The World Health Organization defines health as “a state of complete physical, mental, and social well-being” (
1). Much of the discipline of economics is allegedly devoted to the maximization of some notion of expected utility, supposedly taking into account all aspects of an agent’s preferences. The goal of the discipline of positive psychology is sometimes articulated as “the scientific study of the strengths that enable individuals and communities to thrive” (Positive Psychology Center, University of Pennsylvania;
https://ppc.sas.upenn.edu/). However, our actual empirical studies in medicine and public health, in psychology, in economics, and in many other disciplines are often restricted to very narrow outcomes. Empirical research in health typically addresses only a single disease; many psychological studies focus only on the alleviation of symptoms; empirical studies in economics not infrequently only examine effects on income or the production and consumption of goods and services. If a central goal of these disciplines is more fundamentally contributing to some broader notion of human well-being, then it would seem that the empirical studies and the measures used should more often consider a broader conception of well-being and flourishing, and that our investigations into etiology should likewise examine the causes and interventions that most contribute to human flourishing, broadly conceived. In this paper, I would like to outline a proposal concerning shifting empirical research in that direction. I will discuss a number of broader outcome measures that might be used, and I will discuss, based on current evidence, what seem to be substantial determinants of human flourishing. I will finally comment on the implications of this for policy and for future empirical research in the biomedical and social sciences (
2–
10).
On Human Flourishing
Various measures of subjective well-being have been proposed in the positive-psychology literature (
11–
14). Some of the most widely used measures concern either happiness conceived of as a positive affective state, sometimes referred to as “hedonic happiness,” or alternatively overall life satisfaction, sometimes referred to as “evaluative happiness” (
15). Representative questions, often rated on a scale of 0–10, include the following: “In general, how happy or unhappy do you usually feel?” (
14) or “Overall, how satisfied are you with life as a whole these days?” (
16). More recently, broader composite measures have been proposed encompassing numerous aspects of psychological well-being (
17–
21). These composite measures sometimes include positive affect and life satisfaction but also a collection of others such as meaning, purpose, autonomy, self-acceptance, optimism, positive relationships, mastery, self-determination, resilience, personal growth, vitality, engagement, and self-esteem. Different measures combine different subsets of these various attributes. These broader composite measures or certain items of these broader measures are sometimes referred to as measures of “eudaimonic” happiness or well-being (
15). As measures of psychological well-being, many of these may be reasonable. However, there are long-standing traditions that suggest that flourishing consists of something more than one’s mental state and how one feels about various aspects of life.
Notably absent from most of these lists is, for example, virtue. However, in the philosophical literature, arguments have been put forward that virtue is a central component of flourishing; Aristotle argued that happiness is attained by action in accord with virtue (
22). There is a tradition in philosophy of the cardinal virtues: that at the foundation of all of the moral virtues and character strengths lie four fundamental virtues upon which all others depend. These four are sometimes referred to as: prudence or practical wisdom; justice; fortitude or courage; and temperance or moderation (
23). Perhaps aspects of fortitude are touched upon in “resilience”; perhaps aspects of temperance in “self-determination”, but what of justice or wisdom? A focus on purely psychological aspects of life misses these.
Also notably absent from the aforementioned list of aspects of psychological flourishing is health. However, health is arguably central to a person’s sense of wholeness and well-being. Possibly some of the reason health is excluded is so as to be able to examine relationships between positive psychological states and subsequent physical health, and indeed there is a reasonably well-established literature that has done this (
24–
26). Composite measures of psychological well-being might indeed be better predictors of subsequent health than simply using life satisfaction. However, if what is of principal interest is an overall assessment of complete well-being, or flourishing, then health should arguably be included.
Moreover, even if we were to restrict consideration to an assessment of psychological well-being, it is not clear why the composite measures of psychological well-being are preferable to overall self-assessed life satisfaction, as a fundamental assessment for tracking the progress of life. The life satisfaction measure allows an individual to weight the various components of psychological well-being, and other aspects of life, as he or she sees fit. Must one include all of the psychological states above? Someone might not want to give much weight to optimism on the grounds that those who are overly optimistic may be more likely to have a distorted view of reality (
27–
29). Someone might likewise not want to give much weight to “self-acceptance” because excessive self-acceptance might hinder growth in virtue or character. Life satisfaction measures, in which an individual weights the various aspects of their life as they see fit, might thus be a better summary of psychological well-being.
However, life satisfaction or psychological well-being do not capture all that we would ordinarily mean by flourishing. That flourishing is yet broader seems clear from the possibility that a person may feel satisfied with life, and yet be utterly depraved, or without meaningful social relationships, or entirely dependent upon narcotics. Would we say such persons are flourishing? Something beyond psychology seems to be in view with flourishing. If some notion of flourishing is ultimately of interest, then health itself, along with psychological well-being, and virtue, would all seem to be central components.
Flourishing itself might be understood as a state in which all aspects of a person’s life are good. We might also refer to such a state as complete human well-being, which is again arguably a broader concept than psychological well-being. Conceptions of what constitutes flourishing will be numerous and views on the concept will differ. However, I would argue that, regardless of the particulars of different understandings, most would concur that flourishing, however conceived, would, at the very least, require doing or being well in the following five broad domains of human life: (i) happiness and life satisfaction; (ii) health, both mental and physical; (iii) meaning and purpose; (iv) character and virtue; and (v) close social relationships. All are arguably at least a part of what we mean by flourishing. Each of these domains arguably also satisfies the following two criteria: (i) Each domain is generally viewed as an end in itself, and (ii) each domain is nearly universally desired. I would suggest that these two criteria—of being ends and being universally desired—may be useful guides in decisions concerning the domains that should be included in national surveys and polls to assess flourishing.
If, however, we think about flourishing not only as a momentary state but also as something that is sustained over time, then one might also argue that a state of flourishing should be such that resources, financial and otherwise, are sufficiently stable so that what is going well in each of these five domains is likely to continue into the future for some time to come. Financial and material stability would generally not be viewed as ends in themselves but may be important in the preservation of those goods that are their own ends. For flourishing over time, it might thus also be good to assess financial and material stability as well. I would in no way claim that these domains above entirely characterize flourishing. Someone who is religious for example would almost certainly include some notion of communion with God or the transcendent within what is meant by flourishing. I would only argue here that, whatever else flourishing might consist in, these five domains above would also be included, and thus these five domains above may provide some common ground for discussion.
The measurement of well-being in each of these domains is in no way straightforward. Each has a large literature devoted to it (
12,
13,
15,
16,
30–
33). There will be no perfect measures. However, to make progress, some summary measure seems better than none at all (
34). There are of course numerous existing composite measures of psychological well-being (
17–
21), and some might argue that these should be adequate; but, as noted above, these generally do not capture broader components of flourishing such as health, and often also do not assess virtue. I have, in the
Appendix: Flourishing Measures, proposed two summary measures. The first measure includes questions on each of these five domains described above; the second measure, in addition to these five domains, also includes questions on having sufficient stability and financial resources so that flourishing is likely to continue. The former measure is perhaps conceptually more satisfactory as a measure of flourishing, at a given point in time, as each of the domains arguably constitutes its own end. The latter measure, which includes financial and other resources, may be the better measure in practice as it will likely indicate flourishing over a longer stretch of time. For these proposed measures, I have selected two questions in each of these five, or six, domains based principally on prior measures that have some empirical validation and are already used with some frequency in the literature (
14,
16,
30,
31,
34–
36).
There is of course a certain arbitrary element in the selection of questions and, in some of these domains, such as virtue or meaning, considerable work remains to be done on measure development and validation. An attempt was, however, made to select these questions on principled grounds. It seemed good, whenever possible, to make use of questions that are already being frequently used in surveys, polls, and past research, so as to facilitate comparison when used for evaluative or research purposes. Often these questions used in prior surveys had been subject to some degree of prior empirical validation. Thus, the questions on life satisfaction, positive affect, mental and physical health, and meaningful activities were selected as those already used by the Organisation for Economic Co-operation and Development (
16), the United Kingdom (
34), US General Survey (
35), the World Mental Health Composite International Diagnostic Interview (
36), and many others. The questions on close social relationships which likewise have been asked regarding prior research, were taken from the Campaign to End Loneliness measure (
31). Only the items on character and virtue are entirely newly proposed here, because, although several multiitem measures of specific virtues have been developed (
32), there appears to be essentially no literature on more global single-item virtue measures. Any attempt at such assessment is of course only going to be partially adequate. Of the two character–virtue questions in
Appendix: Flourishing Measures, the first is intended to provide some assessment of prudence and justice, and the second of fortitude and temperance. I would propose, with no clear way of weighting across domains, to simply sum the scores of each. This too is, of course, not entirely adequate, as, for example, financial resources may play a more important role at levels below the poverty line than in higher ranges. I in no way view this as being the best possible measure, but see it rather as a proposal that might be used until something more satisfactory emerges. The measurement of flourishing using the various domains above could also of course be carried out with alternative or additional questions.