Long perceived as sexually aberrant, persons with disabilities have made headway in recent years breaking down societal and attitudinal barriers that exclude many from leading sexually active lives. This progress has been uneven, often depending on a person’s type of disability. For example, evolving societal attitudes support the equal right of persons with physical disabilities to sexual intimacy, even if the means by which to fulfill this right (e.g., accessible social clubs) remain elusive. By contrast, persons with intellectual disabilities seeking volitional sex still face multitudinous attitudinal barriers.

This chapter argues that chronic pain (CP) represents an important and neglected type of disability. CP has important similarities to more familiar physical disabilities, but it cannot be regarded as a “mere difference,” and it fits uncomfortably under standard social models. The case of CP illustrates the need for flexibility in the definition of and social response to disability.

Many patients’ assessments of quality of life with disability, disease, and reliance on certain treatments become more positive several years into life with these health states. For example, when patients who have been living with colostomies for up to five years are compared to healthy controls and to former colostomy patients whose colostomies were reversed, current patients assign significantly higher utility to living with colostomy. “Adaptation,” as this phenomenon is sometimes called, is prevalent for such diverse health states as paraplegia, deafness, rheumatoid arthritis, various cancer types, reliance on hormone replacement therapy, and reliance on dialysis.

The troika of chapters in this Part demonstrates, in dissimilar contexts and in varied ways, the deleterious effects of clumsily applying, misconstruing, or violating disability-based civil rights laws. Underlying and uniting the three chapters is the impact of misunderstanding disability as an identity category and a subject of normative social justice. Stated more in line with the book’s theme and its Introduction, these contributions highlight some of the real-world manifestations of viewing disability as deficit rather than as difference.

In the United States, a patchwork of privacy and antidiscrimination laws protects the rights of people with disabilities: the Health Information Portability and Accountability Act (HIPAA) protects disability-related patient data as it flows from one healthcare provider to another. If the information leaks out of the healthcare system, laws such as the Americans with Disabilities Act (ADA) and the Fair Housing Act (FHA) can contain it and mitigate its effects. This patchwork of laws often succeeds in preventing disability discrimination. However, emerging technologies such as artificial intelligence (AI) are rendering it ineffective.

Anyone fortunate enough to live beyond middle age is at risk of developing dementia, a widely feared disability. Public perceptions of dementia are overwhelmingly negative. Indeed, it is not unusual to hear people say they would not want to live if they developed the condition.

The four chapters in this part, each in its own way, raise and begin to propose answers to the enormously challenging question of society’s responsibilities toward persons with disabilities when it comes to the provision of healthcare. Although all four are one in recognizing and documenting the all too abundant and profound ways in which persons with disabilities are disadvantaged (many of which are not obvious to persons whose lives are not touched by disability), they differ markedly in their proposals to rectify these problems.

In his classic work Just Healthcare, Norman Daniels speaks about the role of healthcare institutions in supporting fair equality of opportunity: such institutions seek to prevent, restore, and compensate for loss of “normal species functioning.” Daniels understands “normal species functioning” as functioning without disease. He assumes that individuals whose normal functioning cannot be restored are outside the normal opportunity range and have severe physical or mental disabilities. Healthcare institutions that provide supportive care to these individuals fall outside the bounds of justice.

The late singer-poet-novelist Leonard Cohen entitled one book of verse Let Us Compare Mythologies. In a sense, all of the chapters in this Part ask us to do exactly that. I do not mean “mythology” in a pejorative sense, but in all its anthropological splendor: taking facts on the ground and understanding them as part of a coherent sense-making worldview, albeit one that may not be falsifiable in a standard sense. But if that still seems pejorative, perhaps we might instead say “Let Us Compare View-Masters,” a reference to the red stereoscopic viewers that have delighted children (and adults) for decades by allowing us to enter static renderings with depth perception of lands real and imagined.

The use of quality-adjusted life-years (QALYs) to set healthcare priorities has been criticized as unfair to people with disabilities that affect their health or lifespan. For instance, because many quality-of-life assessments associate paraplegia with lower quality of life, individuals with paraplegia are assigned lower priority for transplantable organs when those organs are distributed using QALY-based approaches. This consequence of using QALYs to set priorities has prompted a variety of responses. Some have argued that priorities should be set using life-years rather than QALYs. Others have argued that discriminating against people with disabilities is justified.

The primary claim of this chapter is that public health law can integrate medical and social understandings of disability in ways that promise to reduce disability stigma and enhance epistemic justice. However, models of disability currently embedded in public health law do precisely the opposite, at least partly due to the fact that public health laws have historically assimilated medicalized models of disability. Such models are born in the nineteenth century, and they continue to exert outsized and problematic effects in shaping the impact of public health law on disabled people. Accordingly, it is impossible either to understand the deficiencies of prevailing (medical) models of disability codified in public health law or to propose solutions without sufficient grounding in the nineteenth-century roots of those models.

Protecting patients with disabilities against discrimination in the provision of healthcare, especially violations of their civil or human rights, requires an understanding of the common biases that undermine equal treatment in clinical, diagnostic, and therapeutic contexts. Nevertheless, this topic is rarely acknowledged in legal or social scientific studies of bias in healthcare decision-making. Consequently, prejudices against persons with disabilities – “ableism” – in these settings remain prevalent and unaddressed.