Notes from "Philosophical Reflections on Disability"

Book Discussed

Ralston, D. C., & Ho, J. (Eds.) (2010). Philosophical reflections on disability. Dordrecht: Springer.

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In another blog post, I was taking notes on Houtenville et al. (2009), Counting Working-Age People with Disabilities.  I got as far as page 28 and came back again to the question of how to define disability.  I had recently borrowed a copy of this book by Ralston and Ho, and decided to check it out.  So here are some notes that came to mind as I perused a few chapters of that volume.

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Chapter 1:  Introduction

The introduction just summarizes and comments on the book's various articles.  I used it to help select which chapters to focus on, in the brief time I had available.

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Chapter 2:  Silvers, A. (2010). An essay on modeling: The social model of disability. In D. C. Ralston & J. Ho (Eds.), Philosophical reflections on disability (pp. 19-36). Dordrecht: Springer.

Among its many interesting insights and much information that was new to me, I found this chapter somewhat illogical in spots.  For example, Silvers says, “[T]here is not nor can there be such a thing as a social model of disability” and goes on to refer to “the so-called social model” (p. 21) and to “supposed models of disability” (p. 22).  But then she goes ahead and talks about the social model in terms that indicate she does think it exists, with comments such as “[T]he medical and social models portray disability in very different ways” (p. 22).

Her point there seems to be that the social model is a model in the sense of being a “collection of claims” (p. 23) rather than somehow being a “simplified representation” or “replica” (p. 22) of disability.  But that seems like an odd point.  How would one construct a representation of disability, as though it were a tangible object instead of a concept?  This so-called “collection of claims” seems par for the course, where concepts are concerned.  That’s what models are, in this kind of context:  “Theoretical representations that simulate the behavior or activity of systems, processes, or phenomena.”  The social model of disability describes disability as a system or process in which society takes an impairment and makes it into a disability.

That was an isolated example until I got to page 31 or so.  I was learning a lot, and I was mostly engaged.  But then she said this:

Of course, we cannot infer from our sense of one’s condition’s being less preferable than some others that it also is inherently bad.  We often prefer someone else’s condition to our own – someone richer, smarter, handsomer, or more generous than ourselves – without condemning our own state as bad. . . . So the fact that not being disabled may be preferable to being disabled does not entail that the state of being disabled is bad.  The social model counsels the acceptance of disability as being a natural state of some people . . . . 

I wasn’t sure it mattered if disability was “bad.”  The point was, it’s less preferable.  Lots of things are “natural” – hepatitis, for example – and yet not desirable.  If we consider ourselves ugly or poor, that’s a comparative judgment that we would typically like to address by magically becoming beautiful and rich.  That’s natural too, even if such a belief might actually make us less happy, or if the magic didn’t ultimately yield the imagined results.  Whatever.  At the point of decision, we go toward what is more desirable because, on many levels, this is the approach that tends to keep us alive and healthy.  The word “bad” is irrelevant; however you phrase it, people generally don’t want to have disabilities, and there are good reasons for that.

Silvers (pp. 34-35) feels that the social model  may now be nearly as entrenched as the medical model (in which disability is identified as a flaw in the person that should be corrected), and that each has its usefulness from particular values perspectives.  But she says that a problem arises when a focus on the social model causes funding to be directed toward modifications of social conditions rather than toward prevention and cure.

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Chapter 8:  Merriam, G. (2010). Rehabilitating Aristotle: A virtue ethics approach to disability and human flourishing. In D. C. Ralston & J. Ho (Eds.), Philosophical reflections on disability (pp. 133-151). Dordrecht: Springer.

This article prompted me to write a separate post regarding overpopulation, eugenics, and the right to reproduce.  

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Chapter 13:  Tollefsen, C. (2010). Disability and social justice. In D. C. Ralston & J. Ho (Eds.), Philosophical reflections on disability (pp. 211-227). Dordrecht: Springer.

Tollefsen distinguishes citizenship from well-being.  His conclusion (p. 223) is thus:

[T]he moderately disabled, the temporarily dependent, the “normal” human person, the profoundly retarded, the brain damaged, and even those in a persistent vegetative state, are all alike as regards the fundamental reason that justifies political authority:  all are inadequate in some respect or other for their own flourishing.  All lack self-sufficiency in regards to the conditions necessary for them to achieve the level of well-being they are capable of . . . . No special attempt need be made to see any of them as citizens, or potential citizens, or even like citizens, in order to see that they fall within the fundamental scope of the political authority’s concern, the basic commitment “to foster the dignity and well-being of all persons within [the state’s] borders” [source of quote unspecified].

In other words, contra Nussbaum (2006), Tollefsen sees a person in a persistent vegetative state as being nonetheless a human being.  That, however, does not warrant his postulation of a state’s commitment to foster well-being of everyone within its borders.  A state might decline to do so, rightly or wrongly, for illegal immigrants, prisoners, and others; it might also do so unequally on a variety of grounds, including one’s individual or collective (as e.g., part of an influential constituency) wealth or political power or lack thereof.

Tollefsen does acknowledge that the state has to provide many things, including infrastructure and internal and external security, and therefore that there are limits to what the state can do, to be determined through prudent judgment.  “Such limitations,” he says (p. 224), “are not matters of injustice.”  As philosophers sometimes do, however, he repeatedly makes assertions that could be empirically supported, refuted, or qualified.  For example (p. 224):

[F]amily members such as parents and spouses, friends, and parishes all have a better grasp of the particular needs and capacities of individuals with disabilities, and all have a greater capacity for emotional involvement and sustained commitment than do any agents of the state. . . . The state should not be in the business of taking over the care of the disabled . . . .

These assertions seem quite unlikely in particular cases.  Caregivers do not tend, in any event, to be qualified professionals, and they are also not insurance companies.  For a variety of discriminatory, agenda-driven, resource-related, and competence-related reasons, parishes and other local organizations may lack the capacity and/or inclination to care effectively for people with disabilities.  It is not clear, from this essay, why the handling of disabilities would be considered a predominantly private matter, while the handling of criminal behavior is not.

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Chapter 14:  Englehardt, H. T., Jr. (2010). The unfair and the unfortunate: Some brief critical reflections on secular moral claim rights for the disabled. In D. C. Ralston & J. Ho (Eds.), Philosophical reflections on disability (pp. 229-237). Dordrecht: Springer.

When I read this chapter, I had just read an article about health care in the United States – about how expensive and illogical the health care system has been.  I had wondered about questions of affordability and logic while reading materials about disability as well.  Whatever was going to happen in the realm of disabilities in the future, it seemed that cost and rationality would be important considerations.

Englehardt (p. 231) says this:

Disease and disability are surely, ceteris paribus, unfortunate.  The issue is whether they are unfair in a way that generates general secular moral claim rights against others who did not cause the disease or disability.

In response, he concludes that “Moral diversity, the fact of moral pluralism, undermines the self-evident character often attributed to claim rights for care, support, and accommodation” (p. 235).  In other words, not everyone prioritizes the same things.  His position seems to be that it is not entirely certain that society ought to put its full resources behind all forms of environmental manipulation, making everything more accommodating for people with disabilities, when there are other things that we could do with the money.

What we have, Englehardt says, is political compromises, not moral certainty.  Disabilities get a certain amount of funding, and not more or less, as a result of advocacy on behalf of disability-friendly perspectives.  “In such circumstances, entitlements for the disabled will not enjoy a secular moral authority.  They will simply be outcomes that it will usually be prudent to accept” (p. 236). 

Definitions of Disability

The Web is filled with references to handicapped people and disabled people and people with disabilities.  But what is a disability?

Iezzoni and Freedman (2008) describe a "medical model of disability" (p. 332) originating in the 19th century. That model, they say, treats disability as a form of illness; and illnesses, in the medical model, are typically diagnosed in individuals and treated by doctors.  Against this, Iezzoni and Freedman contrast the "social model" (p. 333), which considers disability a social phenomenon.  In the words of the Fundamental Principles of Disability (1975) produced by the now apparently defunct Union of the Physical Impaired Against Segregation, "Disability is something imposed on top of our impairments, by the way we are unnecessarily isolated and excluded from full participation in society" (p. 3, cited by Oliver (1996, p. 22)).  In other words, there are a great many physical and mental impairments - the need to wear eyeglasses is an example - but not all impairments are treated equally; some result in much more isolation or stigma than others.

Within the social model of disability, Iezzoni and Freedman (2008) favor the definitional approach adopted by the World Health Organization's (WHO, 2009) International Classification of Functioning, Disability and Health (ICF):

The ICF puts the notions of ‘health’ and ‘disability’ in a new light. It acknowledges that every human being can experience a decrement in health and thereby experience some degree of disability. Disability is not something that only happens to a minority of humanity. The ICF thus ‘mainstreams’ the experience of disability and recognises it as a universal human experience. By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability. Furthermore ICF takes into account the social aspects of disability and does not see disability only as a 'medical' or 'biological' dysfunction. By including Contextual Factors, in which environmental factors are listed ICF allows to records the impact of the environment on the person's functioning.  [I have notified the webmaster of incoherence in that last sentence.]

Iezzoni and Freedman (2008) note, however, that different definitions serve different purposes, and that at present there are numerous legal definitions in use in the United States.  Two of the most prominent definitions they cite are those of the Americans with Disabilities Act of 1990 (ADA) and the Social Security Administration (SSA).  Section 12102(1) of the ADA defines disability as meaning, with respect to an individual, "(A) a physical or mental impairment that substantially limits one or more major life activities of such individual; (B) a record of such an impairment; or (C) being regarded as having such an impairment."  By contrast, the Social Security Advisory Board (2003) says that the Social Security Act of 1956 defined disability as “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration” (p. 3); but this definition, they say, is increasingly subject to challenge.

The Census Bureau is yet another important source of disability definitions.  Definitions used by the Census Bureau in recent years include the definition of "work disability" in the Current Population Survey; the definition of disability in the Survey of Income and Program Participation; and the definition of disability in the American Community Survey (ACS).  Among these and other data sources that have been used by the Census Bureau, the ACS is especially useful for obtaining local data at the city and county levels.  The 2008 ACS Subject Definitions operationalize the concept of disability in a set of related questions posed to survey participants:

Using models of disability from the Institute of Medicine and the International Classification of Functioning, disability is defined as the restriction in participation that results from a lack of fit between the individual’s functional limitations and the characteristics of the physical and social environment. So while the disability is not seen as intrinsic to the individual, the way to capture it in a survey is to measure components that make up the process. The American Community Survey identifies serious difficulty in four basic areas of functioning: vision, hearing, ambulation, and cognition. Described below, the ACS asks respondents about serious difficulty and the resulting data can be used individually or combined. The ACS also includes two questions to identify people with difficulties that might impact their ability to live independently. In the 2008 American Community Survey, there are three disability questions, two with subparts totaling six questions in all . . . . (p. 38).

These various definitions, including especially that of the ACS, will be relevant to further exploration of data on disabilities within the U.S.