In many fields there has been increasing interest in questions of flourishing or complete human well-being.1–8 This may be seen as a promising development with the potential to restore or instil a greater focus on a more complete fulfilment of the human person. And yet, there is arguably also some associated danger in that by focusing on complete human well-being, the distinctive contributions and specialties of a given discipline, or institution, or profession may be neglected. No person or institution can be made wholly responsible for the entirety of the flourishing of individuals or societies. Each discipline or specialty has its own contribution to make. In efforts that consider human flourishing and the human person more holistically, it thus becomes important to specify what is within the appropriate scope or purview of each discipline or institution in terms of the contribution that it can reasonably make towards the promotion of flourishing. Neglect of this point may be what lies behind some of the criticisms9–15 of the WHO’s definition of health as ‘a state of complete physical, mental, and social well-being’.16 These criticisms include that the defintion is overly broad, extends beyond the purview of medicine, provides a standard that is too demanding, is impossible to operationalise, and leads to an endless expansion of what are considered rights.9–15 These issues and criticisms need to be taken seriously if questions of flourishing are to be brought into discussion within medicine and public health.

In this paper, I will put forward proposals concerning the proper purview of various health-related institutions as they pertain to flourishing including medicine, psychiatry and clinical counselling, and public health and public policy. The first section will provide a brief discussion of the concept of flourishing; the following sections will each put forward a proposal for the proper scope of flourishing respectively for medicine, psychiatry and clinical counselling, and public health and public policy (see table 1), along with brief comment on the implications of the various proposals.

Table 1

Framework for the proposed scope of flourishing in medicine and public health

Flourishing

I have elsewhere defined ‘flourishing’ as ‘the relative attainment of a state in which all aspects of a person’s life are good, including the contexts in which that person lives’.4 17 Defined as such, flourishing is an ideal. It is not something we ever fully attain in this life. We all are flourishing only in a relative sense with respect to that ideal. Flourishing is multi-dimensional. Certain aspects of a person’s life may be good, and others not. Flourishing arguably includes, among other things, one’s happiness, health, meaning, character, relationships and financial resources.4 Flourishing moreover arguably further extends to the contexts in which a person lives also being good. One might distinguish between flourishing and well-being, insofar as well-being concerns all aspects of a person’s life being good, as they pertain to that individual, whereas flourishing pertains to all aspects of a person’s life being good, including the contexts in which that person lives.17 We are social and communal beings, and part of our own flourishing is constituted by the well-being of our communities. Flourishing thus encompasses well-being. With this understanding, let us now turn to potential proposals for the aspects of flourishing that arguably fall within the proper scope of each of medicine, psychiatry and clinical counselling, and public health and public policy.

Scope of flourishing in medicine

It seems clear that the practice of medicine ought to attend to the maintenance and restoration of the health of the body.18–21 However, the role of medicine with regard to aspects of a person’s life that extend beyond the body is more complex. On the one hand, many decisions concerning the health of the body affect an individual’s mental, social and spiritual life as well. In some instances, the promotion of physical health will positively contribute to a patient’s mental and social well-being. However, in other cases, various goods and ends may come into conflict. Various surgeries may extend years of disease-free survival but also seriously compromise a person’s quality of life, or capacity to work, or ability to function sexually.5 In such cases, the end of bodily health or longevity may come into conflict with other aspects of well-being. Decisions concerning promoting various aspects of the health of the body may potentially adversely affect other aspects of the ‘health of the person’ or that person’s flourishing. While it is reasonable that a clinician should take such implications into account in deciding, along with the patient, on the best course of action,5 21–23 it also seems clear that the role of clinician is not appropriately construed as the maximisation of all aspects of a patient’s flourishing. The physician is not interchangeable with a marital counsellor, priest or career coach. Different institutions and different caring offices have different roles with regard to addressing different aspects of well-being.

However, given the implications of medical decisions concerning the health of the body for the health of the person, one way to construe the proper purview of medicine might be as follows23: the proper purview of medicine may be taken to be the health of the body, along with those aspects of flourishing that are affected by decisions concerning the health of the body. This in no way makes clinicians responsible for the full flourishing of the person, but nevertheless acknowledges that their actions have a role in the promotion, restoration, and maintenance of such flourishing. Often, the promotion of bodily health will be consonant with the well-being of a person in a broader sense. Putting a cast on a broken arm will in most cases not only foster restored physical well-being but will also eventually facilitate mental and social well-being also. However, when surgeries or medications have serious side effects, various ends and goals can come into conflict, and in such cases, it is important to consider the well-being of patients, and their preferences and goals, and the priorities they give to various ends, more holistically. This, arguably, is part of the purview of medicine.

Taking the purview of medicine to be the health of the body along with those aspects of flourishing that are affected by decisions concerning the health of the body need not be seen in conflict with the position taken by others that the end of medicine is health,18 21 24 with health understood as bodily health and in a narrower sense than the WHO definition. Even in maintaining that the end of medicine is bodily health, the purview or scope of considerations for medicine extends beyond this proper end because of the relation of medicine, and the decisions made within medicine, to other ends. When decisions affect a plurality of ends, these other ends must also be taken into account.

The consideration of well-being in medical decision-making pertains to the role of clinicians as caregivers. Patients desire care for the whole person and most healthcare practitioners desire to care, not just for the body, but for the person.25–27 Patients value their capacity to carry out different roles in life, often within workplaces or family contexts, and their capacity to do so pertains to the well-being of the person. Such care for the person requires that the clinician have some sense of the whole of a person’s life. While specialisation and division of labour within medicine has its advantages with regard to technical capacity, it also has the potential to threaten the understanding of the whole. Attention must be given to a patient’s emotional, relational and potentially spiritual well-being4 16 26–31 and such matters often cannot be easily addressed or documented in medical records readily transferable across numerous medical practitioners. Addressing the well-being of the patient, even in a limited scope as this pertains to decisions concerning the health of the body, will require time and compassionate care. It will require training beyond narrow technical confines. It will require an understanding of what is constituted by a person’s flourishing; it will require a genuine concern for the well-being of others; and it will require healthcare systems and practices that allow clinicians to be attentive to such matters.

Scope of flourishing in psychiatry and clinical counselling

The proposal above concerning the purview of medicine as the health of the body and also those aspects of flourishing that are affected by decisions concerning the health of the body arguably pertains to internal medicine, but the proper purview of psychiatry may be yet broader still.

Psychiatry is not infrequently envisioned as addressing mental health, understood broadly, and not only in terms of the health of the brain.26 32–36 Full consideration of mind-body relations30–36 extends beyond the scope of this essay. However, mental health, understood in a broader conception of the wholeness of the mind as it pertains to the entire human person, is not coextensive with, but does include a substantial portion of what might be understood by flourishing. While some may embrace a potentially expansive scope for psychiatry, including enhancing numerous aspects of a person’s flourishing, others may consider this beyond the proper purview of psychiatric practice.

If, in contrast, mental health is understood in a much narrower sense as wholeness of the mind as it pertains to the proper functioning of the brain, this arguably tightens the conception considerably. Mental health in this narrower sense may be viewed by most as clearly being within the purview of psychiatry. There are complexities as to how wholeness of the mind is to be understood, or what types of mental functioning are to be considered normal, and there will be disputed territory,32–36 but the same is true with other aspects of health and medicine.

However, restricting the purview of psychiatry to addressing mental health in this narrower sense may be viewed by some as in fact being too restrictive and especially so in light of the connections between a person’s physical, social and spiritual life and their mental well-being. The loss of a particular relationship, or some other good, may lead to a substantial decline in mental well-being. Because of such losses, depressive symptoms may ensue, even if the brain is functioning properly and the mental experience, although negative, may yet still be reasonable and normal in light of that loss, as is arguably often the case with bereavement. Helping a patient through a loss or through a relationship difficulty or through a relatively normal process of grief would be considered by many within the bounds of psychiatric practice.

An intermediate position might be to take the purview of psychiatry to be the promotion, maintenance and restoration of the wholeness of the mind as it pertains to the proper functioning of the brain, along with those aspects of flourishing concerning which the patient and clinician together agree through dialogue to address. Such a position would take, at a minimum, as the object of psychiatric care, the wholeness of the mind that arises from the proper function or malfunction of the brain, and would allow the psychiatrist to restrict his or her attention to this narrower conception of mental health. However, it would also allow the joint pursuit, for those psychiatrists and those patients who desired it, of other aspects of the patient’s flourishing. Such a position admittedly introduces potential heterogeneity in the scope of psychiatry across practices. However, it allows a minimum set of goals which psychiatric practice should pursue while also allowing flexibility for the aims of specific psychiatrists or practices, to be considerably more expansive.

Such a perspective would open the possibility for, though not require, within the practice of psychiatry, various activities and interventions intended to promote well-being, or to foster virtues that may be related to mental health,37–42 rather than more narrowly restricting focus to addressing mental disorders. For such approaches to be effective it would be important that the psychiatrist and the patient be relatively aligned as to these broader aims being a part of the clinical relationship. It would not necessarily be essential that the psychiatrist and patient fully agree on their understanding of flourishing, so long as there were sufficient agreement to pursue particular aspects of well-being valued by the patient. Moreover, there may, in many cases, be considerable overlap in the patient’s and the clinician’s understanding of well-being, even if this agreement is not perfect. Agreement as to joint pursuit of broader aims for the patient’s flourishing will often only be possible through dialogue concerning the life and goals of the patient, and concerning both the patient’s and the clinician’s understanding of well-being. In principle, this could be carried out also within medicine more broadly,30 43 though doing so may require the development of a broader set of competencies. The extent to which that might be done may vary by specialty and practice within medicine.

While clarification as to how well-being is to be understood and what aspects of well-being are to be pursued may be viewed as a lofty aspiration, psychiatric care will often in practice itself contain an implicit understanding of what goods and ends are being sought.44 45 It may be helpful then to more explicitly clarify this, so as to facilitate better care and to come to an awareness of the areas of agreement, along with the differences in perspective, in what the patient and clinician see as the most important goals to pursue.

Similar considerations pertain to clinical counselling as well. Within clinical psychology or counselling, the focus will generally be less on the proper functioning of the brain, and more on the person’s life as a whole, on the person’s flourishing. It may be the case that a clinical psychologist or a counsellor does not necessarily feel comfortable addressing all aspects of a person’s flourishing, or all of their various pursuits of well-being, but may feel comfortable addressing some subset of these. Through dialogue, it will often once again be possible to come to an agreement between the counsellor and the patient as to which aspects of a patient’s flourishing are going to be discussed and pursued.41 46 An understanding of the patient’s and the counsellor’s various views and values will help clarify the scope of what might be addressed. Consonant values and understandings may help broaden the scope of care, but once again a number of goals and ends, such as improving relationships and growth in character, may be shared even if the counsellor and patient come from somewhat different perspectives. The proper purview of counselling with regard to flourishing might thus be simply taken as those aspects of flourishing concerning which the patient and clinician together agree through dialogue to address.

Scope of flourishing in public health and public policy

While it might in principle be possible to achieve some level of agreement on the understanding of flourishing and on the most important values, goods, and ends between a patient and a clinician or potentially even between a patient and an entire practice, these considerations of agreement and consensus become more challenging within the context of public health and local, national and international public policy. In such contexts, decision-making within a pluralistic society must often take place amidst differing and competing visions as to what constitutes the good. As such, public health and public policy priorities are often reduced to matters of physical health and economic considerations. This is arguably often done because these are goods around which it seems to be comparatively easier to attain consensus. Physical health is nearly universally valued and is considered important both in its own right and also in that it often facilitates attaining other ends. Economic considerations likewise constitute important means in the pursuit of numerous, and potentially divergent, goals and ends. However, to reduce public health and public policy considerations to bodily health and economic resources is to effectively embrace a highly impoverished view of human well-being. Public health and public policy efforts ought to aspire to something greater. The difficulty, however, is that in a pluralistic context it can be challenging to navigate competing conceptions of the good.

Even in pluralistic contexts, however, there is arguably more potential for achieving consensus concerning well-being than is often acknowledged. While the vast majority of people do indeed value bodily health, and having sufficient financial resources, they also care about more than these. Almost everyone desires to be happy; almost everyone wants to have a sense of meaning and purpose; almost everyone wants to strive to be a good person; almost everyone wants good relationships, and also good communities, contexts and environments. These are other aspects of well-being around which it might be possible to achieve a relatively broad consensus.4 If this is so, the potential implications for public health and public policy efforts are arguably far-reaching. Rather than a near exclusive focus on physical health and economic considerations, it might instead be proposed that the proper purview of public health and public policy ought to be those aspects of flourishing around which broad societal consensus can be attained. The degree of consensus that can be attained as to which aspects of what is understood as flourishing truly are good will of course vary by context, but in many cases, this would include not only physical health and income, but also happiness and life satisfaction, meaning and purpose, character and virtue, close social relationships, and good communities.4 17

The specification and expansion of the ends considered in policy does not necessarily lead to straightforward policy decision-making as certain policies may potentially enhance some aspects of flourishing and hinder others, or may enhance the flourishing of some persons but hinder that of others. What we should be seeking is ultimately the flourishing of the whole of society, and ideally policy efforts would encompass a twofold principle that advancing flourishing should pertain to all people, and also to the whole of the person.30 47 Whenever possible, policies should be sought that enhance various aspects of flourishing without hindering other aspects, and that enhance the flourishing of many while not impeding that of others. This is undoubtedly challenging, and conflicts will arise, but a focus on what values are clearly shared and on empowering more local communities may, in many settings, provide helpful ways forward.30 43 47 48 In any case, an expansion of the ends in view within policy would result in a rather broader set of considerations taken into account in decision-making than is the case at present.

Given that as individuals we are ultimately aiming at the health of the person, at flourishing, and that we arguably ought to be doing so collectively as a society, a shift of public health and public policy efforts to promote flourishing, at least insofar as we can obtain general consensus, would seem desirable.4 7 8 There is, moreover, now also ample evidence that various aspects of psychological and social well-being themselves affect both physical health and economic outcomes.4 5 7 49 50 The ends that are being sought are consonant with one another. A widening, and a change in emphasis, with regard to public health and public policy would more powerfully advance a broader range of ends.

Conclusion

This paper has offered an outline of a framework concerning the scope of flourishing within medicine, psychiatry and counselling, and public health and public policy. These practices are of course inter-related, and further work on coordinating these practices with one another, and with other practices and institutions that promote flourishing such as schools, workplaces, religious communities and arts organisations, would be valuable. A clearer understanding of what aspects of flourishing do, and do not, lie within the bounds of each institution and practice has the potential to better enable the pursuit of societal well-being.

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