Disabled enough? Public health and Lysias’s For the Disabled Man

I read Lysias’s oration For the Disabled Man with a double vision I cannot switch off. I am a physician trained in public health and preventive medicine, and I live with a physical disability (spastic tetraparesis with dystonia). So I recognize both people in this twenty-four-century-old courtroom: the official who weighs whether an impairment ‘counts’, and the citizen who must prove, in public, that he is disabled enough to deserve help yet capable enough to be believed. That discomfort is exactly why the text still matters to public health. In fourth-century bc Athens, a citizen stood before the Boule, the administrative council of the democracy, fighting not for his freedom but for the right to be seen as what he actually was, producing what can be read as one of the earliest recorded instances of disability advocacy in Western history.1–3 What looks like a legal defence is really an argument about stigma and who gets to count as a worthy citizen. My argument is simple: public health should stop asking disabled people to prove they deserve care and start designing systems that assume their credibility and build in accommodation by default, shifting the burden of proof from the person to the system. The facts were simple. Athens paid a modest allowance to citizens who could not work and owned little. The speaker received it until an accuser claimed he was not entitled: the man owned a workshop, he could ride a horse, and so he was not ‘really’ disabled. The Boule had to decide whether his impairment genuinely justified public support.1 Anyone who has sat on, or in front of, a modern disability board will find the dynamics familiar. The claimant must show his disability is ‘sufficient’, justify his coping strategies (the workshop, the horse), and fend off the insinuation that he is gaming the system. Swap the Boule for a civil-invalidity commission and the horse for a mobility aid, and the conflict is unchanged: the burden of proof falls on the most vulnerable person, who must be ‘disabled enough’ to merit assistance yet ‘able enough’ to remain a worthy citizen. I have filled in those forms myself; the rhetoric of suspicion has not aged a day. Lysias turns that suspicion on its head. He does not merely assert an impairment; he argues that his client’s efforts to stay independent should not disqualify him from support. The workshop is offered not as evidence of ability but of need; the horse not as a luxury but as an essential accommodation.1 The same struggle appears in modern care as ‘aversive ableism’, the gap between what clinicians say they believe and what their implicit bias reveals. Among more than 25 000 healthcare providers, VanPuymbrouck and colleagues found that most denied prejudiced attitudes, yet implicit-association testing revealed a preference for non-disabled people in 83.6%.4 Patients thus face what philosophers call ‘testimonial injustice’, in which accounts of their own bodies and needs are discounted.5 Iezzoni and colleagues found that 82.4% of US physicians believed people with significant disability have a worse quality of life than others, an assumption that is rarely neutral: it shapes clinical decisions and how resources are shared.6 The consequences are measurable: in the UK, people with intellectual disabilities die markedly younger than the general population, and many of these deaths are classified as avoidable, often through diagnostic overshadowing and a failure to make reasonable adjustments.7 This is the performance the system demands. The claimant must appear helpless enough to justify help yet show enough agency to be a credible narrator, a precarious balance whose cost, when it tips, is borne by the person, not the system. Services often fail to accommodate complex intersections of disability and health need,6,8 in effect requiring patients to fit standardized categories of ‘sick’ to receive care. When someone steps outside the script, like an invalid who rides a horse or a wheelchair user who looks ‘too healthy’, support tends to waver. I have learned to read the moment when a professional recalibrates because I do not match it. Lysias’s oration also challenges the binary logic of the ‘medical model’ of disability. The accuser argues from function: can you work, can you ride? Lysias replies with an argument that anticipates the ‘social model’.9 His client’s disability emerges from the interaction between impairment and socioeconomic context: without the allowance, survival is impossible; without the horse, mobility is lost. The workshop is adaptation within constraint, not proof of capacity. This distinction is not academic. An estimated 1.3 billion people, about 16% of the world’s population, live with significant disability and face health inequities that translate into greater barriers to care and premature mortality.10 The newly launched Lancet Commission on Disability and Health calls this a systemic failure, not individual misfortune, pointing to a life-expectancy gap of up to 14 years and demanding health systems that genuinely include disabled people.11 Prevention is often where the gap widens first: people with disabilities are routinely left out of screening, vaccination, and health-promotion programmes built around a non-disabled default.12 Yet systems still treat disability as an individual pathology to be corrected rather than a social interaction to be supported, forgetting that ‘functioning’ is largely a product of the resources and accommodations available, not of biological capacity alone. The same gap between stated values and practice is mirrored in international law. The UN Convention on the Rights of Persons with Disabilities has been ratified by 193 parties (192 states and the European Union), signalling near-global consensus.13 But far fewer, currently 110, have ratified the Optional Protocol, which lets individuals and groups bring complaints directly to the Committee on the Rights of Persons with Disabilities when their rights are violated.14 The distance between those two numbers is eloquent: a world willing to recognize disability rights in principle yet hesitant to submit to binding external scrutiny when those rights are denied. Italy illustrates both sides: it ratified the Convention and its Optional Protocol together in 2009, and it established a national disability ombudsman by legislative decree in 2024 (operational from 2025), the Autorità Garante nazionale dei diritti delle persone con disabilità, tasked with monitoring compliance with the Convention.15 Whether such bodies become real channels for enforceable accountability rather than symbolic reassurance is exactly the test the Boule poses. Like the Athenian council, modern states are often more comfortable granting support as an act of benevolence than acknowledging it as an enforceable entitlement, open to challenge by the very people it is meant to protect. The Boule was not a panel of medical experts but a civic body of citizens delivering a collective judgement on social responsibility. The question before it was not purely clinical (Is he disabled?) but ethical (What do we owe one another?). The disabled man of Athens asks a harder question than any clinical checklist allows. Health equity is, in the end, a matter of dignity, and we still treat it as optional. The systems we build today, like the court of the Boule, are ultimately judgements about our collective values. The disability rights movement put it bluntly, ‘Nothing about us without us’16: the people a system is built for should help build it, not merely receive it. Justice for the disabled man, in the Agora and in the modern clinic alike, remains an unfinished task. I write this both as someone who studies these systems and as someone they are meant to serve, and I would like the next reading of Lysias to feel less like a mirror. Conflict of interest. The author declares no conflict of interest. This work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. No new data were generated or analysed in support of this work. Giovanni Emanuele Ricciardi, MD, PhD candidate