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When We Talk About Quality of Life

A fierce debate regarding the way in which we talk about "quality of life" took place in Norway this spring. In an attempt to defend selective abortion of chromosomal abnormalities such as Down syndrome, Aksel Braanen Sterri (a newspaper columnist at the time) pondered whether such lives are "worthy of living." According to Sterri, a life with Down syndrome is significantly less worth than a "normal" life. Thus, women carrying fetuses with Down syndrome must be justified in choosing abortion.

Sterri's reflections were an exercise in applied moral philosophy. Enraged respondents, however, would not accept the reflections as mere speculations. According to some—including relatives of people with Down syndrome—Sterri crossed a line of decency when implying that the value of life of persons with Down syndrome (or similar disabilities) is reduced merely because of the syndrome.

Quality of life vs. moral value

There is a pattern here. In many bioethical debates, declarations of quality of life are taken to concern the moral value and dignity of the same life. For instance, when proponents declare that assisted suicide should be offered because some people have abysmal quality of life, opponents often respond that ascribing low quality of life to a person robs that same person of his or her moral value. Thus, if dignity is to be upheld, we must not make assertions about people’s quality of life.

However, the distinction between quality of life and the moral value of life is an important one—and must be upheld. We need a specific language for speaking about the many aspects of quality of life. When we talk about quality of life we must be able to do so frankly, without being taken to devalue the moral value, dignity and moral rights of the person involved.

This distinction is well-known to philosophers, but it must be restated and introduced within public debates on bioethics. On the one hand, there is the moral value of the human person, which is closely related to human dignity and the moral right to life. This moral value should always and everywhere be affirmed as intrinsic, equal among all fellow humans, and—importantly—independent of quality of life.

What is quality of life?

On the other hand, there is quality of life—which we also should be allowed to speak of. I propose a distinction between subjective and objective quality of life. Subjective quality of life is the person’s own assessment of how well their life is going, as when people are asked: “On a scale from one to ten, how satisfied are you with your life?” However, for any given person this number appears to be quite stable. For instance, the lottery winner’s boost to subjective satisfaction is only temporary. Before long, he or she is more or less back at his or her default happiness level. Therefore, even though assigning a number regarding how well life is going provides a glimpse into the person’s life and their assessment of it, such a numerical value is arguably of limited value.

Objective quality of life, however, is a much subtler notion. Arguably, Aristotle’s account of the good life—eudaimoniagot the basics right: the good life involves living in accordance with virtue. And the virtues are the character traits, such as bravery and wisdom, that define the good person. The person who is truly flourishing is realizing the capacities central to their nature as human being. In an account of the virtues, therefore, we see the contours of what it means to live a good life; to flourish, to have objective quality of life. Having such a life is truly desirable.

Obstacles to the realization of such objective quality of life can be external factors such as poverty, but also internal factors such as diseases, a lack of virtue or a developmental disorder. Consider a person with a moderate degree of intellectual disability. He or she could have high subjective quality of life. When it comes to objective quality of life and the realization of human abilities, however, things become more complex. Certain paths towards the good life—perhaps those most strongly reliant on cognitive skills—will be wholly or partially closed for that person. This is sad, but nevertheless a fact. However, the person might have developed other important skills to a high degree, such as the ability to give and receive love. Again, my point is that we need a vocabulary to speak of such matters without being taken as reducing the person’s moral value and human dignity.

Where does this leave subjective quality of life? The hedonist’s grave error is to exalt such satisfaction to the only thing that truly counts. For some governments, quantifiable notions of life satisfaction have gained traction and assumed a wholly unearned significance. In such jurisdictions, moving citizens up the scale has then been touted as an important goal—perhaps even the overarching goal—of politics.

The much richer concept of eudaimonia, on the other hand, is what a morally sane community should strive for. A morally upright society educates its young so that they have the opportunity to realize the virtues in their own lives.

However, any given account of the virtues, of flourishing and of objective quality of life, might be more or less off the mark. Famously, Aristotle’s blind spots led him to a notion of virtue too centred on cognitive abilities and—according to himself—unattainable for women and slaves. We are not likely to make this particular mistake, but must take care not to make other similar mistakes that we are more prone to. Simply put: Any plausible account of the good life must be sufficiently “open” to give room for a plenitude of good lives.

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