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In order to account for problematics that exceed the limits of purely        biomedical considerations, another mid-level theory has been selected. The choice to        focus on the account of capabilities developed by Nussbaum reflects a resolution to        formulate such problematics within a more politically-informed framework. Indeed, a        considerable amount of deliberations surrounding the development of pre-emptive        psychiatry falls directly under the scope of public policy - be it healthcare measures or        more general programs - and therefore needs to be politically motivated in addition to        being ethically justifiable. 

Adopting a form of political liberalism, Nussbaum’s account of the capabilities        approach borrows what one might call a ‘statement of intent’ from Rawls, in the sense        that one of its primary aims is to provide principles which can be recognised as        legitimate and applied in a pluralistic society. Consequently, the idea of a potential        overlapping consensus in which holders of a variety of views - philosophical, secular or        religious - can convene, is at the heart of the capabilities approach (Nussbaum, 2013,        p.79). As a mid-level political doctrine relying on a similar kind of reflective equilibrium        as Beauchamp and Childress’ principlism, then, I argue that the capabilities approach        brings a distinct, though complementary, set of concepts to the table.  

Nussbaum follows Sen in defining capabilities as ‘substantial freedoms’: a set of        (usually interconnected) opportunities to choose and to act (Nussbaum, 2013, p.20).        The notion is complex, as well as multi-faceted: the substantial freedoms mentioned        above - or combined capabilities - encompass both the fluid and dynamic abilities residing              inside a person, but also the freedoms or opportunities created by a combination of        personal abilities and a certain political, social, and economic environment (Nussbaum,        2013, p.20). Internal capabilities , which are ‘trained or developed traits and abilities,            developed, in most cases, in interaction with the social, economic, familial, and political        environment’, must be distinguished from innate aptitudes that can potentially be        nurtured ( basic capabilities ) (Ibid. p.21). Additionally, on the other side of capability is         

functioning : ‘a functioning is an active realization of one or more capabilities’        (Nussbaum, 2013, pp.24-25). A list of ten central capabilities has been identified by        Nussbaum: life ; bodily health ; bodily integrity ; senses, imagination, and thought ; emotions ;                     

practical reason   ; ailiation ; other species ; play ; control over one’s environment (Nussbaum,                    2013, pp.33-34). 

To include the intricate notion of capabilities in the context of this dissertation        opens up highly pertinent perspectives. First and foremost, it allows for the        introduction of a clearer idea of governmental and societal responsibility, especially        with regards to groups and individuals presenting specific vulnerabilities. As a        grounded theory enriched by the experiences, the stories and the identified needs of the        people concerned, the capabilities approach also provides fundamental tools for the        identification and the management of such vulnerabilities. 

Nussbaum’s approach is indeed deeply normative, adopting from the very start        a clear evaluative and ethical stance (Nussbaum, 2013, p.28). At its heart is the notion of        dignity, and the idea that society has a responsibility both to protect and to promote        living conditions worthy of people’s dignity (Ibid., p.30). Indeed, the capabilities        approach asserts that an affirmative task for governments stems from the existence of        such entitlements (Nussbaum, 2013, p.65): ‘fundamental rights are only words unless        and until they are made real by government action’ (Ibid., p.65). Closely related to        Beauchamp and Childress’ account of the ‘fair-opportunity rule’, which states that       

undeserved disadvantages induce a right in justice to some form of assistance        (Beauchamp, Childress, 2009, p.250), and their idea of a decent minimum (Ibid., p.259),        the capabilities approach therefore advocates for the existence of positive rights, and of        the moral obligations that derive from them. 

Two additional notions, which were introduced by Wolff and de-Shalit in       

Disadvantage (2007), are of particular importance in the context of this dissertation:       

fertile functionings   and corrosive disadvantages . Because capabilities are not hermetically          isolated from one another but, on the contrary, intricately interconnected and        interdependent, some might prove to be particularly fertile, promoting the        development and flourishing of others, while some circumstances might turn out to be        quite deleterious to a series of capabilities. A useful consequence of the incorporation of        fertile functionings and corrosive disadvantages is that it allows for a form of        hierarchisation and prioritisation in the management of scarce resources for the        policymaker: ‘just as politicians have reason to spend scarce resources on the most        fertile capabilities, expecting those to generate improvement in yet other areas, so they        have reason to focus their energies on removing what Wolff and de-Shalit call corrosive        disadvantage , types of capability failure that lead to failure in other areas’ (Nussbaum,        2013, p.99). 

The main reason why the notions of capabilities, fertile functionings and        corrosive disadvantages provide particularly effective tools in order to address issues        related to the development of pre-emptive psychiatry is that, as mentioned previously,        they stimulate a more sophisticated understanding of specific vulnerabilities, beyond        the restricted scope of a purely biomedical vulnerability. The identification of corrosive        disadvantages, for example, leads to the incorporation of vulnerabilities related to        societal and environmental conditions that are also shown to be correlated to higher        risks in psychiatry. The capabilities approach is quite well suited to the analysis of such        larger issues: ‘often these will be failures connected to marginalization, stigma, and        other forms of group-based powerlessness, giving societies reason to adopt        group-based remedies, even though the end in view is always the full empowerment of        each individual’ (Nussbaum, 2013, p.100). I will expand on Rogers, Mackenzie and       

Dodds’ work on vulnerability theory in Chapter 5, but I can point out here that their        contributions are consonant with the capabilities approach and Wolff and de-Shalit’s        work on fertile functionings and corrosive disadvantages. 

The need for pre-onset early interventions, in medicine or other fields, is        therefore well accounted for by the capabilities approach. Inspired by Heckman’s work        on the topic, Nussbaum admits that ‘a great deal of human potential is being wasted by        the failure to intervene early both through programs designed to enhance the future        human being’s health in utero and through programs after birth’ (Nussbaum, 2013,              p.194). 

The capabilities approach, as a mid-level political, liberal and pluralistic theory,        provides substantial advantages in the ethical evaluation of pre-emptive psychiatry,        mainly through its capacity to conceptualise and deal with vulnerabilities exceeding the        scope of biomedicine. Furthermore, at the heart of this approach is an intricate idea of        well-being, or quality of life, in line with the pluralistic one developed throughout this        dissertation. Indeed, the compatibility between principlism and the capabilities        approach arises in great part from their rich and complex conceptualisation of the idea        of well-being, both admitting the coexistence of multiple, legitimate ends.  

First and foremost, it is because the notion of development is so central in        Nussbaum’s approach that the idea of well-being, closely related to it, becomes itself        quite crucial: ‘the purpose of development is to create an enabling environment for        people to enjoy long, healthy, and creative lives’ (Mahbub ul Haq, as cited by Nussbaum,        2013). As a result, there are two concomitant axes developed in parallel to each other in        the capabilities approach: one aims to provide the means for a comparative assessment        of well-being (or quality of life), while the other delineates an account of basic social        justice (Nussbaum, 2013, p.18). One primordial characteristic of Nussbaum’s account of        well-being is its refusal to reduce the notion to one single value, despite emerging        challenges appearing with the inability to compare and aggregate clearly across        individuals or populations. The approach ‘takes each person as an end , asking not just                      about the total or average well-being but about opportunities available to each person.       

It is focused on choice or freedom [...] The approach is resolutely pluralist about value ’                          (Nussbaum, 2013, p.18). A clear definition of quality of life is absent from Nussbaum’s        capability-based theory of justice, due to its decisive adhesion to political liberalism.        Despite their interconnectedness, the central capabilities remain distinctive, irreductible        and heterogeneous areas of freedom. All need to be secured and protected, regardless of        one another: ‘when capabilities have intrinsic value and importance (as do the ten on        my list), the situation produced when two of them collide is tragic: any course we select        involves doing wrong to someone. This situation of tragic choice is not fully captured in              standard cost-benefit analysis’ (Nussbaum, 2013, p.36). And the flaws of such standard        cost-benefit analyses and Gross Domestic Product calculations (GDP) are carefully        outlined and stressed in Nussbaum’s argumentation - a necessary feature of her analysis        in order to legitimise the decision to opt for an adaptative, unspecific account of        well-being.  

At the centre of such recriminations is the allegation of oversimplification: ‘the        GDP approach aggregates across component parts of lives, suggesting that a single        number will tell us all we need to know about quality of life, when in reality it doesn’t        give us good information’ (Nussbaum, 2013, p.49). Utilitarian approaches are not        spared; four different issues, more or less problematic depending on the account        selected, are identified. It is argued that, as a measure of quality of life, utilitarianism        aggregates across lives in the same way GDP calculations do; that it unjustifiably        aggregates across components of lives; that it fails to account for the malleability of        preferences and satisfactions; and, finally, that in defining satisfaction as a goal, it        greatly undervalues freedom (Nussbaum, 2013, pp.51-55).  

While some of the issues identified by Nussbaum are indeed quite problematic,        as was recognised in a previous section, I would like to argue here that her decision to        focus on a form of welfare utilitarianism centred on preference satisfaction is somewhat        unwarranted. Preference satisfaction might actually be said to be the least sustainable        form of utilitarian value theory (Scarre, 1996, p.133), in great part for the reasons        highlighted above. A favoured approach would be the ideal, inclusive-end conception of        well-being I mentioned earlier: ‘an inclusive-end view of happiness singles out neither       

pleasure nor any other individual element as the whole of happiness, but sees happy        existence as a coherent construction out of a variety of complementary parts - a        construction on which the subject can look with satisfaction’ (Scarre, 1996, p.141). This        inclusive-end account of well-being seems more in line with Nussbaum’s own        conceptualisation, especially if one admits that a very similar type of political action        derives from it. The most efficient way to promote well-being would be to ‘create the        basic political, economic and educational conditions which permit [people’s] chosen        lifestyles to be realised. The most fruitful happiness-enhancing service which        utilitarians can render is generally to facilitate individuals’ own efforts to live the        lifestyle of their choice’ (Ibid., p.142). In recognising the partial incommensurability of        these diverse ends and, therefore, the difficulty in implementing comparative value        judgements, such an account might be said to be quite a weak version of utilitarianism -        or another form of consequentialism altogether. However, by admitting outright the        existence of such complications, this ideal, inclusive-ends account offers a convincing        understanding of well-being, in addition to being compatible with both the principlist        and the capabilities approaches. As conceded by Nussbaum herself, the capabilities        approach, being outcome-oriented, can be seen as a cousin of consequentialism, or even        as a form of political, non-welfarist consequentialism (Nussbaum, 2013, p.95): ‘in this        sense it is reasonable to classify the capabilities approach with approaches that focus on        promoting social welfare - understanding welfare, of course, in terms of capabilities,        not the satisfaction of preferences’ (Ibid., p.96). I believe that an outcome-oriented        approach like this one suits my purposes quite well. 

As applied as a topic like the development of pre-emptive psychiatry might be,        meta-ethical questions and other purely theoretical interrogations are unavoidable in        the ethical evaluation of these medical practices. If one wishes to understand the source,        the nature or limits of our moral justifications, one necessarily has to turn to highly        theoretical lines of enquiry. The topic of this dissertation would indeed gain a lot from        a deeper analysis of its implications as well as the assumptions it relies on. The idea of        prevention itself, in medicine, in politics, or economics, etc., is particularly complex and        necessarily engages with deeply abstract notions, such as risk, or vulnerability. For        reasons of efficiency, though, the choice has been made, here, to strictly limit the scope       

of these interrogations to their practical consequences and implications. It is only        insofar as there are actual repercussions - in the treatment of at-risk individuals, in the        attitudes of the general population, on the duties of psychiatrists, etc. - that such        theoretical enquiries will be pursued.  

To conclude this more methodological section of my dissertation, I want to        stress once again the necessity to adopt a comprehensive, adaptable and explanatory        framework for the evaluation of pre-emptive psychiatry. With these constraints in        mind, mid-level approaches appear to offer the most coherent and pragmatic option,        offering clear normative (moral and political) guidance, while seeking to reach a form        of equilibrium between our beliefs and our principles.   

Chapter 2 - Current State of Research in