The Capability Approach (AMEE 97)

Abstract

Sandars and Sarojini Hart introduce the capability approach as a theoretical and practical framework for medical education. The authors examine how personal agency and social conditions transform resources and aspirations into genuine opportunities and achievements. Through hypothetical cases involving longitudinal community attachments and widening participation policies, they suggest integrating support for student choices and personal growth into existing reflection and mentoring practices.

Introduction

AMEE Guide No. 97 by John Sandars and Caroline Sarojini Hart applies the capability approach to medical education. The guide reviews theoretical discussions of human development alongside examples from educational practice. It outlines methods for design and evaluation using two hypothetical scenarios. Its framework broadens the purpose of medical education to include preparing doctors to lead personally fulfilling lives while supporting the growth of their patients and colleagues.

Human development and the capability approach

The capability approach originated in economics and human development research. Research by Amartya Sen, who received the 1998 Nobel Prize in Economics, examined impoverished rural communities in India. It focused on genuine opportunities to use resources to pursue a valued life. A person with land and water may aspire to grow vegetables. Achieving this goal depends on access to irrigation water and the legal conditions governing land ownership.

The capability approach links well-being and quality of life to genuine opportunities to choose and pursue a valued life. Central to this view of social justice is empowering individuals and communities to control their own lives.

Core concepts of the capability approach

Capability denotes the freedom and opportunity to achieve valued ways of doing and being. Functionings represent what a person actually does or becomes. A capability set comprises available opportunities, whereas achieved functionings are the outcomes a person realizes. Because people choose particular life goals, some capabilities remain unrealized.

Resources encompass personal assets (self-efficacy, health, knowledge, property), social assets (networks, professional recognition), and environmental conditions (location, climate). An aspiration set consists of what people want to do and become. Conversion factors facilitate or constrain the progression from resources to aspirations, from aspirations to capabilities, and from capabilities to achievements. These factors include personal aptitudes, educational background, organizational resources, policies, rules, and cultural practices.

Internalizing constraints leads to adaptive preferences. Women might take for granted social expectations that restrict their access to higher education. Interpreting a person’s expressed hopes requires examining the conditions that shaped those aspirations.

Decision-making as an essential aspect of the capability approach

Choice shapes aspirations, capability sets, and decisions about which functionings to achieve. Conflicts and trade-offs often emerge among personal, professional, and educational goals. Sen’s framework distinguishes agency freedom (the freedom to choose) from agency achievement (the realization of those choices).

A universal list proposed by Martha Nussbaum identifies central capabilities to be secured for everyone. Sen’s framework emphasizes the freedom of individuals and communities to determine the capabilities they value. Sociocultural norms influence decision-making. Collective deliberation and critical reflection help people understand the conditions shaping their choices. A ‘strong evaluator’ makes judgments consistent with personal values while recognizing the conversion factors that enable or constrain those choices.

Capability approach as a framework for education

In education, the capability approach focuses on personal growth and equal opportunities for learners. Researchers have applied this framework to special education, women’s education, transitions after age 16, and access to higher education. The framework also addresses the ability to respond to uncertainty and build collaborative relationships. Drawing on John Dewey and Carl Rogers, the guide defines reflection as interpreting the meaning of an experience and modifying subsequent actions.

Central role of education in the expansion of capabilities

Education expands both abilities and opportunities. Reading skills enable participation in environmental discussions, and learning mathematics can open unexpected career paths.

Teachers and educational institutions act as conversion factors. Educators respect students’ choices while introducing challenges to prompt reflection.

Examples of the use of the capability approach in education

A study by Melanie Walker (2006) examined a ‘cross-cultural marketing’ module. University students from diverse backgrounds valued subject knowledge and reflective self-understanding. The students developed practices for critically examining new knowledge and respecting cultural differences among their peers. Teachers supported this learning process while honoring students’ choices and agency.

A study by Hart (2012) drew on Pierre Bourdieu’s concept of field to examine young people’s aspirations for higher education in the United Kingdom. Several factors constrained their choices and ability to realize those aspirations: anticipated financial burdens, inadequate study spaces in poor housing, varying levels of parental support, mixed perceptions of the value of higher education, expectations to care for younger siblings, and difficulties discussing aspirations with peers.

Using the capability approach for the development and evaluation of education

The guide outlines four methods for educational design and evaluation. Nussbaum’s (2001) list comprises 10 capabilities: life, bodily health, bodily integrity, senses, imagination and thought, emotions, practical reason, affiliation, other species, play, and control over one’s environment. Researchers debate how it accommodates individual choice and context.

A study by Walker (2008) investigated what students valued in their learning environments. Open-ended individual interviews and focus groups identified 11 capabilities, accompanied by detailed contextual descriptions and student quotations.

Box 2 of the original paper presents the following list.

Capabilities to achieve and exercise in higher education
1. Knowledge
2. Social relations
3. Critical thinking
4. Imagination and empathy
5. Recognition and respect
6. Active and experiential learning
7. Autonomy
8. Confidence
9. Active citizenship
10. Deliberative dialogue with others
11. Having economic opportunities

The method proposed by Ingrid Robeyns (2005) calls for explicit, justified lists that reflect local circumstances. It balances ideals with feasibility and avoids overlapping dimensions. The authors note that prescriptive lists may only partially capture freedom of choice or the factors that constrain it.

Hart’s (2012) approach specifies the unit of evaluation, what to measure, and which capabilities to prioritize. Researchers use interviews or focus groups to explore aspirations, potential functionings, achieved functionings, and the freedom to choose and realize them. The questions explore what people want to do and become, alongside the conditions that facilitate or hinder these goals. Mind maps and think-aloud protocols support data collection and help learners understand themselves.

Challenge of medical education in the 21st century

Drawing on the 2010 Lancet Commission Report, the guide examines patient-centered, team-based, interprofessional, and values-based education. It addresses concerns about competency-based curricula focused on exam preparation and narrow performance metrics. These may limit opportunities to develop professionalism, ethics, and social justice, as well as learners’ emotional, cultural, and social growth. The guide defines professional formation as a process of growth that upholds personal and professional values.

Capability approach as a framework for medical education

The first hypothetical case involves a longitudinal community attachment during the first year of medical school. Before the attachment, students list up to 20 personal and professional aspirations. During the initial meeting, they discuss these goals with a tutor and peers and identify a capability set to develop. They record the remaining aspirations for later reflection. Aspirations might include understanding primary care, applying basic science to clinical settings, developing self-direction, and gaining cultural perspectives.

Programs can use goal-attainment scaling for assessment at the beginning and end of the attachment. For instance, a student’s score for understanding cultural perspectives might increase from 2 to 5. During the final reflection phase, students review how assessments focused on memorization and limited clinical exposure restrict learning. The guide illustrates single-loop learning by having students raise these issues with a student–faculty committee. It demonstrates double-loop learning by questioning why the institution excluded students from decisions about assessment methods.

The second hypothetical case evaluates a widening participation policy. The individual student serves as the unit of evaluation. Semi-structured interviews explore aspirations, capability sets, achievements, and the freedom to choose and realize them. This evaluation examines family background, cultural context, prior education, and peer networks. It also investigates how admissions policies, teaching methods, assessments, support systems, and interactions with faculty and peers affect student achievement. The evaluation process prompts students to reflect, providing a learning opportunity.

Introducing the capability approach in medical education curricula

The guide proposes integrating the capability approach throughout the curriculum while maintaining essential clinical competencies for patient safety. As a first step, medical schools can explicitly incorporate personal growth, agency, and social justice into their mission statements. Institutions can implement the approach through basic science and clinical education, existing reflective activities, and formal mentoring and interview systems.

Conclusion

The guide concludes that the capability approach supports curriculum development and evaluation when educators understand learners’ aspirations and address constraints on their realization.

Reading notes

Students list up to 20 aspirations and define a capability set for the current stage with tutors and peers, making goal selection itself part of the educational process. The increase from 2 to 5 points on the Goal Attainment Scaling for understanding cultural perspectives illustrates a hypothetical case. These figures illustrate a method for evaluating the achievement of chosen goals rather than the magnitude of observed effects.

The double-loop learning proposed by the authors moves from raising assessment issues with the student-faculty council to questioning why students were excluded from decisions about assessment methods in the first place. The guide explains its methods through two hypothetical scenarios. It does not present empirical findings on organizational change.

References

Sandars, J., & Sarojini Hart, C. (2015). The capability approach for medical education: AMEE Guide No. 97. Medical Teacher, 37(6), 510–520. https://doi.org/10.3109/0142159X.2015.1013927