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Habilitation, Health, and Agency
This page intentionally left blank
Habilitation, Health,
and Agency

A Framework for Basic Justice

L aw re n c e C . B e cke r

1
1
Oxford University Press, Inc., publishes works that further
Oxford University’s objective of excellence
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Copyright © 2012 Lawrence C. Becker

Published by Oxford University Press, Inc.

198 Madison Avenue, New York, New York 10016
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data

Becker, Lawrence C.
Habilitation, health, and agency : a framework for basic justice / Lawrence C. Becker.
p. cm.
Includes bibliographical references (p. ).
ISBN 978-0-19-991754-9 (acid-free paper) 1. Political science—Philosophy.
2. Justice. 3. Health. 4. Medical ethics. I. Title.
JA79.B35 2012
320.01′1—dc23 2011044543

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
For Charlotte
This page intentionally left blank
 Contents

Introduction 3

Part 1: Habilitation and Basic Justice

Preface to Part One 11
1. Concepts and Conceptions: Basic Justice and Habilitation 13
1. Basic Justice 13
2. Habilitation: Concept and Conception 18
3. Normative Theories with a Close Connection to Habilitation 20
4. Habilitation: Conception and Framework 27
2. The Circumstances of Habilitation for Basic Justice 30
1. Humean Accounts 30
2. Functional Abilities in a Given Range of Environments 32
3. Summary of the Circumstances of Habilitation 40
4. The Centrality of Health and Agency 40

Part 2: Health, Healthy Agency, and the Health Metric

Preface to Part Two 43
3. Eudaimonistic Health: Complete Health, Moral Development,
Well-Being, and Happiness 45
1. Health, Well-being, and Virtue 46
2. A Unified Conception of Health, Positive and Negative 51
3. The Science of Mental Health, Happiness, and Virtue 55
4. Health, Happiness, and Basic Justice 59
4. Good Health as Reliably Competent Functioning 67
1. Basic Health: An Integrated, Limited General Concept 69
2. Habilitation, Coping Abilities, and Agency 72
3. Good (Basic) Health as Reliably Competent Functioning 75
5. Robustly Healthy Agency 81
1. The Health Metric 82
2. Health Science: Limited and Unified 87
3. Habilitation into Robustly Healthy Agency 89
viii Contents

6. Healthy Agency as the Representative Good for Basic Justice 95

1. Healthy Agency versus Wealth and Income 95
2. Healthy Agency versus Pluralism 98
3. The Representativeness of Habilitation into Healthy Agency 101
4. Theory All the Way Down: A Public Policy Objection 105

Part 3: Healthy Agency and the Norms of Basic Justice

Preface to Part Three 113
7. Healthy Agency and Its Behavioral Tendencies 115
1. Dispositions toward Health and Habilitation 115
2. Dispositions about the Subject Matter of Justice 118
8. Healthy Agency and the Norms of Basic Justice 141
1. Habilitative Necessities and Justice 142
2. Habilitative Stability, Strength, and Efficiency 146
3. Second-order Norms 152
4. Moving beyond Basic Justice 155

Part 4: Relevance, Influence, and Prejudice Revisited

Preface to Part Four 157
9. Relevance, Influence, and Prejudice 159
1. Exclusionary Reminders 159
2. Comprehensiveness and Representativeness 161
10. Conclusion and Extrication 166
1. Health, Individual Liberty, and Social Stability: A Fantasy 166
2. Approximations to Health 167
3. Pseudo-problems and Elusive Targets: Sensible Replies to the Foole 168
4. Hope rather than Fantasy 178

Acknowledgments 181
Bibliography 183
Index 191
Habilitation, Health, and Agency
This page intentionally left blank
 Introduction

This book offers a way of reorienting normative theories of distributive justice

around conceptions of habilitation, health, and agency. It asks readers for a pause
in perennial debates about competing principles of justice in order to consider a
constellation of ideas that can reframe the whole theory-building enterprise. If the
book achieves its overall aim, it will have described a useful and attractive new
conceptual framework for theories of distributive justice generally. It will not have
argued for or against any particular normative theory of justice.
The novelty of this conceptual framework—the habilitation framework, as I will
call it—lies more in the arrangement and articulation of its parts than in the parts
themselves. Those parts (habilitation, basic justice, basic good health, and robustly
healthy agency) are reassuringly familiar, taken one by one.
As used here, habilitation is about equipping someone or something with ca-
pacities or functional abilities. Basic justice (as opposed to ideal justice) is the most
fundamental part of the subject. Basic good health (as opposed to perfect health)
is about health fundamentals, but includes psychological as well as physical health.
Robustly healthy agency is a strong form of functional competence.
All of this will sound vaguely familiar, but unless it is explicated with some care,
the arguments of the book will not be as precise and consistent as they need to be.
Such explication begins later in this introduction in “The Plan of the Book and a
Short Lexicon for It,” and continues as needed. The philosophical argument that
flows from these ordinary concepts is much less familiar than the concepts them-
selves, but the aim here is to make that argument commonsensical: novel, perhaps,
but illuminating rather than contentious.
Such common sense is often welcome in ethics. At least that is so in the large area
in which all plausible normative theories converge on similar conclusions about
right and wrong, good and bad, justice and injustice—even when they disagree
about method and first principles. It would be alarming if the habilitation frame-
work offered novel ideas about murder, promise keeping, contracts, cooperation,
self-interest, benevolence, and so on—ideas different from settled transcultural and
transhistorical social norms, as well as those that libertarians and communitarians,
4 Habilitation, Health, and Agency

individualists and collectivists, liberals and conservatives, utilitarians and social

contract theorists all endorse. Novelty should be more welcome, however, if it is
confined to the philosophical considerations that ought to ground such agreement
between theories—theories that are otherwise very different in their conceptions of
ideal justice, and in utopian visions of it.
So in order to bring out the way in which the habilitation framework applies to
normative theories of justice generally, this book will be confined to the area in
which they diverge least: basic justice, as I will call it. And readers should not
expect to find any new distributive principles proposed here. Rather, the book
is about background ideas: material from which distributive principles can be
developed, criticized, adopted, applied, revised, refined, or rejected no matter
what specific theory of justice one is pursuing.

Three Proposals
The argument of the book yields three overarching proposals for philosophical
theories of basic justice: (1) that those theories ought to adopt a particular concep-
tion of habilitation as a framing device for their inquiries; (2) that they ought to
adopt a particular conception of basic good health as the representative good for
basic justice; and (3) that they ought to adopt a specific aspect of health—namely,
robustly healthy agency—as the target for basic justice. As a whole, the book is
essentially an explication of those concepts and conceptions, together with an ar-
gument for the three proposals about them.
Those numbered proposals (and the disclaimer about the deliberate absence of
distributive principles) will be repeated throughout the book as canonical state-
ments of its aims, even though many of the terms in them or in the air around
them will be initially obscure until the explication of them is complete. “Habilita-
tion,” for example, is a particularly challenging case. It is an abbreviation for a
complex conception that will have to be developed at considerable length. (It will
be given an initial gloss in the short lexicon below, and developed more fully in
Chapters 1–2, and 7–8.)

The Absence of Distributive Principles

Notice that these proposals are all about the metric or currency or representative
good involved in theories of justice. They are not about any specific list of basic goods,
specific ranking of them, or specific distributive principle. In short, they do not give
any principled account of how goods ought to be distributed. Nor do they tacitly
assume any such principles, or deliberately leave them lurking in the background.
 Introduction 5

Thus, by extrapolation from Elizabeth Anderson’s pithy account of the theoretical

necessity for both a metric and a distributive rule in a normative theory of justice
(Anderson, 2010, 81–83), the proposals offered here do not constitute such a theory.
As the argument of the book develops, however, it will be natural to wonder
whether the proposals in it inadvertently prejudice some choices about normative
principles. Such questions will be addressed at various points throughout the text.
It is clearly true that the habilitation framework, and the health metric and target
projected from it, are likely to make it difficult to justify one or another distributive
principle in a given environment. But it will turn out that such special difficulties
either are attributable to the principles themselves (because they are intrinsically
more difficult than others to justify) or are attributable to special features of a
given environment.
For example, on the latter point, consider how life on a desolate frontier
sparsely populated by nomadic tribes, or in a barely survivable environment (a
high-tech colony in Antarctica, or on the moon) might plausibly call for different
distributive principles from those best suited for a large-scale, densely popu-
lated, affluent, industrialized society. The habilitation framework is sensitive to
such environmental variables and thus cannot be expected to impose exactly
the same justificatory burdens or benefits on all distributive principles in all
environments. What is possible, or even necessary, on a camping trip with a few
friends will not always work well when scaled up to a large industrialized society
(Cohen, 2009), and if the habilitation framework shifts normative burdens on
distributive principles accordingly, that is a good thing.

Antecedents and Analogs

As far as I am aware, no one else has proposed to give habilitation, health, and agency
such a central role in theories of distributive justice. Sometimes, one or another of
these concepts has played a leading role in a particular normative theory, but that is
quite different from giving the three of them leading roles in all theories of justice.
And the deliberate omission of distributive principles from this account may make
the whole project seem even more peculiar. Is it believable, at this late date, that
everyone has so far missed something of central relevance to all theories of justice? Is
it worthwhile trying to find something like this rather than getting on with a specific
normative enterprise? Such worries may raise eyebrows, if not hackles.
It may help at this point, then, to notice the way in which this book will be anal-
ogous to (or even an expanded version of) three familiar preparatory projects that
are typically embedded in specific normative theories of distributive justice.
The circumstances of justice. One of these projects is an account of the circum-
stances of justice—that is, an account of those aspects of the human condition that
6 Habilitation, Health, and Agency

give rise to questions of justice in the first place, and for the need to theorize about it
in some way that can have practical consequences. (Think of Hume’s list: moderate
scarcity, limited altruism, and approximate equality of power and vulnerability.)
There will be an explicit analog to this in Chapter 2, which will describe the circum-
stances of habilitation for basic justice.
Basic goods. Another familiar project is getting an account of the goods that are
especially salient for any theory of distributive justice. (Think of Rawls’s preparatory
account of basic goods, or Walzer’s account of social goods.) There is an analog to
such a project here, in the discussion of eudaimonistic health, the health metric, and
the healthy agency target—all in Part Two of the book (Chapters 3–6). But identi-
fying goods that are especially salient is not equivalent to giving such goods norma-
tive priority. A normative theory may go on to do that, but the habilitation framework
will not. It will simply discuss the way in which health and healthy agency are, from
a practical point of view, especially useful as a metric and a target, respectively.
The goals of justice. A third analogous project is an account, in very general terms,
of the goals of justice—the ultimate goals we are seeking by adopting principles or
constructing theories of justice. Is our aim to minimize the way people interfere
with each other, so they can separately pursue their own lives and projects? Is it to
maximize the sort of cooperation that allows people to achieve things together that
they could never achieve alone? Or is it to create and maintain the best form of life,
or the best form of society, independent of the happiness of the individuals in it or
its other collective achievements? (Think of the discussions of those questions in
Plato’s Republic.) In the arguments to follow, the focus is mainly on the second of
these three questions about the goals of justice: the things we can achieve together
that we cannot achieve by ourselves. But the habilitation framework speaks to all
three of the questions, as well as some others.

The Plan of the Book and a Short Lexicon for It

Since understanding the book’s central aims depends on an initial understanding
of some terms that are antiquated (e.g., habilitation) or ambiguous (e.g., health), it
will be helpful to address those matters briefly now, along with an equally brief
account of the plan of the book.
Habilitation. Some current English dictionaries do not have an entry for “ha-
bilitation” at all, and the online Oxford English Dictionary now (2011) marks its
verb form as obsolete. That is odd, since the term is alive and well in medical
contexts and in the ordinary concept of rehabilitation. There it continues to mean
just what the OED says it used to mean in general usage: habilitation is “the action
of enabling or endowing [a person or thing] with ability or fitness; capacitation,
qualification.” Here I will often refer to it just as the process of equipping a person
 Introduction 7

or thing with capacities and/or functional abilities, usually as relevant to a given

environment.
It is important to keep in mind the diversity of objects that can be habilitated.
One can habilitate oneself as well as others, and one’s physical and social environ-
ment as well as some specific set of people in it. I will make this point repeatedly,
but it plays a particularly important role throughout Part Four (Chapters 7–8),
where the extent of the parallelism between traits of basic virtue and traits of basic
good health is explored at length.
It is equally important to keep in mind three other things. One is that human be-
ings need habilitation and rehabilitation of various forms throughout their whole life-
times; except intermittently, we are not self-sufficient, nor can we become so. Another
is that our need for habilitation is not just equivalent to our need for survival equip-
ment; we need, as well, the equipment to thrive. Without that, we languish, and ulti-
mately put our survival itself at risk. And the third is that much of this habilitation has
to be self- provided. We wither, become weak, fail to develop many important abilities,
and ultimately fail to thrive if we cannot habilitate ourselves in any important respect,
or when everything we need we receive like manna from heaven. These matters will
figure in arguments throughout the text, particularly with respect to healthy agency.
Basic justice. As noted earlier, the subject of the book is not the entirety of dis-
tributive justice, but rather its most basic part—the area in which plausible the-
ories of justice diverge least, and in fact in large part converge. This part can be
described in a number of substantive ways—for instance, by reciting a familiar list
of uncontroversial basic goods, rights, or practical possibilities for negotiation
among people who hold very different comprehensive theories of justice. Chapter
1 will mention such lists, but there—as well as elsewhere throughout the book—
the argument will rely only on the items in such lists that are connected, in a stable
way, to a more general, schematic concept of basic justice.
That general concept, addressed in Chapter 1, limits the subject matter of basic
justice to those matters of moral concern over which we have some actual control,
either through social institutions or individual conduct, and about which we can
require things of ourselves and others on grounds we have jointly reasoned out and
can practicably enforce.1 Included in this general concept, by implication at least, are

1
T. M. Scanlon defines the domain of his inquiry in What We Owe to Each Other (1998, 6–7), in a
similar way, though he declines to identify it with justice. He says it is concerned with the “domain of
morality having to do with our duties to other people, including such things as requirements to aid
them, and prohibitions against harming, killing, coercion, and deception.” But he goes on to say that
“[i]t is not clear that this domain has a name . . . [other than, perhaps,] ‘the morality of right and
wrong.’” He says that the part of morality he has in mind is “broader than justice, which has to do par-
ticularly with social institutions. ‘Obligation’ also picks out a narrower field, mainly of requirements
arising from specific actions or undertakings.” He thinks the phrase “what we owe to each other” is an
apt name for this part of morality and argues throughout his book that this domain “comprises a dis-
tinct subject matter, unified by a single manner of reasoning and by a common motivational basis.”
8 Habilitation, Health, and Agency

the types of social norms that generate the rules of “natural” justice (e.g., that similar
cases should be treated similarly) and a short list of vaguely described basic goods.
The argumentative strategy of the book will be to explicate that schematic con-
cept of basic justice and notice the way it points toward the need for an elaborate
conception of habilitation. Habilitation, in turn, develops into a way of giving the
schematic concept of basic justice a more determinate content—one that orga-
nizes and clarifies the points of convergence among philosophical theories. These
points are argued in Chapters 2–8.
Framing devices. Using any framing device for philosophical argument does
several things. For one, it defines the general area of discussion, operating logically
as the definition of the universe of discourse. Then, in doing so, it inevitably defines
the edges of the discussion, putting some matters close to those edges (or even
beyond them) and making others central. Finally, the frame also helps to define a
focus—or perhaps, as in a painting or photograph, a set of focal points to which
the eye is drawn in sequence. And if the frame is three-dimensional—a frame-
work—it defines the architectural possibilities as well; the sorts of things that can
be built upon it.
The framing devices for distributive justice currently in play include at least these:
fair agreement for mutual advantage between fully cooperating members of society;
the maximization of aggregate welfare, well-being, or opportunity for well-being
(within a given society, or in a global context); the pursuit of an ethical ideal in which
reason, will, and desire are harmonized; the improvement of social life and indi-
vidual well-being in genuine communities characterized by shared values, solidarity,
and mutual benevolence; the improvement of individual well-being and chances for
a good life through the realization of human capabilities or through the protection of
individual rights and liberties; the neutralization or correction of disadvantages that
are the product of bad luck. One could go on.
It is useful to notice, however, that these framing devices are offered as a defining
condition of a type of normative theory of justice—or perhaps even of a specific
instance of that type—and the whole thing is then put forward against rivals. Crit-
icism then comes from those rivals, or from inside the specific theory, but is typi-
cally aimed at dismantling or improving that theory, or type of theory, as a whole.
By contrast, the framing device proposed here is more abstract: that all philo-
sophical inquiry into matters of basic justice should be framed in terms of the
concept of habilitation. This is not an effort to replace any specific type of norma-
tive theory but rather to recast the framing devices they all use. It is in that sense a
meta-theoretic proposal, criticism of which can be separated from criticism of
specific types or instances of normative theory. Arguments on these matters ap-
pear throughout the book, but most pointedly in Parts One and Two (especially
Chapters 2, 4, and 6).
 Introduction 9

Eudaimonistic health. The habilitation framework gives a central place to “com-

plete” health, defined so as to include physiological and psychological functioning
within an environment, on both the negative (e.g., disease) side of the health led-
ger and its positive (e.g., well-being) side as well. And the resultant focus on health
is a focus on what is necessary for each individual, with a particular set of endow-
ments, to develop and sustain various levels of good health in various environ-
ments. See especially Chapter 3.
Robustly good (eudaimonistic) health. The definition of good health will be the
key to the health scale, and in a nutshell, the definition of robustly good health that
will be adopted here is “reliably competent physiological and psychological func-
tioning in a given environment.” The so-called negative definition of health, in
which health is treated as the absence of pathology, while it naturally receives a
good deal of attention in philosophy of medicine and bioethics, is inappropriate
here, since it does not adequately cover good health and well-being.
The arguments in Chapters 3–4 and 7–8 develop this focus on robustly good
eudaimonistic health in terms of its conceptual connections to ethical theory and
contemporary health science. One aim (Chapters 7–8) is to show the extent of the
convergence between the norms of basic justice and the motivational structure
and behavioral dispositions of the sort of agency characteristic of good health.
Another aim (Chapters 4–6) is to show that the focus on this sort of health—and
in particular the part of it we may call healthy agency—gives us a currency to use
in theories of justice that is equal to or superior to other candidates, such as lib-
erties, entitlements, capabilities, opportunities, well-being, luck, or various combi-
nations thereof.
Representative goods. The notion of a representative good is straightforward.
Practical problems are often simplified if we can find a single, observable, and
scalable item from which it is possible to infer the presence, absence, quantity, or
quality of all the items with which we are concerned. That single item can then
become an index for the whole bundle of items we must consider. This is especially
important in a theory of distributive justice, where we continually face allocation
problems under conditions of scarcity. Answering questions of who should get
how much of what there is to distribute depends upon solving—or at least working
around—the indexing problem.
Chapters 5–6 concern the definition of an operationalizable health scale, running
from worst to best. The definition of the health scale is followed by the proposal that
focusing on a particular region on the scale—robustly good health—provides us
with a plausible upper boundary for what might be required (as a matter of basic
justice) with respect to health. More generally, however, the argument is that health
can function as a representative good in normative theories of distributive justice,
and that at least for basic justice it is superior, in that role, to various standard
10 Habilitation, Health, and Agency

alternatives such as wealth and income, subjectively defined welfare or well-being,

or preference satisfaction.
Goals and targets. The third proposal of the book is that a particular region of
robustly good health—namely, robustly healthy agency—yields an appropriate
target for basic distributive justice, even though healthy agency is only one of the
goals we have for health, let alone for basic justice itself. It turns out that hitting, or
approximating, that target will get us to the other goals as well, with a minimum of
wasted effort, since healthy agency is causally connected and approximate to the
entire bundle of goals involved. And the healthy agency target is appropriately
limited as well, being far from perfect health but even farther from the bottom of
the health scale.
The arguments for this proposal are in Chapters 4–6. They are closely entwined,
however, with the discussions of agency throughout the book, especially those in
Chapters 7–8. They also rely heavily on the landscape of problems framed by the
conception of the circumstances of habilitation (Chapter 2), as well as the arguments
for eudaimonistic good health as the representative good for justice (Chapter 6).
Rhetorically, these arguments rely on the intriguing relationships between goals
and targets—especially in practical circumstances in which outcomes cannot be
guaranteed, and thus one must choose strategies rather than outcomes. Consider:
even if the archer’s only goal is to hit the physical target on the range, the target
that the archer will actually choose to aim at will be determined by distance,
windage, expected velocity of the arrow, and so forth—and may be quite different
from the goal. The archer’s actual target will be a virtual one hovering in the vi-
cinity of the actual goal. The argument here is simply that robustly healthy agency
covers the other goals well enough that using it as the virtual target will always be
sufficient to get to a best approximation to all the goals. The arguments on these
matters are found most explicitly in Chapter 6, and throughout Part Four
(Chapters 9–10).
 Part 1
Habilitation and Basic Justice

Preface to Part One

The two brief chapters in Part One explicate the concepts of basic justice and
habilitation (Chapter 1), and the circumstances of habilitation for basic justice
(Chapter 2). These preparatory materials are necessary for the arguments of Parts
Two, Three, and Four, but they have a supplemental purpose as well. That purpose
is to introduce an essential strand of the argument running throughout the rest of
the book: namely, that theories of basic justice should be reoriented in a funda-
mental way—a way that encompasses not only the urgent problems about conflict,
cooperation, and coordination under circumstances of scarcity and competing
purposes but also encompasses the equally urgent problems about habilitation,
health, and the common goals growing out of them.
Typical accounts of basic justice, after all, are implicitly framed by an almost
irresistible narrative—human history written as the story of appalling conflict,
malice, and resulting injustice, both political and personal. At a political level, this
is the story of war and peace, grinding poverty and lavish wealth, slavery and free-
dom, subjugation and dominance—all of it driven by the struggle for survival in
circumstances of scarcity, egoism, fixed loyalties, and the ability of a few to tri-
umph over the many, and to organize their labor. At a personal level, this is the
story of fear and greed, hatred and love, cruelty and kindness, selfishness and
altruism, and above all, appetites for pleasure and triumph. The emphasis in both
stories is on humans who have conflicting primal impulses at war within them-
selves, and which perpetually threaten to put them at war with each other. The
emphasis throughout is on the undeniable, ever present reality of basic injustice.
These chapters emphasize a different aspect of human history. This is a story
about the equally undeniable persistence of basic justice, along with injustice, and
the intimate connection of both to the necessity for human habilitation. It pro-
poses that focusing on the circumstances of habilitation—that is, the circumstances
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