Elisabeth Gedge argues that dignity should have a place in bioethics.
Appeals to dignity have a long history in ethics. Philosopher Immanuel Kant suggests that human dignity denotes the inherent value of all humans by virtue of their autonomy (capacity for free and rational choice). Catholic religious thinkers claim that humans possess dignity because they are made in the image of God. The concept of dignity has also helped to shape human rights documents. For instance, the Preamble to the 1948 Universal Declaration of Human Rights claims that “the inherent dignity of all members of the human family is the foundation of freedom, justice and peace in the world,” and the 2005 UNESCO Declaration on Bioethics and Human Rights calls dignity the “overarching principle of bioethics.”
Dignity emphasizes the intrinsic and equal value of all humans.
However, bioethicists have recently criticized uses of the concept of dignity when trying to settle ethically contentious clinical or policy issues. This is because the concept appears to raise several problems. First, if dignity resides in the capacity for autonomous choice, not all humans will be afforded dignity because not all humans are fully autonomous. For example, young children and those whose capacities are limited because of age or illness are not fully autonomous. Second, if dignity is based on a religious viewpoint it is problematic because religious foundations for ethical claims have limited force in a secular society. Third, appeals to dignity are often made by both sides of an ethical debate. For example, “dying with dignity” suggests that dignity in dying can only be preserved when we have the choice of physician-assisted death. Yet others maintain that taking a human life, even out of compassion, violates our fundamental value and dignity.
Critics such as Udo Schüklenk and Anna Pacholczyk, and Ruth Macklin reject appeals to dignity as “feel-good” slogans. They argue that the concept of dignity is not helpful for determining the rightness or wrongness of healthcare actions or policies. They believe we would be better off jettisoning the concept of dignity and relying on principles and norms such as beneficence (promoting the welfare of others), non-maleficence (avoiding harming others), and justice (treating others equally and fairly), along with respect for autonomy (where appropriate).
Nevertheless, there are reasons to retain the concept of dignity in ethics.
For one thing, the courts frequently appeal to dignity in making decisions of ethical significance to Canadians. For instance, in Carter v Canada (the recent Supreme Court decision on physician assisted suicide), the Court declared “An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy” and maintained that denying physician assisted death to seriously and irremediably ill people removed a choice “that may be very important to their sense of dignity and personal integrity” and that is “consistent with their lifelong values and that reflects their life’s experience.”
The Court’s commentary suggests that dignity relates to the meaning we have made of our lives through our choices and our relationships. A recent clinical study supports this interpretation. In that study, Chochinov and his team measured the sense of dignity of terminally ill patients before and after an intervention. They propose that health care providers embrace what they name “dignity-conserving care.” The patients were invited to share stories from their own lives that would paint a picture of who they were, what they valued, and their hopes and aspirations for their loved ones. Based on positive changes in patient-participants’ sense of dignity, Chochinov developed norms of behaviour for health care workers. These norms emphasized the importance of acknowledging the uniqueness and value of each patient, and of forming a connection between providers and patients, based on compassion and a recognition of shared humanity.
Although critics believe that dignity-conserving care is nothing more than respecting autonomy and meeting patient needs, the work of the Chochinov team singles out an important relational dimension to dignity. In attending to another’s sense of dignity by acknowledging them as bearers of meaning and value, we demonstrate their equal worth and we signal our shared membership in the moral community.
A relational approach to dignity avoids the problems noted earlier. Acknowledging the status and value of others as members of the moral community is not limited to those capable of rational decision-making, nor must it be based on a commonly accepted religious worldview. The very young, or those compromised by illness or cognitive disability, may nonetheless be in meaningful relationships of caring or being cared-for that can bestow a sense of dignity and worth. A preoccupation with autonomy overlooks the moral significance of such relationships.
Elisabeth Gedge is an Associate Professor in the Department of Philosophy at McMaster University.