- 1 According to a study conducted by the U.S. health network NiceRx and published in December 2022, t (...)
1Today, the average lifespan of human beings worldwide is about 73 years.1 Subjects are increasingly likely to reach old age due to improvements in survival, and the share of the elderly in the total population is increasing due to reduced fertility. This contemporary trend makes important a conceptual and empirical analysis aimed at defining what well-being in late adulthood consists of and how it can be increased.
2Talking about well-being in relation to old age is often perceived to look like a contradiction. Old age is reputed as something that is in risk of being far removed from well-being, a time when the quality of life is inevitably lower than in earlier stages of existence. Aging indicates those changes that accumulate over time and, as a whole, make us feel more vulnerable and fragile. According to some researchers, aging is a slow process that begins with our very existence and will proceed at different speeds for each of us. But as much as, in a broad sense, the word aging refers to the changes that occur throughout the lifetime of an organism, or the process by which we change ourselves as a function of time, in a narrow sense, talking about aging means dealing with the concepts of loss of function and decay that expose us to an increased risk of developing diseases or going into death (Jin, 2010). As shown by an empirical study involving more than 4,500 healthy elderly people residing in twenty different nations, regardless of age, gender, and nationality, the relationship between quality of life and satisfaction about one’s health status is expressed as a function of the ways in which people are prepared to cope with changes occurring at the physical, psychological, and social levels (Low et al., 2013). Late adulthood is marked by major physical and mental changes that contribute to an increased likelihood of incurring health and disability problems. From the physical point of view, all or most elderly people face specific adaptations due to the loss of physical strength and positions of privilege and confidence with the associated risk of progressive isolation. From the mental point of view, excluding some severe and/or frequent mental disorders such as dementia, the elderly have to cope with a decline in mental functions that mainly affect memory, attention, language and intellectual functions; the elderly may perceive a general lowering of intellectual efficiency with consequent loss of speed in the execution of mental operations. Such changes not only generate obvious difficulties in the elderly person’s daily life, but can also have important effects on the psychological level: the elderly person becomes less self-confident and more aware of a state of increasing precariousness and inadequacy. Added to these physical and mental changes are the profound changes related to social roles and relationships. Retiring, losing one’s role as a son/daughter, or losing one’s role as a spouse can not only radically alter one’s self-perception, but can also bring the risk of isolation or alienation. Moreover, changes in family composition and living arrangements and transitions from work to retirement are identified as important triggers of income variation in the elderly. Aging is not exclusively a biological issue; it is a phenomenon in which biology, psychology, culture and society are intermingled in complex ways. All these reasons reinforce the idea that the perception of a good quality of life is an extremely important factor in modulating attitudes and expectations during these delicate times of personal revolution. As much as old age brings inevitable and specific limitations that require special considerations and attention, it is entirely possible to enjoy a good life even in late adulthood. Some scholars speak of “successful aging”, pointing out that the normal aging process can also lead to a transformation of individual abilities in a positive way: one can lose what is not being used, what has not been useful over a lifetime, and at the same time one can improve in the subjectively most meaningful abilities. Baltes and Baltes, for example, speak of processes of selection, optimization and compensation, related to minimizing disadvantages due to the partial loss of unused functions and enhancing the most important ones (Baltes and Baltes, 1991). The elderly person, for example, may have more time to attend to emotional relationships, to engage in cultural interests outside his professional sphere that can enrich his personality and help him make sense of his present condition. Even his hobbies can be enhanced and perhaps assume that prominent place he has always desired. However, there is no doubt that favorable surrounding conditions are needed to steer aging in a positive direction.
3Taking into account the objective vulnerabilities and specific difficulties of old age, is it possible to ensure successful aging? How should well-being in the elderly be understood? How can the quality of life of this population group be increased? A definition of the criterion of well-being with reference to the elderly is essential, especially considering that the specific vulnerabilities of this segment of the population change the perceived value of different capabilities, compared to younger people. Such a definition can be an inspiration for identifying normative criteria that can develop both an ethic that takes into account the peculiarities and needs of the elderly and public policies aimed at providing sufficient levels of quality of life for the entire elderly population.
4But what theory of well-being can best account for this particular period of human life?
5When philosophers address the concept of well-being, they are interested in delineating what increases the quality of people’s lives; by establishing that well-being can be defined as what is good for the individual who is living that life, philosophers ascribe a specification of normative content to that description in order to delineate and provide the best theory of well-being. Therefore, the different conceptions of well-being aim to clarify what makes a life good or bad (not in the moral sense), what improves or worsens a person’s existence. In the next section I present, if only superficially, the main conceptions of well-being in the contemporary panorama with the aim of understanding which normative theory proves to be the most effective in its application to concrete situations.
- 2 For a detailed account of well-being theories see Guma, 2020.
6Considering the main conceptions of well-being in the contemporary philosophical field, it is possible to identify three major groups of theories: objective, subjective and mixed (or hybrid). According to objective theories of well-being, there are good or bad, positive or negative, things for individuals regardless of whether they wish to possess or avoid them. Well-being is defined apart from the mental states of the subject, and resides, for instance, in the possession of certain primary goods or basic needs. These positions include, for example, theories of needs, including economic needs. These are interesting approaches: considering the great strides made in recent times toward increasing human longevity, it is clear that there is an objective need for every elderly person to protect themselves from falling into poverty during an increasingly long retirement period. Focusing on the concept of economic well-being, reinforced by health as an additional dimension, thus appears to be an indispensable starting point for enabling individuals to have a good quality of life (Zaidi, 2017).
7For the subjective doctrines of well-being, what is good for the individual coincides with a state of pleasure or preference satisfaction derived from his or her personal mental states. For subjectivists, something can increase the quality of a person’s life only if he or she is the one who wants it, appreciates it, or desires it. Among these theories are proponents of hedonism and philosophers of desires’ fulfillment. These approaches certainly state that old people’s evaluations and feelings about their lives seem to several researchers the most important to determine and to evaluate well-being, because there is enormous variability among the elderly in physical and mental state, vitality, contentment, loneliness, and economic tranquility (Ferring & Boll, 2010).
8The theorists of mixed approaches of well-being suggest that to examine an individual’s level of well-being it is necessary to simultaneously consider two aspects grasped by objectivists and subjectivists, respectively: on the one hand, the objective value that certain goods have within the life of each human being, and on the other hand, the subjective value that the individual places on these goods. For the theorists of mixed approaches, what is good for a person can be defined as something composite, able to account for the objectivity of the good and the subjectivity of the individual. Among this group of theories we find, for example, the capability approach, to which the next section will be dedicated.
9Identifying the most satisfactory normative specification is necessary to respond to concrete ethical situations in which it appears critical to consider and understand what improves the life of the individual under consideration. Certainly, an argument in favor of an objectivist theory of well-being lies in the fact that values such as autonomy, knowledge, health, and good affective relationships actually seem to enhance people’s lives. Moreover, establishing which goods increase the quality of life, regardless of personal characteristics and attitudes, provides guidelines on what to consider to increase well-being. In situations of illness, disability, and care, it might facilitate having to deal with a list of objective values, explicitly denoting what is better for the elderly person. This is also true from a political and social point of view. Well-being surely depends on the quality of certain objective conditions in which life is lived. Objective approaches point to material and general conditions external to the subject to achieve a good level of well-being and, in doing so, capture an important aspect of life from the perspective of the person experiencing it. Moreover, by not considering an individual’s desires and preferences, such approaches can eliminate the problem of patient’s competence that is often present within the medical practice: it is sometimes difficult to determine whether or not individuals are autonomous and aware of their own choices, whether they are psychically capable of deciding for the solution that is actually best for them. Having a universally valid list of goods would solve this difficulty. However, accounts of the objective list have the difficulty of being too rigid: they leave no margin for individual differences and do not take subjective experience into account. If well-being is to be understood as what is good for the person who is living that life, the phrase “for the person who is living that life” calls to mind his or her particular individuality, his or her point of view.
10Generally, the main reason for endorsing a subjective theory of well-being is the belief that only the individuals concerned can point to what is inherently good for them. This insight, which is widely shared, is expressed, for example, by Railton: «it does seem to me to capture an important feature of the concept of intrinsic value to say that what is intrinsically valuable for a person must have a connection with what he would find in some degree compelling or attractive, at least if he were rational and aware. It would be an intolerably alienated conception of someone’s good to imagine that it might fail in any such way to engage him» (1986, p. 9). If a subject’s evaluative attitudes are a guide that can show what is of value, the subjective approach to well-being is correct. Such a conception respects the intuitive subjectivity of the concept of well-being by giving freedom to the subjects to determine what increases the quality of their life and, at the same time, emphasizes the importance of the dimension external to the persons. The appropriateness of a subjective theory of well-being also seems to be confirmed by a number of empirical studies that have shown how the concept of well-being affects the subjective sphere and the evaluations everyone gives to the quality of their lives (Dodge et al., 2012; Zikmund, 2003).
11However, even in this case, problems arise: people are not always rational and do not always have all the relevant information available about the objects of their desires. Sometimes it happens, for example, to desire something only because one does not know that one could desire something else. Moreover, it is the actual conditions themselves that require one to consider some objective parameters. In practice, well-being becomes relevant in multiple situations. The importance of taking people’s quality of life into account is given by human needs and the frameworks that have been created in our contemporary society. The importance of having an objective frame of reference is determined not only by constitutive human fallibility but also by two other factors. The first depends on the inevitable, we might say, extraneous nature of the analysis. When it comes to a theory of well-being we are always in a situation where someone is concerned about what is good, what is better for another individual. This other makes it necessary to consider objective factors as well: after all, what else could one start from in an attempt to determine what is good for another individual? The second factor that makes it important to have objective parameters lies in the particular need for objectivity possessed by certain contexts in which well-being is central. This is the case, for example, in medicine, of the relationship between doctor and patient, in those situations in which a subject appears unable to achieve functioning. In these circumstances it is essential to refer to some objective aspects that give a frame of reference about what might be the best for the person who is living that life. Although it is always up to the person concerned to have the final word, having an objective starting point is a must in these situations.
12It seems that both objective and subjective approaches have some hard challenges to overcome. Within gerontology a definition including objective as well as subjective dimensions of well-being is recommendable (Birren et al., 1991). Objective factors based upon external judgements include, for example, physical health, functional ability, cognitive capacity, economic status, and environmental factors. Subjective factors based on self-perceptions are, for example, life satisfaction, self-rated health, and self-esteem.
13As I show in the next section, the framework offered by Sen’s capability approach provides a mixed theory of well-being that allows consideration of both the objective and subjective aspects necessary to assess well-being.
14At the core of the capability approach formulated by Sen are the “capabilities” and “functioning” of the individual. The purpose of the theory is to develop a reflection that can ensure a “good life” in which the individual’s basic capabilities can be fully achieved.
15In considering well-being, Sen considers the notion of «human flourishing» to be central; a person’s well-being lies in the development of his or her capabilities and the exercise of their respective functioning. Through the unfolding of one’s capabilities, a person can self-actualize, flourish and be well. For Sen there are two different – but closely related – notions to consider in a conception of well-being:
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«functioning-achievements»: «how does he or she live, what are the various things that the person succeeds in doing, and so on. This is, of course, a bundle of diverse personal achievements rather than one number (like ‘utility’ or ‘real income’). But a bundle of achievements can be converted into a numerical index, if and when such a simple measure is needed»;
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positive freedom; «of freedom, concentrating not only on what a person does, but what the various things are that he or she can do. The capability to function is freedom in a ‘positive’ sense» (Sen, 1986, p. 188).
16Given these two factors, it appears that for Sen, well-being consists in achieved functioning and the relative positive freedom to achieve it. The importance of the notion of capabilities is related to the value assumed by positive freedom: capabilities essentially reflect the freedom to acquire functioning; to the extent that functioning constitutes well-being, capabilities represent individual freedom to acquire well-being (Sen, 1992). Sen introduces the concept of «well-being freedom», by defining it as «the general idea of the freedom to achieve well-being» (Sen, 1985, p. 201). Well-being freedom can be interpreted as the freedom to choose whether or not to achieve a functioning. A person unable to acquire a particular functioning has a lowering of his or her quality of life, but the same cannot be said of an individual who could acquire that functioning and, by choice, does not. The good for the individual consists of the ability to achieve valid functioning and, at the same time, the freedom to have various options for functioning. It is the individual who chooses his or her own well-being, but he or she must be in a position to choose it. The individual’s quality of life is evaluated on the basis of the individual’s assessment of his or her own functioning. In this sense, an acquired functioning – or a failure to function – is important in determining the degree of well-being based on how the individual perceives it: Sen, therefore, does not underestimate the importance of acquired functioning, but emphasizes how the opportunity to choose it is even more relevant in calculating a person’s quality of life: an individual can increase his or her quality of life if he or she is free to do this or be that. The processes implemented by a subject to achieve a particular functioning are not variables endowed with an independent value, but rather tools for increasing one’s quality of life. The positive freedom of being able to choose is thus not merely a means, but an important value in itself.
17Sen’s conception of well-being is a mixed theory of well-being in that it contains both subjective and objective elements. On the one hand, Sen criticizes subjectivist positions, especially the utilitarian one, in that, relying mainly on the individual’s mental states, they do not consider, for example, the problem of adaptive preferences. The individual must have the capability to achieve valuable functioning. On the other hand, Sen does not accept the idea of outlining an objective conception that is impersonal and therefore not attentive to individual differences: the individual must enjoy «well-being freedom». Sen does not propose a fixed list of relevant functionings and capabilities, but presents a very broad and indefinite set of possible objects of value, coinciding with all possible capabilities of human beings.
18Human beings are extremely different from one another, leading to different needs. A conception of well-being cannot avoid this reality. If one were to stop at this conclusion, Sen might define a completely subjective conception of well-being. However, for the author, it is also true that individuals may find themselves in conditions of deprivation or suffering not by choice, but by actual lack of opportunities and capabilities: the subject can adapt to conditions that are negative for him by experiencing them as positive. This is because what individuals prefer responds to the social and environmental conditions in which they are embedded. Thus, well-being cannot be considered only from a subjective point of view, because there is a risk of evaluating a good for the individual that does not actually improve his or her life, but rather makes it worse (although such a good is experienced as desirable by the person himself or herself). For this reason, in Sen’s conception, a subject’s well-being also depends on factors beyond how existence appears to him or her: there are certain functioning that can be considered generally good for all subjects. This, however, does not lead Sen to advocate the existence of objective goods, valid independently of the subject, because «the good life is inter alia also a life of freedom» (Sen, 1985, p. 202).
19Sen’s approach has received several objections. Some have pointed to the possible difficulty of harmonizing the objective aspects with the subjective ones: how do the “objective” features of the approach systematically combine with the “subjective” aspects? The capabilities Sen speaks of are to be interpreted as objective parameters that it is necessary to ensure in order for each individual to achieve a good level of well-being. As much as there are individual differences and as much as these differences lead Sen to deny the possibility of defining a priori a list of capabilities to be considered in the assessment of well-being, the author makes it clear that from time to time, in each society, it will be possible to identify capabilities that are objectively deemed important for achieving a good level of well-being. A particular society interested in implementing and protecting the quality of people’s lives can understand what may be the fundamental capabilities that need to be ensured in order to provide each individual with the practical and objective conditions to have the freedom to achieve his or her well-being. The subjective aspect is combined with the objective characteristics precisely because of the application of the concept of freedom of well-being: in the various particular cases, each subject will choose whether and how to develop the objective capabilities guaranteed by society, exercising the functioning that he considers good for him. The objective aspect of the approach is thus combined with the subjective aspect without too much difficulty: there are basic capacities that we can consider objectively important for achieving a good level of well-being, yet we cannot know a priori whether the development of those capacities and the exercise of the respective functionings is really what is best for an individual when he or she is faced with the choice of what is best for his or her life. It will be up to the individual to decide whether and how to exercise his or her functionings related to the objective capabilities that have been granted to him or her.
- 3 Sen addressed some difficulties in the empirical application of the capability approach in The Liv (...)
20Another objection leverages the openness left by Sen on what capabilities to consider in determining well-being. Some scholars assess this choice as Achille’s heel of the theory (Qizilbash, 1998, p. 54). As noted above, «Sen’s reason for not filling out such a list has to do with pluralism – the view that there are several forms of life that are good – and his desire not to give priority to any particular conception of the good life» (Qizilbash, 1998, p. 53). Qizilbash reads in Sen’s choice a flaw in the capabilities approach and believes it leads to difficulties: Sen fails in that he risks being incomplete by not providing a specific theory of the good life. For Nussbaum, Sen’s decision is also problematic: the author remains at a subjective level, as the assessment of functioning is, in general, left to the individual whose life is being examined. Surely the search for parameters to identify capabilities and functioning is a difficulty in the empirical application of the capabilities approach.3 It does not seem to be easy to grasp a person’s positive freedom: what an individual might or might not do or be is not easily delineated. What an observer can understand in reality are his or her actual and, for the most part, already accomplished choices. Identifying, quantifying, and measuring the set of capabilities seems to be a substantial problem. In cases of extreme poverty, it might be easier to identify how an individual’s well-being could be improved as he or she is in a state of high deprivation; some minimal goals of well-being are easily traced, such as, for example, the degree of nourishment, or the level of mortality. But in industrialized societies, the issue seems to become more complicated. However, for Sen, the choice not to provide a list of relevant functioning and capacities, and to propose a broad and indefinite set of goods can be considered a strong point of his theory. By exclusively considering what is good for the subject, Sen focuses on individual differences and on various possible conceptions of the good. This leads him to deny the possibility of listing what capabilities are to be considered in the assessment of well-being, as this would be a partial and questionable list. It is the individual who determines which functioning is valuable; it will therefore be the individual who determines which acquisitions of functioning increase his or her quality of life. It is true that without a precise list, at the political and public level, the problem remains open as to which capabilities to focus on to ensure equality of capabilities; but delineating human capabilities and functioning would be the result of arbitrary choices unable to account for ineradicable human diversity. Different subjects have different needs: any theory of egalitarianism should embrace this simple yet obvious truth. What capabilities to seek to increase thus remains a matter of public evaluation and choice that is affected by the culture and values present in the society in which it is made.
21The advantages of taking the capabilities approach to consider the well-being of older people are several. First, the conception provided by Sen appears to be an optimal choice because the language and perspective of the capabilities approach fit without any difficulty into the multidisciplinary context of discussing the quality of life of older people: the various empirical disciplines concerned with aging and the physical, mental and social condition of older people speak spontaneously and naturally about capabilities and functioning. Taking a theoretical perspective that considers well-being by assessing precisely capacity and exercise of their respective functioning thus seems a good way to develop a theoretical reflection capable of contributing to the discussion on the quality of life during old age. Moreover, the fact that the capabilities approach is a suitable and easily assimilated theoretical framework in the various disciplinary contexts that consider the elderly can also be a valuable aid in practice. For as is well known, an elderly person’s ability to preserve adequate functional capacities depends on multiple factors that are not only objective but also subjective, involving his or her personal condition, his or her adaptation to age-related changes, and the modification of his or her lifestyle to reduce certain risk factors. Each elderly person will have not only specific difficulties and related to his or her particular physical, mental and social condition, but will also have his or her own way of responding to that condition and his or her own way of increasing well-being. The mixed aspect of Sen’s proposal can simultaneously satisfy both the need to have general objective parameters capable of guiding societies and social welfare facilities interested in ensuring a good quality of life for the elderly population, and the need to consider the great differences among individual elderly people.
22On a practical level, considering that the specific vulnerabilities of the elderly are closely related to changes in the perceived value of different capabilities compared to younger people, a theory that aims to identify the specific capabilities to be considered when examining well-being seems an excellent way to help understand how to ensure a good and flourishing life for the elderly. Through multidisciplinary work, the core capabilities of the elderly could be defined and thus provide guidelines for any society interested in increasing the well-being of this particular segment of the population. A number of empirical studies show that what matters most to the elderly is the maintenance of their capabilities to function. The much-expressed desire to “age well” is not to be understood simply as the ability to preserve an optimal state of physical health, but rather as maintaining one’s functional capacities concerning the satisfaction of one’s personal needs, preserving decision-making abilities, maintaining a social role and participation, preserving and developing interpersonal relationships, and possessing a good degree of mobility (WHO, 2020).
- 4 The United Nations General Assembly has proposed 2021-30 as the decade of healthy aging, calling o (...)
23For the purposes of identifying the capacities to be developed and protected to ensure a good quality of life for the elderly, the macro areas of action that the United Nations General Assembly has deemed important for healthy aging can also be considered: the development of a friendly environment encompassing physical, social and economic aspects; the fight against aging aimed at changing prejudices, stereotypes and discrimination present toward older people; access to good integrated care pathways; and guarantees of quality continuing long-term care.4 Considering this new perspective from the perspective of the capabilities approach can help identify the various objective dimensions (environmental, social, psychological, and physical) needed to be considered in order to define the specific capabilities to be secured and protected for the purpose of enabling each elderly individual to achieve the functioning that he or she perceives to be best for his or her well-being. These capacities should be elaborated taking into account the possible stressors that the elderly have to manage and the psychosocial and physical risk factors that may exacerbate the normal difficulties of the elderly such as inactivity, depression, economic poverty, poor emotional sphere, poor nutrition, toxicity of the environment, absence of social services specific to this age group, and inadequate relationship with the health care system.
24Concretely, once the general capabilities of late adulthood have been defined, it would be important to develop and support programs and interventions for the promotion of these capabilities, so that every elderly person can be in a position to be able to realize his or her tendencies and inclinations. Social welfare facilities, for example, could be aimed at supporting and ensuring such capabilities, so that the elderly person can have the basic conditions to achieve a fulfilling old age. In addition to the dissemination of knowledge on the topic, action should also be taken at the level of care systems (health and social care) to stimulate the implementation of interventions aimed at supporting the elderly in adapting to change. Effective interventions to be proposed could be, for example, cognitive training, reminiscence and promotion of social participation.
25There is enormous variability among the elderly in physical and mental state, vitality, wisdom, contentment, enthusiasm, loneliness, and economic comfort. For some, late adulthood can be a time of choice and opportunity, but for others (especially those living below or near the poverty level, or with severe physical infirmities) these last years of life can prove to be bad and tragic. The degree of diversity among people certainly makes it difficult to generalize about the level or possibilities of well-being for a certain segment of the population; however, a conceptual and empirical analysis that aims to define certain objective guidelines for increasing well-being in late adulthood is now central to our contemporary age. Further research focused on the empirical implementation of Sen’s theory should be focused on tracing a list of general capabilities to enable the elderly population to have the opportunity and freedom to achieve valuable functioning. As mentioned above, considering the particular frailties of this age group, these general capacities should take into account the situation in which the elderly person lives (at home, in an institution, in hospital), the possible nature of the distress in which the elderly person finds himself/herself (functional, organic, social), and the affective and relational sphere of the elderly person.
26Sen’s capabilities approach, in addition to offering several conceptual advantages, provides compelling arguments for identifying variations in individual attributes and circumstances and how these differences explain the varying degrees regarding the utilization of means useful to achieve the specific end of well-being. Furthermore, in considering the «well-being freedom», this theory stresses the importance of taking into account that people must able to choose a life they have reason to value. It is the aspect of opportunity or freedom that determines well-being, not what is revealed in a person’s actual preferences.