Discussion
Ability-based notions of health and disease encourage dialogue, reflection and deliberate interpretations when a person’s functional capacity is assessed. Some doctors may feel that value-laden and relational notions of health and disease appear alien, even as tools for reflection. The definition of disease may appear vague. A purely scientific notion of disease may appear to have a higher level of precision. Many doctors would agree, however, that «sick leave and sickness absence are complicated social processes» (12). Given this complex reality I claim that applying an ability-based set of concepts in the NLWA system could work well – it could spark a debate on how concepts of disease are used among doctors. Furthermore, parts of the health services often employ a bio-psycho-social medical model, for example in primary health care, in psychiatry and in physical medicine and rehabilitation. In my opinion, there is a good conceptual coherence between the bio-psycho-social model and the ability-based notions of health and disease discussed here.
A value-laden notion of disease is unlikely to present any particular legal problems; as mentioned above, the National Insurance Court has endorsed it (3). In legal practice, it is crucial to establish the facts of the matter. A value-laden notion of disease implies that a medical description for purposes of assessing an entitlement to a benefit remains a neutral description of what are recognized as the medical facts (including the relevant social conditions of the patient, the patient history, treatment, medical status, reduced functional capacity and likely prognosis) as well as what could conceivably increase the patient’s functional capacity. Most often, the value component will not be explicitly articulated; it constitutes the backdrop for the assessment. For example, the doctor should be empathic and try to see the matter from the patient’s point of view. As long as the doctor strives to remain objective and impartial in his/her assessments, the use of a value-laden notion of health will be unlikely to generate any negative consequences from a legal point of view (2, p. 391 – 403).
It may seem obvious to ask whether ability-based notions of health and disease will inevitably lead to liberalization in the use of disease-based social benefits. I disagree with this claim. Being value-laden, the concepts open up to a discussion of the values that the NLWA should uphold in a welfare state based on solidarity. On the one hand there are key values, such as the idea that work is important for human dignity. Being able to provide for oneself is a good thing, and for most people, working is conducive to their health. Keeping a job is often positive in itself, even though accompanied by some pain and discomfort. On the other hand there are other important values, such as the conviction that people who have suffered bodily and mental damage to an extent that significantly reduces their functional capacity should have the right to fulfil their need for financial security from communal sources. Between these values a balance must be struck. In my opinion, this balance can best be promoted by engaging in a continuous reflection on values, within the NLWA system as well as in society as a whole. The existence of NLWA is based on fundamental humanistic values with roots going back to the care that monasteries and guilds in European medieval society provided to the poor and needy (2). However, it is a task for contemporary democratic social debate to clarify the values that will define whether citizens should be granted social benefits or not. Potential value conflicts call for the development of an NLWA code of ethics. Some of these value reflections ought to conclude with guidelines to help medical practitioners in their assessments of the functional capacity of those suffering from disease and reduced health.