摘要：Current theoretical approaches to bioethics and public health ethics propose varied justifications as the basis for health care and public health, yet none captures a fundamental reality: people seek good health and the ability to pursue it. Existing models do not effectively address these twin goals. The approach I espouse captures both of these orientations through a concept here called health capability. Conceptually, health capability illuminates the conditions that affect health and one's ability to make health choices. By respecting the health consequences individuals face and their health agency, health capability offers promise for finding a balance between paternalism and autonomy. I offer a conceptual model of health capability and present a health capability profile to identify and address health capability gaps. VARIOUS ETHICAL approaches provide different justifications that underlie health care and public health. Some models assert consumer rationality in health behaviors and a willingness to forgo care beyond the individual's means. Other approaches focus on fair processes, equality of opportunity, utilitarianism, or equal distribution of goods. Libertarians emphasize autonomy. However, none of these approaches captures a fundamental reality in the health ethics realm: people seek both good health and the ability to pursue it. Existing models cannot effectively address these twin goals because they typically favor either a consequentialist (outcome-oriented) or a proceduralist (procedure-oriented) perspective. The approach I develop captures both these intuitions in a concept I call health capability. Health capability integrates health outcomes and health agency. Why is it so difficult for some populations or individuals to translate health resources into health outcomes? Why have health literacy efforts been only moderately successful? Why do some individuals have such difficulty adhering to specific treatment regimens? Why are some individuals harmed or helped by cultural norms about health behaviors? Conceptually, health capability enables us to understand the conditions that facilitate and barriers that impede health and the ability to make health choices. It offers a more accurate evaluation of the aim and success of social policies and change. Health capability is comprised of both health functioning and what I call health agency. I define health agency as individuals' ability to achieve health goals they value and act as agents of their own health; health agency achievement represents what one's realized actions are compared with potential actions. 1 Health functioning is the outcome of the action to maintain or improve health. It is comprehensive, inclusive of mental and physical health functioning and more. Health is constitutive of, but different from, well-being or quality of life. These theoretical distinctions and others have been discussed extensively elsewhere. 2 By respecting both the health consequences individuals face and their health agency, health capability offers promise for striking the delicate balance between paternalism (the practice of an individual or state interfering with the choices of another individual with the justification that the individual or population will be better off or protected from harm) and autonomy (to live one's life according to one's own reasons and motivations). Health capability allows the assessment of a wider range of injustices, beyond the distribution of resources or liberties, to include attributes and conditions affecting individuals' freedoms: self-management, decision-making ability, skills, knowledge and competence, and social norms and relations, as well as structures within which resource distribution takes place. This approach seeks to enable individuals to exercise personal responsibility for their health through health agency. Rather than justifying health, health care, or public health through equality of opportunity, this approach rests on human flourishing as the philosophical justification for enabling all to be healthy. It holds that health functioning and health agency are the ultimate ends of justice, not equality of opportunity. A more comprehensive analysis of the theoretical foundations and framework for health and social justice based on the “health capability paradigm” is provided elsewhere. 2 Bioethics and public health ethics aid in the understanding of ethical reasoning as it applies to health, health care, and public health. Bioethics evolved to establish individual autonomy, the right to refuse care, and the right to voluntary and informed consent as preeminent moral principles. 3 Public health ethics places priority on principles of necessity, effectiveness, proportionality, public justification, and least infringement. 4 But for much of the past several decades, these principles have focused too narrowly on issues surrounding the allocation of material and financial resources to solve problems. 5 Moreover, some approaches have overemphasized individual autonomy and procedural processes in judging the rightness of health care delivery. Others have focused on utility or health maximization or even broader forms of well-being. 6 The health goals of a just society, however, are to ensure all individuals the ability to be healthy. 7 , 8 Despite considerable progress in bioethics and public health ethics, neither field has successfully developed a theoretical paradigm for achieving this aim. Building on a theoretical framework 2 that advances the health capability paradigm, I aim to illuminate what individuals are actually able to be and do in an optimal environment (health capability) versus their current environment (health achievement). Assessing and understanding the gap between these 2 states of affairs will improve our ability to foster health capability. A comparison between other ethical approaches—such as equality of opportunity, equality of resources, or even equality of welfare or dimensions of well-being—and a health capability paradigm raises some important distinctions. One such distinction concerns social obligation. Unlike other approaches, the health capability paradigm purports that the fundamental societal obligation is to ensure conditions for all to be able to be healthy, not to ensure equal welfare, or happiness, or employment opportunities. And unlike libertarianism, it does not support individuals opting out of social guarantees and their responsibilities to help pay for those guarantees. Thus, under universal health insurance, one cannot opt out of paying premiums or taxes for premiums, although one may opt to abstain from using health care or public health measures oneself. Another contrast is between the health capability paradigm and the narrow focus of disease diagnosis and epidemiology, which does not necessarily take into account individuals' ability to navigate the health system and the broader environment to access needed health care and public health services. Nor does that narrow focus help us to adequately understand the constraints individuals face in their ability to be healthy. Additionally, these approaches are more positivist than normative in their orientation. The health capability paradigm recognizes that health capability gaps for individuals and populations can be reduced by both individual-level interventions to improve health functioning and health agency and policies to improve the broader social and physical environment. A health capability profile can analyze the impact of individual interventions and social policies by explicitly measuring categories of individual health functioning, health agency, and the more general social factors enhancing or inhibiting health capability. I offer a conceptual model of health capability, 7 , 8 define the concepts and domains basic to health capability, and, for its operationalization, present a prototype health capability profile. I identify key indicators for each health capability domain and begin to illustrate how to use these indicators to develop measures of health capability. As a first sketch of these ideas, this article opens up an opportunity to discuss, refine, and develop valid and reliable components of such a profile. Although grounded in capability theory, which has roots in Aristotelian notions of human flourishing, the conceptualization of health capability I develop creates an intellectual space at the intersection of a number of different disciplines, including public health, health policy, medicine, health psychology, decision theory, behavioral economics, theories of addiction, social epidemiology, 9 and broader social scientific theory. Despite the location of this work at this interdisciplinary nexus, I argue that the concept of health capability is distinctive and unique in a number of critical aspects from what these other disciplines have brought forth for our edification and consumption. The principles guiding the content and measurements of the health capability profile are rooted in capability theory; the theory of health capability and its uniqueness as a concept in bioethics and public health ethics has been developed in further depth elsewhere. 7 , 10 , 11
