Critical reflections on occupational justice: Toward a rights-based approach to occupational opportunities

Abstract

French

Background.

Occupational justice is cited throughout the occupational science and occupational therapy literatures despite little scholarly attention either to its definition or to how situations of occupational justice are identifiable.

Purpose.

This paper aims to contribute a critique of occupational justice, explore the concepts of justice and (occupational) rights, and support a capabilities approach to inform rights-based occupational therapy practices.

Key Issues.

No clear definition of occupational justice or differentiation from social justice exists despite the longevity of the concept, and theorists frequently confuse the concepts of justice and rights. A rights-based focus provides an unambiguous mandate for occupational therapists, with the capabilities approach offering a cross-disciplinary framework to inform rights-based practices.

Implications.

The concept of occupational rights is consistent with the rights-based focus advocated by the disabled people’s movement, articulated by the United Nations’ Convention on the Rights of Persons With Disabilities, and affirmed by the World Federation of Occupational Therapists’ position on the centrality of occupation to health, well-being, and human rights.

Keywords

Capabilities Critical Human rights Theory Well-being

The idea of occupational justice recurs throughout the literatures of both occupational science and occupational therapy despite scant scholarly debate concerning the actual definition of this concept and thus of how situations of occupational justice might be identified. In a conceptual review, Durocher, Gibson, and Rappolt (2014) noted that the literature pertaining to occupational justice is dominated by just two theorists and observed that “proposed definitions of occupational justice and related terms lack conceptual clarity, have not been developed with reference to other bodies of scholarly work, and are not supported by empirical evidence” (p. 427).

Frank (2012) contends that evolving discourses surrounding occupational justice and injustice require occupational scientists to empirically study and critically analyze these ideas. Accordingly, this paper seeks to add to the remarkably small body of work that critically analyzes occupational justice. A critique entails exposing and exploring the assumptions and unchallenged modes of thought that inform our practices (Foucault, 1997). The present critique is offered in a spirit of intellectual engagement and with the hope of encouraging scholarship and debate. The aims of this paper are threefold: first, to sketch the evolution of the concept of occupational justice, highlight conceptual confusions, and foreground some of the inherent issues that have been neither acknowledged nor addressed; second, to highlight the utility of the idea of occupational rights in the context of disability rights activism and global, interdisciplinary interest in human rights; and third, to highlight the value to occupational therapy’s rights-based practices of the capabilities approach: a concept that melds human rights and people’s opportunities to “do.”

Critics have drawn attention to the near-homogenous positioning of occupational science’s and occupational therapy’s dominant theorists, highlighting the tendency to misrepresent Western perspectives as being universal rather than culturally specific and noting a failure to acknowledge theorists’ positioning as integral—not incidental—to the shaping of theory (Hammell & Beagan, 2016). It is therefore relevant to preface this paper by declaring its author’s position as a White, comfortably middle-class, middle-aged, heterosexual Anglophone female who enjoys positive mental health and no physical impairments and who is a citizen both of North America and the European Union. Clearly, this ultraprivileged positioning corresponds very closely with the social statuses held by internationally dominant theorists of occupational therapy and occupational science. The perspectives that derive from our minority positions and that inform and shape our ideas are inevitably and unavoidably blinkered, slanted, and incomplete. Moreover, the unearned advantages and benefits that accrue to those who share with me these privileged social positions are a manifestation of the unjust and inequitable occupational opportunities that this paper seeks to address.

A Brief History of Occupational Justice

The genesis of the concept of occupational justice has been recounted by Wilcock and Townsend (2000); Townsend and Wilcock (2004a, 2004b); Stadnyk, Townsend, and Wilcock (2010); and Townsend and Marval (2013). The term was first articulated by Wilcock (1998), who defined occupational justice as “the promotion of social and economic change to increase individual, community, and political awareness, resources, and equitable opportunities for diverse occupational opportunities which enable people to meet their potential and experience well-being” (p. 257). Occupational justice was thus defined as an action: as the promotion of change to increase equitable opportunities.

Following efforts to enable some Australian occupational therapists to contribute their perspectives to an evolving definition, occupational justice was subsequently described by Wilcock and Townsend (2000) as “equitable opportunity and resources to enable people’s engagement in meaningful occupations” (p. 85). Occupational justice was accordingly characterized now as both opportunity and as outcome: as the accomplishment of equitable opportunities. Further efforts to draw people from the minority world—Western Europe, Australia, and North America—into their dialogue resulted in an exploratory theory of occupational justice (Townsend & Wilcock, 2004a, 2004b) but no actual definition. However, Townsend and Wilcock (2004a) explained that “the concept of occupational justice rests on the idea that individuals are different and have different needs. Different needs are expressed through the occupations that comprise daily life, since humans are autonomous, occupational beings” (p. 249).

More recently, Nilsson and Townsend (2010) described occupational justice “from a Western perspective as a justice of difference: a justice to recognize occupational rights regardless of age, ability, gender, social class, or other differences” (p. 58). The idea of a “justice of difference” derives from the philosophical work of Young (1990), who described a justice of difference as being based on opportunity regardless of difference. However, because it is unclear what constitutes a just response to the different needs of different people, how a just response might be determined, and who would be empowered to make such a judgement, a working definition of occupational justice remains elusive.

Exploring the Nature of Justice

The next section explores the concept of justice (following which, the concept of rights will be explored), drawing from the work of philosophers who have discussed these important issues for millennia.

It is, perhaps, surprising that the concept of occupational justice has been articulated with little reference to the long and illustrious scholarly literatures pertaining to justice. The term justice refers to fairness, equitableness, or reasonableness in the way people are treated or decisions are made and in the way benefits and burdens are distributed. It is regarded by philosophers as an essentially individualistic ideal for attaining deserts and entitlements and thus opposed to a more collectivist ideal that would value equality of outcome (Flew, 1979).

Three forms of justice are commonly identified: distributive justice, which addresses the specific benefits or burdens that ought to accrue to specific recipients; retributive justice, which addresses the ethical appropriateness of specific punishments for wrongdoing; and corrective justice, which concerns the ethical appropriateness of compensating for loss (Honderich, 1995). In addition (and as noted above), Young (1990) has argued for a “justice of difference,” which pertains to equality of opportunities to “do” and that challenges unjust constraints on people’s lives. This justice of difference is said to extend the notion of distribution of benefits to focus on opportunities for “doing” rather than solely on “having” material resources.

The idea of justice incites debates concerning equality. Philosophers contend that “justice requires the equal treatment of equals” (Flew, 1979, p. 188), although they acknowledge the inherent problem posed by the reality that people are not equal. The metaphor of the “level playing field” is often invoked within neoliberal discourses to contend that everyone has equal opportunities. In reality, “a level playing field leads to unfair competition when the players are unequal” (Chang, 2007, p. 218), by virtue, for example, of their inequitable access to education, their differing abilities, the structural inequities they confront, or their marginalized social status. This inequality of access to opportunity emphasizes the importance of striving for equity of opportunity rather than for a justice that focuses on equality. Equality demands the same conditions for everyone, regardless of their abilities, needs, or the structural disadvantages constraining their lives, leading to inequity and injustice if the “players” are unequal. Thus, Thomas Jefferson reportedly observed that “[t]here is nothing more unequal, than the equal treatment of unequal people” (cited in MacLachlan, Mannan, & McVeigh, 2016, p. 152).

Equity, instead, demands the creation of conditions through which equality of opportunity becomes possible. Thus, Sen (1999, 2010) and Nussbaum (2006), who have explored disability from the perspective of the capabilities approach (discussed below), have noted that disparities (inequalities) in the opportunities available to disabled people to live an ordinary life with the same rights as others lead to their consequent requirement for additional resources (Wilkinson-Meyers et al., 2015). This imperative for additional (unequal) resources speaks to the importance of striving for equity of opportunity.

Further, it is relevant to acknowledge that the word justice is not one that is held universally in high regard. Justice holds profoundly negative connotations for many indigenous and colonized people who have experienced—and continue to experience—“White man’s justice”: a system designed and administered by the dominant, colonialist population. Indeed, many colonized people consider “justice” to be a racist, oppressive, and manifestly unjust concept. Occupational therapists’ aspirations to engage in culturally safe practices suggest that knowledge about how concepts such as justice are perceived by diverse peoples should inform our professions’ theoretical constructs.

In the context of occupational therapy, Nilsson and Townsend (2010) noted that occupational justice is “a justice to recognize occupational rights” (p. 58; emphasis added). Occupational justice has further been explained as describing “a vision of society in which all populations have the opportunities, resources, privilege, and rights to participate to their potential in their desired occupations” (Whiteford & Townsend, 2011, p. 65; emphasis added). If occupational justice is about recognizing occupational rights, perhaps occupational rights are the appropriate focus of attention from theorists and therapists?

Is Occupational Justice a Definable Concept, and Is It a Useful Concept?

Acknowledging that both occupation and justice are culturally defined concepts that differ in different global contexts, some influential theorists have explicitly resisted providing a definition of occupational justice. This is problematic for at least two reasons. First, occupational justice is being discussed and taught in occupational science and occupational therapy programs around the world, yet “generally accepted ideas about occupational justice have not yet been consolidated” (Durocher, Gibson, et al., 2014, p. 418). It would seem premature to infuse ideas concerning occupational justice throughout university curricula when it remains impossible to state what occupational justice is. As Bailliard (2016) contends, it is important that the philosophical bases of our theories and interventions are “sophisticated, well-articulated, sufficiently critiqued, and responsive to differing needs” (p. 13). This is important in education, and it is important in practice. (The compounded problems in defining occupational injustices have been outlined in Hammell and Beagan [2016].)

This theoretical ambiguity leads to a second problem: If occupational justice is an important, relevant, and pressing construct (Whiteford & Townsend, 2011), it would surely be helpful to be able to state clearly what it is. Although Whiteford and Townsend (2011) have argued that occupational justice is an evolving concept, there is little evidence of evolution toward a clear definition during the past decade. If we cannot state what occupational justice is, how shall we encourage others to work with us to reach this goal? Indeed, what is the goal?

In their conceptual review, Durocher, Gibson, et al. (2014) identified Stadnyk et al.’s (2010) evolving theory of occupational justice as the only comprehensive theory of occupational justice. However, Durocher, Gibson, et al. identified some fundamental problems with this evolving theory that included a lack of information to explain the emergence of key concepts and the absence of evidence either to support these concepts or to explain proposed relationships between the concepts. In light of the persisting difficulties in articulating a clear definition of occupational justice, it is, perhaps, worth pondering whether this actually constitutes a useful concept or whether the undeniably important issues underlying the notion of occupational justice might best be addressed through recourse to different frameworks and terminology?

Durocher, Gibson, et al. (2014) noted that the number of scholars who have contributed to the occupational justice literature is remarkably small, which raises the obvious question of whether occupational scientists and occupational therapists find this to be a useful construct. Hammell (2008) suggested that lack of conceptual clarity might have inhibited widespread development or adoption of the concept of occupational justice, a suggestion that was echoed by Durocher, Gibson, et al. (2014), who pondered, “Perhaps the lack of conceptual clarity…discourages scholarship in the field?” (p. 428). Moreover, because theorists often use the words justice and rights interchangeably, it would seem that even theorists are uncertain as to the concept for which they are advocating.

Can (and Should) Occupational Justice Be Demarcated From Social Justice?

Although Townsend and Wilcock (2004a) have endeavoured to differentiate between social justice and occupational justice, they have not outlined a coherent theory of social justice (Durocher, Gibson, et al., 2014, p. 421) from which a theory of occupational justice might be differentiated and have not provided a succinct and consistent definition of occupational justice from which comparisons with social justice might be clearly demarcated.

Critics have queried the use of the term occupational justice and whether this term creates “an artificial and unnecessary communication gap” (Braveman & Bass-Hagen, 2009, p. 10) when so many other theorists, professionals, and advocates use the term social justice. Durocher, Rappolt, and Gibson (2014) contend that a lack of engagement with other disciplines and use of profession-specific language may deter others from embracing the notion of occupational justice. This scenario appears inevitable, given that many others are already working to achieve social justice, and it is of fundamental importance, because the small number of occupational scientists and occupational therapists makes accomplishing meaningful changes toward occupational justice inordinately difficult in the absence of collaboration with others. The professions of nursing (Canadian Nurses Association, 2009; Kirkham & Browne, 2006), social work (Martinez & Fleck-Henderson, 2014), and physical therapy (Edwards, Delany, Townsend, & Swisher, 2011), for example, all bring their unique disciplinary perspectives, knowledge, and skills to addressing a common issue using a common language: social justice. It is important to consider what occupational therapists, alone, might accomplish with their unique focus on something they call occupational justice. Moreover, considerable efforts might be wasted in striving to recruit those already working for social justice to support an unfamiliar cause we have chosen to name “occupational justice.”

Indeed, many professionals and activists are already engaged in struggles to achieve social justice for and with people whose opportunities for meaningful occupational engagement are seriously restricted, struggles that we might frame as pertaining to occupational justice but that those already engaged in this endeavour do not.

Within the nursing literature, Kirkham and Browne (2006) have explored the implications of adding the word social to that of justice. They note that, together, the terms draw attention to the ways in which injustices are maintained through social institutions and relationships, underscore the application of justice to groups and populations, and highlight “the embeddedness of individual experience in a larger realm of political, economic, cultural, and social complexities” (Kirkham & Browne, 2006, p. 325). This argument is of relevance to discussions of occupational justice, which have focused, almost exclusively, on the occupations undertaken by individuals, with scant attention to the impact of occupational engagement—or lack of occupational engagement—on or with families or communities (Durocher, Rappolt, et al., 2014). Moreover, Kirkham and Browne (2006) contend that social justice “provides a moral compass that refocuses us to see beyond an individualistic perspective” (p. 337) and also encourages collective action to address the root causes of inequities. For a profession such as occupational therapy, these are important and timely concerns.

It is crucial for occupational therapists to communicate clearly in the same language as our colleagues if we are to work collectively with our colleagues, clients, policy makers, and activists toward common goals. Moreover, if the issues specific to occupational justice cannot be discussed within a common framework of social justice, one wonders why not?

In addition to the ethical imperative to work with others to address violations of human rights, there is another important issue: Adopting a social justice perspective enables occupational therapists to enquire into the nature of our own practices. For example, do we as professionals treat people equitably and fairly, or do we provide services based not on need but on the ability to pay? Do we strive to assure equality of service provision throughout inner cities, urban, suburban, and rural areas? Do we ensure that clients attain the equipment, access, and services they require to equalize their occupational opportunities, or do we act as resource gatekeepers and as collaborators with unjust social policies (Curtin & Hammell, 2006; Hammell, 2007)? In the United States, Gupta and Taff (2015) have described how “occupational therapists’ clinical decision making is dictated by the client’s insurance plan, which specifies the parameters of eligible services including the type of treatment, intensity, and duration” (p. 247). Such critical self-examination within our profession is rare, and occupational therapists have seldom attempted to determine whether their professional practices are consistent with social justice. Focusing, instead, on occupational justice could enable such ethical issues to remain comfortably in the shadows.

Having briefly highlighted some of the problems inherent to the concept of occupational justice, let us shift to examining the concept of human rights and of occupational rights.

Exploring the Nature of Rights

Philosophers explain that the concept of “rights” pertains to “a person’s entitlements as a member of society” (Flew, 1979, p. 306). To have a right, therefore, “is to have something society ought to protect me in the possession of” (Mill, cited in Flew, 1979, p. 306). Flew (1979) emphasizes that the word ought is important, and it is a word that differentiates the ideals of justice from the entitlements of rights. In contrast to notions of distributive justice, philosophers explain that rights “refer to doing more than having” and to the conditions that enable or constrain action (Young, 1990, p. 25). Rights, therefore, are not about having but about doing and about the opportunity to choose and to act (Hammell & Iwama, 2012).

Kallen (2004) explained that universally endorsed human rights address three themes:

the right of every human being to participate in the shaping of decisions affecting their own life and that of their society (freedom to decide); reasonable access to the economic resources that make that participation possible (equality/equity of opportunity); and affirmation of the essential human worth and dignity of every person, regardless of individual qualities and/or group membership (dignity of person). (p. 15)

Within this ideological framework, philosophers identify two main claims or rights: to freedom and to well-being. Well-being is defined as “having the general abilities and conditions needed for achieving one’s purposes by action” (Honderich, 1995, p. 776), and both freedom and well-being are reflected in the capabilities approach, outlined later in this paper.

Although it has often been argued that the language of rights has its roots in European thought and history—and, indeed, many writers elect to cite only European thinkers in their scholarship on human rights (thereby subtly reinforcing the hegemony that Western ideas are somehow more evolved than others)—this is not a culturally specific concept but one with old and diverse roots (Murumba, 1998), for example, in Indian and Chinese traditions (Nussbaum, 2011; Sen, 1997, 1999). Because human rights are based upon respect for the dignity, worth, and equality of every person, principles of human rights are entirely consistent, for example, with the African philosophy of Ubuntu (Sherry, 2010). Indeed, drawing from the scholarship and wisdom of a diversity of global peoples, it can be demonstrated that concepts of human rights are to be found within every religious and cultural tradition (Ife, 2008; Nipperess & Briskman, 2009); they are a cross-cultural invention (Murumba, 1998). Moreover, the individualistic language that traditionally shaped the human rights discourse has been challenged and expanded by those who understand human rights as pertaining also to groups of people (Murumba, 1998).

Rights: A Common Perspective Employing a Common Language

The concept of rights has been of central importance to disability activists (Driedger, 1989). The United Nations’ (2006) Convention on the Rights of Persons With Disabilities (CRPD) “reframed the health and wellbeing of individuals with disabilities as a human right” (Groce & Trani, 2009, p. 1801). Importantly, this convention “emerged from the intense lobbying and engagement with disabled activists from around the world” (Iriarte, McConkey, & Gilligan, 2016, p. 6). Malinga and Gumbo (2016) emphasize that the agenda for promoting the human rights of disabled people arose not from the largess of the United Nations but from the efforts of international, multidisciplinary organizations of disabled people who employed the language of human rights to assert their claims to equality and self-determination and their right to participate in every sphere of society.

In the context of disability, the language of rights is also employed within the literatures of medicine and rehabilitation. Writing in the Lancet, for example, Officer and Groce (2009) observed that removing barriers to participation so that disabled people have equality of opportunity with all others is a matter of human rights. Indeed, the CRPD’s rights-based approach is highlighted for its importance in enabling the medical community, researchers, policy makers, and disabled people to work together with a common language toward the achievement of equality of access and participation for disabled people (Stein, Stein, Weiss, & Lang, 2009). Congruent with this common language, Skempes and Bickenbach (2015) called for a “rights-based” approach “to organize, strengthen, and extend rehabilitation services” (p. 824). Occupational therapists, utilizing a rights-based approach to enhancing people’s occupational opportunities, could contribute immeasurably to this work of strengthening and extending rehabilitation services.

Human Rights and Occupational Therapy

The promotion and protection of human rights and dignity are integral to the promotion of human health and well-being (Mann et al., 1994). Some occupational therapists in the global North (e.g., Hammell & Iwama, 2012) and South (e.g., London, 2008) have asserted their profession’s responsibility and obligation to engage with human rights and have identified the imperative of making human rights “a core aspect” of professional practice (London, 2008, p. 1). Occupational participation is identifiable both as a component of the human right to well-being and as a determinant of health, and occupational therapists have asserted that all people have both a need and a right to engage in meaningful occupations throughout their lives (American Occupational Therapy Association, 2011).

The human right to occupation has also been addressed in an important statement issued by the World Federation of Occupational Therapists (WFOT; 2006). This position statement, comprising six principles and an additional qualifier, asserts the human right to occupational participation. Although it has been claimed that “the concept of occupational justice has been taken up by the World Federation of Occupational Therapists in its Position Statement on Human Rights” (Hocking, 2012a, p. 1367), that “WFOT endorsed fully the UN Universal Declaration of Human Rights when it published a position statement that includes its stand on occupational justice” (Wilcock & Townsend, 2014, p. 547), and that “WFOT has publicly endorsed efforts to advance occupational justice in a Position Statement on Human Rights” (Townsend & Marval, 2013, p. 218), nowhere in the WFOT statement of principles is occupational justice mentioned. This is a clearly articulated statement that pertains explicitly to rights.

This highlights a fundamental problem that pervades the occupational science and occupational therapy literatures, wherein the terms justice and rights are frequently used interchangeably as if they hold the same meaning. It is erroneous to collapse rights into justice and misleading to discuss justice as if it is a pseudonym for rights. However, if occupational scientists and therapists believe that justice and rights pertain to the same thing, then this intriguing and unique perspective needs to be argued cogently and with reference to existent literature from philosophy, law, political science, and bioethics, for example, that asserts the opposing point of view.

Occupational Rights: A Tentative Concept

It has been claimed that the outcome of occupational justice results in attaining one’s occupational rights (Stadnyk, 2007). Townsend and Wilcock (2004b) delineated four occupational rights: “to experience occupation as meaningful and enriching,” “to develop through participation in occupations for health and social inclusion,” “to exert individual or population autonomy through choice in occupations,” and “to benefit from fair privileges for diverse participation in occupations” (p. 80). Although it is unclear how these four specific rights were identified (Durocher, Gibson, et al., 2014), the question arises as to whether occupational rights—not justice—constitute the ultimate focus and appropriate goal toward which occupational therapy might aspire to strive.

Hammell (2008) suggested that the concept of occupational rights might be more useful than that of occupational justice and proposed that “the concept of occupational rights could usefully and succinctly be defined as the right of all people to engage in meaningful occupations that contribute positively to their own well-being and the well-being of their communities” (p. 62). In response, Durocher, Gibson, et al. (2014) correctly observed that Hammell “did not explicitly differentiate her use of the term from [Townsend and Wilcock’s], nor did she comment on their definitions” (p. 423) and, further, that “Hammell (2008) did not provide a clear rationale for her preference for the term occupational rights” (p. 427). In a subsequent paper, Hammell and Iwama (2012) explored relationships between well-being and human rights, between well-being and occupation, and between well-being and occupational rights. They suggested that the concept of rights is potentially more useful to occupational therapists than that of occupational justice and argued that

while justice invokes metaphorical images of scales and balances, and is a concept open to charges of moral relativism, rights state, unequivocally what all people are entitled to expect (Nipperess & Briskman, 2009; Young, 1990), and thus offer a clearly definable mandate to occupational therapists. (Hammell & Iwama, 2012, p. 386)

Critics contend that the imposition of ideas and concepts from an élite, dominant global minority upon the global majority reflects and reproduces colonialism (Hammell, 2015d) Thus, although supporting the definition of occupational rights suggested by Hammell (2008), Hammell and Iwama (2012) also called for theorists to commit to rigorous efforts to seek out diverse global perspectives—that have tended to be overlooked, unacknowledged, or discounted—both to achieve inclusivity and relevance and to counter theoretical tendencies to colonialism and imperialism. Accordingly, they proposed that “the conceptualization and definition of ‘occupational rights’ cannot be dictated in a colonial manner by Western theorists…but must be informed by a diversity of cultural perspectives” (Hammell & Iwama, 2012, p. 392). Clearly, definitions of occupational justice or occupational rights cannot be accepted as definitive just because they have been articulated and published by influential Western theorists.

Advancing the concept of occupational rights, Hammell (2015b) proposed that this foregrounds the importance of equitable occupational opportunities and provides occupational therapists with a language for articulating approaches to practice that would accord with the WFOT (2006) Position Statement on Human Rights. Although the occupational rights to which people aspire will be different and will be articulated differently by different people in different global places and spaces—and although the inequities that prohibit the attainment of occupational rights will also be different—it should not be impossible to learn from people from diverse cultural backgrounds and to collaboratively elaborate a working definition of occupational rights that would be relevant beyond the parameters of the privileged minority world (as WFOT accomplished with its position statement). A clear definition of occupational rights could surely be identified if people in diverse global places perceived this to be a worthwhile endeavour.

The ability to communicate clearly is an important attribute of any attempt to articulate the right to equitable occupational opportunities. Cockburn, an occupational scientist and occupational therapist, unequivocally identified equality of educational opportunity for disabled children in Cameroon as a human rights issue in extensive newspaper articles published both in the United Kingdom (Arias & Pérez, 2015a) and internationally (Arias & Pérez, 2015b). Using the language of human rights, Cockburn’s contention was communicated clearly to a vast global readership without recourse to discipline-specific concepts or ambiguous definitions. Moreover, the contribution of an occupational therapist to addressing violations of human rights was readily apparent, supporting the contention of this paper: that the focus of occupational science and occupational therapy ought to be on occupation as a human right.

Occupation as a Human Right

Whiteford (2014) emphasized the importance of the WFOT (2006) position statement, which specifically identified and addressed occupation as a human right. In the process, she identified two central concerns with the conceptualization of occupational justice: “One is how justice is constructed and understood and the other is the framing of the right to engage in occupations as a human right” (Whiteford, 2014, p. 175; emphasis added). These are fundamental concerns.

Hasselkus (2004) had already argued that

our traditional categories of occupation such as work, leisure, and self-care…and Western ideologies about individualism and independence are current professional boundaries that need to be broken. The focus of occupational therapy needs to be on the right of all people to occupational engagement and enrichment. (p. xiii)

Subsequently, Wilcock and Townsend (2014) encouraged occupational therapists “to consider the centrality of occupation to people’s survival, health, and well-being as a human rights issue” (p. 541; emphasis added).

In light of evident and persisting difficulties with defining, identifying, and assessing both occupational justice and occupational injustice (Hammell & Beagan, 2016), it is proposed that a focus on occupational rights might be more constructive, such that occupational injustices are understood, clearly and simply, as violations of people’s occupational rights. Occupational scientists and occupational therapists are already well positioned to engage in rights-based discourses and practices: by publicizing the evidence demonstrating a clear linkage between engagement in specific occupations and human health and well-being and by emphasizing the positive effects of certain patterns of occupation, the negative effects of others, and the impact on individual and population health of violations of occupational rights (Durocher, Rappolt, et al., 2014). Occupational scientists and therapists could foreground the significant body of evidence concerning the social determinants of health and assert the fundamental importance of the human right to engage in meaningful occupations that contribute positively to human health and well-being, both as individuals and as communities. This approach would resonate with the WFOT (2006) Position Statement on Human Rights and the United Nations’ (2006) CRPD, documents that “clearly situate occupational therapists’ mandate within a rights-based framework” (Hammell, 2015a, p. 451). All these steps toward achieving rights-based practices could be facilitated by using a concept already defined, developed, and deployed by a wide range of international academics and practitioners: the capabilities approach.

Capabilities: A Promising Concept for Collaborative Action on Occupational Rights

The capabilities approach was conceived by Amartya Sen (1985, 1999, 2005) as a means of examining issues of economic and human development from a human rights perspective. It has since been embraced and adopted by many researchers and practitioners, not solely within such fields as development studies, economics, social policy, political philosophy, political science, engineering, special needs education, disability studies, social medicine, and public health (see Dubois & Trani, 2009; Frohlich & Abel, 2014; Marmot et al., 2012; Terzi, 2005; Venkatapuram, 2011) but also within several health and social care professions. The capabilities approach thus provides an opportunity for sharing a framework, agenda, and language with others committed to improving the quality of people’s lives through attainment of their human rights.

Occupational scientists and occupational therapists are beginning to acknowledge the relevance and importance of the capabilities approach (Bailliard, 2013, 2016; Mousavi, Forwell, Dharamsi, & Dean, 2015; Townsend, 2012; Townsend & Marval, 2013) and have suggested that employing a capabilities perspective might provide a helpful and relevant framework through which occupational therapists might address the rights asserted in the WFOT (2006) Position Statement on Human Rights (Bailliard, 2016; Hammell, 2015c). However, although the capabilities approach has been adapted and adopted by those within disability studies, the scholarly effort to rigorously critique the capabilities approach in the context of occupational therapy has not yet been undertaken.

Although a complex and evolving concept, the capabilities approach is concerned with a simple issue: “What are people actually able to do and to be? What real opportunities are available to them?” (Nussbaum, 2011, p. x). Capabilities are defined not solely as individuals’ (or collective) abilities but as the freedoms or opportunities created from a combination of personal (or group) abilities and resources, and the social, political, and economic environment (Nussbaum, 2011; Sen, 1999). The capabilities approach can be employed to address both individual abilities and the capabilities of collectives (couples, families, communities, populations) and acknowledges that the capabilities of groups and of group members are not simply the product or sum of individual capabilities (Dubois & Trani, 2009; Graham, Moodley, & Selipsky, 2013; Stewart, 2005; Trani, Bakhshi, & Rolland, 2011).

The essence of this approach lies in its definition of capabilities as the opportunity to choose what one wishes to do and to be, and to act on these wishes. Understanding occupational engagement in terms of capabilities encourages occupational therapists and scientists to focus not solely on whether people have the abilities to do the things they would value doing but on whether their circumstances actually allow them to choose and to do what they would like to do (Sen, 2005). Within a capability framework, disability is thus understood to constitute the limitation of opportunities that results from the interactions between an individual’s impairment or illness and their other personal characteristics (for example, their age and gender) and their available resources (their strengths and assets) and their environment (Mitra, 2006). Although the problems and disadvantages confronted by disabled people are often regarded as inevitable consequences of their limited abilities, the capabilities approach promotes consideration of those ableist and disabilist attitudes and religious, cultural, economic, political, legal, social, and institutional structures that interact to constrain the opportunities and reduce the quality of life for so many people with impairments (Bakhshi & Trani, n.d.).

Venkatapuram (2011), who explored the importance of the capabilities approach to the achievement of health justice, observed that people’s “abilities to be healthy are significantly socially produced (i.e., nurtured, protected, restored, neglected, or thwarted) by a range of political, economic, legal, cultural, and religious institutions and processes operating locally, nationally, and globally” (p. 3). The capabilities approach takes into account the influence of social structures and constraints not solely upon the available opportunities but on the choices people can envision and are equitably able to make (Robeyns, 2005; Trani, Bakhshi, Noor, & Mashkoor, 2009). This approach thus addresses the importance of the human right to freedom—to participate meaningfully in the decisions that impact one’s life and community—and focuses attention on “the socially structured and inequitable shaping of choice” (Frohlich & Abel, 2014, p. 210). People have neither equal opportunities to choose nor equal choices to act, and this constitutes “the basis of inequity in society” (Frohlich & Abel, 2014, p. 210).

Moreover, cultural values shape and govern the cultural “templates” or “scripts” that frame the life expectations for members of a culture (Goffman, 1959), such that socialization within any culture is a process of “learning the scripts” (Barnartt, 2001, p. 64). These cultural scripts establish “the possible parameters” for the lives of people “like me” (Rogers & Swadener, 2001, p. 4). Thus, Saleeby (1994) explained, “there is an inevitable connection between what people do and what they think they can do” (p. 356). Choices are not equally available but are constrained by both structural barriers and cultural norms and expectations. This knowledge challenges a belief that permeates occupational therapy theory: that humans are autonomous beings who share universal abilities and opportunities both to choose their occupations and to act on their choices.

It has already been noted that the capabilities approach provides a foundation from which to strive toward equity of opportunities, choice, and participation through the provision of enhanced resources to those with enhanced needs (Sen, 1995, 1999). It has therefore been identified as being naturally allied with professions such as physical therapy (Edwards et al., 2011) and would also seem to be an appropriate tool for occupational therapists (Hammell, 2015c), whose espoused aims clearly match Sen’s own. Bailliard (2013) noted,

If occupation is a primary mechanism through which humans develop and exercise their capabilities, and humans are entitled to the “opportunity to benefit from development” (United Nations General Assembly, 2000, p. 2), then access to occupation is a basic human right. (p. 353)

And it is the attainment of basic human rights that the capabilities approach was designed to address.

Addressing Capabilities: Maintaining a Critical Approach

If occupational scientists and therapists aspire to address occupational opportunities from a human rights perspective, this will require a commitment to a critical approach to understanding and addressing capabilities. As Young (1990) contends, “without…a critical stance, many questions about what occurs in a society and why, who benefits and who is harmed, will not be asked” (p. 5). It is possible that, using a capabilities approach, a clinician might recognize those barriers to occupational opportunities that impact an individual client, such as a lack of wheelchair-accessible community swimming pools. In response, that clinician might advocate for modifications to a specific pool: adopting an individual approach to address an individual problem. And, indeed, a wealth of research literature has focused on enhancing individuals’ abilities to maximize their community participation. But if the capabilities approach is to be employed from a critical perspective—as Sen clearly intended—it becomes possible to focus on the bigger picture and to recognize that community pools across Canada have been constructed to suit the needs of certain sorts of people. From this perspective, it becomes possible to identify, for example, the ideological underpinnings of policy decisions and community planning; the ableist values that inform particular social arrangements that benefit some groups while disadvantaging others; and the impact of neoliberal principles that encourage, for example, the privatization of community resources and that eschew government responsibility (Steger & Roy, 2010). Instead of attempting to change one community pool at a time, efforts could now be directed “upstream,” to target the policy makers and urban planners who decide through their actions, for example, which children will have opportunities to swim and which will not, which parents will have the opportunity to accompany their children to the pool and which will not, which communities will have accessible facilities and which will not. If occupational therapists are committed to addressing human rights from an occupational perspective, it is not enough to identify individual injustices; rather, the ideological and structural mechanisms that produce and perpetuate injustices need to be identified and addressed (Gerlach, 2015; Hocking, 2012b). Focusing on occupational rights might facilitate this endeavour.

Conclusion

Venkatapuram (2011) contends that “the main advocates of the capabilities approach have already done much over the past three decades to argue that capabilities theory should be a general theory of human well-being across all societies, rich and poor, East and West” (p. 80). And it is the contention of this paper that the capabilities approach provides occupational science and occupational therapy with a general theory of human well-being. This is an approach that has already been embraced by many who are working toward human rights and is one to which we could usefully contribute our knowledge and expertise concerning human occupation and its centrality both to human well-being and to occupational rights. Moreover, this paper concludes that occupational therapists could most effectively highlight and address occupational inequities and injustices through focusing on violations of occupational rights, congruent with the rights-based approaches advocated by the international disabled people’s movement, articulated in the CRPD, and affirmed in the WFOT Position Statement on Human Rights.

Key Messages

The idea of occupational justice lacks a clear definition, and theorists experience ongoing difficulties with differentiating the concept of justice from that of rights.

The concept of occupational rights reflects the World Federation of Occupational Therapists’ (WFOT; 2006) Position Statement on Human Rights.

The capabilities approach aligns with WFOT’s position, facilitates international and cross-disciplinary collaborations, addresses the structural factors that constrain the occupational opportunities of countless people, and identifies occupation and its centrality to health and well-being as a human rights issue.

Footnotes

Acknowledgements

I extend sincere appreciation to Isla Whittington (in Aoteroa/New Zealand) and Alison Gerlach (in Canada) for the stimulating and thought-provoking conversations that inspired this paper.

Funding

No funding was received in support of this work.

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