QUALITY OF LIFE-THREE COMPETING VIEWS PETER SANDE

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QUALITY OF LIFE - THREE COMPETING VIEWS

ABSTRACT. The aim of the present paper is to describe three different attempts, which have been made by philosophers, to define what quality of life is; and to spell out some of the difficulties that faces each definition. One, Perfectionism, focuses on the capacities that human beings possess: capacities for friendship, knowledge and creative activity, for instance. It says that the good life consists in the development and use of these capacities. Another account, the Preference Theory, urges that satisfying ones preferences, or desires, is what improves ones quality of life. And a third account, Hedonism, sees life-quality as consisting in the enjoyment of pleasure and the avoidance of pain. The paper describes and evaluates objections to each of these views, thereby displaying their weaknesses and strengths. Since no view comes out as the right one there is a choice to be made. At the end of the paper it is being discussed how well each of the views cohere with different methodologies used in quality of life research. Also it is suggested that considerations about what the research is to be used for are relevant. KEY WORDS: quality of life, perfectionism, preference-satisfaction, hedonism, pleasure, theories of the good life, autonomy

Over the last decades there has been a growing interest to develop and use tools to measure human quality of life. For example quality of life measures are increasingly used in the screening of the health status of population groups and to assess various forms of medical treatment. The aim is to involve the view of the patients rather than just focussing on mortality and other objective measures. This aim is widely endorsed. However, nonetheless many people feel uneasy about the very idea of measuring peoples quality of life and about the use of quality of life measures in decision making. Thus the concept of quality of life can seem to have implications to which many people strongly object. One such implication is that there is a universal standard in the light of which it is possible at least in principle to assess the quality of anyones life, regardless of who they are or what their situation is. Another alleged implication is the paternalist view that information about the quality of life should be pressed into service by politicians and planners to interfere with the imprudent ways in which many people choose to lead their lives. A little reflection reveals that the second implication does not really follow from the concept of quality of life. There is nothing odd or selfcontradictory about the view that in some (or all) spheres of life there are good moral reasons not to interfere with peoples lives - even where that
Ethical Theory and Moral Practice 2: 1123, 1999. 1999 Kluwer Academic Publishers. Printed in the Netherlands.

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interference would have a positive effect on the quality of life of the people interfered with. It depends on ones moral outlook whether or not one ought to act so as to promote other peoples quality of life. Even if it is decided that quality of life matters from a moral point of view, its importance may be limited by other and more weighty concerns, such as respect for autonomy. In any case, any sane account of what promotes a higher quality of life (in sophisticated creatures like human beings, at least) is bound to include, as an important element, the ability to direct ones own life, and this obviously eases any tension between quality of life and autonomy. Some of those who make use of the concept of quality of life may even try to reject the first implication. They may argue that the concept of quality of life in modern quality of life research is to be defined in terms of preference-satisfaction. Since preferences are subjective and are fixed from the perspective of the individual who has the preferences, no standard is imposed. However, this defence of the concept of quality of life simply misses the point of the objection. To claim that quality of life should be defined in terms of preference-satisfaction is still to endorse a universal standard, viz. that preference-satisfaction and only preference-satisfaction is what makes a persons life go well. Here it may be retorted that even though, formally speaking, the objection is correct, there is no real issue. Preference-satisfaction is admittedly taken for granted as a standard, but since this standard is both uncontroversial and highly plausible there is no problem. However, against this it should be pointed out that in the course of the history of philosophy a number of contrasting visions of the good life have surfaced; and that these visions are still very much alive. Preferencesatisfaction, viewed as a candidate for such an answer, faces some serious philosophical objections. It must be acknowledged, indeed stressed, at the outset, of course, that it must be possible to conduct quality of life research without having to engage in endless philosophical discussions about what is for a persons life to go well. What this research requires is not the resolution of a long and so far inconclusive debate in philosophy, but the making of an explicit, consciously adopted assumption about what, in the context of the given research, is meant by quality of life. Moreover, ideally the researcher ought to be aware of any problems and limitations of this assumption. The aim of the present paper is to describe three quite different attempts, which have been made by philosophers, to define the concept of a good life; and to spell out some of the difficulties that faces each definition.

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1. THREE NOTIONS OF THE GOOD LIFE

Looking at the philosophical tradition there seems to be three main answers given to the question, What makes a persons life go well? Perfection that the person realises important human potentials Pleasure and absence of pain that the person has pleasant mental states and avoids painful or unpleasant ones Preference-satisfaction that the person gets what he wants Accordingly three different views about the nature of the good life may be defined: Perfectionism, Hedonism and the Preference Theory. In many real-life cases these views will deliver the same verdict about a persons quality of life. Thus a person who develops his skills, engages in political life and has a good family life, is often also a person who feels reasonably happy and to a great extent manages to get what he wants. However, it is easy to imagine examples where the three views give different verdicts. A person may lead a life which realises important human potentials but which at the same time is filled with pain and frustration. (The life of the novelist, Virginia Woolf, may be an example of this). Another person may live in accordance with the slogan Dont worry, be happy, but fail to fulfil important human potentials. Perfectionism and the preference theory are in one sense opposites. The preference theory simply identifies quality of life with what seems attractive from the individual persons point of view. Contrary to this, perfectionist views define quality of life in a more objective way, i.e. with a specific content not tied to the subjective perspective of the affected person, and are therefore often these days labelled objective list accounts. Hedonism is in one respect close to the preference theory and in another respect like perfectionism. Quality of life is defined in terms of mental states, according to the hedonist; and since mental states are given in a first person, subjective perspective, there is a clear connection here with the preference theory. On the other hand like perfectionism hedonism claims that quality of life has a specific content. There may indeed be a partial overlap between perfectionism and hedonism. A life full of pleasure may be seen as the realisation of one important human potential; and in some recent objective list accounts of the good life pleasure actually features on the list.

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In the following sections of the paper the three views will be presented and discussed in more detail. The aim of the discussion is to point out and explain the strengths and weaknesses of each view.

2. PERFECTIONISM
The classic formulation of perfectionism is given by the Greek philosopher Aristotle (1934) in a work now known as the Nicomachean Ethics. According to Aristotle every living being has an essence which sets a goal for the life of that being. Man is a social and rational animal. Thus there are two kinds of fundamental goals in the life of man: social/political goals and intellectual goals. According to Aristotle, to realize these goals a man must develop and make active use of both moral and intellectual virtues. Few philosophers today would buy the whole Aristotelian story about the nature of man. But quite a few accept the key Artistotelian idea that there are a number of substantial human values at least some of which have to be realized for a human life to count as a good life. They would therefore say that there is more to a good life than mere pleasure or preferencesatisfaction; a good life must realise important human potentials. For example, a life devoted to the counting of blades of grass to take a typical philosophers example will not be a good life even if the grass counter feels happy devoted to that. (Cf. Rawls, 1971, p. 432. It should be noted that Rawls himself does not draw a perfectionist conclusion from the example.) Perfectionism clearly appeals to widely shared intuitions about what constitutes a good life. Thus having a good family life, being creative artistically or otherwise, gaining knowledge, having success professionally, being politically active, having friends and the like, are normally thought to contribute to the value of a human life. To have a good life one need not be successful in all of these respects, but if one falls short in all or most respects ones life will be a poor life. Despite this it is fair to say that perfectionism is not part of mainstream of modern moral philosophy; and a number of arguments have been produced to show that perfectionism is, after all, not a tenable position. Three such arguments will be considered here. The first I shall call the argument from autonomy (cf. Sumner, 1992, pp. 78). According to this perfectionism is wrong because it does not respect the view of person whose quality of life is in question. For example, according to perfectionism it may be best for a person to develop his talents

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even though he prefers doing things for which he is less talented. Thus someone who has the talent to become a very good mathematician may prefer to live the life of a mediocre organic farmer. The view that it contributes to his quality of life to stick with maths seems counterintuitive. This objection presupposes that a persons preferences define what is good for her. However, often people do things which run counter to their long term self-interest. Interestingly, if the argument is tenable it will also tell against defining quality of life in terms of happiness, because what people prefer may sometimes turn out to make them unhappy. The second argument I shall call the argument from lack of demarcation (cf. Sumner, 1992, p. 6). The notion of quality of life is usually applied to humans only. By a natural extention it may also be applied to some animals; but it does not seem to be applicable to plants or other non-sentient organisms. However, the idea underlying perfectionism is that the quality of an individuals life is enhanced by flourishing, i.e. the fulfilment of potentials characteristic of things of the kind to which the individual belongs. There is no obvious reason why a plant (say) should not have a quality of life thus defined. Why, then, are non-sentient organisms excluded? There seem to be two ways in which an adherent of perfectionism may reply to this point. Both accept the consequence just described that, for perfectionists, the notion quality of life extends to plants and other living beings. The first reply also accepts that plants and other living beings are the object of moral concern. (For independent reasons this view has been accepted by a number of moral philosophers within so-called environmental ethics.) The other reply goes in the opposite direction. It severs the connection between being a subject to which the notion quality of life may be applied and being a subject that deserves moral concern. Plants have a quality of life, according to this reply, but this does not mean that their quality of life is a matter for moral concern. These two replies reaffirm the point made above, that whether or not a certain notion of quality of life is acceptable depends on the further context within which the notion is used, e.g. on whether or not possessing a quality of life is thought to have moral implications. The third argument takes as its starting point perfectionisms presupposition that humanity has an essence on the basis of which characteristic human values may be defined. It doubts, however, that humanity has an essence and it is also sceptical about the notion that this essence, even if it existed, could serve to define substantive values. For example, if human essence is defined in terms of molecular genetics it is hard to see how one could derive quality of life standards from it. This may be called the antiessentialist argument.

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Two sorts of reply are typically given to the anti-essentialist argument. The first and more ambitious reply insists both that humanity has an essence and that this can be used to define quality of life. Thus the Canadian philosopher, Thomas Hurka (1993), argues that humans qua living beings have three essential characteristics: they have a body, they engage in practical rationality, and they engage in theoretical rationality. On the basis of this he defines standards in the light of which a human may be said to fare better or worse. The other reply is to defend perfectionism without essentialism. Typically perfectionism will then take the form of a so-called objective list of human values which are not derived from or otherwise based on a account of human nature. Thus James Griffin (1986, pp. 6472) gives the following list of prudential values that are valuable in any life: Accomplishment, the components of human existence, understanding, enjoyment, and deep personal relations. (Cf. also Scanlon, 1993). Each of these replies faces well-known problems. The ambitious reply may be thought to be over-ambitious. Thus it may be doubted whether it is possible in any interesting sense to base substantive human values on a plausible account of human nature. Whether this doubt is justified, of course, must be decided on the basis of a close scrutiny of Hurkas argument something that falls without the scope of the present paper. Perfectionism without essentialism has the opposite problem of being too unambitious. Compared to its essentialist cousin, it can seem to erect an account of the good life on unstable foundations. Thus it may be claimed that the stipulated objective list of values is imperfectly grounded and ad hoc. To sum up, perfectionism undoubtedly has certain intuitive appeal. However there are also a number of arguments which can be raised against defining quality of life in its terms. Whether or not these arguments are decisive must among other things depend on how well the two other notions of quality of life stand up to closer scrutiny.

3. THE PREFERENCE THEORY

The obvious antidote to perfectionism is the preference theory (cf. Brandt, 1979; Hare, 1981; and Nordenfelt, 1994). Here quality of life is defined in terms of preference-satisfaction. A good life is one in which the person in question gets what he wants. This view has the advantage of being very simple; and there is a clear link between quality of life and the observable behaviour of the person in terms of revealed preferences, i.e. preferences

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displayed in a persons action. Thus it is possible to study quality of life by empirical methods. Also there is much less of a tension between promoting a persons quality of life and respecting her autonomy than there is with perfectionism. Indeed it might be argued that there is no such clash, since respecting a persons preferences is the same thing as respecting that persons autonomy. The problem of demarcation can also be dealt with, since preferences are only ascribed to sentient creatures. Finally, the view is clearly compatible with an anti-essentialist outlook on the world. However, the preference theory seems to be vulnerable to other sorts of objection. The first and most obvious is that there may be cases of preference-satisfaction which, intuitively, do not contribute positively to a persons quality of life. This I will call the argument from irrelevant preference-satisfaction . One such example is given by the British philosopher Derek Parfit (1984, p. 494):
Suppose that I meet a stranger who has what is believed to be a fatal disease. My sympathy is aroused, and I strongly want this stranger to be cured. We never meet again. Later, unknown to me, this stranger is cured.

The problem here seems to be lack of awareness. The person who has the relevant preference is simply not aware that the preference is being satisfied. The sympathetic person lacks relevant knowledge. He may even be dead! A related problem might be temporal dislocation. Thus the preference may be a past preference which the person no longer holds. It does not seem to matter that this is now satisfied. A final possibility in this context could be the travellers failure to react. Thus a preference may be satisfied where there is no doubt that the person has the preference and is aware that it is being satisfied but where he does not feel pleased or satisfied by the satisfaction. The normal way of overcoming these obstacles is by adding requirements which preferences must satisfy to count as contributions to a persons quality of life. Lack of awareness, for example, can be dealt with by adding an experience requirement which says that only if a person is aware of a preference being satisfied (or frustrated) does it affect his quality of life. Temporal dislocation can be dealt with by adding a requirement of contemporaneity that is, by insisting that the satisfaction of a preference only contributes to a persons quality of life to the extent that the person holds the preference at the moment of its being satisfied. When it comes to disappointment the remedy seems to be to add an informationrequirement to require, in other words, that the person with the preference understands fully what would be involved in its being satisfied. Given this,

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the satisfaction of a preference will enhance ones quality of life only if the preference is such that one would retain it on being given more (or perhaps full?) information about what to expect from its satisfaction. It is worth adding that the requirement may also be elaborated so as to say how deeply the information should internalized. In this vein, the American philosopher, R. B. Brandt (1979, p. 11) has prescribed nothing less than cognitive psychotherapy. These replies to the argument from indifferent preference-satisfaction do not so much defend the preference theory as aim to transform it so that it no longer gives rise to the counterintuitive examples. The second argument may be called the argument from increases in quality of life without preference-satisfaction. An obvious example here is a happy surprise, i.e. a persons experiencing something with enjoyment where there seems to be no associated preference to be satisfied. Here the adherent of the preference theory may suggest that what makes a surprise improve a persons quality of life is that we immediately aquire a preference for the state which we are in to continue. However, this seems rather strained. Why couldnt there be a state that is really nice but which we nonetheless only want to last for a very short moment? Alternatively it could be argued that happy surprises improve quality of life because retrospectively we would prefer them to their nonoccurrence. However, it would not then be clear whether preferences do any independent job in accounting for what quality of life is: by definition, retrospective preferences occur after happy surprises, but the surprises seem to make things go better the moment they occur. The adherent of the preference theory may, of course, try to deal with the problem by envoking an enduring, general preference for the experience of happiness produced by the surprise. The third argument, which may be called the argument from lack of substance, says that the preference theory lacks content in the sense that the theory does not really tell a person how to have a good life. If someone asks how he should live it is no answer to say that he should aim to satisfy his preferences, since what the person is in essence asking is which preferences to have and cultivate for the future. To this the preference theory may reply that he does indeed have a more substantive account of quality of life which allows him to deal with counterintuitive examples like those discussed in connection with the argument from irrelevant preference-satisfaction. However, then it seems that there is more to the preference theory than just the satisfaction of preferences. And this, it seems, must be a separate account of the good life. The first two arguments discussed in this section suggest that what

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matters is not preference satisfaction as such but an associated positive feeling. Thus a good candidate for a more substantive account of quality of life is hedonism.

4. HEDONISM
Hedonism is the view that quality of life consists in the presence of pleasant (in a wide sense of the word) mental states and the absence of painful or unpleasant ones. This view clearly avoids the problems about indifferent preference-satisfaction which haunt the preference theory; it also has no problem with happy surprises and the like. Furthermore the view can answer the argument from lack of demarcation raised in connection with perfectionism. According to hedonism the notion of quality of life will only apply to humans and other sentient animals. Intuitively, this is attractive. The classic formulation of hedonism was given by the English laywer and philosopher, Jeremy Bentham. He gives the following account of how pleasure and pain contribute to a persons quality of life:
To a person considered by himself, the value of a pleasure or pain considered by itself, will be greater or less according to the four following circumstances: 1. Its intensity. 2. Its duration. 3. Its certainty or uncertainty. 4. Its propinquity or remoteness. (1789, p. 64)

Bentham does not claim that all the experiences of pleasure and pain which contribute to a persons well-being are of the same kind. He allows that there are any varieties of pleasure and pain, some of which, such as orgasm and migraine, are basic and simple, and others of which, such as victorious chess and grief, are more sophisticated. He does, however, claim that in so far as experiences contribute to a persons well-being they share a certain quality, the quality of being pleasant or painful, and that on the basis of this shared quality we can compare the amount of well-being gained or lost in various situations. This, though, gives rise to the first argument facing hedonism, which is the argument from lack of a shared mental quality. (Cf. Griffin, 1986, p. 8). This argument proceeds by listing examples of positive (or negative) mental states and then invites the reader to see for himself that there really is no shared mental quality. A relevant list could, for example, be: the

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enjoyment of a good meal; the pleasure of being creative; the pleasure of reading a good novel; or finding out that one is not HIV-positive. In case of negative states it could be: nausea; the experience of intense physical pain; the anxiety when one is waiting to have a suspicion of cancer confirmed or disconfirmed; or the frustration felt when one is not able to walk around or do other of those things which are normally taken for granted. It does not seem possible to discern a shared experienced quality in all these mental states. Neither does it seem possible to discern some other dimension in the light of which different sorts of pleasant states may be compared in terms of intensity. To this the hedonist may reply by simply giving up the assumption of a shared mental quality. There is no need to assume that there is only one type of pleasant mental state. There are many ways of enjoying pleasure, and they need not be such that there is a common experienced quality running through all of them. But the fact that the property pleasure (as applied to mental states) can be instantiated in many different ways does not undermine the claim that it is because a mental state is pleasant that it is good. As mentioned in a previous section, hedonism is in one way related to perfectionism. Like perfectionism hedonism gives a substantive account of the good life, and indeed it may be seen as a version of an objective list account of quality of life - one with the special feature that the list only contains mental states. (Cf. Kagan, 1992, p. 175). This may invite an objection which may be labelled the argument from extending the objective list. The argument simply says that, since hedonism is essentially an objective list theory, any refusal to extend the list to include non-mental states, such as friendship and knowledge, would be arbitrary. The hedonist may reply by appealing to the intuitions that favour the preference theory over perfectionism. He can point out that a good life must reflect the subjective point of view of the person in question. Quality of life means not only that a persons life instantiates value, but also that the life is valuable to that person. And pleasure, plus the absence of pain, is not only valuable, but valuable from the point of view of the affected person. However, this in turn gives rise to an argument typically raised from the perspective of the preference theory. This argument may be labelled the argument from the fact that mental states matter differently to different persons. The key premise of the argument is that particular sorts of pleasant or painful mental states might matter more to one person than they do to another. Take the case of pain. It is well known that people have very different pain thresholds. Cases have even been reported where people with

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chronic pain have undergone brain surgery, and where, after the surgery, the patients report that while they still feel the same pain sensation, it no longer matters to them. (Trigg, 1970, pp. 125142). Therefore, the argument runs, what affects the quality of a persons life is not pleasure, pain and other mental states, but how much these states matter to the person in question. There seem to be two ways in which the hedonist can reply to this argument. The first is by saying that when a mental state matters differently to two persons it cannot be the same state, i.e. a state of pleasure or pain with identical duration and intensity. Thus the patients in the stated example are wrong when they report after the surgery that they still feel the same intensity of pain. This reply may seem rather desparate and ad hoc. It is certainly hard to prove in the surgery example, and the general idea that how much a pleasure or pain matters to you cannot vary independently of variation in intensity and duration looks unpromising. The other reply is to accept the conclusion and then go for a view that represents a hybrid of the preference theory and hedonism. According to this view, which has been labelled preference hedonism (cf. Parfit, 1984, p. 493) quality of life consists of the presence of pleasurable (and the absence of painful) mental states, but just how much these mental states improve a persons quality of life depends on how much they matter to the person in question.

5. DISCUSSION
There is, then, no simple and obvious answer the question , What is quality of life? At least three kinds of answer perfectionism, the preference theory and hedonism have been developed by philosophers, and as should be clear from the previous discussion, each of these views has something to be said for it. Equally, each can be challenged by powerful arguments. Thus the question about what quality of life is has not as yet received a final and definite answer. It may be that there is no definite answer, and probably the answer depends very much on the context within which the question is being asked. This leaves a difficult question to the person who wants to do quality of life research: What should I in the context of my own research mean by quality of life? The answer to this question may interact with two sorts of considerations, methodological and ethical. Different methods for measuring quality of life lend themselves more or less well to different notions of quality of life. Measures focussing on biological, psychological and social functioning can easily be interpreted

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within a perfectionist framework to function well is what it is all about for a perfectionist. If on the other hand the researcher tries to make people rank a broad spectrum of outcomes his measurements will lend themselves more naturally to a preference theory. Finally, if the researcher is mainly focussed on registering psychological well-being and distress her data will be very relevant as viewed from a hedonist way of thinking. If the researcher, for one reason or another, is committed to a certain notion of quality of life this is also important in the discussion of methodology. The researcher needs to consider how the data recorded may be interpreted so as to say something about quality of life in the specified sense. For examples measures of functioning do not in any direct way inform about preference satisfaction or pleasure/suffering. So if these measures are to be used within the framework of a preference or hedonist conception of quality of life, there is need for a great deal of critical discussion. Methodology is not the only consideration that constrains what the quality of life researcher should mean by quality of life. There are also ethical considerations. Which definition is relevant may depend on the purpose of the relevant investigation into the quality of life of a person or a group of persons. Is it to articulate the perspective of these persons? Or will it form the basis of allocation of public health care resources? With the former purpose the preference theory may be appropriate, whereas with the latter purpose in mind it may be more appropriate to build on perfectionism or hedonism.

ACKNOWLEDGEMENTS
The author wants to thank Roger Crisp, Niels Halberg, Karsten Klint Jensen, Klemens Kappel, Kasper Lippert-Rasmussen, Paul Robinson and an anonymous referee for very useful comments on earlier versions of this paper.

REFERENCES
Aristotle, The Nicomachean Ethics. The Loeb Classical Library. Cambridge, MA: Harvard University Press, 1934. Bentham, J, An Introduction to the Principles of Morals and Legislation. (1789), quoted from John Stuart Mill, Utilitarianism. London: Collins/Fontana, 1962. Brandt, R.B., A Theory of the Good and the Right. Oxford: Clarendon Press, 1979, 362 pp. Griffin, J., Well-Being, Its meaning, measurement, and moral importance. Oxford: Clarendon Press, 1986, 412 pp.

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Hare, R.M., Moral Thinking. Oxford: Clarendon Press, 1981, 241 pp. Hurka T., Perfectionism. Oxford: Oxford University Press, 1993, 222 pp. Kagan S., The Limits of Well-Being, in Paul E.F., F.D. Miller, Jr. & J. Paul (eds.), The Good Life and the Human Good. Cambridge: Cambridge University Press, 1992, pp. 169189. Nordenfelt, L., Towards a theory of happiness: A subjectivist notion of quality of life,. in Nordenfelt, L. (ed.) Concepts and Measurement of Quality of Life in Health Care. Dordrecht: Kluwer, 1994, pp. 3557. Parfit, D., What makes someones life go best?, Reasons and Persons. Oxford: Oxford University Press, 1984, pp. 493502. Rawls, J., A Theory of Justice. Cambridge, MA: Harvard University Press, 1971, 607 pp. Scanlon, T., Value, Desire, and Quality of Life, in Nussbaum M. & A. Sen (eds.), The Quality of Life. Oxford: Clarendon Press, 1993, pp. 185200. Sumner, L.W., Two theories of the Good, in Paul E.F., F.D. Miller, Jr. & J. Paul (eds.), The Good Life and the Human Good. Cambridge: Cambridge University Press, 1992, pp. 114. Trigg, R., Pain and Emotion. Oxford: Clarendon Press, 1970, 187 pp.

The Royal Veterinary and Agricultural University Copenhagen Denmark

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