Philosophical Quality of Life and Ethical Dimensions

If we pay close attention to the different ways in which the concept of quality of life is used in health care, it is possible to make one’s way successfully through this semantic minefield. In order to do so it is important to distinguish four different senses of the notion of quality of life.

Quality of life as a property of the individual. First, the notion of quality of life is used to refer to some characteristic or state of being of the individual person. A quality of life (whether good or poor) is something one has or possesses, much as one has a physical characteristic or an occupation. Understood in this way, one’s quality of life is not essential to one’s identity or self-esteem. As such it has no straightforward moral significance. A poor quality of life (due to ill health, loss of a job, breakdown of personal relationships, or the like) is not necessarily a sign of a person’s moral failing, and it says nothing about the intrinsic value of life as such, or even about the moral value of that particular life at that particular time.

Quality of life as a goal of care. A second common meaning of quality of life defines it as a goal of care. The moral point of our dealings with another (whether the situation be health care or some other form of relationship) is to sustain and improve the quality of life. In this sense, quality of life becomes a benchmark to guide human activity and a concept of assessment and evaluation. But notice that the evaluation here is directed primarily at the caregiver and the caregiving process, not at the recipient of care, who partakes of the quality of life achieved but is not judged by it. Moreover, quality of life can be thought of as an interaction between the person and his or her surrounding circumstances, including other people. Thus understood as a goal or outcome of care, an improved quality of life may be a change (for the better) in the person’s symptoms or perceptions; or it may be a change in the person’s relationship with his or her environment. Medical cure, symptom relief, psychological happiness, or social empowerment may all be goals of care as comprehended by the concept of quality of life.

Quality of life as a social situation. Next, quality of life may refer to a state of interaction between an individual and his or her social and physical environment. Here a certain quality of life is not a property of the individual per se, but a function of that individual’s form of life. So understood a low quality of life assessment does not necessarily suggest a negative evaluation of the person or his worth; it can equally well imply a critical evaluation of the person’s environment and indicate ways in which that environment could be changed so as to enhance the quality of life according to some scale of norms such as justice, freedom, health, happiness, and the like.

Quality of life as the moral worth of a life. Finally, it must be acknowledged that the term quality of life is sometimes used to refer to the moral worth or value of a person and his or her life. Pushed to its logical extreme, this understanding of the quality of life takes us to the infamous Nazi concept of ‘‘life unworthy of life,’’ (lebensunwertes Leben), which was used to rationalize everything from active euthanasia of those with disabilities to the genocidal death camps. To say that a person has no quality of life or a very low quality of life is to say that prolonging this person’s life has no moral significance, either to the person himself or to society.

In this author’s view, it is a mistake to use quality of life as a measure of the moral worth of human beings. The notion of the moral worth of a life is logically quite distinct from the notion of quality of life. An account of moral worth is based on an underlying account of humanness or the human person; an account, that is, of what it is to be human. The concept of quality of life, on the other hand, is based on an account of a person’s inherent capacities and external circumstances. Quality of life may tell us what is required in order to become (more fully) human, but never about the value of being human.