Medical Model vs Social Model of Disability

So, this is a post where it’s not so much that I have a strong opinion on the various topics, but that in reading on the topic I can’t help but think that using philosophy and philosophical methods — specifically wrt conceptual analysis — would really help clear things up. Here Ania Onion Bula talks about the Medical and Social models of disability, and presents them as a dichotomy: either we take the Medical model, or the Social one, and she prefers the Social one.

So, to start, what are these models. First, we need to start with the idea of an impairment:

Impairment is a loss or deviation of normative physiological, psychological, or anatomical structure or function that can be caused by injury, illness, or congenital condition. It’s the description of what is happening in your body. So for example in the case of deafness, the impairment is a loss of hearing caused by x factor. Or in the case of my arthritis, it is the physical damage to my hip and the inflammation in the joint, caused by my arthritis.

Disability in turn is the restriction or inability to perform certain tasks or activities.

Under the Medical model, people have a physical or mental impairment, and that impairment itself leads them to be unable to do certain important things, and so they have a disability. Under the Social model, they may have an impairment, but it is the way that society is structured that turns that into a disability, as society is structured under the assumption that most people do not have that impairment and so there is no real need or desire to structure society to accommodate them. To put it simpler, the Medical model talks about people being disabled, while the Social model focuses on people being differently abled. Thus, the Medical model puts more focus on removing the impairment, while the Social model puts more focus on changing society to accommodate those different abilities.

The problem is that there are a lot of impairments that really do seem like they themselves are the main barrier to the life satisfaction of those who have them, like blindness, deafness, and so on, and so where the person’s life would definitely be greatly improved if the condition was simply eliminated. She tries to address that:

What about people who are disabled in more socially understood ways, like deafness, or blindness, or autism, who want a cure?

To start with, understand that many people who want a cure, want it because society makes it hard to exist otherwise. It would be like wanting a pill that would turn you straight because the world treat homosexuality as if it is something evil and not because it is evil in and of itself.

In order for it to be an ethical choice, one option cannot lead to punishment. If you punish someone for not taking a cure, how is it different from forcing them to take it?

This seems incredibly condescending to those who are blind or deaf, especially, as it seems to argue that they aren’t capable of determining whether or not, in general, they’d be better off not being blind or deaf because of some societal attitude. And this becomes even more problematic when we consider that the implication of this argument is that blind and deaf people’s lives would not be richer if their conditions were cured, which seems utterly ludicrous. There’s no societal change we can make that would allow a blind person to actually, say, really see a lovely sunset, or a deaf person to be able to experience a lovely symphony. It really does seem like their conditions deprive them of some experiences that they could have if they didn’t have it, and so curing their condition would at least give them significantly more choices of experiences and thus allow them to perhaps lead far more fulfilling lives.

It seems to me that for anything that we would generally and rightly call a “disability”, the main determining factor will be whether removing the condition, in and of itself, would greatly improve their quality of life. Let me use an example of mental conditions to highlight this, and talk about depression and introversion. Given that clinical depression, in and of itself, causes reduced affect and motivation and often leaves those people with a duller and less fulfilling inner life — for example, not being able to take pleasure in things that do give you pleasure — it would seem reasonable to suggest that simply eliminating the condition would improve their life no matter how accommodating society is to depression. Even if they could function reasonably well in society, those who have clinical depression still aren’t going to be capable of enjoying it as much as they might want. That doesn’t seem to be true for introversion, as there’s no argument that you can make that if you converted an introvert to an extrovert that therefore their life would automatically be better regardless of how society treats introverts. If society wasn’t so extrovert focused, there wouldn’t be any significant issues with being introverted. And we can thus call clinical depression a disability, and introversion simply a personality trait that is no better and no worse than any other. Thus those who are clinically depressed are disabled, and those who are introverted are, in fact, merely different.

So if we are going to talk about disabilities and have to choose either the Medical model or the Social model, it really does seem like the Medical model is the way to go for conditions where it really is the case that simply eliminating the condition would in and of itself improve the person’s quality of life, which includes her example of someone in a wheelchair. However, the dichotomy between the Medical model and the Social model is, in fact, a false one.

What we have come to understand is that there are people who have conditions, through no fault of their own, that in and of themselves limit their abilities. That means that, in some cases, they are going to be limited in what they do and what they can do based simply on the fact that they have that condition. For example, blind people are not going to be able to experience the visual sensation of a beautiful sunset. But there are, in fact, a number of cases where their condition simply makes them different, and so not fit into the standard model of the majority. Now, when people simply don’t fit the norm we tend to be less willing to accommodate them, instead asking them to accommodate so that the majority don’t have to make efforts to handle rare cases. But when someone has a medical condition, we are, in fact, more willing to make reasonable accommodations. That’s because simply being different is seen as being a choice, while being disabled is seen as not being a choice. But the long and short of it is that we can see someone as being hampered primarily by their impairment in some cases while recognizing that in some cases they are being hampered primarily by how society is structured.

Once we understand this, we ought to be see that society does need to, at least morally, accommodate these conditions. But that accommodation has to be “reasonable”. And for an accommodation to be reasonable, it seems to me that at least this condition must be met: It must be at least slightly easier for them to accommodate you than it would be for you to work around the condition.

This does lead to something she complains about:

Acting as though chronic illnesses or even just severe temporary illnesses like cancer, are not disability further plays into the ableist idea that people have to prove they’re “disabled enough”. Many people with chronic illnesses struggle with insecurities related to their own disability. We feel as though we are doing something wrong by asking for accessibility.

But I think her interpretation here is false. The whole point is to assess whether or not the proposed accommodation is the appropriate one for the situation. Let’s look at some of the things she proposes as reasonable accommodations:

When I was in university, for example, I was frequently too sick to come to class. A part of this had to do with the fact that I took the bus to and from school. The bus route did not have consistent access to restrooms. As a result, if I was having the kind of day where I’m running to the bathroom frequently, a bus trip put me in the situation of risking having a public accident. Taking the bus is also exhausting. It takes longer, is inconsistent with whether or not I will be able to sit down, involves me having to walk to the stop, and so it uses up more spoons. Some days I had to stay home, not because I didn’t have the energy for class itself but because I didn’t have the energy for the additional tasks that physically going to class would entail.

Under the medical model, there is not much I can do except maybe take so many pain meds that anything I try to learn that day will likely be gone forever before I’m even done processing the prof’s sentence.

Under the social model, however, there would be additional options – the professor could work with me to let me watch the lecture from home via skype, or pre-recorded videos. The professor could assign assignments that would make it possible for me to learn and show the work, without having to be physically there. Perhaps the university could help arrange some sort of ride share or carpooling program so that I can spend less of my energy going to class.

Now, most universities in Canada, at least, have departments dedicated to accessibility, even for temporary conditions. And that was 20 years ago, so she almost certainly had access to that if she went to a Canadian university. So there might well have been options, especially if Skype was an option. But let’s look at what options she could drive herself that might improve her situation. For example, if she needed to miss class because of her illness, there’s a time-tested method for getting what she missed, which is borrowing the notes from another student. If she made her concerns clear to the professor, that might be something that the professor could help facilitate, as well as the car pooling issue. As for assignments, that’s harder, but again I was accommodated for a broken wrist where they had a student volunteer sit with me and write things out for me, and I proctored an exam one for a student who had a condition that required that she have extra time to write it. The only issue is where you get participation marks, but again for an actual disability — as, for example, opposed to someone who is introverted — accommodation could be made for that by, say, not counting those marks.

While her thoughts here might just be suggestions, what they do — and what her huge “Treat disabled people as people!” rhetoric pushes — is the idea that she has an issue and other people need to do things to accommodate that. But in any discussion of accommodation what the person themselves can do and ought to do comes into play. For missing classes, it’s a reasonable question to ask why she can’t just get the notes from someone else. Sure, it isn’t as good, but it ought to work.

What if instead we created a world that accommodated different ways of being? Imagine a classroom where students had access to both a noise room and a quiet room to work in, and they could come and go and choose as they please? Imagine having access to different styles of chair to fit what they feel most comfortable sitting in, or have the option to stand or kneel or even pace. Imagine if schools made it possible for you to learn in different ways so that you could get information in the ways that work best for you, and if you could present your gained knowledge in the way most comfortable for you.

But again here we see the very self-centered view of accommodation. There’s little thought here put into how this would impact the teacher or, well, everyone else. Being able to come and go as you please doesn’t work if the teacher wants to do a group lesson, and there are too many students in classes to do everything individually. And this also applies to, well, everything else on the list. I like to pace while I think, too, but I don’t do it in meetings because it will bother everyone else. We can’t really accommodate what everyone would want or what works best for them, as that would be too chaotic. That’s one of the reasons why having separate classrooms where things can be done more individually is a benefit, and then you can integrate for classes and conditions where accommodation isn’t as required. But the entire attitude here is indeed a “I want this, so restructure society for me!” and while that might work and benefit society in general, it might not either.

Here’s the most egregious one:

It is about teaching hearing children and adults the appropriate sign language for the region they’re in so that it isn’t up the Deaf person to have to undergo either painful treatments or go through speech therapy if they can’t or don’t want to.

So, the “reasonable accommodation” is for everyone in the world to learn sign language because they might come across someone who is deaf who can’t or won’t do things to make that less or unnecessary and thus might need to communicate with them in sign language. Also, since the region matters, they might have to relearn it, again just so that they can communicate with someone there who, again, happens to be unable to communicate any other way. That’s … kinda ridiculous. She tries later to argue that this could be a benefit for people who are not deaf, but shouldn’t that be their choice? Are we all going to have to learn to write in braille too? Ultimately, part of agency is accepting the consequences of your choices. If this deaf person chooses not to learn things that could help them, we aren’t obligated to bend over backwards to accommodate them. If we are going to have to do things and put in the effort, they are going to have to, too.

This is why my minimum condition compares the effort that the disabled person would have to make to the effort that the others would have to make. If it would be easier for the disabled person to work around their condition than it would be for us to accommodate it, it seems the height of selfishness to insist that we need to do the accommodation. But on the other hand, if us accommodating it would be easier than their working around it, what excuse do we have for not accommodating it? And all of this comes from rejecting the false dichotomy of the “Medical vs Social model”.

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6 Responses to “Medical Model vs Social Model of Disability”

  1. Ania Onion Bula Says:

    Reading this makes it obvious this is not a struggle you have not experienced, or if you have, that you were lucky enough to do so in conjunction with other areas of privilege (money, gender and identity, etc.)

    yes, disability departments exist and nominally are meant to provide accommodations for anyone who needs them. But how often are people granted those accomodations without trouble? Without a fight? Without forms of punishment like being considered a troublemaker by professors you have to rely on for recommendations, to act as supervisors, etc. What about people who are still struggling to find the right diagnosis that explains their accessibility needs?

    I write this from a place of experience and research. Disability justice and social justice are not just what I study and write about (and have been published about by the way), but what I live and experience every day. Almost all of my friends are disabled people from all over the world.

    Moreover, you managed to skip every other post that was meant to be taken in conjunction with this one as a follow up, or even in some cases as a post most readers had read before. Including:

    https://the-orbit.net/splainyouathing/2015/09/08/is-disability-misery/

    https://the-orbit.net/splainyouathing/2017/03/23/people-want-cure/

    https://the-orbit.net/splainyouathing/2016/10/25/dear-doctors-need-talk/

    Not to mention my book: Young, Sick, and Invisible.

    There is a reason this post is called 101. It is meant to be an introduction to the idea before expanding on deeper intricacies of what is involved.

    Ultimately though, you are coming at this from someone imagining what it would be like to experience any of these, right now after all your existing experiences and not as someone who has lived this way for a long time or perhaps was even born this way. To you, going blind would be a loss BECAUSE you were born and have lived most of your life as a seeing person. It is how you think about and relate to the world, it is how you frame your worldview. Someone who hasn’t, however, who has lived their whole life being blind, or deaf, or otherwise, frames their world – experiences and relates to it – differently. Being given sight suddenly could be as disorienting as suddenly having it taken away because it would force them to develop new ways of interacting with the world, without the learned experience from childhood of how to limit sensory input. It would be like walking out from a pitch black room into a room filled with intense bright white light. Except that where your eyes can adjust in moments, an older person would take months or even years to retrain and relearn how to think and interact with the world.

    • verbosestoic Says:

      I think you’ve made a lot of presumptions here, and also — or perhaps because of that — aren’t addressing my post,

      yes, disability departments exist and nominally are meant to provide accommodations for anyone who needs them. But how often are people granted those accommodations without trouble? Without a fight? Without forms of punishment like being considered a troublemaker by professors you have to rely on for recommendations, to act as supervisors, etc. What about people who are still struggling to find the right diagnosis that explains their accessibility needs?

      The procedure, as I recall it, is that at the beginning of the semester the professor puts in the syllabus and reads to the class that if someone needs accommodation, they go to the office and arrange things with them. The office assesses the situation and works out an accommodation, often with the resources — volunteer and otherwise — of that office. The professor never hears about the situation if it is determined that accommodation is not warranted. And often they have to do nothing and make no changes to accommodate the student. This means that there’s less chance of the professor and the student clashing, and often the professor can simply ignore the issue and let the office decide what works and what doesn’t. Will there NEVER be such cases, where the professor feels that they are facing an unreasonable demand or that the accommodation is not warranted? Of course not. But this model is the one that seems to allow for accommodation while potentially insulating the student from such issues the best. Which is especially important because there is no way to restructure society so that no one would need accommodation.

      I write this from a place of experience and research. Disability justice and social justice are not just what I study and write about (and have been published about by the way), but what I live and experience every day. Almost all of my friends are disabled people from all over the world.

      This is a blatant appeal to authority, which ignores my actual arguments, which included examples of things that no societal change could give blind and/or deaf people, and a comparison of depression and introversion to show that the main barrier in the former seems to be their condition while in the latter it seems to mainly be society. You didn’t address any of that.

      Moreover, you managed to skip every other post that was meant to be taken in conjunction with this one as a follow up, or even in some cases as a post most readers had read before.

      This is where your false presumptions come into play, as I HAVE read those. And note that this also indicates that you didn’t, at least, really pay attention to the post, because the second one on your list is one that I QUOTED in this article, to comment that you were being quite condescending to say that blind and deaf people who think that their lives would be improved with a cure really only think that because of social stigma and how society is structured. Surely, even by your own arguments. THEY are better suited to judge that than you.

      Ultimately though, you are coming at this from someone imagining what it would be like to experience any of these, right now after all your existing experiences and not as someone who has lived this way for a long time or perhaps was even born this way. To you, going blind would be a loss BECAUSE you were born and have lived most of your life as a seeing person.

      My examples were of things that the person simply could not do with those conditions. If you want to argue that those things aren’t necessarily good, feel free, but this is a completely invalid assessment of my argument.

      Being given sight suddenly could be as disorienting as suddenly having it taken away because it would force them to develop new ways of interacting with the world, without the learned experience from childhood of how to limit sensory input.

      Sure, there may be cases where even if a cure was available the person’s life wouldn’t be better off if they took it for various reasons. I accept that. I even accept that we wouldn’t want to exclude such cases from accommodation. However, to some extent they would have to evaluate what they are losing by not seeking a cure vs the risk and hardship of taking the cure, and accept what they would be losing. And, again, for anything properly considered to be a disability there will be things that society cannot give them no matter how hard it tries.

  2. kidvelociraptor Says:

    Yeah, I’ll admit I don’t see the 2 models as mutually exclusive at all, & some of the original article’s suggestions went waaay too far. I shared it because I liked the idea of the social model of disability, & had never heard of it before.
    My California college made zero accommodations for my physical disability, though. The only 2 things they could offer me were a volunteer to take notes for me, & a special chair, which was… exactly like all the other uncomfortable, shitty chairs, except no one else could sit in it, I guess. Nothing that would have, you know, helped. I also dropped out of high school because the classes were a mile apart, & I couldn’t walk that far anymore. There was a shuttle between buildings occasionally, but never reliably. I was 16 & depressed because I had just crushed my spinal cord. I just gave up. Still haven’t graduated.

    • verbosestoic Says:

      Well, obviously I’m in favour of accommodation and don’t think that all cases are accommodated properly in all areas. I WILL say that while I don’t know your specific case, in high school if you had pushed for accommodation you would have been far more likely to get it than, say, I would for complaining that walking in the rain messes up my glasses and makes it so that I can’t see, and I’D be more likely to get it than someone who was just seen as out of shape.

      That’s why I worry about moving to the Social Model, since it risks presenting these things as “differences”, which then might be seen as choices, and in general we don’t feel any need to accommodate, at least not overly much, other people’s choices, and in fact feel perfectly fine trying to convince them to choose otherwise.

      As for accommodation itself, your college example drives my view that accommodation should involve all of the relevant parties sitting down and figuring out what works for everyone, because while we don’t want to try to impose ridiculous accommodations on the majority, by the same token there’s not much point in an “accommodation” that doesn’t actually address the problems the person who needs to be accommodation is actually having.

  3. Andrew Says:

    In todays society, the language of justice is freely dragged into situations that have nothing to do with it. Justice is the language of right and wrong, of obligation and payment.

    If I you injure me such that I am unable to walk, then “justice” would claim that this creates an obligation between you and I. Your action creates a “cost” that you need to pay. But if I am born unable to walk, I have no claim of “justice” on anyone. No particular individual or party is responsible for my condition, no-one owes me a specific “debt”, and from a “justice” perspective no-one “must” accommodate me.

    Compassion is different. You may choose to accommodate me out of a concern for my well being, and there’s a strong case to be made that such accommodation strengthens society even if it is materially sub-optimal. You might also choose to accommodate me because it provides you with some other benefit. These are both good things, but neither of them fall under “justice”.

    Verbs is on the right track when he talks about the effort of accommodation. If the cost of accommodation is small, then to not do so suggests a lack of compassion and could be described as uncaring and selfish. But as the cost becomes larger, and especially when the many start experiencing significant inconvenience to accommodate the few, the question is raised “perhaps you’re just not cut out for this?”. That I would prefer to do something, even that I feel that my life would be more meaningful if I did something, does not imply that I ought to be able to do it, especially if other people have to make allowances for me significantly over and above what they do for others. Discrimination is only unjust when the attribute being discriminated on is largely irrelevant to the decision. Discrimination on relevant attributes may lack compassion, but it’s rarely an issue of “justice”.

    The calculus of accommodation is important, but that calculus requires moral models that “justice” is unable to bear.

    • verbosestoic Says:

      I didn’t make it, but there is a case to be made that if the effort is too enormous for everyone involved, then the person should decide that that sort of thing isn’t open to them and work around it. Obviously, being Stoic-leaning I’m pretty amenable to that idea. That’s why I specified “Less effort to accommodate than it would take for them to work around it” as a minimum standard; there are more issues to deal with around here, but that has to be the starting point for what it means for accommodation to be reasonable.

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