Reimagining Health—Flourishing

Clinicians spend substantial time monitoring patients for adverse outcomes. By assessing patients for high blood pressure, abnormal blood glucose levels, or cancer recurrence, clinicians may equate absence of disease with health. Public health officials, meanwhile, regularly track rates and leading causes of mortality, morbidity, or risk factors (eg, tobacco use, obesity, drug overdoses) that similarly apply a “deficits” framework to health. These approaches, while necessary and valuable, can fall short of capturing what is most important to people in their daily lives. A patient cares not only about physical health and test results “within normal limits” but also more broadly about being happy, having meaning and purpose, being “a good person,” and having fulfilling relationships. If health truly is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (as defined by the World Health Organization 70 years ago), measurements must better capture outcomes that people consider central components of well-being. Clinicians now can consider a proliferation of moreholisticmeasuresof“well-being”frommedicine,psychology, economics, sociology, and government.1 Such measures come closer to capturing an individual’s complete well-being but often still fall short. Long-standing efforts to gauge life satisfaction—including shorter-term patient satisfaction surveys—can sometimes reflect whether patients received the care they wanted,2 rather than whether that care actually enhanced well-being; they can be socially isolated, or struggle with addiction to opioids, for example, despite good patient satisfaction or life satisfaction rankings. Measuring life expectancy at birth, a common public health metric, focuses primarily on length of life, only sometimes acknowledging quality dimensions. While the health-related quality of life index developed by the Centers for Disease Control and Prevention (which includes physical health, mental health, functional limitations, pain, and vitality) is a valuable development, its operationalization usually excludes questions of purpose and meaning that serve as major components of human wellbeing. Meanwhile, psychological well-being measurements, whether focusing on happiness or resilience, vitality, stress, or loneliness, typically ignore physical health. None of these metrics fully captures what people almost universally regard as essential to well-being. Furthermore, questions of character, defined as moral excellence and long viewed as central to well-being in almost all philosophical and religious traditions, are also often neglected. The term flourishing, used for thousands of years and literally meaning “to grow” or “to prosper,” represents a powerful way to view health in its fullest sense.1 Flourishing has for years been effectively promoted by Seligman in the positive psychology literature, and the PERMA model (Positive emotions, Engagement, Relationships,Meaning,Achievements)hasadvancedresearchinto psychologicalwell-being.However,becausethismodeladdresses neither physical well-being nor questions of character, a recently proposed alternative measure of wellbeing, “the flourishing index,” divides universally desired factorscontributingtoflourishinginto6keydomains1:happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material security. In contrast to many previously proposed measures that are not as comprehensive, the flourishing index addresses 5 universally desired domains that constitute ends, as well as a sixth (financial and material security) that constitutes a critical means to securing them.1 Self-report quantitative questions for the index are given in the Table and Supplement.3 The index has been used in numerous countries4 and has potential applications for clinical care as well as for population health, as discussed below.1 Additionally, population studies indicate that the domains related to psychological well-being are not only desired as ends, but also shape physical health. For example, meta-analyses have indicated that purpose in life is associated with reduced mortality risk (RR, 0.83; 95% CI, 0.75-0.91)5 as is life satisfaction (RR, 0.88; 95% CI, 0.83-0.94). 6 Conversely, loneliness and social isolation are associated with increased mortality risk (RR, 1.29; 95% CI, 1.06-1.56). 7