Powers and Faden s Concept of Self-Determination and What It Means to Achieve Well-Being in Their Theory of Social Justice

PUBLIC HEALTH ETHICS VOLUME 6 NUMBER 1 2013 35 44 35 Powers and Faden s Concept of Self-Determination and What It Means to Achieve Well-Being in Their Theory of Social Justice Diego S. Silva, Dalla Lana School of Public Health, Joint Centre for Bioethics, University of Toronto Corresponding author: Diego S. Silva, Dalla Lana School of Public Health, Joint Centre for Bioethics, University of Toronto, 155 College Street, Suite 754, Toronto, Ontario, Canada M5T 1P8. Email: diego.silva@utoronto.ca Powers and Faden argue that social justice is concerned with securing and maintaining the social conditions necessary for a sufficient level of well-being in all of its essential dimensions for everyone (2006: 50). Moreover, social justice is concerned with the achievement of well-being, not the freedom or capability to achieve well-being (p. 40). Although Powers and Faden note that an agent alone cannot achieve well-being without the necessary social conditions of life (e.g. equal civil liberties and basic material resources, such as food and shelter), it seems that achievement requires that an agent actually pursue the six dimensions of well-being. In this article, I question the extent to which an individual has an obligation to achieve well-being, even if he or she would choose to do otherwise. For example, can an agent choose to forgo being healthy even if all the social conditions are met in her life, thereby choosing to not achieve well-being? It remains unclear how the dimension of self-determination coheres with the remaining five dimensions of well-being and the extent of society s obligations toward an individual s achievement of well-being, even in those instances when society s actions may go against an individual s right to self-determination. Introduction In this article, I argue that it is unclear whether Madison Powers and Ruth Faden s theory of social justice, namely that of sufficiency of well-being as presented in their book Social Justice: The Moral Foundations of Public Health and Health Policy, requires: (i) that society provide the necessary social conditions for an individual to achieve or try to achieve a sufficient amount of the six dimensions of well-being or (ii) that society provide the necessary social conditions for an individual to choose whether to achieve or try to achieve a sufficient amount of the six dimensions of well-being. The confusion stems from two separate but interrelated ideas in Social Justice that require greater clarity: first, one must determine the extent to which an agent has an obligation to achieve or try to achieve well-being in his or her own life, or whether an agent has the choice to merely disregard those actions for which he or she is in control but which he or she nonetheless chooses not to pursue knowing that the result will be falling below a sufficient level of well-being in his or her life. At times, it appears that Powers and Faden argue that an agent has a moral obligation to actually achieve or try to achieve some sufficient amount of well-being, while in other passages of their book they seem to argue only that society has an obligation to provide the necessary social conditions for well-being to support individuals in their pursuit of a sufficient amount of well-being, if they so choose. Second, the extent of society s obligation (including governments and individual members of the public) to ensure that everyone achieves a sufficient amount of the six dimensions of well-being and how this coheres with an agent s choosing to willfully bring him- or herself below a sufficient level in any one of the six dimensions of well-being is unclear. These two interpretations of what social justice demands, as an obligation to achieve versus choosing to achieve, appear to be mutually exclusive. The dimension of self-determination, which includes the concept of personal choice and which...guarantee individuals a degree of protection against the interference by the state or one s fellow citizens in their choices and actions (p. 26), appears to conflict with Powers and Faden s doi:10.1093/phe/pht003 Advance Access publication on 1 February 2013! The Author 2013. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org

36 SILVA notion of justice, which is concerned with achievement of well-being, not the freedom or capability to achieve well-being (Powers and Faden, 2006: 40). If one were to argue that the idea of justice-as-achievement and the dimension of self-determination cohere, then there remains the need for further clarification as to how they cohere. The section An Overview of Social Justice as Sufficiency of Well-Being of this article will outline my understanding of Powers and Faden s theory of social justice as sufficiency of well-being. In the section An Obligation to Achieve Well-Being for Oneself?, I introduce two possible interpretations of what justice demands and try to reconcile them. In the section Balancing Self-Determination and the Other Dimensions of Well-Being, I discuss some possible difficulties in balancing the two articulations of justice, in particular as these relate to the limits of public support to achieve states of well-being in light of the dimension of self-determination. There are, at least, two reasons why discussions about the limits of society s obligation toward ensuring a sufficient level of well-being in peoples lives is important given the dimension of self-determination: first, it is important to clarify possible objections to Powers and Faden s arguments in order to improve their theory, especially given the influence of their book Social Justice in the field of public health ethics. Second, as a brief perusal of many of the papers published in Public Health Ethics would indicate, in public health there exists an ongoing tension between acknowledging the importance of self-determination as a key political value in many democratic states with the need to curtail choice and freedom often for the well-being of the individuals themselves [e.g. consider questions about the moral permissibility of using nudges in public health (Blumenthal-Barby and Burroughs, 2012)]. An Overview of Social Justice as Sufficiency of Well-Being According to Powers and Faden, social justice is concerned with securing and maintaining the social conditions necessary for a sufficient level of well-being in all of its essential dimensions for everyone (Powers and Faden, 2006: 50). Their argument seems to contain, at least, three key aspects: an articulation of the necessary social conditions to secure and maintain social justice, an understanding of well-being as being constituted by the six dimensions of well-being and an articulation of sufficiency. Moreover, Powers and Faden develop their theory of social justice as a non-ideal theory, meaning that they attend to all those aspects of the social structure that exert a profound and pervasive effect on the development of each of the essential dimensions of human well-being separately and in combination under actual social conditions (p. 31, emphasis original). Stated simply, Powers and Faden are concerned with social justice in the real-world given complex real-world conditions. Powers and Faden s theory of justice is a theory of social justice, i.e. it is not merely concerned with just political and economic institutions or structures, but also with other, perhaps less well-articulated or less well-understood social conditions or structures that affect one s well-being. Powers and Faden note that: While the importance of political, social, economic, and certainly legal institutions should not be understated, we do not take an exclusively institutional view of the basic social structure. Social conventions and customs have similarly profound and pervasive effects on human development... Social customs affect more than material well-being. They affect also the moral relationships between persons. (pp. 31 32, emphasis original). It seems that Powers and Faden contrast their theory of social justice, which includes concerns with social customs, to those theories that only concentrate on institutions 1 or, more precisely, developing just institutions. Justice denotes a concern with more than how governments (p. 50) or economic distribution (p. 64; 74 75) affect the social determinants of well-being (i.e. the background conditions to well-being). For example, a theory of social justice that takes seriously all social conditions, including conventions or customs (e.g. the pressures that women may feel to be the primary persons responsible for raising children in Toronto in 2013), cannot merely occupy itself with considerations of just institutions (e.g. Canadian constitutional protections against discrimination on the basis of gender). According to Powers and Faden s moderate essentialist position (i.e. that there are some necessary or indispensible conditions for well-being such that a life substantially lacking in any one of these [dimensions] is a life seriously deficient in what it is reasonable for anyone to want ) (2006: 29), there are six dimensions of well-being, which they acknowledge may not be exhaustive. The six dimensions are: health, personal security, reasoning, respect, attachment and selfdetermination. 2 All the dimensions of well-being are independently important or essential and not reducible to any other dimension (e.g. personal security cannot be

WHAT IT MEANS TO ACHIEVE WELL-BEING 37 reduced to a concern for health) (2006: 28). It is important to note that, first, Powers and Faden s non-ideal theory acknowledges that each dimension will influence, to varying degrees, the other dimensions of well-being and that social determinants (e.g. income, gender, etc.) will also affect various dimensions differently depending on the various contexts of individuals lives (2006: 64 66). Second, influenced by the capabilities and functioning theories of Amartya Sen and Martha Nussbaum, Powers and Faden note that in their version of moderate essentialism, there are distinct dimensions of well-being and that, for each dimension, a part of its value lies in what states are achieved and another part often consists in our active role in bringing the states about (2006: 38). Therefore, the dimensions of well-being appear to be both valuable as states-of-being and valuable as one attempts to bring about states-of-beings that are mutually reinforcing of each other in the context of certain background conditions (i.e. the social determinants). For example, the difference in wages between men and women who work the same or similar jobs differentially affects the ability to make certain life choices (e.g. from where and what kind of groceries one might purchase), which in turn affects how healthy they may be, which affects how successful and productive they may be in their jobs, which affects their personal sense of selfrespect and the various relationships they might have in their lives and so on and so forth. In addition to being concerned with the various conditions of social justice and the various dimensions of well-being, Powers and Faden claim that their position is one of broad egalitarianism, which entails that some kinds of inequalities stand in need of moral justification (2006: 50). In other words, if there is an intuition that people deserve to have equal amounts of the six dimensions of well-being, then there needs to be an explanation as to why, at times, it is morally permissible for there to be differences in the amount of the dimensions of well-being between individuals. It seems that Powers and Faden maintain that sometimes justice demands that society adopt an egalitarian position vis-à-vis individuals (i.e. that persons are treated equally and the relational ideal of strict egalitarianism holds, namely that justice always involves a concern for how some fare in comparison to others and not simply a concern for the worst off because they are doing badly in absolute terms (2006: 50). The reason that strict egalitarianism needs justification in the first place stems from some traditional objections, primarily the leveling-down objection, which states that if strict egalitarianism were sound, then intentionally worsening the lives of some so that their well-being was on par with other members of society would satisfy strict equality and the relational ideal of strict egalitarianism, which seems intuitively morally impermissible (p. 52 53). Therefore, Powers and Faden acknowledge the need to provide an argument as to why, at times, we should care about the strict equality and relational ideal found in strict egalitarianism, while at other times justice demands that the absolute conditions of individuals should take precedence; or, in their words: [o]ne need not think that the positive aim of justice is equality in order to think that something is problematic about large relative inequalities (2006: 56). Powers and Faden thus put forward their theory of sufficiency of well-being. Traditionally, sufficiency theories argue against economic egalitarianism while maintaining that [w]ith respect to the distribution of economic assets, what is important from the point of view of morality is not that everyone should have the same but that each should have enough (Frankfurt, 1987: 21; emphasis original), i.e. that everyone should have enough money or resources to lead a good life, whatever one s conception of the good. Powers and Faden maintain, however, that if one only cares about a sufficiency account of economic goods, then one must abandon any intuition toward strict equality and the relational ideal, as found in egalitarianism, i.e. if all we care about is securing a sufficient amount of resources per person, whatever those might be, then once that threshold is met, the amount of remaining inequality is of no moral concern (Powers and Faden, 2006: 56). Moreover, unless one articulates what justice entails, or what goods must be pursued, a question persists: a sufficient amount of money or resources are necessary for what? As Powers and Faden note: [b]efore economists can estimate the minimum level of resources each individual would need to meet their basic needs for the essentials of life, they need some prior notion of what those minimum essentials are (2006: 58). Therefore, Powers and Faden argue that justice demands that everyone achieve a sufficient amount or level of the dimensions of well-being, where sufficiency seems to be understood as having enough of each dimension of well-being characteristically present within a decent life (2006: 15; emphasis original). What is sufficient will differ based on the dimension in question and the historical context of a given individual (Powers and Faden, 2006: 15). For example, perhaps one could argue that having access to a gynaecologist is part of a reasonable threshold of healthcare that every woman ought to receive in Canada in 2013 but not necessarily limitless access to cycles of in-vitro fertilization. It seems that some dimensions, like health, function on a

38 SILVA gradient or range (i.e. one can have, and demand, more or less healthcare or those conditions that lead to health). 3 Meanwhile, for other dimensions of well-being, such as respect, a sufficient threshold just is an equal amount among all members of society and thereby functions in a binary manner [e.g. respect among members of a society (23; 63)]. Therefore, Powers and Faden maintain that a theory of sufficiency of well-being will account for those instances in which strict equality holds (e.g. respect) and those instances when inequalities are morally permissible given a certain threshold amount is met (e.g. health). In summary, Powers and Faden s theory of sufficiency of well-being is as follows: justice demands social conditions (including political, economical, legal and social institutions and customs) that allow for individuals to achieve a sufficient amount (whether understood as a threshold along a continuum or a binary condition to be satisfied by equality) of the six dimensions of well-being. Given that Powers and Faden s theory is non-ideal, social justice demands that when individuals have less than a sufficient amount of each of the dimensions, that these needs must be met, especially those deprivations that negatively affect the ability to enjoy other dimensions. Who is obligated to meet the needs of people will differ based on the specific circumstances of each situation; however, both individual and collective action are necessary for promoting justice (48). 4 For Powers and Faden the job of justice in its most pressing role demands permanent vigilance and attention to social and economic determinants that compound and reinforce insufficiencies in a number of dimensions of well-being (2006: 78). An Obligation to Achieve Well-Being for Oneself? Assuming that this general overview of Powers and Faden s theory of social justice is sound, an important ambiguity remains: does justice require: (i) that society provide the necessary social conditions for an individual to achieve or try to achieve a sufficient amount of the six dimensions of well-being, whereby an agent has an obligation to strive toward his or her own well-being or (ii) that society provide the necessary social conditions for an individual to choose whether to achieve or try to achieve a sufficient amount of the six dimensions of well-being. It seems clear that for Powers and Faden, social justice at least requires that society provides the necessary social conditions so that people can achieve well-being, if they so choose: What is relevant for public policy and political theory is the difference in how well-being is brought about and how we ought to define the legitimate role of others, including the agents of the state, in bringing about valuable outcomes. We cannot achieve many things for others, but we can do things that support or enable others to achieve those outcomes themselves... We can design institutions that enable persons to be more likely to have and exercise their capabilities for affiliation and respect, and this is the outcome that justice aims for. At bottom, we care centrally about well-being, but we recognize also that many societal duties related to bringing it about involve a supportive role (2006: 40; emphasis added). This passage seems to indicate that governments and non-governmental entities, including private persons (p. 48), have an obligation to support and promote the means by which individuals achieve a sufficient level of well-being in all six dimensions and that the job of justice is determining how this occurs in a morally defensible manner. The reason that we should care about enabling and providing the support for individuals to achieve well-being is because, as Powers and Faden note, we cannot achieve well-being for others (or more precisely, cannot achieve many things for others ). However, it is unclear how the word cannot is being used in this context: (i) as it is physically impossible to achieve well-being for others or (ii) we (society) are morally prohibited to bring about someone else s well-being or (iii) it depends on the dimension and the situation at hand whether we cannot either physically or morally bring about someone else s well-being. The importance of the word cannot in this context exists because there is another possible understanding of what justice demands under Powers and Faden s theory of sufficiency of well-being, whereby an agent has an obligation to try to achieve well-being in his or her own life. It might be that justice demands that people actually achieve a sufficient amount of each dimension of well-being, i.e. actually be healthy, actually have a certain amount of reasoning, etc. Powers and Faden write: [t]he moral importance of each of these dimensions, therefore, is inaccurately accounted for as centrally concerned with development of capabilities that individuals can exercise if they choose. The central concern of justice, then, is with achievement of well-being, not the freedom or capability to achieve well-being

WHAT IT MEANS TO ACHIEVE WELL-BEING 39 (2006: 40). If we return to the earlier description of the six dimensions of well-being in this essay, the dimensions could be understood as states to be achieved or choosing to bring about such states, i.e. to be x and to choose to be x (2006: 38). It seems then, e.g. that not only can we be healthy or act so as to be healthy, but rather that we could potentially choose to act so as to be unhealthy; for Powers and Faden, however, if social justice requires that we be healthy (or achieve or try to achieve a sufficient amount of health), then all persons must strive to be healthy in their own lives. There may be two reasons why, assuming the achievement of some aspect of a dimension of well-being is reasonably possible, the individual and society must pursue it: for both the sake of the individual and for the sake of others, in particular, for the sake of developing and acting in a morally sound manner toward others. The justification for requiring the achievement of states of well-being may stem, in part, from what each member of a society owes other members: We want to be respected by ourselves and by others, not simply for us and others to have the capability to exercise respect if we, or they, so choose. We want to form attachments to others for our own sake and for reasons of sustaining just institutions and practices. What we want is the success of these attachments, not simply that some can form them if they so choose. Justice requires not just the capability for attachment if individuals wish to exercise it; rather it is essential for the capability to be developed and exercised for the success of other-regarding morality...in some sufficient measure, the actual development and exercise of reason is essential to the functioning of society and the well-being of others, no less than respect. The same might be said of a certain level of good health. The moral importance of each of these [six] dimensions, therefore, is inaccurately accounted for as centrally concerned with development of capabilities that individuals can exercise if they choose. The central concern of justice, then, is with achievement of well-being, not the freedom or capability to achieve well-being. (Powers and Faden, 2006: 40; emphasis added). For example, it is not just that for a decent life an individual must not be racist for the sake of him- or herself (a trait that goes against, at least, the dimension of respect), but moreover, that the individual and society should strive to remove racist beliefs from individuals so as to ensure that other persons are treated in an equal and just manner. Yet, even if we set aside the issue of achieving states of well-being for the sake of others, it seems that Powers and Faden are arguing that we all have a moral obligation to achieve states of well-being for our own sake, i.e. one might argue along the lines of other essentialist or objective list theorists and state that there are goods, one must try to achieve in one s life for one s own sake. Perhaps the characterization of an agent having an obligation to achieve well-being is too strong and subject to two objections: first, the main thrust of Powers and Faden s argument about the role of the agent in the achievement of his or her own well-being is that the agent s actions are never sufficient for achieving the six dimensions of well-being in his or her own life without pre-existing social conditions and structures. Powers and Faden write:...our active participation in bringing about our own well-being is not definitive of our well-being (2006: 39). Although it seems prima facie true that an agent alone is not definitive of his or her well-being, the agent s striving toward his or her own well-being is a necessary condition for achieving well-being. But if social justice should be concerned with achievement, and the agent is a necessary condition for the achievement of well-being, then the agent has an obligation to act toward the achievement in (at least) his or her own life. Second, one might object that any plausible account of social justice will concede that it is not always possible to achieve well-being. Powers and Faden note [w]hile a threshold level of well-being across each dimension may not be present (or even possible) for everyone, our list of essential dimensions of well-being is offered as an account of those things characteristically present within a decent life, whatever a person s particular life plans (2006: 15; emphasis original). Later in their book, Powers and Faden note [t]hat some fare worse in terms of health outcome is not, for that reason alone, necessarily unjust according to the sufficiency view; but health disparities may be deemed unjust when they are avoidable outcomes (61). Taking these two points together, perhaps what is important from a social justice viewpoint is not that x is about to die but rather whether death for x could be avoided (or reasonably avoided given the technology and resources available to other members of that society at that given moment in time). Therefore, despite everyone s best intentions and actions, including the agent s, sometimes the thresholds of sufficiency along the various dimensions of well-being cannot be achieved. However, at most, this objection indicates that there may be times when it is impossible to achieve well-being; still, it seems that as long as there are actions to be taken by the individual or society to achieve well-being, then the various

40 SILVA parties are required to execute said actions, even if the agent would want to choose otherwise than pursing his or her own well-being. The importance of clarifying whether there exists not only an obligation to ensure the social conditions so that individuals reach a sufficient amount of the dimensions of well-being, if they so choose, or an obligation for an individual to achieve a sufficient level of the six dimensions (when possible), stems from an objection that Powers and Faden foresee and try to address, namely, that such a theory of social justice might demand (or seem to demand) significant interference with the choices and actions of individual members of a society, and is therefore not in keeping with our intuitions on the value of self-determination. Powers and Faden write: [i]t is important to note that our account of well-being itself, since it includes respect for persons and the value of self-determination, sets further limits on what others might justly do to bring about good outcomes (2006: 40 41). Stated differently, having self-determination and respect as two of the six dimensions of well-being potentially protects against the possibility of socially dictating how individuals must shape their lives and what it means to achieve the other four dimensions of well-being. This might also explain why Powers and Faden articulate that their theory of social justice is not merely concerned with institutions, but also customs and conventions; we need to protect against the possibility of interference from members of society into the lives of individuals through customs as well. Therefore, it seems that when Powers and Faden write that we cannot achieve many things for others, the word cannot denotes that sometimes it is physically impossible to achieve x on behalf of another (e.g. health) and that it is sometimes morally prohibited to achieve x on behalf of another (e.g. if doing so interferes with self-determination). If this is indeed the correct, more moderate, interpretation of Powers and Faden s notion of social justice, then it seems that further explanation is required to determine when social justice imposes an obligation onto agents to actually try to achieve their own states of well-being and moreover, when the state and private agents have an obligation to impose social conditions to improve the chances of achieving well-being for others, potentially against the choices of others. 5 Powers and Faden need to provide an explanation of when society is and is not morally obligated to ensure that agents achieve or try to achieve well-being in their own lives, even if they would choose to do otherwise. Balancing Self-Determination and the Other Dimensions of Well-Being Assuming that both articulations of social justice are somehow compatible, i.e. the need to achieve well-being and the choice to achieve well-being, two questions remain: first, how do we balance the dimension of self-determination vis-à-vis the achievement of the other five dimensions of well-being? Second, what are the obligations and limits that the state and other agents have toward any other individual s achievement of well-being? 6 Powers and Faden argue that they...do not claim that individuals would be acting irrationally or unjustly if they themselves make trade-offs among the dimensions. An individual may well be rational and morally entitled to make a trade off, for example, sacrificing physical health for the sake of pursing refinement of reasoning abilities (2006: 30). Although it will often be the case that the six dimensions of well-being are mutually and positively reinforcing, it is possible that attempting to achieve two or more dimensions at any given moment may, at times, conflict within an individual, these situations are not of interest here; rather, it may be that there are times when an individual merely chooses to act so as to go against his or her own well-being. Although Powers and Faden do not provide a definition of self-determination, they do provide some aspects of self-determination that are commonly held among different theorists. In its most simple articulation, self-determination is comprised of civil liberties (including negative liberties such as freedom from interference from others, including the state), but it also includes the need for some basic material resources so as to be self-directed (e.g. food, shelter, etc.). Self-determination includes a guarantee that individuals receive...a degree of protection against the interference by the state or one s fellow citizens in their choices and actions (2006: 26). Moreover, self-determination seems to include...being in a condition in which our ends contribute effectively to the shaping of the course of our lives (p. 27) but this does not entail that absolute freedom of choice or no restrictions (e.g. isolation during infectious disease outbreaks). Finally, self-determination is not only essential because of what other dimensions or goods it might bring about, but also it is essential to be self-determining for the sake of being self-determining. In other words, regardless of what instrumental benefits one might derive from

WHAT IT MEANS TO ACHIEVE WELL-BEING 41 valuing self-determination, it is not merely an instrumental good (p. 26 29). It seems plausible, however, that if society allows persons to be self-determining, individuals will make choices that might go against some commonly held notions of what is best under the other dimensions of well-being, even if society tries to correct for insufficiencies in the other dimensions. For example, imagine Jason is the CEO of a large corporation. He was born into a wealthy family that easily met all his material needs and was a top athlete as a child. His parents loved him very much. Jason is intelligent and has a number of great friends. He is also morbidly obese and will, in all likelihood, die prematurely unless he drastically changes his eating habits and begins to exercise. Imagine also that Jason understands the ill effects of obesity on his health. Some potential exists, therefore, for Jason to not achieve a sufficient level of health as a dimension of well-being, even though he could choose to alter his lifestyle. 7 Now given that Powers and Faden repeatedly state that the primary concern of social justice is correcting the determinants that lead to large and reinforcing insufficiencies among multiple dimensions of wellbeing, Jason will not be a priority for their theory of justice. Despite Jason the CEO not being a priority of justice, his being morbidly obese must matter, at least to some degree, given that social justice is concerned with the achievement of well-being; it is not enough for him to choose whether or not to be healthy, but rather, Jason must actually be healthy (after all, he is not achieving one of the dimensions of well-being despite having the real possibility of doing so). One might object and argue that at some point, individuals must take responsibilities for their actions, particularly when society provides for all civil liberties and material needs necessary for a sufficient amount of self-determination. If this position is sound, one must provide some understanding of when an individual is responsible for his or her actions and under what conditions. For example, must an individual have all of his or her civil liberties and material needs satisfied in order to classify as responsible for his or her actions? If not, how do we determine the amount and kinds of social conditions a society should provide such that all actions thereafter are the sole or primary responsibility of the individual agent? Turing to the second question, what exactly are the obligations and limits of society (in the form of shaping and manipulating social conditions) toward ensuring that individual members actually achieve a sufficient amount of each dimension of well-being? Powers and Faden do not provide any concrete rules or procedures on how to achieve social justice because, as they note, [a] sufficient minimal level of well-being is not something that can be defined apart from a particular social context (2006: 60). Despite arguing that establishing a sufficient amount of each dimension is context-driven, they do provide at least one overarching maxim, namely, that one must attend to the social and economic determinants that compound and reinforce insufficiencies in a number of dimensions of well-being (2006: 78). However, beyond this maxim, how should society institute social conditions that best promote a sufficient amount of the dimensions of well-being while not limiting an individual s ability to be selfdetermining? Even if one agrees with Powers and Faden that what it means to have a sufficient amount of well-being will differ given the particularities of an individual s life, are there some general rules that society can follow when establishing just social conditions so as to best promote self-determination? At the very least, it appears that states have an obligation to coordinate collective actions (Powers and Faden: 48) in order to establish and protect civil liberties and to facilitate basic distribution (and redistribution) of resources to ensure that everyone s basic needs are met, i.e. that everyone have a sufficient amount of material resources necessary to achieve a sufficient amount of well-being, including the dimension of selfdetermination. As Powers and Faden note, a number of other theories of justice have tried to address the various issues related to civil liberties and distribution of wealth or resources. Although these sorts of issues are central to their thesis, Powers and Faden argue that their theory of social justice is equipped to move beyond mere considerations of civil liberties and economic distribution (2006: 57). For example, although they argue that governments are in a position to mobilize collective action, this does not entail that individuals and nongovernmental entities have no duties (p. 48). In addition to governments and non-governmental entities having an obligation to promote justice, Powers and Faden maintain that economic distribution cannot be justice s only concern and that certain dimensions, such as respect and attachment while influenced profoundly by economic inequalities, are affected every bit as much by social practices and norms (p. 64). Therefore, in addition to concerns about civil liberties and material distribution by governments, Powers and Faden maintain that a non-ideal theory of justice must include obligations by governments and non-governmental entities (including private citizens or individuals) toward improving other determinants that shape the dimensions of well-being, i.e. other social conditions.

42 SILVA At this point, it seems that we need to return to the discussion of social customs and conventions as part of what constitute social conditions. According to Powers and Faden, and borrowing from arguments and observations by J. S. Mill, social customs and conventions play an important role in shaping how individuals enjoy or fail to enjoy, and whether they can reach a sufficient amount of, the dimensions of well-being. For example, one s ability to obtain a sufficient amount of respect and attachment will depend on, in part, the prevalence of sexism and racism in a society (32). Reversing and eliminating occurrences of sexism and racism will probably include the need for governments to spend money on anti-sexism and anti-racism campaigns as well as ensuring that all persons, regardless of gender or race, have access to the same life opportunities (e.g. through constitutional protections). However, one might argue that the elimination of sexism and racism cannot be the exclusive domain of government; it requires a change in social customs as well, a task that might be more nebulous and difficult than changing laws. It is unclear, however, how to define an obligation for governments and non-governmental entities toward ensuring (or help ensuring) just social conditions and the actual achievement of well-being, while at the same time guarding against the imposition of social customs so that individuals achieve sufficient levels of the dimensions of well-being that are not potentially unduly restrictive of self-determination. In other words, we all have an obligation to be just and promote justice, but how? It seems difficult to reconcile some kind of social obligation to promote justice (whatever theory of justice one might espouse) unless self-determination is given some kind of primacy (although perhaps not absolutely primacy at all times) over other dimensions of well-being without succumbing to the possible errs of imposing social customs and conventions on others; hence, why philosophers, such as Mill and Immanuel Kant, give liberty primacy in the public realm in the first place. 8 For example, one might interpret Mill s introduction of the harm principle in On Liberty as a protection of liberty and as a restriction as to when government may intrude into the lives of individuals because government is itself subject to being swayed by social customs or conventions through democratic processes (Mill, 2009: 5 8). In other words, the reason many political theories traditionally give primacy to liberty over other possible goods (or rights or dimensions of well-being) is to protect against the potential tyranny of the majority, including tyranny in the form of social customs and conventions. 9 Despite the descriptions of the six dimensions of well-being by Powers and Faden, greater thought needs to be given to each dimension in the contexts of the lives of individuals by the individuals themselves, i.e. individuals need to provide their own interpretations and meanings of the six dimensions. For example, whether to endure pain at the end-of-life, one might argue, should be a personal matter, but doing so seems to allow for different articulations of what sufficiency of health means for different individuals at different moments of their lives in different contexts (a point that Powers and Faden would seem to accept). Although further thought needs to be given as to what exactly is a sufficient amount of each dimension of well-being, individual and particular understandings of the dimensions may be susceptible to interference by others through social customs and conventions (e.g. consider the ongoing debate surrounding euthanasia). What it means to achieve a sufficient amount of each dimension of well-being is itself a normative enterprise that ought to be guarded against pressures of social convention and customs [a conclusion that Powers and Faden reach as well (2006: 32)]. Even if Powers and Faden claim that individuals are not acting irrationally or unjustly when they balance the various dimensions of well-being, it is unclear whether there is an obligation to interfere with individuals who simply choose not to fulfill some dimension of well-being, not because they have a need to trade-off incompatible goods, but rather because they simply choose not to fulfill or achieve a particular dimension (e.g. Jason, the obese CEO did not necessarily trade-off an amount of another dimension of well-being to be in his current state of health). For example, do we, as a society, care if someone is racist or if someone acts like a racist? Where we are only concerned with supporting or enabling individuals to reach a sufficient amount of the dimensions of well-being, if they so choose, it seems that what we care about is if someone acts in a racist manner. Society should care about people acting like racists, because it denies equal opportunities in life and equal respect to other members of that society; racism matters insofar as it negatively affects other members of society. But should we also care that an individual is a racist for the sake of that individual, and if so, must the public act so as to correct this trait? 10 If justice is understood as being concerned with actually achieving states of well-being, an individual should care that not only he or she does not act in a racist manner, but also that he or she is not an actual racist or hold racist beliefs. So to what extent should governments and non-governmental entities care about correcting deficient character traits in persons, even in those cases when the negative character traits are generally considered to be obviously bad but do not affect other members of a

WHAT IT MEANS TO ACHIEVE WELL-BEING 43 society? It seems difficult to fix these traits and help individuals actually achieve a sufficient amount of the six dimensions of well-being (e.g. respect and reasoning) without imposing social customs, no matter how obviously true they might seem to a majority of people. Conclusions Powers and Faden s theory of social justice is primarily concerned with the achievement of the six dimensions of well-being in the lives of those persons who are systematically and repeatedly disadvantaged and whose lives could improve by changing the social conditions of peoples lives. Although an individual alone cannot achieve well-being, it is necessary that an individual strive toward the achievement of well-being in his or her own life, even under the most favorable of social conditions, if achievement of well-being is the correct measure of social justice. However, if we ought to be concerned with the achievement of social justice and not only the ability to achieve social justice, if an agent so chooses, then Powers and Faden need to explain whether an agent can choose to act against his or her own well-being under the dimension of self-determination, and the extent to which society is obligated to ensure that an individual achieve a sufficient level of well-being in his or her own life. Acknowledgements I would like to thank Sally Bean, Mark Bronson, Carina Fourie, Maxwell Smith and Public Health Ethics s two anonymous reviewers for their helpful comments on previous drafts of this article. Thanks also to Agomoni Ganguli Mitra, Verina Wild and all the participants at the Meeting the Authors: Ruth Faden and Madison Powers workshop at the University of Zurich for the insightful comments and critiques of my article. Special thanks to Ruth Faden and Madison Powers, who during the meeting were not only humble and congenial while others critiqued their book, but were also happy to help improve people s objections. Conflicts of interest None declared. Notes 1. It is unclear whether Powers and Faden are making a distinction between social institutions and social conventions or customs and if so, what exactly is that distinction and what role might this distinction play in their theory. Perhaps the word institution denotes that x explicitly and formally regulates or shapes y, whereas a custom or convention denotes that x implicitly and informally regulates or shapes y? 2. I will not discuss the details of the individual dimensions, as such detail is unnecessary for this essay; however, I will discuss the dimension of selfdetermination in greater detail in the latter part of the article only insofar as it affects the readers possible interpretation of Powers and Faden s concept of social justice. 3. By using the term sufficient in the sense of thresholds, levels, or amounts along a given range or continuum, it seems that Powers and Faden are committed to the notion that (at least some of) the dimensions of well-being can be quantified, or at least, discussed metaphorically using the language of quantity. 4. For example, Powers and Faden note...it seems reasonable to us to suppose that the specific obligations [to assist others] will differ among those under a duty to provide assistance. Some duties to provide assistance...can only be discharged collectively (2006: 48). 5. Recall that for Powers and Faden, justice is concerned with securing and maintaining the social conditions necessary for a sufficient level of wellbeing in all of its essential dimensions for everyone (2006: 50). 6. This second question is perhaps a re-articulation of a position held by Powers and Faden: What is relevant for public policy and political theory is the difference in how well-being is brought about and how we ought to define the legitimate role of others, including the agents of the state, in bringing about valuable outcomes (2006: 40). 7. All this, despite his parents insistence that he eat his broccoli as a child. 8. That Mill and Kant espouse very different arguments as to why liberty should be given primacy in public interactions (the former on broadly utilitarian grounds, the latter on broadly deontological grounds) demonstrates that the potential primacy of liberty is not exclusively the domain of any one theory or theorist. 9. Powers and Faden do note that their view of the irreducible importance of self-determination [does not] entail any claim that it is the synoptic value or the single dimension of well-being to which all

44 SILVA others are subordinate (2006: 28); however, they do not provide any further defense of this claim as it was not a key passage of their argument or book. 10. Recall: We want to be respected by ourselves and by others, not simply for us and others to have the capability to exercise respect if we, or they, so choose (p. 40). References Blumenthal-Barby, J. S. and Burroughs, H. (2012). Seeking Better Health Care Outcomes: The Ethics of Using the Nudge. The American Journal of Bioethics, 12, 1 10. Frankfurt, H. (1987). Equality as a Moral Ideal. Ethics, 98, 21 43. Mill, J. S. (2009). On Liberty and Other Essays. New York: Kaplan Publishing. Powers, M. and Faden, R. (2006). Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford University Press.