Cognitive Disability In A Society of Equals

This paper considers the range of possible policy options that are available if we wish to attempt to treat people with cognitive disabilities as equal members of society. It is suggested that the goal of policy should be allow each disabled person to establish a worthwhile place in the world and sets out four policy options: cash compensation, personal enhancement, status enhancement and targeted resource enhancement. The paper argues for the social policy of targeted resource enhancement for individuals with cognitive disabilities, in the form of providing cash with some limits on its use. Taking the example from the UK of ‘self-directed support’ it is argued that such policies can be cost-effective and advance the autonomy of people with cognitive disabilities, especially when compared with current policies of centrally provided services. 1 This paper was prepared for the Stony Brook conference on Cognitive Disability in September 2008. I am very grateful to the organisers, Eva Kittay, Licia Carlson and Sophia Wong for the invitation to speak, and for their comments on my presentation. I am also very pleased to thank Henry Richardson for his stimulating reponse to the paper, which has led to several improvements, as well as other member of that audience. The paper was also presented at a seminar at the University of Melbourne, and I am also very grateful to the participants on that occasion. It is common among disability activists to remark that disability presents a ‘challenge’ (Hunt, 1998). It is also said, although much less commonly, that disability can be a ‘blessing’, both at a theoretical and practical level. This may sound an extraordinary idea, but behind it is the notion that if a society is able to think through and successfully confront issues of disability, doing so will make it more compassionate, more secure in its sense of community, and more understanding both of human vulnerability and dependence, and of human nature and potential. If the ‘challenge’ is shirked ‘the blessing’ will be lost and this will affect how society treats all of its members, disabled or able-bodied. Egalitarian political philosophy has been slow to take up the challenge of disability, although the picture, thankfully, is changing fairly rapidly. One obstacle to progress has been the relatively rigid framework within which some leading egalitarian theorists have approached questions of justice, and, by implication, disability. For a certain group of theorists the main issue for egalitarianism is that of deciding what the ‘currency’ of justice should be; whether it should be a resource based metric of income and wealth, or a welfare based metric of preference satisfaction or welfare. But to view matters this way seems to commit one to the following proposition: injustice is a matter of having too few resources or too little welfare. Therefore, it seems, justice requires transfer of resources from one person or group to another, either because resources are the currency of justice, or because they are a good way of generating welfare or preference satisfaction. Accordingly, despite their differences, many contemporary theories of justice seem to have the consequence that injustice is to be corrected by cash compensation. Whatever its appeal in other situations, the idea that financial compensation is the appropriate way of remedying disability seems blinkered, in that it fails to capture, and thereby to address, the reasons why the claims of disabled people have a particular social salience. Although many disabled people lack money, it seems implausible to say that social policy in respect of disability should consist purely of monetary transfers. My task, then, is to look at the possibilities for social policy regarding cognitive disability, and to consider their possible philosophical underpinnings or justifications. The question I want to address 2 Simon Duffy, in conversation. As will become evident I owe much of the following to discussions with Simon. here is not so much how to understand cognitive disability in itself, or in its variations, but to consider the range of possible policy options that are available if we wish to treat people with disabilities as equal members of society, and of these, which are most appropriate and feasible for people with cognitive disability. Of course, the prospects for incorporating people with disabilities – especially cognitive disabilities into society as ‘full equals’ maybe somewhat bleak, at least in the short-term. Nevertheless it may well be possible to do better than is commonly done at present, and progress may well be more likely if the issue is framed in terms of the aspiration to create a society of equals, encompassing all. Consequently, rather than starting with a theory of justice that, by implication, suggests that compensation, in some form of other, should be our policy goal, I would like to proceed in a different way: by considering what it is that disabled people so often lack, at least without further help and support, and what, therefore, should be the orientation of social policy. In a discussion of what he calls the phenomenological model of disability, the social theorist Gareth Williams proposes that people with disabilities need to ‘re-negotiate their place in the world’, or in an alternative phrase ‘re-establish their place in the world’ (Williams 1998, 240). Assuming that ‘place in the world’ means ‘worthwhile place in the world’ and that the issue for those born, rather becoming, disabled is one of establishing, rather than re-establishing, a place in the world, the question, then, is what it would be for a disabled person to establish a worthwhile place in the world? By ‘worthwhile’ I mean worthwhile to the individual concerned, rather than ‘valuable to society’, although for many people, of course, what it is to have a worthwhile life will involve being able to contribute to the lives of others, whether that contribution is modest or extensive. But if disability presents a challenge to egalitarian theories of justice, then cognitive disability amplifies it. Although there are several important exceptions, a high proportion of philosophical writing on disability, as well as social policy, has concentrated on physical disability, and within physical disability reduced mobility. It is not clear that solutions presented to problems of physical disability will have much relevance to cognitive disability. But before exploring this, it is necessary to put some theoretical machinery in place. In my own previous work on disability I have set out a conceptual framework in which different types of policy approaches to disability can be classified, and their advantages and disadvantages explored (Wolff, 2002, 2009a, 2009b). Ultimately in this paper I shall attempt to apply the framework to issues of cognitive disability, relying heavily on some innovative policies recently introduced in parts of the UK. First, though, the framework. As a preliminary I need to set out in schematic form a simple social theory that will help illuminate the issues I need to explore here. Let us begin by consider any given individual, whatever their disability status. What will determine the opportunities that this person has to find a worthwhile place in the world? Crudely there are two sorts of factors we need to enter into the calculations: first what the person has at their disposal; and second what they can do with it. The first of these categories we can call ‘resources’; this includes external resources, such as money, control over parts of the external world, family support and so on, as well as ‘internal resources’, which include a person’s skills, talents and abilities, and crucially in this case, cognitive powers. However, you cannot ‘read off’ from an individual’s resources their chances of leading a life they value. You also need to know facts about the social structures within the society in which they live; the influence of tradition, religion, language, culture and other social norms (such as what counts, within that society, as an acceptably ‘normal life’); the configuration of the material and natural environment, and perhaps other things too. Slightly misleadingly I shall refer to all of this as ‘social structure’, even though it also has material, legal, cultural and ‘attitudinal’ aspects too. Thus the overall formula comes to this: the interaction of your resources with the social structure within which you find yourself determines your opportunities to find a worthwhile place in the world. A crude example: in some agricultural societies a man is more likely to have opportunities to live a life he values if he is physically very strong; in technically advanced societies physical strength becomes of more marginal significance. Both resources and social structures determine an individual’s chances of being able to find a worthwhile place in the world. Against this framework we can see that what is commonly called the medical model of disability suggests that people with disabilities have a less extensive set of ‘internal resources’ than others, and recommend that society acts to boost this set largely by medical means. By contrast the social model prefers to say that social structures discriminate against people with certain resourcebundles and thus we need to change social structures to eliminate such discrimination. But what we can see is that the question of whether the ‘medical model’ or the ‘social model’ is the ‘correct’ account of disability is misplaced. Disability is at least in part a matter of a lack of ‘fit’ between a person and the world in which he or she lives. The medical model suggests that changes to the person are the correct way of attempting to achieve a better fit, while the social model suggests that the world, rather than the person, should change. What we need to explore, however, is what reasons there are for preferring one or other strategy. But we should also notice that ‘changing the person’ (what I call ‘personal enhancement’) and changing the world (what I call ‘status enhancement’) are not the only possible approaches to increasing an individual’s opportunity to find a worthwhile place in the world. It is also possible to transfer resources to someone to boost their opportunities. In one way, of course, we have been here before; the notion of compensation is that of providing individuals with a resource of a particular kind: money. And I have already suggested that I do not find this an appealing way of attempting to address the disadvantage of disability, at least if it is adopted as a complete approach. However, not all transfer of resources is compensation in the sense of giving an individual full private property rights over the object transferred. Consider, for example, governments that provide wheelchairs for those with mobility problems. Although the issue rarely, if ever, arises, typically such wheelchairs are not given as private property. For example, if the person recovers mobility she would be expected to return the wheelchair, and not to sell it. Not only should it not be sold, it should not be dismantled to make a go-cart for her children. The wheelchair is given for certain purposes and not others, and there are limits to its use. The situation is even more obvious with respect to the social policy of providing state-funded carers for disabled or elderly people. In such a case it is quite obvious that they are not provided as individual private property: carers are not slaves to do the bidding of their owner, whatever it is. Rather, they are provided in order to perform certain services, and not others. For example, a disabled person could not require his carer to work as a banker rather than as a carer, even if doing so would create enough extra cash to employ another carer with money to spare. Just as property can be provided with ‘strings attached’ as to its use, so can money. For example, in some UK universities visually impaired students are given an extra budget to spend on computers or for people to read to them. They cannot spend the money on beer, even if they promise to spend less on beer than they would be permitted to spend on computers, thereby saving the university cash. The point is that the money is given for certain purposes and not others, and it would be considered an abuse to use it for something else, even if that were preferred. This type of intervention I call a ‘targeted resource enhancement’, in that the resources provided are targeted towards a certain purpose. There is, however, I admit, something puzzling about this type of policy – familiar though it is – which Ronald Dworkin has brought out very well in an example of a paraplegic violinist. Suppose we offer this person a very expensive mobility device, but they reply ‘that’s very kind of you, but if you are to spend so much money on me I’d much rather have a new violin’ (Dworkin, 1981, 243). I think most of us will be pulled in two directions: the only reason why we are offering anything is because of limited mobility, and therefore there seems to be something almost exploitative to use the resources in some other way. But on the other hand, if the violin is no more expensive, it just seems mean or spiteful to refuse. This is a troubling example, and I will return to it towards the end of this paper. However, to sum up this part of the discussion, we now have four policy options that can be used to attempt to address the disadvantage of disability. The first is ‘compensation’: providing disabled people with cash, or goods in kind, in the form of full liberal private property, to ‘make up for’ the disadvantage of disability. The second is ‘personal enhancement’: to take steps to improve the ‘internal resources’ of the disabled person, whether through surgery, medicine, education or training. The third is ‘targeted resource enhancement’: to provide resources for the disabled individual, whether money or other goods, but with some sort of strings attached, so not in the form of free private property. Finally there is ‘status enhancement’: to change the social, material, or cultural structure so that individuals are able to do more with the resources they have, rather than provide them with extra resources of some kind. As already noted, the social model of disability favours status enhancement as a response to disability, and it is easy to see why. Changing the world, rather than the person, is a way of accepting individuals in their differences, rather than making them adapt to the world. Hence it respects individuals and communicates a message of acceptance and inclusion. It is also, typically, nonstigmatising in that no one need identify as disabled in order to benefit from social policies of status enhancement. For example, once hotel rooms and other buildings are made fully accessible no wheelchair user will need to ask for special treatment. Hence, especially in cases of physical disability, policies of status enhancement often seem appealing. Rather than spend resources to ‘act on the impaired body’ we can spend resources changing the world so that more types of bodies no longer seem impaired in any way that interferes with the person’s chances of finding a worthwhile place in the world. This, after all, is the point of the disability legislation we see now throughout the developed world. Now it would be naïve to say that status enhancement is always to be preferred. Where medical intervention is cheap, quick, safe and effective it seems the obvious way to address disability. Furthermore status enhancements can be very expensive, and have other costs. For example changing building codes could mean that some formerly public buildings will have to close. But still, status enhancement is often an attractive approach for physical disability (Wolff, 2009b). However, it is far less clear that status enhancement is even possible for cognitive disability. What would it be to change the world so that those with cognitive disabilities were equally able to find a worthwhile place in the world as others? Can we even imagine what this would be? In fact, one philosopher who has tried to imagine such a thing is Dan Wikler, at least in some limited contexts. Considering the question of whether people who are ‘mildly retarded’ have sufficient foresight, and other intellectual abilities, to be bound by contracts, Wikler considers the possibility of changing the legal regime so that legal contracts are no longer binding in the way they are at present, so that the mildly retarded could then make the same sort of legal commitments as others, and thereby avoid paternalism. This would be a status enhancement in my terminology: the mildly retarded would be given a new opportunity through changes to the legal structure. Wikler, however, appears to reject such a suggestion on the reasonable grounds of the enormous social cost. The fact is that much of what makes modern life possible now relies on binding and enforceable contracts that in turn assume a particular level of intellectual competence. To change the world so that such a bar is lowered would have tremendous costs (Wikler, 1979). What, then, is to be done for people with cognitive disabilities if status enhancement – the remedy of choice for physical disability – is not possible? Of course various forms of personal enhancement – training, education – are highly appropriate remedies, yet in many cases there are limits to what can be achieved. What can be done to give people with cognitive disabilities a greater chance of finding a worthwhile place in the world? It will be helpful to start by considering the opposite: the way in which such people are so often denied such a place, and I want to do this by means of taking a detour through the recent history of disability policy in the UK, which I am sure must have echoes elsewhere. It is, of course, well known that until fairly recently it was standard practice for people labelled as disabled – especially, but not only, those said to have mental disabilities to spend their lives in special institutions, often in semirural settings or on the edges of towns, where they lived with other people in similar conditions, and with those who were there to take care of them. Unless they had first established a life elsewhere they would have been unlikely to have friends outside the institution, and visits from family members would typically have been special occasions, such as weekend afternoons, rather than built into the fabric of everyday life. Such places were often called ‘asylums’ as if they were places of special retreat and protection. In the analysis of some critics, though, the reverse is true: they allowed members of mainstream society to take refuge from those people who were disturbing to deal with. Thus, it is claimed, the main function of homes for disabled people was to ensure that the rest of us need have little to do with them. In the worst cases they were likened to prisons, with inmates having no rights to leave. This changed during the 1980s with the Conservative government policy of introducing ‘care in the community’, strengthening individual rights, and closing down many such facilities. No doubt there were economic motives behind such changes, but whether intended or unintended, they have done a certain amount to bring disabled people into contact with broader society. Yet the transition is only half made. In many cases disabled people see few people other than family members, service professionals, and other disabled people at day centres. To some degree, day centres have taken the place of homes for the disabled, in that they keep disabled people occupied, but away from nondisabled people. Imagine yourself in the shoes of a person who attends a day centre. It is likely that you will be collected by a coach or mini-bus, which then winds round town for an hour or two picking up others. On arrival at the day centre there may be a visit from reluctant school children, required to help out as part of a social education programme, or from volunteers or others who will engage on a variety of levels, but often tending towards the patronising end of the spectrum, while watching television fills the empty spaces. You would be fed a meal of a quality you almost certainly would have not have paid for, followed by an afternoon of cursory activities, under the head of ‘occupational therapy’, which is half-way between nursery school and the hospital ward. Then back into the coach for a couple of hours, before being dropped off to watch some more television in your parents’ home. This is a caricature, perhaps, but not a wild one. Probably many ordinary citizens have given very little thought to what happens at a day centre, unless a story of abuse makes the newspapers. But the broader concern is not the possibility of abuse, but the mundane, dreary routine of it all. Although, no doubt there are many exceptions and examples of good practice, the danger is that such arrangements turn a person into a passive subject: a consumer rather than a producer; a recipient rather than a provider; someone who needs to be kept occupied or entertained, but has little to contribute to others except as an employment opportunity or for ‘doing good’. Individual life becomes an epiphenomenon of other people’s decisions. Although the idea of complete independence is a myth, near complete dependence isn’t, hence the movement within disability activism towards ‘independent living’ (see, for example, Brissenden, 1998). But the main point is that even in these times of ‘care in the community’ disabled people can still lack opportunities for a worthwhile place in the world. Against this background, it is fascinating and highly encouraging to see new policy options developing. In particular I want to lay out an experimental approach that has been used in the UK for the social care of teenagers and young adults with learning disabilities. Previously many of these people were living in group homes, away from their families, or spending their days at day centres, having very little option in the services available to them. In some locations, such care has been replaced with and an approach called ‘Self-Directed Support’, which centres around the idea of providing disabled people with their own individual budget, and giving them control over how it is spent. Here, from the agency’s report on its services are the key steps involved: • Step 1 Everyone is told their level of entitlement their Individual Budget and they decide what level of control they wish to take over their budget. • Step 2 People plan how they will use their Individual Budget to get the help that’s best for them; if they need help to plan then advocates, brokers or others can support them. • Step 3 -The local authority helps people to create good Support Plans, checks they are safe and makes sure that people have any necessary representation. • Step 4 People control their Individual Budget to the extent they want; there are currently 6 distinct control options, from direct payment to having a service commissioned by your local authority. • Step 5 People can use their Individual Budget flexibly; they can use statutory services (the cost of which is taken out of the Individual Budget) and other forms of support; if they change their minds they can quickly re-direct their Individual Budget. • Step 6 People can use their Individual Budget to achieve the outcomes that are important to them in their context of their whole life and their role and contribution within the wider community • Step 7 The authority continues to check people are okay, shares what is being learned and can change things if people are not achieving the outcomes they need to achieve. (Waters and Duffy, 2007, 9.) Of course those with very severe cognitive disability many not be able exercise much choice; but very often they can exercise some, when supported by family, or social workers. And some is better than none. In saying this I am not assuming that having choice is always better than not, for clearly there can be circumstances in which offering individuals choice can make their lives worse. For example, those without resources to make a good choice might be better off when their options are severely restricted. Equally, for all of us there are cases where choices can be bewildering, overwhelming or use mental resources that we would rather reserve for other purposes. My point is the far more restricted one that for almost all people having some level of choice will, with suitable support, improve their lives. I am not supposing that for all people at all times increasing choice is always a benefit. It is clear that the scheme just sketched out has a number of very obvious advantages over more centralised services (Poll and Duffy, 2008). First, giving individuals control over their budget may well mean that the money is used more efficiently than it would have been by the local authority, in the sense that people will have an incentive to find the most cost-effective ways of achieving their ends. Rather than relying on suppliers who have a central procurement contract, for example, they can seek out cheaper ways of achieving what they want. They can stop the supply of things they don’t want or need, but might come as part of a standard care package. And if they get things wrong and make mistakes, soon there will be a new payment and lessons will have been learned. Equally, the agency can learn from the experience of individuals too. If one person finds a novel way of achieving a goal, or even dreams up a new goal, the agency will learn about it and can pass on advice to others for general benefit. 3 I thank Henry Richardson for encouraging me to clarify this point. But perhaps most interesting of all, even if the money is spent badly, giving individuals with cognitive disabilities such control over their budget is a way of bringing much more autonomy into their lives, which would otherwise be virtually disempowered. As I put it above, their lives would be the epiphenomenon of other people’s decisions. With self-directed support this is no longer true, or at least a measure of independence is provided, and in many cases a good deal of control over one’s environment becomes possible, breaking through much of the paternalism of central support services. There are however, some obvious worries. On first hearing about this scheme I was concerned that, given that it is based on the transfer of financial resources, it is a form of compensation for disability, which I have suggested above, is an inappropriate remedy. At first I felt that I would have either to withdraw my objection to compensation, or dogmatically disapprove of what seems to me an extremely promising social policy. However, in discussion with the designers of these services I became convinced that the scheme is not one of compensation, but, in my terms, targeted resource enhancement. The money is not handed over as private property, but given for specific purposes and is subject to scrutiny and audit. In cases of failure the agency can refuse to approve certain expenditures, although I am told that so far in practice this rarely, if ever, happens. The people involved understand the scheme well enough so as not to abuse it, and seek help if they are in difficulties. And the agency is keen to allow people to experiment. If it goes badly you can spend the money a different way next time. They would not allow the money to used for anything that was illegal, or endangered the health and safety of the individual (whether through action or neglect) but the strings, though present, are very light. The agency itself is keen to avoid the term ‘compensation’ and echoing my own terminology of ‘targeted resource enhancement’, now refer to it as ‘conditional resource entitlement’. A second concern is that the scheme appears to place a heavy burden on carers. When given the choice of paying to go to a day centre, or using the money for other things, the day centre is used significantly less than before, and money is spent on other activities or on care at home. Does this mean, then, that parents, and especially mothers, have a much higher burden of care? So far it appears that this concern is not shared by the carers themselves. In some cases mothers are quite happy to be paid enough so as not to have to take a job, or to reduce to part-time work, so as to be able to spend more time with their child. In other cases care is shared among an extended family. Within an extended family there is also sometimes a relative who has difficulty finding steady work, yet would be very happy, and find it rewarding, to act as a part-time paid carer. Most families report that self-directed services has made an improvement to everyone’s life, including increasing contact and support from volunteer non-family members, which is something of a welcome surprise. So this particular objection seems misplaced. However, it has to be admitted that if it turned out that the burden on carers increased in a way that reduced the quality of the carers’ own lives, then there would be good reason for discussing whether the scheme simply replaces one form of disadvantage or injustice with another, which could even be more severe. A third concern is that of the likely decline of public goods like day centres. If most of the disabled people in my town choose not to spend their money on the day centre, what will happen? Most likely it will close down, and those who enjoyed going there will not be able to. This, indeed, is a traditional objection to giving individuals control over their own decisions with respect to public amenities, such as libraries or public swimming pools: there can be collective action problems which require collective solutions. However, the agency has a number of replies. Suppose it is true that a number of people might want to continue to go to the day centre, but that it disappears after the move to self-directed support. This would be a pity, but is it such a pity that it justifies forcing many people to use services they don’t want so that some can get access to what they want? It is not even clear that it would be justified to give a minority no choice about how money is spent on their behalf even if the majority wanted to continue. Perhaps the answer is to rely on the logic of the market: if day centres are to continue in existence, they have to be made good enough to survive competition with other ways of spending scarce cash. In practice, however, it appears that individuals do choose to continue to go to day centres but for fewer days each week than before. This is easy to understand, of course. Many people will appreciate the variety of a number of different ways of spending their time, and repetition can be stultifying whether it takes place inside or outside the home. Finally, we need to return to Dworkin’s example of the paraplegic violinist. It appears that if self-directed support were applied to his case, then the first step is that he will be assessed on the basis of his need, and given a particular budget. If he then chooses to spend it on a violin, that will be his business. The question, then, is whether self-directed support should be extended to physical disability. The case, I think, is arguable. There is a very important difference between those with cognitive disability and those with physical disability. Typically, those with cognitive disabilities have very little scope in their lives for autonomous decision-making. Hence self-directed support provides them with something new and extra; with a good that they wouldn’t otherwise have in terms of a measure of control over the environment. Those with physical disability may or may not be in this position, but it is less likely that giving physically disabled people control over their budget opens up a whole new avenue of value and experience. Of course it is likely to have other advantages but they do not seem so overwhelming. Consequently, accepting self-directed support for the cognitively disabled does not entail accepting it for other cases of disability (although the arguments do not exclude it either). In making the arguments in defence of self-directed support as a form of targeted resource enhancement I do not want to be interpreted as assuming that autonomy has some sort of lexical priority among values, and that everything should be done to advance individual autonomy. While, of course, I do have views about the place of autonomy in the scheme of values (see Wolff and deShalit, 2007) nothing in this paper is intended to pre-suppose a specific theory of well-being or of value. Rather I need only to make some reasonably uncontroversial assumptions that, I believe, will be acceptable from a wide range of viewpoints. First, that generally speaking autonomy is valuable. Second, that people with cognitive disability very often have little scope for the exercise of autonomy in their lives. And finally, that other things being equal it is very good to increase the autonomy of those who currently have very little. Others may wish to make greater claims for the importance of autonomy, but that is not my purpose, and not necessary, here. I need also make a remark about resource allocation. Nothing I have said in this paper takes a stand on the question of how important it is to address the claims of people with cognitive disabilities when there are also other urgent demands on scarce social resources. I do not wish to give the impression that I believe that such claims will always be the most important when in competition with others, or that it would be wrong or inhuman to discuss questions of resource allocation when thinking about what society ought to do for people with disabilities. In thinking through public policy approaches, much will depend on the urgency of other claims and the resources society has to meet them. I take this issue very seriously, and have discussed it elsewhere (Wolff, 2009b) but will not repeat that discussion here. The form of targeted resources enhancement discussed here, so it appears, provides an important policy option and likely advance on other existing forms of support, which are of course, targeted resource enhancements of a different type. There remains the question, however, of how far something like self-directed support would achieve the goal of creating an inclusive society of equals for people with cognitive disabilities. It seems clear that whatever improvements it can bring to the lives of people with cognitive disabilities in helping them find a worthwhile place in the world, it still hardly guarantees that we will have created a society in which all are valued as equals. Accordingly it is worth revisiting the question of the possibility of status enhancements for people with cognitive disability. Now, I above endorsed Wikler’s argument against the status enhancement of, say, reducing the cognitive demands necessary to enter a binding legal contract. The argument was that the type of changes that would lead to a fully inclusive social policy would have intolerable broader social costs in terms of making certain sorts of important legal and business relations impossible. I do not want to withdraw my endorsement of that argument, but it is worth noticing that it is an argument against one very specific form of status enhancement, and it would be hasty to assume that it applies with equal force against all forms of status enhancement. For example, one of the factors that people with cognitive disabilities face is the prejudicial, even hostile, attitudes of others. Attempting to change this, through education and collective reflection, should be an urgent priority of social policy. Yet such a change is, in my terms, a status enhancement, as would be changes to the law to strengthen the rights of people with cognitive disabilities and to remove forms of discrimination. And there does not seem any natural extension of Wikler’s argument to show that such policies would have intolerable costs; indeed the opposite seems to be the case. Hence although, as we have seen, there are limits to the extent to which status enhancement can be used to improve, it by no means follows that only targeted resource enhancement should be used in social policy towards people with cognitive disabilities. It appears that some forms of status enhancement remain essential, as does personal enhancement in the form of education, training and certain forms of therapy. In sum, there is no single, simple, route to equality and indeed no combination of policies will be guaranteed to achieve it. 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