L. On the nature of health. 2nd revised ed.
are also essential ingredients in the implicit philoso- Dordrecht: Kluwer Academic Publishers; 1995.
phy of the ICF. However, the ICF also puts an 6. Fulford KWM. Moral theory and medical practice. Cambridge:
emphasis on the actual performance of actions. This Cambridge University Press; 1989.
is entailed by the performance qualifier that is 7. Nordenfelt L. Health, science and ordinary language. Am-
sterdam: Rodopi Publishers; 2001.
included in the ICF. I have given some arguments 8. Nordenfelt L. Action, ability and health: Essays in the
for questioning the relevance of this qualifier if it is philosophy of action and welfare. Dordrecht: Kluwer Academic
intended to have a place in the concept of health or Publishers; 2000.
For personal use only.