2.6: The A-module: the non-optional core of all capability theories
What, then, is the content of the A-module, which all capability theories should share? Table 2.2 presents the keywords for the eight elements of the A-module.
Table 2.2 The content of the compulsory module A
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A1: Functionings and capabilities as core concepts A2: Functionings and capabilities are value-neutral categories A3: Conversion factors A4: The distinction between means and ends A5: Functionings and/or capabilities form the evaluative space A6: Other dimensions of ultimate value A7: Value pluralism A8: Valuing each person as an end |
2.6.1 A1: Functionings and capabilities
Functionings and capabilities are the core concepts in the capability approach. They are also the dimensions in which interpersonal comparisons of ‘advantage’ are made (this is what property A5 entails). 17 They are the most important distinctive features of all capabilitarian theories. There are some differences in the usage of these notions between different capability theorists, 18 but these differences do not affect the essence of these notions: capabilities are what people are able to be and to do, and functionings point to the corresponding achievements.
Capabilities are real freedoms or real opportunities, which do not refer to access to resources or opportunities for certain levels of satisfaction. Examples of ‘beings’ are being well-nourished, being undernourished, being sheltered and housed in a decent house, being educated, being illiterate, being part of a supportive social network; these also include very different beings such as being part of a criminal network and being depressed. Examples of the ‘doings’ are travelling, caring for a child, voting in an election, taking part in a debate, taking drugs, killing animals, eating animals, consuming great amounts of fuel in order to heat one’s house, and donating money to charity.
Capabilities are a person’s real freedoms or opportunities to achieve functionings. 19 Thus, while travelling is a functioning, the real opportunity to travel is the corresponding capability. A person who does not travel may or may not be free and able to travel; the notion of capability seeks to capture precisely the fact of whether the person could travel if she wanted to. The distinction between functionings and capabilities is between the realized and the effectively possible, in other words, between achievements, on the one hand, and freedoms or opportunities from which one can choose, on the other.
 At least, this is a widespread view, certainly in the social sciences, policy studies, and in a significant part of philosophy — and I think it is a view that is helpful for the interdisciplinary, practical orientation that the vast majority of capability research has. 20 That means one cannot be a human being without having at least a range of functionings; they make the lives of human beings both lives (as opposed to the existence of innate objects) and human (in contrast to the lives of trees or animals). Human functionings are those beings and doings that constitute human life and that are central to our understandings of ourselves as human beings. It is hard to think of any phenomenological account of the lives of humans — either an account given by a human being herself, or an account from a third-person perspective — which does not include a description of a range of human functionings. Yet, not all beings and doings are functionings; for example, flying like a bird or living for two hundred years like an oak tree are not human functionings.
In addition, some human beings or doings may not be constitutive but rather contingent upon our social institutions; these, arguably, should not qualify as ‘universal functionings’ — that is, functionings no matter the social circumstances in which one lives — but are rather ‘context-dependent functionings’, functionings that are to a significant extent dependent on the existing social structures. For example, ‘owning a house’ is not a universal functioning, yet ‘being sheltered in a safe way and protected from the elements’ is a universal functioning. One can also include the capability of being sheltered in government-funded housing or by a rental market for family houses, which is regulated in such a way that it does not endanger important aspects of that capability.
Note that many features of a person could be described either as a being or as a doing: we can say that a person is housed in a pleasantly warm dwelling, or that this person does consume lots of energy to keep her house warm. Yet other functionings are much more straightforwardly described as either a being or a doing, for example ‘being healthy’ (a being) or ‘killing animals’ (a doing).
A final remark. Acknowledging that functionings and capabilities are the core concepts of the capability approach generates some further conceptual questions, which have not all been sufficiently addressed in the literature. An important question is whether additional structural requirements that apply to the relations between various capabilities should be imposed on the capability approach in general (not merely as a particular choice for a specific capability theory). Relatively little work has been done on the question of the conceptual properties of capabilities understood as freedoms or opportunities and on the question of the minimum requirements of the opportunity set that make up these various capabilities. But it is clear that more needs to be said about which properties we want functionings, capabilities, and capability sets to meet. One important property has been pointed out by Kaushik Basu (1987), who argued that the moral relevance lies not in the various capabilities each taken by themselves and only considering the choices made by one person. Rather, the moral relevance lies in whether capabilities are truly available to us given the choices made by others, since that is the real freedom to live our lives in various ways, as it is truly open to us. For example, if a teenager lives in a family in which there are only enough resources for one of the children to pursue higher education, then he only truly has the capability to pursue higher education if none of his older siblings has made that choice before him. 21
2.6.2 A2: Functionings and capabilities are value-neutral categories
Functionings and capabilities are defined in a value-neutral way . Many functionings are valuable, but not all functionings necessarily have a positive value. Instead, some functionings have no value or even have a negative value, e.g. the functioning of being affected by a painful, debilitating and ultimately incurable illness, suffering from excessive levels of stress, or engaging in acts of unjustifiable violence. In those latter cases, we are better off without that functionings outcome, and the functionings outcome has a negative value. Functionings are constitutive elements of human life, which consist of both wellbeing and ill-being. The notion of functionings should, therefore, be value-neutral in the sense that we should conceptually allow for the idea of ‘bad functionings’ or functionings with a negative value (Deneulin and Stewart 2002, 67; Nussbaum 2003a, 45; Stewart 2005, 190; Carter 2014, 79–81).
There are many beings and doings that have negative value, but they are still ‘a being’ or ‘a doing’ and, hence, a functioning. Nussbaum made that point forcefully when she argued that the capability to rape should not be a capability that we have reason to protect (Nussbaum 2003: 44–45). A country could effectively enable people to rape, for example, either when rape is not illegal (as it is not between husband and wife in many countries), or when rape is illegal, but de facto never leads to any punishment of the aggressor. If there is a set of social norms justifying rape, and would-be rapists help each other to be able to rape, then would-be rapists in that country effectively enjoy the capability to rape. But clearly, rape is a moral bad, and a huge harm to its victims; it is thus not a capability that a country should want to protect. This example illustrates that functionings as well as capabilities can be harmful or have a negative value, as well as be positive or valuable. At an abstract and general level, ‘functionings’ and ‘capabilities’ are thus in themselves neutral concepts, and hence we cannot escape the imperative to decide which ones we want to support and enable, and which ones we want to fight or eliminate. Frances Stewart and Séverine Deneulin (2002, 67) put it as follows:
[…] some capabilities have negative values (e.g. committing murder), while others may be trivial (riding a one-wheeled bicycle). Hence there is a need to differentiate between ‘valuable’ and non-valuable capabilities, and indeed, within the latter, between those that are positive but of lesser importance and those that actually have negative value.
The above examples show that some functionings can be unequivocally good (e.g. being in good health) or unequivocally bad (e.g. being raped or being murdered). In those cases, there will be unanimity on whether the functionings outcome is bad or good. But now we need to add a layer of complexity. Sometimes, it will be a matter of doubt, or of dispute, whether a functioning will be good or bad — or the goodness or badness may depend on the context and/or the normative theory we endorse. An interesting example is giving care, or ‘care work’. 22 Clearly being able to care for someone could be considered a valuable capability. For example, in the case of child care, there is much joy to be gained, and many parents would like to work less so as to spend more time with their children. But care work has a very ambiguous character if we try to answer whether it should be considered to be a valuable functioning from the perspective of the person who does the care. Lots of care is performed primarily because there is familial or social pressure put on someone (generally women) to do so, or because no-one else is doing it (Lewis and Giullari 2005). There is also the hypothesis that care work can be a positive functioning if done for a limited amount of time, but becomes a negative functioning if it is done for many hours. Hence, from the functionings outcome in itself, we cannot conclude whether this is a positive element of that person’s quality of life, or rather a negative element; in fact, sometimes it will be an ambiguous situation, which cannot easily be judged (Robeyns 2003).
One could wonder, though, whether this ambiguity cannot simply be resolved by reformulating the corresponding capability slightly differently. In theory, this may be true. If there are no empirical constraints related to the observations we can make, then one could in many cases rephrase such functionings that are ambiguously valued into another capability where its valuation is clearly positive. For example, one could say that the functioning of providing care in itself can be ambiguous (since some people do too much, thereby harming their own longer-term wellbeing, or do it because no-one else is providing the care and social norms require them to do it). Yet there is a closely related capability that is clearly valuable: the capability to provide hands-on care, which takes into account that one has a robust choice not to care if one does not want to, and that one does not find oneself in a situation in which the care is of insufficient quantity and/or quality if one does not deliver the care oneself. If such a robust capability to care is available, it would be genuinely valuable, since one would have a real option not to choose the functioning without paying an unacceptable price (e.g. that the person in need of care is not properly cared for). However, the problem with this solution, of reformulating functionings that are ambiguously valuable into capabilities that are unequivocally valuable, is the constraints it places on empirical information. We may be able to use these layers of filters and conditions in first-person analyses, or in ethnographic analyses, but in most cases not in large-scale empirical analyses.
Many specific capability theories make the mistake of defining functionings as those beings and doings that one has reason to value. But the problem with this value-laden definition is that it collapses two aspects of the development of a capability theory into one: the definition of the relevant space (e.g. income, or happiness, or functionings) and, once we have chosen our functionings and capabilities, the normative decision regarding which of those capabilities will be the focus of our theory. We may agree on the first issue and not on the second and still both rightly believe that we endorse a capability theory — yet this is only possible if we analytically separate the normative choice for functionings and capabilities from the additional normative decision of which functionings we will regard as valuable and which we will not regard as valuable. Collapsing these two normative moments into one is not a good idea; instead, we need to acknowledge that there are two normative moves being made when we use functionings and capabilities as our evaluative space, and we need to justify each of those two normative moves separately.
Note that the value-laden definition of functionings and capabilities, which defines them as always good and valuable, may be less problematic when one develops a capability theory of severe poverty or destitution. We all agree that poor health, poor housing, poor sanitation, poor nutrition and social exclusion are dimensions of destitution. So, for example, the dimensions chosen for the Multidimensional Poverty Index developed by Sabina Alkire and her colleagues — health, education and living standard — may not elicit much disagreement. 23 But for many other capability theories, it is disputed whether a particular functionings outcome is valuable or not. The entire field of applied ethics is filled with questions and cases in which these disputes are debated.  Is the capability of parents not to vaccinate their children against polio or measles a valuable freedom? If employees in highly competitive organisations are not allowed to read their emails after working hours, is that then a valuable capability that is taken away from them, or are we protecting them from becoming workaholics and protecting them from the pressure to work all the time, including at evenings and weekends? As these examples show, we need to allow for the conceptual possibility that there are functionings that are always valuable, never valuable, valuable or non-valuable in some contexts but not in others, or where we simply are not sure. This requires that functionings and capabilities are conceptualised in a value-neutral way, and hence this should be a core requirement of the capability approach.
2.6.3 A3: Conversion factors
A third core idea of the capability approach is that persons have different abilities to convert resources into functionings . These are called conversion factors : the factors which determine the degree to which a person can transform a resource into a functioning. This has been an important idea in Amartya Sen’s version of the capability approach (Sen 1992a, 19–21, 26–30, 37–38) and for those scholars influenced by his writings. Resources, such as marketable goods and services, but also goods and services emerging from the non-market economy (including household production) have certain characteristics that make them of interest to people. In Sen’s work in welfare economics, the notion of ‘resources’ was limited to material and/or measurable resources (in particular: money or consumer goods) but one could also apply the notion of conversion factors to a broader understanding of resources, including, for example, the educational degrees that one has.
The example of a bike is often used to illustrate the idea of conversion factors. We are interested in a bike not primarily because it is an object made from certain materials with a specific shape and colour, but because it can take us to places where we want to go, and in a faster way than if we were walking. These characteristics of a good or commodity enable or contribute to a functioning. A bike enables the functioning of mobility, to be able to move oneself freely and more rapidly than walking. But a person might be able to turn that resource into a valuable functioning to a different degree than other persons, depending on the relevant conversion factors. For example, an able-bodied person who was taught to ride a bicycle when he was a child has a high conversion factor enabling him to turn the bicycle into the ability to move around efficiently, whereas a person with a physical impairment or someone who never learnt to ride a bike has a very low conversion factor. The conversion factors thus represent how much functioning one can get out of a resource; in our example, how much mobility the person can get out of a bicycle.
There are several different types of conversion factors, and the conversion factors discussed are often categorized into three groups (Robeyns 2005b, 99; Crocker and Robeyns 2009, 68). All conversion factors influence how a person can be or is free to convert the characteristics of the resources into a functioning, yet the sources of these factors may differ. Personal conversion factors are internal to the person, such as metabolism, physical condition, sex, reading skills, or intelligence. If a person is disabled, or if she is in a bad physical condition, or has never learned to cycle, then the bike will be of limited help in enabling the functioning of mobility. Social conversion factors are factors stemming from the society in which one lives, such as public policies, social norms, practices that unfairly discriminate, societal hierarchies, or power relations related to class, gender, race, or caste. Environmental conversion factors emerge from the physical or built environment in which a person lives. Among aspects of one’s geographical location are climate, pollution, the likelihood of earthquakes, and the presence or absence of seas and oceans. Among aspects of the built environment are the stability of buildings, roads, and bridges, and the means of transportation and communication. Take again the example of the bicycle. How much a bicycle contributes to a person’s mobility depends on that person’s physical condition (a personal conversion factor), the social mores including whether women are generally allowed to ride a bicycle (a social conversion factor), and the availability of decent roads or bike paths (an environmental conversion factor). Once we start to be aware of the existence of conversion factors, it becomes clear that they are a very pervasive phenomenon. For example, a pregnant or lactating woman needs more of the same food than another woman in order to be well-nourished. Or people living in delta regions need protection from flooding if they want to enjoy the same capability of being safely sheltered as people living in the mountains. There are an infinite number of other examples illustrating the importance of conversion factors. The three types of conversion factor all push us to acknowledge that it is not sufficient to know the resources a person owns or can use in order to be able to assess the wellbeing that he or she has achieved or could achieve; rather, we need to know much more about the person and the circumstances in which he or she is living. Differences in conversion factors are one important source of human diversity, which is a central concern in the capability approach, and will be discussed in more detail in section 3.5.
Note that many conversion factors are not fixed or given, but can be altered by policies and choices that we make. And the effects of a particular conversion factor can also depend on the social and personal resources that a person has, as well as on the other conversion factors. For example, having a physical impairment that doesn’t allow one to walk severely restricts one’s capability to be mobile if one finds oneself in a situation in which one doesn’t have access to a wheelchair, and in which the state of the roads is bad and vehicles used for public transport are not wheelchair-accessible. But suppose now the built environment is different: all walking-impaired people have a right to a wheelchair, roads are wheelchair-friendly, public transport is wheelchair-accessible and society is characterised by a set of social norms whereby people consider it nothing but self-evident to provide help to fellow travellers who can’t walk. In such an alternative social state, with a different set of resources and social and environmental conversion factors, the same personal conversion factor (not being able to walk) plays out very differently. In sum, in order to know what people are able to do and be, we need to analyse the full picture of their resources, and the various conversion factors, or else analyse the functionings and capabilities directly. The advantage of having a clear picture of the resources needed, and the particular conversion factors needed, is that it also gives those aiming to expand capability sets information on where interventions can be made.
2.6.4 A4: The means-ends distinction
The fourth core characteristic of the capability approach is the means-ends distinction. The approach stresses that we should always be clear, when valuing something, whether we value it as an end in itself, or as a means to a valuable end. For the capability approach, when considering interpersonal comparisons of advantage, the ultimate ends are people’s valuable capabilities (there could be other ends as well; see 2.6.6). This implies that the capability approach requires us to evaluate policies and other changes according to their impact on people’s capabilities as well as their actual functionings; yet at the same time we need to ask whether the preconditions — the means and the enabling circumstances — for those capabilities are in place. We must ask whether people are able to be healthy, and whether the means or resources necessary for this capability, such as clean water, adequate sanitation, access to doctors, protection from infections and diseases and basic knowledge on health issues are present. We must ask whether people are well-nourished, and whether the means or conditions for the realization of this capability, such as having sufficient food supplies and food entitlements, are being met. We must ask whether people have access to a high-quality education system, to real political participation, and to community activities that support them, that enable them to cope with struggles in daily life, and that foster caring friendships. Hence we do need to take the means into account, but we can only do so if we first know what the ends are.
Many of the arguments that capability theorists have advanced against alternative normative frameworks can be traced back to the objection that alternative approaches focus on particular means to wellbeing rather than the ends. 24 There are two important reasons why the capability approach dictates that we have to start our analysis from the ends rather than the means. Firstly, people differ in their ability to convert means into valuable opportunities (capabilities) or outcomes (functionings) (Sen 1992a, 26–28, 36–38). Since ends are what ultimately matter when thinking about wellbeing and the quality of life, means can only work as fully reliable proxies of people’s opportunities to achieve those ends if all people have the same capacities or powers to convert those means into equal capability sets. This is an assumption that goes against a core characteristic of the capability approach, namely claim A3 — the inter-individual differences in the conversion of resources into functionings and capabilities. Capability scholars believe that these inter-individual differences are far-reaching and significant, and hence this also explains why the idea of conversion factors is a compulsory option in the capability approach (see 2.6.3). Theories that focus on means run the risk of downplaying the normative relevance of not only these conversion factors, but also the differences in structural constraints that people face (see 2.7.5).
The second reason why the capability approach requires us to start from ends rather than means is that there are some vitally important ends that do not depend very much on material means, and hence would not be picked up in our analysis if we were to focus on means only. For example, self-respect, supportive relationships in school or in the workplace, or friendship are all very important ends that people may want; yet there are no crucial means to those ends that one could use as a readily measurable proxy. We need to focus on ends directly if we want to capture what is important.
One could argue, however, that the capability approach does not focus entirely on ends, but rather on the question of whether a person is being put in the conditions in which she can pursue her ultimate ends. For example, being able to read could be seen as a means rather than an end in itself, since people’s ultimate ends will be more specific, such as reading street signs, the newspaper, or the Bible or Koran. It is therefore somewhat more precise to say that the capability approach focuses on people’s ends in terms of beings and doings expressed in general terms: being literate, being mobile, being able to hold a decent job. Whether a particular person then decides to translate these general capabilities into the more specific capabilities A, B or C (e.g. reading street signs, reading the newspaper or reading the Bible) is up to them. Whether that person decides to stay put, travel to the US or rather to China, is in principle not important for a capability analysis: the question is rather whether a person has these capabilities in more general terms. 25 Another way of framing this is to say that the end of policy making and institutional design is to provide people with general capabilities, whereas the ends of persons are more specific capabilities. 26
Of course, the normative focus on ends does not imply that the capability approach does not at all value means such as material or financial resources. Instead, a capability analysis will typically focus on resources and other means. For example, in their evaluation of development in India, Jean Drèze and Amartya Sen (2002, 3) have stressed that working within the capability approach in no way excludes the integration of an analysis of resources such as food. In sum, all the means of wellbeing, like the availability of commodities, legal entitlements to them, other social institutions, and so forth, are important, but the capability approach presses the point that they are not the ends of wellbeing, only their means. Food may be abundant in the village, but a starving person may have nothing to exchange for it, no legal claim on it, or no way of preventing intestinal parasites from consuming it before he or she does. In all these cases, at least some resources will be available, but that person will remain hungry and, after a while, undernourished. 27
Nevertheless, one could wonder: wouldn’t it be better to focus on means only, rather than making the normative analysis more complicated and more informationally demanding by also focusing on functionings and capabilities? Capability scholars would respond that starting a normative analysis from the ends rather than means has at least two advantages, in addition to the fundamental reason mentioned earlier that a focus on ends is needed to appropriately capture inter-individual differences.
First, if we start from being explicit about our ends, the valuation of means will retain the status of an instrumental valuation rather than risk taking on the nature of a valuation of ends. For example, money or economic growth will not be valued for their own sake, but only in so far as they contribute to an expansion of people’s capabilities. For those who have been working within the capability framework, this has become a deeply ingrained practice — but one only needs to read the newspapers for a few days to see how often policies are justified or discussed without a clear distinction being made between means and ends.
Second, by starting from ends, we do not a priori assume that there is only one overriding important means to those ends (such as income), but rather explicitly ask the question: which types of means are important for the fostering and nurturing of a particular capability, or set of capabilities? For some capabilities, the most important means will indeed be financial resources and economic production, but for others it may be a change in political practices and institutions, such as effective guarantees and protections of freedom of thought, political participation, social or cultural practices, social structures, social institutions, public goods, social norms, and traditions and habits. As a consequence, an effective capability-enhancing policy may not be increasing disposable income, but rather fighting a homophobic, ethnophobic, racist or sexist social climate.
2.6.5 A5: Functionings and capabilities as the evaluative space
If a capability theory is a normative theory (as is often the case), then functionings and capabilities form the entire evaluative space, or are part of the evaluative space. 28 A normative theory is a theory that entails a value judgement: something is better than or worse than something else. This value judgement can be used to compare the position of different persons or states of affairs (as in inequality analysis) or it can be used to judge one course of action as ‘better’ than another course of action (as in policy design). For all these types of normative theories, we need normative claims, since concepts alone cannot ground normativity.
The first normative claim which each capability theory should respect is thus that functionings and capabilities form the ‘evaluative space’. According to the capability approach, the ends of wellbeing freedom, justice, and development should be conceptualized in terms of people’s functionings and/or capabilities. This claim is not contested among scholars of the capability approach; for example, Sabina Alkire (2005, 122) described the capability approach as the proposition “that social arrangements should be evaluated according to the extent of freedom people have to promote or achieve functionings they value”. However, if we fully take into account that functionings can be positive but also negative (see 2.6.2), we should also acknowledge that our lives are better if they contain fewer of the functionings that are negative, such as physical violence or stress. Alkire’s proposition should therefore minimally be extended by adding “and to promote the weakening of those functionings that have a negative value”. 29
However, what is relevant is not only which opportunities are open to us individually, hence in a piecemeal way, but rather which combinations or sets of potential functionings are open to us.  Take the following functionings: (1) to hold a job, which will require you to spend many hours on working and commuting, but will generate the income needed to properly feed yourself and your family; (2) to care for your children at home and give them all the attention, care and supervision they need. In a piecemeal analysis, both (1) and (2) are opportunities open to that parent, but they are not both together open to her. The point about the capability approach is precisely that it is comprehensive; we must ask which sets of capabilities are open to us, that is: can you simultaneously provide for your family and properly care for and supervise your children? Or are you rather forced to make some hard, perhaps even tragic choices between two functionings which are both central and valuable?
Note that while most types of capability analysis require interpersonal comparisons, one could also use the capability approach to evaluate the wellbeing or wellbeing freedom of one person at one point in time (e.g. evaluate her situation against a capability yardstick) or to evaluate the changes in her wellbeing or wellbeing freedom over time. The capability approach could thus also be used by a single person in her deliberate decision-making or evaluation processes, but these uses of the capability approach are much less prevalent in the scholarly literature. Yet all these normative exercises share the property that they use functionings and capabilities as the evaluative space — the space in which personal evaluations or interpersonal comparisons are made.
2.6.6 A6: Other dimensions of ultimate value
However, this brings us straight to another core property of module A, namely that functionings and/or capabilities are not necessarily the only elements of ultimate value . Capabilitarian theories might endorse functionings and/or capabilities as their account of ultimate value but may add other elements of ultimate value, such as procedural fairness. Other factors may also matter normatively, and in most capability theories these other principles or objects of evaluation will play a role. This implies that the capability approach is, in itself, incomplete as an account of the good since it may have to be supplemented with other values or principles. 30 Sen has been a strong defender of this claim, for example, in his argument that capabilities capture the opportunity aspect of freedom but not the process aspect of freedom, which is also important (e.g. Sen 2002a, 583–622). 31
At this point, it may be useful to reflect on a suggestion made by Henry Richardson (2015) to drop the use of the word ‘intrinsic’ when describing the value of functionings and capabilities — as is often done in the capability literature. For non-philosophers, saying that something has ‘intrinsic value’ is a way to say that something is much more important than something else, or it is used to say that we don’t need to investigate what the effects of this object are on another object. If we think that something doesn’t have intrinsic value, we would hold that it is desirable if it expands functionings and capabilities; economic growth is a prominent example in both the capability literature and in the human development literature. Yet in philosophy, there is a long-standing debate about what it means to say of something that it has intrinsic value, and it has increasingly been contested that it is helpful to speak of ‘intrinsic values’ given what philosophers generally would like to say when they use that word (Kagan 1998; Rabinowicz and Rønnow-Rasmussen 2000).
In philosophy, the term ‘intrinsic’ refers to a metaphysical claim; something we claim to be intrinsically valuable only derives its value from some internal properties. Yet in the capability approach, this is not really what we want to say about functionings (or capabilities). Rather, as Richardson rightly argues, we should be thinking about what we take to be worth seeking for its own sake. Richardson prefers to call this ‘thinking in terms of final ends’; in addition, one could also use the terminology ‘that which has ultimate value’ (see also Rabinowicz and Rønnow-Rasmussen 2000, 48). 32 This has the advantage that we do not need to drop the widely used, and in my view very useful, distinction between instrumental value and ultimate value. Those things that have ultimate value are the things we seek because they are an end (of policy making, decision making, evaluations); those things that do not have ultimate value, hence that are not ends, will be valued to the extent that they have instrumental value for those ends.
Of course, non-philosophers may object and argue they are using ‘intrinsic value’ and ‘ultimate value’ as synonyms. But if we want to develop the capability approach in a way that draws on the insights from all disciplines, we should try to accommodate this insight from philosophy into the interdisciplinary language of the capability approach, especially if there is a very easy-to-use alternative available to us. We can either, as Richardson proposes, speak of the selected functionings and capabilities as final ends , or we can say that the selected functionings and capabilities have ultimate value — that is, they have value as ends in themselves and not because they are useful for some further end. It is of course possible for a capability to have ultimate value and for the corresponding functioning to have instrumental value. For example, being knowledgeable and educated can very plausibly be seen as of ultimate value, but is also of instrumental value for various other capabilities, such as the capability of being healthy, being able to pursue projects, being able to hold a job, and so forth.
However, the question is whether it is possible to change the use of a term that is so widespread in some disciplines yet regarded as wrong from the point of view of another discipline. It may be that the best we can hope for is to become aware of the different usages of the term ‘intrinsic value’, which in the social sciences is used in a much looser way than in philosophy, and doesn’t have the metaphysical implications that philosophers attribute to it.
2.6.7 A7: Value pluralism
There are at least two types of value pluralism within the capability approach. One type is the other objects of ultimate value, which was briefly addressed in the previous section. This is what Sen called in his Dewey lectures principle pluralism (Sen 1985c, 176). Expanding capabilities and functionings is not all that matters; there are other moral principles and goals with ultimate value that are also important when evaluating social states, or when deciding what we ought to do (whether as individuals or policy makers). Examples are deontic norms and principles that apply to the processes that lead to the expansion of capability sets. This value pluralism plays a very important role in understanding the need to have the C-module C4, which will be discussed in section 2.8.4.
It is interesting to note that at some stage in Sen’s development of the capability approach, his readers lost this principle-pluralism and thought that the capability approach could stand on its own. But a reading of Sen’s earlier work on the capability approach shows that all along, Sen felt that capabilities can and need to be supplemented with other principles and values. For example, in his 1982 article ‘Rights and Agency’, Sen argues that “goal rights, including capability rights, and other goals, can be combined with deontological values […], along with other agent-relative considerations, in an integrated system” (Sen 1982, 4). Luckily, the more recent publications in the secondary literature on the capability approach increasingly acknowledge this principle pluralism; the modules A7 and C4 of the modular view presented in this book suggest that it is no longer possible not to acknowledge this possibility.
The second type of value-pluralism relates to what is often called the multidimensional nature of the capability approach. Functionings and capabilities are not ‘values’ in the sense of ‘public values’ (justice, efficiency, solidarity, ecological sustainability, etc.) but they are objects of ultimate value — things that we value as ends in themselves. Given some very minimal assumptions about human nature, it is obvious that these dimensions are multiple: human beings value the opportunity to be in good health, to engage in social interactions, to have meaningful activities, to be sheltered and safe, not be subjected to excessive levels of stress, and so forth. Of course, it is logically conceivable to say that for a particular normative exercise, we only look at one dimension. But while it may be consistent and logical, it nevertheless makes no sense — for at least two reasons.
First, the very reason why the capability approach has been offered as an alternative to other normative approaches is to add informational riches — to show which dimensions have been left out of the other types of analysis, and why adding them matters. It also makes many evaluations much more nuanced, allowing them to reflect the complexities of life as it is. For example, an African-American lawyer may be successful in her professional life in terms of her professional achievements and the material rewards she receives for her work, but she may also encounter disrespect and humiliation in a society that is sexist and racist. Being materially well-off doesn’t mean that one is living a life with all the capabilities to which one should be entitled in a just society. Only multi-dimensional metrics of evaluation can capture those ambiguities and informational riches.
Second, without value pluralism, it would follow that the happiness approach is a special case of the capability approach — namely a capability theory in which only one functioning matters, namely being happy. Again, while this is strictly speaking a consistent and logical possibility, it makes no sense given that the capability approach was conceived to form an alternative to both the income metric and other resourcist approaches on the one hand, and the happiness approach and other mental metric approaches on the other. Thus, in order to make the capability approach a genuine alternative to other approaches, we need to acknowledge several functionings and capabilities, rather than just one.
2.6.8 A8: The principle of each person as an end
A final core property of each capability theory or application is that each person counts as a moral equal. Martha Nussbaum calls this principle “the principle of each person as an end”. Throughout her work she has offered strong arguments in defence of this principle (Nussbaum 2000, 56):
The account we strive for [i.e. the capability approach] should preserve liberties and opportunities for each and every person, taken one by one, respecting each of them as an end, rather than simply as the agent or supporter of the ends of others. […] We need only notice that there is a type of focus on the individual person as such that requires no particular metaphysical position, and no bias against love or care. It arises naturally from the recognition that each person has just one life to live, not more than one. […] If we combine this observation with the thought […] that each person is valuable and worthy of respect as an end, we must conclude that we should look not just to the total or the average, but to the functioning of each and every person.
Nussbaum’s principle of each person as an end is the same as what is also known as ethical or normative individualism in debates in philosophy of science. Ethical individualism , or normative individualism , makes a claim about who or what should count in our evaluative exercises and decisions. It postulates that individual persons, and only individual persons are the units of ultimate moral concern. In other words, when evaluating different social arrangements, we are only interested in the (direct and indirect) effects of those arrangements on individuals.
As will be explained in more detail in section 4.6, the idea of ethical individualism is often conflated with other notions of individualism, such as the ontological idea that human beings are individuals who can live and flourish independently of others. However, there is no such claim in the principle of ethical individualism. The claim is rather one about whose interests should count. And ethical individualism claims that only the interests of persons should count. Ultimately, we care about each individual person. Ethical individualism forces us to make sure we ask questions about how the interests of each and every person are served or protected , rather than assuming that because, for example, all the other family members are doing fine, the daughter-in-law will be doing fine too. If, as all defensible moral theories do, we argue that every human being has equal moral worth, then we must attach value to the interests of each and every one of the affected persons. Thus, my first conclusion is that ethical individualism is a desirable property, since it is necessary to treat people as moral equals.
But ethical individualism is not only a desirable property, it is also an unavoidable property. By its very nature the evaluation of functionings and capabilities is an evaluation of the wellbeing and freedom to achieve wellbeing of individual persons. Functionings are ‘beings’ and ‘doings’: these are dimensions of a human being, which is an embodied being, not merely a mind or a soul. And with the exception of the conjoined twins, and the case of the unborn child and the pregnant mother, bodies are physically separated from each other. 33 We are born as a human being with a body and future of her own, and we will die as a human being with a body and a past life narrative that is unique. This human being, that lives her life in an embodied way, thus has functionings that are related to her person, which is embodied. It is with the functionings and capabilities of these persons that the capability approach is concerned with. 34 However, as I will explain in detail in section 4.6, from this it does not follow that the capability approach conceptualises people in an atomistic fashion, and thus that the capability approach is ‘individualistic’ — meant in a negative, pejorative way. And it also does not imply that a capabilitarian evaluation could not also evaluate the means (including social institutions, structures, and norms) as well as conversion factors, as well as non-capabilitarian elements of value — as long as we are clear what the role or status of each of those elements is. 35
Note that the use of the term ‘normative individualism’ is deeply disputed. Some scholars see no problem at all in using that term, since they use it in a technical sense that they believe should not be conflated with any pejorative use of the term ‘individualism’ in daily life. Other scholars resist the term ‘ethical individualism’, since they cannot separate it from (a) the notions of ontological and explanatory individualism, and/or (b) from the pejorative meaning that the term ‘individualism’ has in daily life, which is probably close to a term such as ‘egoism’. While the first group is, in my view, right, the second group conveys important information about how the capability approach will be perceived in a broader setting, including outside academia. It may therefore be recommendable to replace the term ‘ethical or normative individualism’ with the term ‘the principle of each person as an end’ whenever possible.
17 See section 2.2 for an explanation of the technical term ‘advantage’.
18 For some core differences in the way Martha Nussbaum and Amartya Sen use the terms ‘functionings’ and ‘capabilities’, see section 3.2.
19 See also section 3.3 which discusses in more depth the kind of freedoms or opportunities that capabilities are.
20 The exceptions are those philosophers who want to develop normative theories while steering away from any metaphysical claims (that is, claims about how things are when we try to uncover their essential nature). I agree that the description of ‘functionings’ and ‘capabilities’ in this section makes metaphysical claims, but I think they are very ‘minimal’ (in the sense that they are not wildly implausible, and still leave open a wide variety of theories to be developed) and hence we should not be troubled by these metaphysical assumptions.
21 Arguably, some of that work is being done by social choice theorists and others working with axiomatic methods, but unfortunately almost none of the insights of that work have spread among the disciplines within the capability literature where axiomatic and other formal methods are not used (and, presumably, not well understood). See, for example, Pattanaik (2006); Xu (2002); Gotoh, Suzumura and Yoshihara (2005); Gaertner and Xu (2006, 2008).
22 On the complex nature of ‘care’, and what the need to care and be cared for requires from a just society, see e.g. Tronto (1987); Kittay (1999); Nussbaum (2006b); Folbre (1994); Folbre and Bittman (2004); Engster (2007); Gheaus (2011); Gheaus and Robeyns (2011).
23 The Multidimensional Poverty Index is developed by the Oxford Poverty and Human Development Initiative (OPHI), under the leadership of Sabina Alkire. See http://www.ophi.org.uk/multidimensional-poverty-index/ for a clear introduction of the Multidimensional Poverty Index. For scholarly papers on the Index, as well as other work done by the scholars in OPHI, see http://www.ophi.org.uk/resources/ophi-working-papers/
24 This is a critique that the capability approach shares with the happiness approach, which also focusses on what it considers to be an end in itself — happiness. Still, capability scholars have reasons why they do not endorse the singular focus on happiness, as the happiness approach proposes. See section 3.8.
25 However, while a focus on available options rather than realised choices is the default normative focus of capability theories, there are some capability applications where, for good reasons, the focus is on achieved functionings rather than capabilities. This will be elaborated in the next section.
26 On the distinction between general capabilities and specific capabilities, see 3.2.4.
27 The relationship between means and capabilities is analysed in more depth in section 3.12.
28 I am using the term ‘normative’ here in the way it is used by social scientists, hence encompassing what philosophers call both ‘normative’ and ‘evaluative’. For these different uses of terminology, see section 2.2. It is also possible to use the notions of ‘functionings’ and ‘capabilities’ for non-normative purposes (see section 3.10). In that case, the basic notions from the core are all that one takes from the capability approach; one does not need this normative part of the core. I will suggest in the concluding chapter 5 that explanatory applications of the capability approach are part of how it could be fruitfully developed in the future.
29 Moreover, further extensions of this proposition may be needed. One issue is that we should not only focus on capabilities that people value, but also on capabilities that they do not, but should, value (see section 2.7.2). Another issue is that the evaluative space should not necessarily be restricted to capabilities only, but could also be functionings, or a combination of functionings and capabilities (see section 2.6.5).
30 For example, if Henry Richardson (2007) is right in arguing that the idea of capabilities cannot capture basic liberties, then one need not reject the capability approach, but instead could add an insistence on basic liberties to one’s capability theory, as Richardson (2007, 394) rightly points out.
31 This distinction, and its relevance, will be discussed in more detail in section 3.3.
32 “[…] the relevant values can be said to be ‘end-point values’, insofar as they are not simply conducive to or necessary for something else that is of value. They are ‘final’, then, in this sense of being ‘ultimate’” (Rabinowicz and Rønnow-Rasmussen 2000, 48).
33 As Richardson (2016, 5) puts it, “all capabilities […] are dependent on the body. Without relying on one’s body there is nothing one can do or be”.
34 Some have argued in favour of what they call ‘collective capabilities’, which I will discuss in section 3.6.
35 However, the question remains whether the capability approach is fully compatible with indigenous world views and normative frameworks, as well as thick forms of communitarianism. This is a question that doesn’t allow for a straightforward answer, and requires more analysis. For some first explorations of the compatibility of indigenous world views with the capability approach, see Binder and Binder (2016); Bockstael and Watene (2016); Watene (2016).


2.3: The Function e^jθ and the Unit Circle
Let's try to extend our definitions of the function \(e^x\) to the argument \(x=jΘ\). Then \(e^{jΘ}\) is the function
\[e^{jθ}=lim_{n→∞}(1+j\frac θ n)^n \nonumber \]
The complex number \(1+j\frac θ n\) is illustrated in the Figure. The radius to the point \(1+j\frac θ n\) is \(r=(1+\frac {θ^2} {n^2})^{1/2}\) and the angle is \(φ=\tan^{−1}\frac θ n\)
This means that the n th power of \(1+j\frac θ n\) has radius \(r^n=(1+\frac {θ^2} {n^2})^{n/2}\) and angle \(nφ=n\;\tan^{−1}\frac θ n\) (Recall our study of powers of z.)
Therefore the complex number \((1+j\frac θ n)^n\) may be written as
\[(1+j\frac θ n)^n=(1+\frac {θ^2} {n^2})^{n/2}[\cos(n\;\tan^{−1}\frac θ n)+j\sin(n\tan^{−1}\frac θ n)] \nonumber \]
For \(n\) large, \((1+\frac {θ^2} {n^2})^{n/2}2≅1\), and \(n\tan^{−1}\frac θ n≅n \frac θ n=θ\). Therefore \((1+j\frac θ n)^n\) is approximately
\[(1+j\frac θ n)^n=1(\cosθ+j\sinθ) \nonumber \]
This finding is consistent with our previous definition of \(e^{jθ}\) !
The series expansion for \(e^{jθ}\) is obtained by evaluating Taylor's formula at \(x=jθ\):
\[e^{jθ}=∑_{n=0}^∞\frac 1 {n!}(jθ)n \nonumber \]
When this series expansion for \(e^{jθ}\) is written out, we have the formula
\[e^{jθ}=∑^∞_{n=0}\frac 1 {(2n)!} (jθ)^{2n}+∑^∞_{n=0}\frac 1 {(2n+1)!}(jθ)^{2n+1} = ∑^∞_{n=0}\frac {(−1)^n} {(2n)!} θ^{2n}+j∑^∞_{n=0}\frac {(−1)^n}{(2n+1)!} θ^{2n+1} \nonumber \]
It is now clear that \(\cosθ\) and \(\sinθ\) have the series expansions
\[\cosθ=∑^∞_{n=0}\frac {(−1)^n} {(2n)!} θ^{2n} \nonumber \]
\[\sinθ=∑_{n=0}^∞\frac {(−1)^n} {(2n+1)!} θ^{2n+1} \nonumber \]
When these infinite sums are truncated at N−1, then we say that we have N-term approximations for \(\cosθ\) and \(\sinθ\):
\[\cosθ≅∑^{N−1}_{n=0} \frac {(−1)^n} {(2n)!} θ^{2n} \nonumber \]
\[\sinθ≅∑_{n=0}^{N−1} \frac {(−1)^n} {(2n+1)!} θ^{2n+1} \nonumber \]
The ten-term approximations to \(\cosθ\) and \(\sinθ\) are plotted over exact expressions for \(\cosθ\) and \(\sinθ\) in the Figure. The approximations are very good over one period \((0≤θ≤2π)\), but they diverge outside this interval. For more accurate approximations over a larger range of θ′s, we would need to use more terms. Or, better yet, we could use the fact that \(cosθ\) and \(sinθ\) are periodic in θ. Then we could subtract as many multiples of \(2π\) as we needed from θ to bring the result into the range \([0,2π]\) and use the ten-term approximations on this new variable. The new variable is called θ-modulo \(2π\).
Write out the first several terms in the series expansions for \(\cosθ\) and \(\sinθ\).
Demo 2.1 (MATLAB)
Create a MATLAB file containing the following demo MATLAB program that computes and plots two cycles of \(\cosθ\) and \(\sinθ\) versus θ. You should observe Figure. Note that two cycles take in \(2(2π)\) radians, which is approximately 12 radians.
clg;
j = sqrt(-1);
theta = 0:2*pi/50:4*pi;
s = sin(theta);
c = cos(theta);
plot(theta,s);
elabel('theta in radians');
ylabel('sine and cosine');
hold on
plot(theta,c);
hold off
(MATLAB) Write a MATLAB program to compute and plot the ten-term approximations to \(\cosθ\) and \(\sinθ\) for θ running from 0 to \(2(2π)\) in steps of \(2π/50\). Compute and overplot exact expressions for \(\cosθ\) and \(\sinθ\). You should observe a result like the Figure.
The Unit Circle
The unit circle is defined to be the set of all complex numbers z whose magnitudes are 1. This means that all the numbers on the unit circle may be written as \(z=e^{jθ}\). We say that the unit circle consists of all numbers generated by the function \(z=e^{jθ}\) as θ varies from 0 to \(2π\). See below Figure.
A Fundamental Symmetry
Let's consider the two complex numbers \(z_1\) and \(\frac 1 {z^∗_1}\), illustrated in Figure. We call \(\frac 1 {z^∗_1}\)the “reflection of z through the unit circle” (and vice versa). Note that \(z_1=r_1e^{jθ_1}\) and \(\frac 1 {z^∗_1} = \frac 1 {r_1e^{jθ_1}}\). The complex numbers \(z_1−e^{jθ}\) and \(\frac 1 {z^*_1} −e^{jθ}\) are illustrated in the Figure below. The magnitude squared of each is
\[|z_1−e^{jθ}|^2=(z_1−e^{jθ})(z^∗_1−e^{−jθ}) \nonumber \]
\[|\frac 1 {z^*_1} −e^{jθ}|^2=(\frac 1 {z^*_1−e^{jθ}})(\frac 1 {z_1} −e^{−jθ}) \nonumber \]
The ratio of these magnitudes squared is
\[β^2=\frac {(z_1−e^{jθ})(z^∗_1−e^{−jθ})} {(\frac 1 {z^*_1}−e^{jθ})(\frac 1 {z_1} −e^{−jθ})} \nonumber \]
This ratio may be manipulated to show that it is independent of θ, meaning that the points \(z_1\) and \(\frac 1 {z^∗_1}\) maintain a constant relative distance from every point on the unit circle:
\[β^2=\frac {e^{jθ}(e^{−jθ}z_1−1)(z^∗_1e^{jθ}−1)e^{−jθ}} {\frac {1} {zi} (1−e^{jθ}z^∗_1)(1−z_1e^{−jθ}) \frac 1 z_1} = |z_1|^2 \;,\;\mathrm{independent} \;\mathrm{of}\;θ! \nonumber \]
This result will be of paramount importance to you when you study digital filtering, antenna design, and communication theory.
Write the complex number \(z−e^{jθ}\) as \(re^{jφ}\). What are \(r\) and \(φ\)?


13.4: Blood Transfusions
By the end of this section, you will be able to:
- Describe steps for administering blood and blood products
- Understand procedures for initiation and transfusion of blood
- Recall different blood transfusion reactions
Blood transfusions are potentially life-saving procedures that replace deficits in blood volume or blood cells with blood donated by the patient (autologous donation) or another individual (Association for the Advancement of Blood and Biotherapies [AABB], 2018). A variety of clinical conditions may require administration of whole blood and blood products, individual components of blood, such as red blood cell s, platelet s, plasma , cryoprecipitated antihemophilic factor (cryo), white blood cells , and granulocytes . They may be needed to increase circulating blood volume after surgery, trauma, or hemorrhage. Other times, blood and blood products may be necessary to increase the number of red blood cells (RBCs) to maintain hemoglobin levels for those with severe anemia or to provide cellular replacement therapy. It is critical for the nurse to learn the proper method of administering blood transfusions and be able to identify potential adverse reactions.
Administering Blood and Blood Products
When administering blood and blood products, the nurse should always verify the provider’s order, including the type of product, amount, date, time, rate, duration of infusion, and specific transfusion instructions, with another qualified provider (AABB, 2018; The Joint Commission, 2021). After verifying the order, the nurse should identify if the patient needs pre- or post-transfusion medications, assess related laboratory values, and understand why the transfusion is indicated for the patient.
The nurse may then explain the procedure to the patient and answer any questions they have. Ask the patient if they have ever received a blood transfusion in the past, and if so, how they tolerated the procedure and if they were premedicated prior to the procedure. Premedicating the patient prior to a blood transfusion may minimize the risk of allergic reaction s to blood products. Indications for premedication may include patients with a history of an allergic reaction to blood transfusions, multiple transfusions, chronic illnesses, anxiety, febrile reaction s, or autoimmune disorders.
Confirm blood type and crossmatch and await notification from the blood bank that the blood or blood products are ready to be administered. Just before obtaining the blood products, collect baseline vital signs, and notify the provider if temperature is greater than 100°F (37.8°C).
Jehovah’s Witnesses may refuse blood or blood product transfusions due to their religious beliefs. These individuals may refuse whole blood or primary blood components but may accept blood derivatives, such as albumin , clotting factor, and immunoglobulins. It is important to assess patient religious beliefs that may interfere with treatment by blood transfusions, but never automatically assume they will refuse the treatment. Instead, educate the patient as to why the blood transfusion is needed, ask the patient about their individual preferences, and respect their wishes if they refuse the blood transfusion. If the patient does refuse the treatment, document the refusal, and notify the provider.
See the competency checklist for Preparing for a Blood or Blood Product Transfusion. You can find the checklists on the Student resources tab of your book page on openstax.org.
Blood Typing and Crossmatching
Blood typing and crossmatching ensure compatibility of the donor’s blood with the recipient’s blood. The blood typing results identify the blood type and Rh factor. And crossmatching is used to check for harmful interactions between the donor’s and recipient’s blood. Blood typing and crossmatching are essential to caring for patient safety when a blood transfusion is required.
Blood Types
Blood type depends on the antigens found in the RBCs. There are four main types of blood: A, B, AB, and O. Type A blood contains type-A antigens. Type B blood contains type-B antigens. Type AB blood contains type-A and type-B antigens. Type O blood has no antigens, making it well suited for donation.
Rh Factor
Rh factor is determined by whether a certain protein, rhesus factor, is present on the RBCs. Blood may be classified as either Rh positive (+) or Rh negative (−). Rh+ blood contains the Rh protein on the RBCs, whereas Rh− blood lacks the Rh protein. Rh+ is the most common blood type, but Rh− blood does not indicate illness or affect one’s health.
The Rh factor is one of the key factors that determine the compatibility of blood for transfusion. For a blood transfusion to be safe and successful, the recipient’s Rh type must match the donor’s Rh type. For example, a patient who is Rh-negative should receive blood from an Rh-negative donor to avoid potential transfusion reactions . Mismatched Rh factors during a blood transfusion can lead to adverse reactions, including hemolysis (destruction of RBCs), fever, jaundice , and more serious complications. Therefore, ensuring compatibility in terms of the Rh factor is crucial to prevent these reactions.
Blood Donors
When receiving a blood transfusion, it is important that the blood of the donor is compatible with the blood of the recipient. Antibodies may trigger immune reactions against blood that is incompatible. Persons with type A blood should only receive types A or O blood. Persons with type B blood should only receive types B or O blood. Persons with type AB blood are universal recipients and can receive types A, B, AB, or O blood.  Type O blood is often used in emergent situations when blood typing cannot be performed.
In addition to the blood type, the Rh factor plays a critical role. Persons with Rh+ blood may receive both Rh+ and Rh− blood. Those with Rh− blood, however, can only receive Rh− blood. For the transfusion to be considered safe, both the blood type and Rh factor must be compatible (Table 13.2).
| Blood Type | Can Donate To | Can Receive From |
|---|---|---|
| A+ | A+, AB+ | A+, A−, O+, O− |
| O+ | O+, A+, B+, AB+ | O+, O− |
| B+ | B+, AB+ | B+, B−, O+, O− |
| AB+ | AB+ | All types |
| A− | A+, A−, AB+, AB− | A−, O− |
| O− | All types | O− |
| B− | B+, B−, AB+, AB− | B−, O− |
| AB− | AB+, AB− | AB−, A−, B−, O− |
Blood Components
Blood may be administered as whole blood or as individual blood components. Individual blood components can treat particular conditions and allow multiple people to benefit from one pint of whole blood. Blood components include RBCs, platelets, plasma , cryoprecipitated antihemophilic factor (cryo), white blood cells , and granulocytes . For example, a patient with low hemoglobin due to anemia can receive a red blood cell transfusion that contains just the RBCs. A cancer patient receiving chemotherapy can receive a platelet transfusion to correct a low platelet count. A person with clotting factor deficiencies can receive a transfusion of fresh frozen plasma to treat their specific clotting disorder.
A red blood cell , also known as an erythrocyte, is the most administered blood component. They carry oxygen from the lungs throughout the body and take carbon dioxide back to the lungs. As the name suggests, RBCs are red in color (Figure 13.23). Commonly referred to as packed red blood cells , they increase hemoglobin and iron levels and improve oxygen levels within the body. They are most frequently administered to patients experiencing anemia.
A platelet , also known as a thrombocyte, is a small, colorless cell fragment that sticks to the lining of a blood vessel to stop bleeding. Platelets are often given to patients experiencing leukemia, blood disorders, or other types of cancer. Some patients with cancer require platelet transfusions as a side effect of chemotherapy, while other patients may have a type of cancer that itself stops the body from creating platelets.
The liquid portion of the blood that carries the red and white blood cells throughout the body is termed plasma . It helps to maintain blood pressure and volume, carries electrolytes to muscles, assists in maintaining pH balance, and supplies proteins for clotting and immunity. Plasma is yellow in color and must be kept frozen to preserve the clotting factor (Figure 13.24). Plasma transfusions are often required for those experiencing liver failure, severe infections, shock, bleeding disorders, or serious burns. During the COVID-19 pandemic, some patients with specific symptoms were treated with convalescent plasma therapy to possibly hasten their recovery.
A portion of plasma that is rich in clotting factors is termed cryoprecipitated antihemophilic factor (cryo). It helps reduce blood loss by slowing or stopping bleeding. It is white in color and must be kept frozen to preserve the clotting factor. Cryo is used for clotting disorders, such as hemophilia and von Willebrand disease.
The white blood cells , also known as leukocytes, help the body fight against disease. They destroy bacteria and create antibodies against bacteria, viruses, and diseases. While your own white blood cells help you to remain healthy, foreign white blood cells may suppress the immune system or be toxic when transfused in other persons. Some patients have very few white blood cells because of severe illness. A transfusion of white blood cells would help their body fight infection, in the same way that more soldiers are brought in to fight a battle.
The granulocytes are a particular type of white blood cell that protect against infection by destroying invading bacteria and viruses. They may be administered to treat infections that are not responsive to antibiotics.
Starting a Blood Transfusion
Before a blood transfusion, there are a number of steps nurses must take. Nurses should ensure completion of blood type determination and crossmatch, obtain baseline vital signs, and collect necessary supplies at the bedside, such as blood tubing and normal saline . The nurse must also explain the procedure to the patient and inform the patient to immediately report symptoms of a possible blood transfusion reaction, such as sweating, chills, chest pain, shortness of breath, headache, back pain, nausea, vomiting, or itching. Then it is time to obtain blood from the blood bank. As a general rule, only retrieve one package of blood or blood products from the blood bank at a time. A transfusion must be started within thirty minutes and must be completed within four hours of obtaining the blood. At the blood bank and once on the unit, the nurse must verify the identity of the patient, transfusion order, transfusion consent, blood type, and compatibility before beginning the transfusion.
Nurse:
Jocelyn, RN
Clinical setting:
Inpatient orthopedic unit
Years in practice:
13
Facility location:
South Carolina
As a nurse for over thirteen years, I have administered blood on numerous occasions. Administering blood requires careful planning to ensure that the process goes smoothly. Over the years, I have learned that up-front preparation can save you a lot of time and effort in the end. For example, prior to obtaining the blood, always check to make sure that the patient’s IV is properly working, that you have a vital sign machine in the patient’s room, and that you have the necessary supplies, such as blood tubing and normal saline.
I encountered a situation in which the patient’s IV was saline locked; I went to hang the blood and found the IV was occluded. After two attempts to restart the IV, the IV team had to be called to restart the IV. Realizing time was ticking, I had to return the blood to the blood bank until the IV could be restarted. Another time, I was attempting to find a vital sign machine, but they were all occupied by the nursing aides. After searching the unit for over ten minutes, I finally located a vital sign machine. Then I had to find another nurse to verify the blood, which took another five to ten minutes. That left a very short window of time for the blood products to be initiated within the given twenty- to thirty-minute window. Other times, I have had the blood in hand and the second nurse waiting for me in the room only to find the blood tubing bin empty in the supply room. Thankfully, I was able to go to another department and borrow blood tubing, but it would have been more efficient to have gathered the blood tubing prior to obtaining the blood. These lessons have taught me to always plan ahead when administering blood so that everything is in the patient’s room and ready to go once the blood has been gathered from the blood bank.
Start the infusion slowly for the first fifteen minutes, rates determined per facility policy. Remain at the patient’s bedside for the first fifteen minutes and monitor for adverse reactions (INS, 2024). After fifteen minutes, retake and document vital signs. If vital signs remain stable and the patient does not display symptoms of a reaction, increase the rate of the blood according to the agency’s policy. Obtain and document vital signs every hour for the duration of the transfusion. Instruct the patient and family to report any unusual reactions immediately (AABB, 2018). Once the transfusion has ended, clamp the blood tubing above the filter, open the roller clamp for the normal saline , and flush the tubing until no visible blood remains in the IV tubing. Disconnect the blood tubing from the patient’s IV and discard the tubing in an appropriate biohazard container. Obtain and document a final set of vital signs as well as the patient’s post-transfusion status.
Verification Protocols
After retrieving the blood or blood products from the blood bank, two nurses must verify the provider’s order and ensure that the blood product label matches the information found on the patient’s blood bank bracelet (AABB, 2018). One nurse should read the information from one source while the other nurse confirms the same information on the other source. Both nurses should verify the serial number, blood component, blood type, Rh factor , and expiration date match. Confirm the identity of the patient as well, by looking at the blood product label and patient’s identification bracelet, the patient’s name, date of birth, and medical record number. Both nurses should document their verification according to the agency’s policy (Figure 13.25). If any discrepancies are noted, do not start the transfusion, and immediately notify the blood bank.
Blood Tubing
When administering blood and blood products , it is critical to use tubing that is specially marked as blood tubing (Figure 13.26). Blood tubing is a Y-tube with a special micromesh filter that prevents blood clots and particles from accidentally being administered to the patient. Make sure that all roller clamps (two above the filter and one below the filter) are closed prior to proceeding. Using one of the Y-connectors, spike a bag of normal saline, unclamp the roller clamp above the Y-site on the saline tubing, squeeze the filter chamber until the saline covers the filter and fills one-third to one-half of the drip chamber . Open the roller clamp below the drip chamber to prime the saline tubing all the way to the distal end of the tubing, then clamp the roller clamp.
Spike the blood with the other Y-tubing by carefully inserting the IV tubing into the port, being careful not to puncture any portion of the blood bag except the port area. Ensure the spike is completely entered into the blood bag. Unclamp the roller clamp on the blood Y-tubing and squeeze the filter chamber until the blood covers the filter. Write the date and time on the blood tubing because blood tubing should be changed at least every four hours to reduce the risk of bacterial growth.
See the competency checklist for Administering a Blood Transfusion. You can find the checklists on the Student resources tab of your book page on openstax.org.
Transfusion Reactions
When administering blood and blood products, there is always a risk of a transfusion reaction. Reactions may be mild or severe and occur within twenty-four to forty-eight hours post-transfusion. Transfusion reactions are categorized as allergic, febrile , hemolytic transfusion, circulatory overload , or bacterial. While a reaction may occur at any point during the transfusion, most reactions typically occur within the first fifteen to twenty minutes after administration. As such, it is critical that the nurse remain with the patient for at least the first fifteen minutes of the transfusion (or longer if required by the agency’s policy) and monitor vital signs. Monitor altered vital signs, such as increased temperature or respiratory rate, closely.
If you suspect a reaction, immediately stop the transfusion, and notify the provider. If the patient experiences an adverse reaction that may be uncomfortable but generally not life-threatening, considered a mild reaction, such as a fever, itching, rash, or mild discomfort at the infusion site, stop the transfusion and notify the provider. Many times, the provider will treat the symptoms (such as administering acetaminophen for a fever or diphenhydramine for itching) and continue the transfusion with close monitoring of the patient.
Moderate reactions are characterized by more pronounced symptoms that can cause discomfort and concern, such as moderate to severe shortness of breath, significant fever, and pronounced skin reactions. Moderate reactions can result from factors like transfusion-associated circulatory overload, more severe allergic responses, or worsening of mild reactions. In the event of moderate reactions, stop the transfusion, and notify the provider. Management of moderate reactions may involve slowing or stopping the transfusion as well as symptom treatment. Severe reactions are the most serious and life-threatening type of transfusion reaction. They can include severe respiratory distress, shock, renal failure, severe hemolysis (destruction of red blood cell s), and cardio vascular collapse . Severe reactions are typically caused by major incompatibilities, such as ABO or Rh mismatches, transfusion of incompatible blood components, bacterial contamination, or acute hemolytic reactions. Severe reactions require immediate discontinuation of the transfusion, aggressive supportive care, and specific treatments tailored to the underlying cause. Management may include administering medications, providing oxygen, and ensuring hemodynamic stability.
In the event a transfusion reaction occurs and the blood is discontinued by the provider, disconnect the blood tubing and start normal saline with new IV tubing to keep the IV line open. If the patient is experiencing shortness of breath, sit the patient upright and start oxygen. Remain with the patient and monitor vital signs every fifteen minutes. Prepare to administer emergency medications, such as antihistamines, fluids, steroids, or vasopressors, depending on the provider’s orders or standing protocols that may be in place. Collect blood and urine samples according to agency policy and provider orders. Check all blood bag labels, forms, orders, and the patient’s identification band to determine whether a clerical discrepancy exists. Keep the blood container, tubing, and transfusion record and send to the blood bank for analysis. Document the symptoms, the time symptoms began, actions taken, as well as the patient’s current condition. Complete an incident report according to the agency’s policy.
See the competency checklist for Managing a Blood or Blood Product Transfusion Reaction. You can find the checklists on the Student resources tab of your book page on openstax.org.
Allergic Reaction
An allergic reaction occurs when the immune system reacts to the donor’s antibodies. Common symptoms of an allergic reaction include flushing, hives, rash, pruritus , difficulty breathing, laryngeal edema , wheezing, and possible anaphylaxis . Treatment for allergic reaction s may include antihistamines, steroids, and epinephrine.
Scenario: Provider ordered two units packed red blood cells (PRBCs). The nurse initiated the first unit of PRBCs ten minutes ago.
Patient: Nurse, I don’t feel so good.
Nurse: Mr. Jackson, can you tell me more about how you are feeling?
Patient: I’m itching all over, and I feel like my throat is tight.
Nurse: Mr. Jackson, I’m going to stop the blood transfusion for a moment until we know what is going on. I’m going to take a look at your arms, legs, and back and listen to your heart and lungs.
[Nurse assesses patient.]
Nurse: Mr. Jackson, I noticed you have a rash on your back and arms. I hear wheezing in your lungs, and your heart seems to be beating faster than usual. I think you are having an adverse reaction to the blood products.
Patient: Am I going to be okay?
Nurse: You are in good hands, Mr. Jackson. I am right here with you. Let’s check your vital signs so we can monitor your condition. If you begin to feel any worse or feel that you can’t breathe, please let me know.
Febrile Reaction
A febrile reaction occurs when there is hypersensitivity to the donor’s white cells, platelet s, or plasma proteins. Febrile reactions cause the body to build antibodies, so this is the most common reaction if the patient has received blood in the past. Common symptoms of a febrile reaction include sudden chills, fever, flushing, headache, and anxiety. Febrile reactions are treated with antipyretics, such as acetaminophen. Depending on the severity of the reaction, the provider may slow, stop, or continue the transfusion. If the transfusion is continued, carefully monitor the patient throughout the transfusion and promptly report any additional or worsening symptoms that may arise.
Hemolytic Transfusion Reaction
A hemolytic transfusion reaction is a severe and potentially life-threatening complication that occurs when a patient receives incompatible blood products. Common symptoms of a hemolytic transfusion reaction include low back pain (first sign), chills, feeling of fullness, tachycardia, flushing, tachypnea , hypotension, bleeding, vascular collapse , and acute renal failure . The patient may also experience a headache, nausea, and hemoglobinuria . Late symptoms may include fever and mild jaundice . Treatment for hemolytic transfusion reactions depends on the severity of the reaction and may include stopping the transfusion, frequently monitoring vital signs, administering IV fluids to maintain blood pressure, providing supplemental oxygen as needed, dialysis, management of bleeding, and supportive measures to manage the patient’s symptoms.
The patient is receiving a unit of PRBCs. The nurse starts the transfusion at a slow rate and remains with the patient for the first fifteen minutes. Five minutes after starting the transfusion, the patient states, “Can I get another pillow to put behind my back? It is hurting a bit, and I can’t seem to get comfortable.” Back pain is a cue that requires a quick-acting response by the nurse; however, there is not enough information to analyze the significance of the cue. The nurse may promptly ask the patient additional questions, such as, “Is your back pain new or was it bothering you earlier today?” “Can you point to where it is hurting?” The nurse may also perform a quick physical assessment to learn more about the cue. Upon assessment, the patient reports that the pain is a new pain occurring in the lower back. Using critical thinking, the nurse quickly considers factors that could potentially cause the symptoms, such as sitting for too long, sleeping on the back wrong, referred kidney pain, or a hemolytic transfusion reaction.
To narrow down a potential cause, the nurse may need to ask additional questions. The nurse asks the patient, “Do you feel any additional symptoms, such as chills, feeling of fullness, nausea, or headache?” The patient reports a slight headache coming on. The nurse obtains a set of vital signs and notes the patient is slightly tachycardic and that their blood pressure has slightly dropped from the baseline vital signs. Upon physical assessment, the patient is flushed and tachypneic. By recognizing and analyzing the quick onset of cues such as lower back pain, headache, tachycardia, blood pressure dropping, flushing, tachypnea, and recent initiation of a blood transfusion, the nurse forms a hypothesis that the patient may be experiencing a hemolytic transfusion reaction , stops the transfusion, and immediately notifies the provider.
Circulatory Overload
A circulatory overload occurs when the blood is administered at a rate faster than the circulatory system can accommodate. Common symptoms of circulatory overload include a rise in venous pressure , dyspnea, crackles or rales , jugular vein distension, cough, and elevated blood pressure. Treatment for circulatory overload includes positioning the patient upright, lowering the feet in a dependent position, diuretics, oxygen, and bronchodilators.
Bacterial Reaction
A bacterial reaction occurs when the blood or blood products are contaminated with bacteria. Common symptoms of a bacterial reaction include rapid onset of chills, vomiting, marked hypotension, and a high fever. Typically, blood cultures and other laboratory tests (complete blood count, coagulation studies, assessment of organ functioning) will be collected to diagnose or confirm this type of reaction. Treatment for bacterial reactions includes antibiotics, increased hydration, steroids, and vasopressors.


1.14.57: Reversible Change
In thermodynamics the term 'reversible' means that in such a system the affinity for spontaneous change \(\mathrm{A}\) is zero; we can in fact characterize the composition of the system by the symbol \(\xi^{\mathrm{eq}}\), indicating a time independent extent of chemical reaction. The composition of the system does not change because the affinity for spontaneous change is zero.
For a reversible change the affinity for spontaneous change is zero at all stages. The composition is represented by \(\xi^{\mathrm{eq}}\), and the rate of change \(\mathrm{d} \xi^{\mathrm{eq}} / \mathrm{dt}\) is zero, at defined \(\mathrm{T}\) and \(\mathrm{p}\). We represent the volume of the system using following equation.
\[\mathrm{V}=\mathrm{V}\left[\mathrm{T}, \mathrm{p}, \xi^{\mathrm{eq}}, \mathrm{A}=0\right] \nonumber \]
This equation means that the volume, a dependent variable, is unambiguously defined by the set of variables in the square brackets, [... ]. The pressure is changed from \(\mathrm{p}\) to \(\mathrm{p} + \Delta \mathrm{p}\), such that the new equilibrium composition is \(\xi + \Delta \xi\) where the affinity for spontaneous change is zero.
\[\mathrm{V}=\mathrm{V}\left[\mathrm{T},(\mathrm{p}+\Delta \mathrm{p}), \xi^{\mathrm{eq}}(\mathrm{p}+\Delta \mathrm{p}), \mathrm{A}=0\right] \nonumber \]
Under these circumstances the change from \(\mathrm{V}(\mathrm{p})\) to \(\mathrm{V}(\mathrm{p} + \Delta \mathrm{p})\) is from one equilibrium state where \(\mathrm{A} = 0\) to another equilibrium state where \(\mathrm{A}\) is also zero. Such an equilibrium transformation is, in thermodynamic terms, reversible. All changes under the constraint that \(\mathrm{A}\) remains at zero are reversible.