Soc Choice Welfare (2008) 31:345350

DOI 10.1007/s00355-007-0283-7
ORIGINAL PAPER

Mutual dependency between capabilities

and functionings in Amartya Sens capability approach
Afschin Gandjour

Received: 26 September 2005 / Accepted: 19 October 2007 / Published online: 1 December 2007
Springer-Verlag 2007

Abstract Amartya Sens capability approach has recently been widely discussed as
a theoretical basis for making resource allocation decisions in health care. The purpose of this paper is to analyze the relationship between capabilities and functionings
in the capability approach. The paper shows that some functionings are not only the
result of capabilities, but also their prerequisite. That is, there is a dual role of some
functionings as both ends and instruments, resulting in a mutual dependency between
capabilities and functionings. Functionings may be a direct requirement for capabilities, but also an indirect one because they ensure the absence of mental disorders or
negative thoughts, both of which are relevant constraints on freedom. This has important implications. It supports a policy that ensures for everyone an initial endowment
of (1) mental and physical health, (2) education, and (3) other functionings with a
direct or indirect impact on capabilities.
How ought we to allocate resources for health and health care fairly? This is a
question that has generated considerable debate among the general public, politicians,
economists, and philosophers. Several ethical theories have competed for influence
in resource allocation decisions in health care, among them utilitarian, deontological, liberal, communitarian, and egalitarian theories. Lately, Amartya Sens capability
approach has become another widely discussed account. Sen argues that health equity
not only requires the achievement of good health and access to health care services,
but also the capability to achieve good health (Sen 2002). With reference to the health

A. Gandjour
Institute of Health Economics and Clinical Epidemiology,
University of Cologne, Cologne, Germany
A. Gandjour (B)
Institut fr Gesundheitskonomie und Klinische Epidemiologie,
Universitt zu Kln, Gleueler Strae 176-178, 50935 Kln, Germany
e-mail: afschin.gandjour@uk-koeln.de

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A. Gandjour

care system, Sen defines capability as the opportunity an individual has to achieve
good health. In a wider context, Sen defines capability as the individual freedom to
achieve functionings such as good nourishment, good health, self-respect, and social
integration (Sen 1996).
To ensure freedom of choice commodities or resources such as income, education,
and food are needed. The ability to use commodities is influenced by personal, social,
and environmental factors (Robeyns 2000). The type of freedom Sen envisages is
positive freedom, i.e., the capacity to do this or be that, in contrast to negative freedom or freedom from constraints. The idea of the capability approach is perhaps best
expressed in Sens own words:
A functioning is an achievement, whereas a capability is the ability to achieve.
Functionings are, in a sense, more directly related to living conditions, since they are
different aspects of living conditions. Capabilities, in contrast, are notions of freedom,
in the positive sense: what real opportunities you have regarding the life you may lead
(Sen 1987, p. 36).
Hence, Sen argues that the functioning bundle a person will achieve in the current
period depends on the individuals current capability set. But he also states that capabilities should not only be valued as a means to achieve functionings, but also intrinsically
(Sen 1999). That is, Sen attaches both instrumental and intrinsic value to capabilities.
This paper will show that the capability set and the achieved functioning bundle in
the current period may depend on the functioning bundle achieved by the individual
in the past. That is, there is also a dual role of some functionings as both ends and
instruments, resulting in a mutual dependency between capabilities and functionings.
1 Mutual dependency between capabilities and functionings
In the following, I will present the argument that the capability to select a set of functionings in the current period requires functionings achieved by the individual in the
past. In other words, I hypothesize a mutual dependency between capabilities and
functionings. Functionings may be a direct or an indirect requirement for capabilities. Examples of functionings that are a direct requirement for capabilities are good
nourishment, health, and education. In fact, Sen himself stresses that physical health
and the absence of poor nourishment are important for peoples liberty to choose
to live as they desire (Sen 1992, p. 67). Similarly, education is required to enhance
capabilities (Drze and Sen 1995).
Functionings may also be an indirect requirement for capabilities because they
ensure the absence of mental disorders or negative thoughts, both of which are relevant constraints on freedom. Mental health can affect both the real capability set
and the capability set as perceived by the individual. In detail, this argument has four
premises: (1) the undistorted perception of available opportunities and the ability to
seize an opportunity are critical elements in the freedom to make a choice; (2) negative
moods and emotions1 are associated with cognitive distortions; (3) negative moods
1 Moods are low intensity, diffuse, and relatively enduring affective states without a salient antecedent
cause and therefore little cognitive content (e.g., feeling good or feeling bad); whereas, emotions are more
intense, short-lived and usually have a definite cause and clear cognitive content (Forgas et al. 2004).

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347

and emotions limit the ability to seize an opportunity; and (4) functionings are a
prerequisite for the absence of negative moods and emotions.
In the following I explore eachof the four premises: premise (1) Sen does not explicitly discuss whether mental disorders or negative thoughts are relevant constraints on
freedom (Chaudhuri and Reboud 2003). Rather, he stresses the role of physical disease
[e.g., see Sen (1992, p. 67) on the impact of malaria on freedom] and the importance of
overall health for freedom (Sen 2002). On the other hand, Sen (1996, p. 52) implies that
those who have low expectations due to repression are unfree . Given that repression
is a type of defense mechanism and that defense mechanisms distort ones perception
of reality, we could generalize that any distortion of ones perception is an obstacle
to freedom; this conclusion provides the first part of premise (1). The second part of
premise (1) is supported by Sens view that each person is a doer and a judge (Sen
1985a). Sen calls this type of freedom agency freedom (Sen 1985a).
Premise (2) It has been well established that moods and emotions can influence
information processing. Numerous studies have shown that negative moods and emotions (as seen, e.g., in depression) are associated with distorted thinking and unrealistic
negative thoughts such as black-and-white thinking and over-generalisation (e.g., see
Nelson 1977; Krantz and Hammen 1979; Lewinsohn et al. 1981; Eaves and Rush
1984; Kown and Oei 1994; Rose et al. 1994; McDermut et al. 1997).
Premise (3) Forgas et al. (2004) summarizes current research evidence by stating
that even slight changes in mood (. . .) can significantly influence motivation, the
goals that people set for themselves, (and) the action plans they formulate. In fact,
a reduction of energy and a decrease in activity is typical of patients with dysphoria or depression according to the ICD-10 Classification of Mental and Behavioural
Disorders (World Health Organization 1992).
Premise (4) There is a large body of research showing that functionings such as
health and social relationships are associated with happiness2 (Donovan et al. 2002).
Although some reverse causality exists, i.e., happy people are more likely to care about
their health and build social relationships, there is also evidence that causality runs
from health and social relationships to happiness (Diener and Seligman 2004).
There seems to be not only a mutual dependency of freedom and functionings, but
even reinforcement. A reverse analogy might help to explain: if we are in a negative
mood, we give up earlier. Thus, we do not achieve what (functionings) we truly want,
which puts us in an even worse mood.
But mental health and functionings achieved in the past may not only directly influence the current capability set, but also through their impact on commodities and their
conversion into characteristics, i.e., the various desirable properties of the commodities in question (Sen 1985b, p. 9). For example, the ability to earn a decent income
is rather low if a person starts with a low level of education and poor health. Similarly,
the nutritious value of food (one of its characteristics) may be low if a person lacks
the ability to cook the food properly due to low level of education.
In the following, I formalize the above arguments using Sen (1985b) specification
of the relationship between commodities, capabilities, functionings, and happiness:

2 Note that an account of happiness incorporates affective state views (Haybron 2001).

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xi = person is vector of commodities,

c() = a function converting xi into a vector of characteristics,
f i () = the personal utilization function of i converting characteristics into,
functionings
Fi = the set of f i from which person i can choose one,
h i () = the happiness function of person i related to the functionings achieved by i.
If the person chooses the utilization function f i () and applies it to the commodity
vector xi , the achieved functionings will be given by the vector bi = f i (c(xi )). The
happiness the person enjoys is given by the vector u i = h i ( f i (c(xi )).
The functioning vectors feasible for person i given a vector of commodities xi is
the set Pi (xi ) = {bi |bi = f i (c(xi )), for some f i () Fi . Person is capability set,
if the choice of commodity bundles is restricted to the set X i , is Q i (X i ) = {bi |bi =
f i (c(xi )), for some f i () Fi and some xi X i }.
Robeyns (2000) has suggested slightly extending this formalization by accounting
for social and environmental factors which influence the conversion of the characteristics of the commodities into functionings. I stick to the original formalization by
Sen in order to keep my suggestion for an extension as clear as possible. As stated,
functionings achieved in the current period are influenced by mental health as well as
functionings achieved by the individual in the past. Mental health and functionings
achieved in the past exert their influence by changing commodities as well as the
conversion functions. Hence, functionings achieved in the current period are given by
the vector bi,t = f i (c(xi (bi,t1 ), bi,t1 ), bi,t1 ), where t refers to the current period,
t 1 to the past period, and xi (bi,t1 ) refers to xi as a function of bi,t1 . This expression of achieved functionings is then inserted into the above definitions of a feasible
functioning set Pi (xi ) and a capability set Q i (X i ).
The relationship between general health and capabilities (Sen 2002) has the same
features as the relationship between functionings and capabilities. Sen argues that we
need to have capabilities in order to decide upon the level of health we aim to achieve
(Sen 2002, p. 660). At the same time he acknowledges that health is required to obtain
freedom of choice (Sen 2002, p. 663). Again, it seems plausible to assume a mutual
dependency and reinforcement between health and freedom. For example, someone
who gets smoking-related health problems might be put in a bad mood, thus feels less
free, and finally smokes even more, further aggravating his or her health problems
[I have adopted Sens (2002, p. 660) viewpoint that smoking can be regarded as
unfreedom to conquer the habit].

2 Conclusions
As stated in the introduction of this paper, Sen makes the existence of health equity
conditional upon the level of achieved health and peoples capability to achieve good
health. What this paper adds is another justification for this requirement, namely the
mutual dependency and perhaps reinforcement of health and capabilities.

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The mutual dependency of functionings such as health and capabilities exists

because some functionings are not only the result of capabilities, but also their
prerequisite, i.e., there is a dual role of some functionings as both ends and instruments. Hence, not only capabilities have intrinsic and instrumental value (Sen 1999),
but also functionings. The capability approach in its current form does not account for
the interaction between capabilities and functionings (such as health) and the importance of moods and emotions in making free choices concerning health and other
functionings. In order to achieve (health) equity, resources thus need to be allocated
in a way that ensures the absence of negative moods and emotions and provides an
initial endowment of valuable functionings. In other words, the ability or freedom
to choose upon the level of functionings (such as health) is not sufficient to achieve
justice; an initial endowment of (1) mental and physical health, (2) education, and (3)
other functionings with a direct or indirect impact on capabilities needs to be ensured
for everyone. Such an arrangement actually reduces the freedom of people because
the set of functionings which is open to choice becomes smaller. The crucial question is what precise level of functionings is required for freedom of choice. Whereas
for mental health this level is clearly defined (absence of negative moods and emotions), for other functionings it seems less obvious and rather an empirical question.
Given the need for mental health, the capability approach indirectly supports a policy that aims at offering more treatment to people with mental disorders and their
caregivers.
Acknowledgments
earlier draft.

The author would like to thank the reviewers for extremely helpful comments on an

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