QUALITY OF LIFE, PHILOSOPHICAL AND ETHICAL DIMENSIONS

The phrase ‘‘quality of life’’ is almost always controversial. The basic idea behind the concept of quality of life is that some characteristics of the person and his or her surrounding environment are better than others from the point of view of the human good or human flourishing. Nearly all the major thinkers of the Western tradition, from Plato and Aristotle through Jeremy Bentham, Immanuel Kant, John Stuart Mill, Karl Marx, Friedrich Nietzsche, and John Dewey have given their preferred accounts of the good or the best human life, as have the world’s great playwrights, poets, and novelists. In recent years the Nobel Prize–winning economist Amartya Sen has made important contributions to the topic. Nonetheless, no single account has ever won universal agreement. Many of these accounts overlap, however, and the outlines of at least three general orientations can be discerned. These are: hedonic theories, rational preference theories, and theories of human flourishing. Despite its difficulty and frequent lack of clarity, the concept of quality of life seems to be an indispensable one, particularly in the domain of health care and social services.

Sources of controversy

One school of thought in philosophy and ethics holds that the concept of quality of life should not be used because it undermines the intrinsic dignity and worth of human life. Something (human life) is being evaluated that should not be evaluated. Human life is valuable for its own sake and not merely as a means for something else. The term quality of life seems to imply that life is not intrinsically worthy of respect, but can have greater or lesser value according to its circumstances.

In addition to those who regard all talk about the quality of life as an affront to the inherent dignity of the human person, objections to the term also come from the disability rights community. From this perspective, the notion of quality of life is part of a broader normalizing ideology in the mainstream culture and works to the detriment of persons with disabilities by perpetuating stigmatization and discrimination against them.

To what does quality of life refer?

If we pay close attention to the different ways in which the concept of quality of life is used in health care, it is possible to make one’s way successfully through this semantic minefield. In order to do so it is important to distinguish four different senses of the notion of quality of life.

Quality of life as a property of the individual. First, the notion of quality of life is used to refer to some characteristic or state of being of the individual person. A quality of life (whether good or poor) is something one has or possesses, much as one has a physical characteristic or an occupation. Understood in this way, one’s quality of life is not essential to one’s identity or self-esteem. As such it has no straightforward moral significance. A poor quality of life (due to ill health, loss of a job, breakdown of personal relationships, or the like) is not necessarily a sign of a person’s moral failing, and it says nothing about the intrinsic value of life as such, or even about the moral value of that particular life at that particular time.

Quality of life as a goal of care. A second common meaning of quality of life defines it as a goal of care. The moral point of our dealings with another (whether the situation be health care or some other form of relationship) is to sustain and improve the quality of life. In this sense, quality of life becomes a benchmark to guide human activity and a concept of assessment and evaluation. But notice that the evaluation here is directed primarily at the caregiver and the caregiving process, not at the recipient of care, who partakes of the quality of life achieved but is not judged by it. Moreover, quality of life can be thought of as an interaction between the person and his or her surrounding circumstances, including other people. Thus understood as a goal or outcome of care, an improved quality of life may be a change (for the better) in the person’s symptoms or perceptions; or it may be a change in the person’s relationship with his or her environment. Medical cure, symptom relief, psychological happiness, or social empowerment may all be goals of care as comprehended by the concept of quality of life.

Quality of life as a social situation. Next, quality of life may refer to a state of interaction between an individual and his or her social and physical environment. Here a certain quality of life is not a property of the individual per se, but a function of that individual’s form of life. So understood a low quality of life assessment does not necessarily suggest a negative evaluation of the person or his worth; it can equally well imply a critical evaluation of the person’s environment and indicate ways in which that environment could be changed so as to enhance the quality of life according to some scale of norms such as justice, freedom, health, happiness, and the like.

Quality of life as the moral worth of a life. Finally, it must be acknowledged that the term quality of life is sometimes used to refer to the moral worth or value of a person and his or her life. Pushed to its logical extreme, this understanding of the quality of life takes us to the infamous Nazi concept of ‘‘life unworthy of life,’’ (lebensunwertes Leben ), which was used to rationalize everything from active euthanasia of those with disabilities to the genocidal death camps. To say that a person has no quality of life or a very low quality of life is to say that prolonging this person’s life has no moral significance, either to the person himself or to society.

In this author’s view, it is a mistake to use quality of life as a measure of the moral worth of human beings. The notion of the moral worth of a life is logically quite distinct from the notion of quality of life. An account of moral worth is based on an underlying account of humanness or the human person; an account, that is, of what it is to be human. The concept of quality of life, on the other hand, is based on an account of a person’s inherent capacities and external circumstances. Quality of life may tell us what is required in order to become (more fully) human, but never about the value of being human.

Philosophical theories of quality of life

Philosophical theories are systematic accounts that can be used to provide a foundation for our beliefs and to sort out those ideas that should be held with rational conviction from those that should be discarded. Thus a philosophical theory of quality of life is an account of what makes human life worth living and an attempt to single out those fundamental elements of human experience or the human condition that provide the content for such an account. In the history of philosophy there are, of course, innumerable such accounts, presented as each philosopher explicates his or her preferred account of the human good. Most of these theories fall into the following three categories:

Hedonic theories. Hedonic theories identify quality of life with states of awareness, consciousness, or experience of the individual. Happiness or pleasure, however those terms are precisely to be defined, are the sine qua non of quality of life. This allows for considerable individual variation in assessing good quality of life because different things make different people happy, but it also allows for some kind of common metric (at least on the negative side) because there are seemingly universal negative states of pain or suffering or unhappiness that all (normal) persons avoid.

An interesting question is whether it is necessary for the person to realize he is happy in order to be happy. In other words, is the kind of happiness (or pleasure) that makes for a good quality of life a direct, unmediated sensation, or is it a psychic state that results from some act of self-interpretation? If it is the former, then it would seem to follow that a person locked in a cell with an electrode implanted in a pleasure center of the brain would be experiencing the highest quality of life. That conclusion must be mistaken and counts against the theory. On the other hand, if the pleasure or happiness the theory requires involves some form of cognitive mediation and secondary interpretation, then persons who have serious cognitive deficits will be automatically judged to have a poor quality of life by definition, and that view seems unduly biased against nonintellectual goods in life.

Rational preference theories. The second type, rational preference theories, define quality of life in terms of the actual satisfaction or realization of a person’s rational desires or preferences. This is a much more objective theory than the hedonic account in that a person need not be aware that his or her preferences are being fulfilled (or need not take pleasure in that knowledge) in order for the quality of his life to be good; it just must be the case that they are being fulfilled in fact. The underlying appeal of theories of this type is the notion that individuals have a good life when the objective state of the world conforms to what they rationally desire.

Theories of human flourishing. Theories of human flourishing attempt to base our understanding of the good life on an account of those functions, capacities, and excellences that are most fully and constitutively human. To the extent that we attain and master those capacities, and to the extent that we avoid those conditions that would stunt or undermine those capacities, we flourish as human beings. Theories of this type also usually have a developmental component built into them, for those most fully human capacities are ones that are not mastered at birth or automatically expressed by instinct, but must be developed and nurtured by education, interaction with others, and practice over the course of a lifetime. To the extent, then, that the individual continues to grow and develop throughout his or her life, the quality of life is enhanced thereby.

Accounts of these most fully human capacities differ among philosophers working in this tradition of theorizing, but as a generalization we can say that philosophical accounts of this type usually emphasize the human capacity to express and to experience meaning in social relationships of intimacy, friendship, and cooperation; the capacity to use reason and to develop and follow a life plan of self-fulfillment and self-realization; the capacity for independence and self-reliance; and the human need for an appropriate social and cultural environment that provides the individual with various types of resources—material, symbolic, spiritual—necessary to live a developmentally human life and to meet both basic and secondary needs.

Future work on quality of life

Reviewing each of these three philosophical approaches to quality of life, one can argue that the concept of quality of life should not be construed as a floor below which no significant societal expenditure of resources is required, and below which personal caregiving efforts may be reduced to the decent minimum. A much better way to think about quality of life is to see it as a ceiling, a potential level of functional capacity and capacity for relationship, toward which caregiving efforts should be designed to strive. The height of this ceiling will not be the same for everyone, and quality of life is not a test that you fail if you do not reach a certain height. But the important point is that quality of life should be used as a teleological concept—setting a goal to reach and a process to reach it, rather than as a prioritizing concept—setting a rank ordering for the allocation of scarce resources.

In conclusion, it is important to note that no one of these philosophical theories has completely carried the day among philosophers, and each of the three is still under development in the philosophical literature on quality of life. None of them offers a complete account; elements of all three are essential to cover the broad range of circumstances and individual needs pertinent to the issue of quality of life in an aging society.

Bruce Jennings

See also Death and Dying; Definition and Measurement; Euthansia and Senicide; Quality of Life; Refusing and Withdrawing Medical Treatment; Subjective Well-Being.

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