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Rapid Responses: Rapid Responses published:
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An offensive slogan
- Hilda Bastian (19 December 2003)
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Dignity not entirely useless
- Simon Woods (19 December 2003)
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On Dignity
- Tim Scott (19 December 2003)
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Reductio ad absurdum
- Stephen M Taylor (20 December 2003)
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Dignity-US Style
- Jay Ilangaratne (21 December 2003)
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"Human dignity" -- prognosis positive
- Joseph C. d'Oronzio (21 December 2003)
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Essential to the doctor:patient relationship
- Peter L Hall (21 December 2003)
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Dignity a useless concept??
- Jayson Rapoport FRCP (22 December 2003)
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Dignity is essential
- Peter D Davies (22 December 2003)
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Dignity is a useful, well-understood concept
- William H Konarzewski (22 December 2003)
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Scientific moral imperialism
- Alexander E Limentani (23 December 2003)
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dignity is an overused concept , it lacks coherence
- baum mylene (23 December 2003)
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Vague is not useless: histories
- Tom Koch (24 December 2003)
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Human Dignity is Fundamental
- Norman M Ford SDB (24 December 2003)
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Dignity is A Social Construct
- Arthur L Caplan (24 December 2003)
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Dignity is not useless
- Idris Baker (24 December 2003)
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What is dignity?
- Anthony Staines (25 December 2003)
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Dignity is a moral imperative
- Stanley M. Giannet (25 December 2003)
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First, Define the Word Dignity
- William G Notcutt (29 December 2003)
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Unusual, overlooked aspect of dignity.
- Sergio Stagnaro (30 December 2003)
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Concepts deserve bedside manners too.
- Peter R. J. Cheyne (31 December 2003)
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Re: First, Define the Word Dignity
- Idris Baker (31 December 2003)
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Dignity as tacit
- Kirk C. Allison (31 December 2003)
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Indignities, Respect for Persons, and the Vagueness of Human Dignity
- Alexander M. Capron, 1211 Geneva 27, Switzerland (31 December 2003)
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America's lost dignity
- Mark Struthers (3 January 2004)
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Dignity as a spiritual concept
- Larry Culliford (9 January 2004)
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Defending Dignity
- Ann Gallagher (12 January 2004)
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Don't confuse dignity with respect
- Mary Catherine Beach, Patrick Duggan and Gail Geller (21 January 2004)
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The utility of dignity
- Stephen J Fletcher (22 January 2004)
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Cloaked Assaults and Wrongful Apologies
- Francis P. Crawley, Amin Kashmeery and Chifumbe Chintu (27 January 2004)
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Clarifying the Concept of Dignity
- Lydia E. Mayer (5 February 2004)
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Dignity: not useless, just a concept in need of greater understanding.
- Miles R Bore (17 February 2004)
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Proposed Definition of Dignity
- Jamie S J Wilson (26 February 2004)
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Nuts and bolts of dignity?
- Ronald F Ingle (1 March 2004)
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Hilda Bastian, Editor, www.informedhealthonline.org Health Research and Education Foundation, Melbourne 3125 Australia
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To read a suggestion that protecting the right to dignity is nothing but a slogan, and flying that argument under the slogan "dignity is a useless concept" made me indignant. I've been the "layperson" suffering through more ethics experts' gobbledygook than I care to remember, so I could be a bit prejudiced I suppose. But...the word dignity has no real meaning of its own and therefore no place in medical ethics? Oh, please. Maybe when there's no indignity possible in illness or medical procedures, when all caregivers, policymakers and members of ethics committees are superhumans incapable of having lapses in empathy, then retiring this notion from active duty could be considered. (A world where no one ever needs an enema, for example.) Dignity in a medical experience, or while dying, apparently has little unique meaning to the author of this piece. But it would be instantly meaningful to more people who have been patients than some of the other words the author uses - and distinct from privacy and "autonomy". A lot of us recognise what people mean when they speak of dignity. Most of us have a good idea of what we mean by being treated with dignity (valuing it highly, too). And by crikey, do we know its opposite! As patients, we inevitably encounter behaviour and experiences that are humiliating, demeaning and frankly - well, undignified. Do we then say, "Oh, I just feel that my autonomy was not respected"? How many of us though, know what this means: "They just left her with no dignity - none at all." How could there be no place for eloquent, recognisable, plain language in discussion of human rights, and no room for a concept that embraces protection from humiliation and shame in medical situations? Competing interests: None declared |
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Simon Woods, Senior Lecturer Bioethics Policy Ethics and Life Sciences Research Institute, Times Square, Newcastle upon Tyne, NE1 4EP
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I have just read Professor Macklin's article and must say I found it refreshing and hard hitting. As an academic working in medical ethics I, like Professor Macklin find the notion of dignity vague and ambiguous although unlike her I am not convinced for example that if dignity has meaning then its meaning can be exhausted by substituting autonomy - I don't believe the two are synonymous. One conclusion might simply be that dignity is therefore meaningless and I am not quite convinced of this either. I was interested in what Professor Macklin had to say about cadavers. As a former cancer nurse I have been in the position, many times, of performing what we call 'last offices' preparing a body for viewing by relatives or removal to the mortuary. If I was teaching a junior colleague how to perform this procedure then a feature of the 'right and proper' way to treat the corpse would be that the body should be treated with respect (dignity?) - for example it would be considered wrong to needlessly expose the genitals or to make lewd jokes about the deceased etc. - now I am not convinced that the only reason it would be wrong to do these things would be out of consideration for the living relatives - it would be easy to construct a situation in which no one else could know or indeed where there were no relatives or loved ones to be offended by us treating the corpse in this way - therefore the sanctions I have just outlined would have no force. I find this conclusion problematic and one way in which I would construct the counter argument is to talk about the deceased person's 'abiding interests' - now this may be a weak argument but I do believe there is a lot more that can be said about interests that might give some substance to the notion of dignity. Here I am presuming that it is possible to identify a person's interests indpendently of their autonomous wishes, if so there is no reason to suppose that a person's interests end on their death. I would suggest therefore that rather than conclude that dignity is a useless concept it should be subjected to a thorough conceptual analysis. Such an analysis may simply lend support to Professor Macklin's claim - then again it may not. Competing interests: None declared |
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Tim Scott, Research Fellow University of York, Department of Health Sciences, Seebohm Rowntree Building, Heslington, YO10 5DD
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I think Ruth Macklin has only identified dignity as a ethical aporia. Instead of responding to policy documents and a desire for operational terminology, she could inquire what other people, especially patients and carers, understand by "dignity". Regarding medical students practising procedures on newly dead bodies, Macklin states: "Some medical ethicists charge that these educational efforts violate the dignity of the dead person. But this situation clearly has nothing to do with respect for autonomy since the object is no longer a person but a cadaver." Life and death are not so clearly separated from one another. It is a naive attitude to language that slots people into categories so neatly and objectively. Some linguists would reply that the definition of a living person is only meaningful in the fuller context of its negative term, cadaver, and vice versa. Hence, I think the terms of Macklin's critique simplistic, her expert view narrow and dogmatic, and dignity, whatever its potentiually rich and complex meaning, quite undented by her analysis. Competing interests: None declared |
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Stephen M Taylor, University of North Texas Health Science Center 2355 N. Hwy. 360 Suite 638 Grand Prairie, Texas 75050
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I find it curious and more that slightly offensive that the author of this article wishes to further reduce our vocabulary for describing important facets of the doctor patient relationship. Dignity, "The quality or state of being worthy of esteem or respect", is not only a synonym for these words. It is, as the definition shows, a state of being inherent in the person referred to. One may treat a patient with respect in the ways the author refers to, like honoring their autonomy, and still not treat them with the dignity they deserve. I have seen many an informed consent filled out by patients treated with little dignity. The way the author refers to respect and autonomy makes them sound like rigidly formed little boxes filled with just so much meaning and no more. I see dignity as a broader term, and one that requires of the medical provider a greater reach and sensitivity to the full embodiment of being human. Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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"Dignity is a useless concept in medical ethics and can be eliminated without any loss of content"--I think the author is likely to receive President Bush's wholehearted approval for elimination of 'human dignity' altogether,rather than restricting it to medical ethics. From the author's own backyard Guantanamo Bay, to Afghanistan via Iraq, illustrate glaring examples of murdering human dignity by the US authorities.Most recently we saw Saddam Hussain being examined physically on our TV screen--another US bullet at killing the concept of dignity. Given the USA's track record,the author won't have to work too hard to eliminate a concept,which has already perished in front of the so called United Nations.Standing shoulder-to-shoulder, I fear that UK might catch this dignity-busting bug fairly soon, with resulting infestation of the European Convention. Competing interests: None declared |
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Joseph C. d'Oronzio, Raoul Wallenberg Visiting Professor in Human Rights 89 Summit Ave. -- Suite 185; Summit, NJ 07901
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Sure, this editorial advances an outrageous hypothesis; it is appropriately controversial and iconoclastic; who would expect less from Ruth Macklin? But I also expect more. The essay tries to carry too heavy a load, itself -- heavier even than "human dignity." Is there a problem with "human dignity" being out there to capture "no more than" that core constellation of ideas and values we treasure and apply? (She writes, '''dignity' seems to have no meaning beyond what is implied by the principle of medical ethics, respect for persons: the need to obtain voluntary, informed consent; the requirement to protect confidentiality; and the need to avoid discrimination and abusive practices.) But it does capture those meanings. Hardly useless, 2 words for 29. ;-) And is there a problem linking bioethical concepts (note, not only "principles") to human rights talk? Human rights (as in the UDHR) and bioethics share too many common roots and branches to be able to prune the whole tree without damage to the whole. I, too, am bugged by many of the appeals to "human dignity" in the context of genetics and reproductive technology. Let's deal with it there. (I am also bugged by the appeals to "patient rights" in the context of regulating managed care insurance schemes. But "patients rights" is not therefore useless. Thick with meaning and history; with ambiguity and sloganeering potential, etc. -- but why "useless?") Lets take these meanings apart when as needed in whatever context, rather than dumping them as "useless" because others utilize them uselessly, or in erroneous ways. Finally, regarding the cadaver-, person-, body- riff that seems to have taken on a life of its own (so to speak) -- I am rather fond of the phrase "human dignity" in the context of death and dying as a very useful secular version of immortality, -- something that none of its constituent elements provide, and certainly much more than all of them combined. For all of this, I hope this change in Macklin's Dx supports a prognosis for "human dignity" that is positive. Ciao and boun 'anno Joseph -- Joseph C. d'Oronzio, PhD, MPH, Raoul Wallenberg Visiting Professor in Human Rights, Rutgers University Center for Historical Analysis Associate Clinical Professor, Department of Health Policy and Management, Mailman School of Public Health, Faculty Associate, Center for Bioethics, Columbia University Executive Director, The Ethics Group, LLC www.EthicsGroup.org 89 Summit Ave. -- Suite 185; Summit, NJ 07901, Competing interests: None declared |
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Peter L Hall, Chair, Physicians for Human Rights–UK Hospice doctor, Pasque Hospice, Great Bramingham Lane, LU3 3NT
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Recognition of the intrinsic dignity of every patient is as love to marriage. Both relationships involve potentially humiliating exchanges - that of the doctor:patient invariably weighted towards feeding the doctor’s sense of worth. No doctor will have the right sense of proportionality without the former, and should not be allowed to practise. Competing interests: Chair, Physicians for Human Rights–UK |
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Jayson Rapoport FRCP, Head of Dept. of Nephrology Kaplan Med. Ctr, Rehovot 76100, Israel
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After reading Prof. Macklin's article about dignity being a useless concept, my previously held belief that those who preach and teach medical ethics are often remarkably out of touch with everyday medical practice, was strongly reinforced. In 30 years of medical practice, I am aware of human dignity constantly, and I hope that my daily work reflects this. To paraphrase US Supreme Court Justice Brennan, I can't define dignity but I know it when I see it. I am aware of it when I talk to patients and their families in words which I hope they can understand;when I tell a patient that he will have to spend the rest of his life on dialysis; when I try to convince him that when all is said and done, life is still worth living; when I try to give the same consideration to rich and poor, private patients and HMO patients, white or black, Christan, Jew or Muslim. In fact, the concept of human dignity, whether you call it dignity or respect for human beings, is basic and all-pervasive, and certainly not a "slogan". I am quite clear as to what it means, as I think are most of the clinicians with whom I work. If the concept of dignity is useless in medical ethics, then I for one would question the utility of medical ethics. Competing interests: None declared |
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Peter D Davies, Consultant Physician Cardiothoracic Centre, Thomas drive, Liverpool, L14 3PE
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I don't know about medical ethics but I know when a patient is treated in such a way that his or her "dignity" is lost. While working in Kenya I noticed that patients could maintain dignity even though there were two to a bed; head to toe. There was a sort of switching off attitude by the one patient when we came to examining the other, so that the second patient's "dignity" could be preserved. I noticed the same here in the UK if patients were too crowded in a casualty or recovery room. If a patient collapsed and needed urgent resuscitation the same "Switch off" attitude could be seen in the others. It seems as though we humans have a way of protecting our own "dignity" and that of others even in the most confined and undignified situations. Competing interests: None declared |
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William H Konarzewski, Consultant Anaesthetist Colchester General Hospital, CO3 4AS
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I am astonished that Ruth Macklin believes dignity is an unhelpful concept. It is regularly used on our intensive care unit and our doctors, nurses and the patients' relatives have no problem understanding that a death with dignity means a death in which the patient is allowed to pass away naturally without unnecessary suffering or anxiety and without the encumbrance of tubes and catheters that distort the appearance of the face and body. We shall continue to allow our patients to die with dignity when it is plain that they are beyond the help of modern medicine. Competing interests: None declared |
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Alexander E Limentani, Director of Public Health East Kent Coastal PCT, Protea House, New Bridge, Marine Parade, Dover, Kent, UK. CT10 3LS
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It is traditional to have a humorous editorial in the Christmas number but I searched in vain for any irony in “Dignity is a useless concept”1. The conclusion “dignity is a useless concept in medical ethics and can be eliminated without any loss of content” is more chilling than amusing. My lack of success parallels Professor Macklin’s failed search for objective criteria validating the concept of dignity, and this is the crux of the issue. There is a tendency for bioethics to require objective criteria for the justification of ethical judgements, reflecting the scientific method of exploring the physical reality of the world. In contrast, when judging whether dignity is a useful ethical concept or not we should take into account whether it has any explanatory force rather than seeking criteria for its validation. If we start from the position that respect for other people is important we are unlikely to conclude that dignity is useless. Dignity was the operative ethical concept creating the furore when bodies were stored outside mortuaries2 and organs were retained without consent3. This is not to give ‘dignity’ (or any other concept) a mystical character that cannot be challenged; rather it more closely reflects our reality and our ethical values. Wittgenstein put it as “rotation of the axis of reference of our examination about the fixed point of our real need”4. This editorial illustrates the ‘imperialistic’ tendency of bioethics to obliterate disagreement and forget precedence. The origin of the concept of ‘dignity’ is not mysterious: Kant, the enormously influential eighteenth century philosopher, recognised that respect for other people was a very important issue for ethics. He contrasted ‘value’ with ‘dignity’ to emphasise the intrinsic worth of persons as ends in themselves and not merely beings of instrumental value5. Much of subsequent continental philosophy can be characterised as a reaction against the empiricism that continues to underlie much modern bioethics, in support of a more human focus. Dignity may be a useless concept to a professor of bioethics, but is of vital importance to clinicians and patients in redressing the balance between scientific development and proper consideration of the needs of the individual. It is an essential component of the quality of care. 1 Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-20. 2 Abbasi K. Death underfunded. BMJ 2001;322:186. 3 Bauchner H, Vinci R. What have we learnt from the Alder Hey affair? BMJ 2001;322:309-10. 4 Wittgenstein L. Philosophical Investigations. Trans. Anscombe GEM. Oxford: Basil Blackwell, 1978, para 208. 5 Paton HJ. The Moral Law – Kant’s Groundwork of the Metaphysics of Morals. London: Unwin Hyman, 1989, II.69. Competing interests: None declared |
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baum mylene, prof of bioethics université catholique de Louvain.
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While the concept of dignity comes back into bioethics discourse as though it was a clear and consensual concept ,I find interesting that Ruth Macklin questions the doxa around this concept I would rather say that it is overused to defend or to forbid euthanasia to defend or to forbid stem cell research and it is clearer in the modifying model of doctor and patient relationship to speak of less consensual concepts as autonomy or respect; or to rethink the pertinence of giving each individual the chance to define the value and content of dignity for himself instead of being a concept working as the "cache - sexe" of conflicting moral convictions in situation of medical decision ,linked to moral issues.Again, lets be careful of concepts which are too consensual, since dissensus is the condition of a healthy democracy. The notion dignity is issued from a metaphysics of being at the image of God and has been translated in human rights discourse as the condition of equality between men. A patient in a state of vulnerability needs to be seen as himself, from his own narrative specificity, which means to remain autonomous in right if not always in fact! Mylène Baum Competing interests: None declared |
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Tom Koch, adj. prof. gerontology Simon Fraser University, Gerontology, 515 Hastings St. Vancouver, Canada V6B 5K3
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That the concept of "dignity" in bioethics is vague does not mean it is useless. The manner of introduction suggests the necessity of its introduction, vague and ill-defined as it is. Dignity as an adjective (i.e. "Death with dignity") was introduced into bioethics at the time that the principle of the Sanctity of Life was being withdrawn from bioethical debate. In the then evolving principled discourse of the field it came to serve as a surrogate for the value of an individual life irrespective of physical condition. This is the way it is often used today, for example, by disability theorists. Absent the Sanctity of life--or a sense of in Margaret Sommerville's words the "sacredness" of human life--something was demanded to give a sense of purpose and value to the individual facing medical trauma. That it came to be employed most in the euthanasia debate shows how little it served, in fact, to replace that sense of human worth irrespective of physical difference or deficit. Ruth Macklin's brief comments serves to focus us again not simply on the vagueness of the concept but the humanity lost in bioethic's clinical turn as well as its thinly principled, historical approach. Tom Koch, Ph.D.
Competing interests: None declared |
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Norman M Ford SDB, Director, Caroline Chisholm Centre for Health Ethics 7/166 Gipps St. East Melbourne Vic 3002, Australia
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There is no doubt that autonomy is a fundamental value for all persons and that its free exercise should be respected and protected by law. There is, however, more to human dignity than exercising autonomy. Our dignity has its foundation in our common rational human nature, in virtue of we are able to understand, to choose, to cherish our privacy and many other values. The living human being is endowed with dignity precisely because he or she is a subject of a rational nature. The exercise of autonomy is valuable for the subject of a human nature, not simply as an abstraction. The human subject of a rational nature is then a primordial and foundational value, regardless of whether the person has the ability to exercise autonomy, for example, a newborn baby or or an unconscious patient. All patients, including newborns and the unconscious, have human dignity and ought to be respected and treated accordingly at all times. Competing interests: None declared |
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Arthur L Caplan, Chair Dept of Medical Ethics University of Pennsylvania
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I am very grateful for Professor Macklin's challenge to defend and define the concept of dignity. I agree with her that this concept is used far more as a slogan than it is a meaningful concept in bioethical debates. She is absolutely right to 'call the question' and challenge those who would use the term to be specific about what they mean. That said, let me offer an analysis that goes beyond her suggestion that dignity is nothing more than a shorthand term for capturing the idea of human autonomy. I think non-autonomous persons and even objects can have dignity. We might say that certain behavior is owed to or deserved by a young child, a fetus, a dead body, an embryo or even a human organ without assigning autonomy to any of these. I would however argue that there is a meaningful sense of dignity that has nothing to do with autonomy. Dignity reflects a moral status that moral agents assign to others. It is conferred on a human being by other human beings. To be specific: we, conscious autonomous moral agents, make the decision to treat our fellow humans as deserving of certain actions--burial, palliation, prayer even if their autonomy is gone. We also decide that certain things may not be done to them--you cannot eat the dead, experiment on those who are PVS or sell the body parts of the deceased. Each of these duties and restrictions needs to be justified--it is not self-evident but the justification can have as much to do with the reaction and impact of a behavior on other moral agents i.e., parents, family members, as it does the person or thing upon whom dignity is being conferred. So, I would maintain that dignity is a moral creation. It refers to the status conferred by those who are moral agents on others--both autonomous and not. It consists of a set of obligations, duties and restrictions on how others and even other objects may be treated by moral agents. There is no inherent property that confers dignity on a human being--it is a social and cultural decision to confer this status (not all human subgroups follow all parts of the Western view of dignity) as part of membership in a moral community. If there are no autonomous moral agents than there is no dignity for it takes a decision by moral agents to create moral standing in others who lack autonomy. Dignity is not meaningless but it is deceptive. If you look to see what inherent properties generate dignity you will not find much. Still we can and do define the boundaries of our moral concern-- we confer moral standing on objects, people and other living things by use of the concept. So dignity is a social or communitarian value that is bestowed not inherently possessed. Admittedly, there is controversy about how dignity can or should be conferred on others and even other things. The human embryo and fetus, cloned embryos and even animals are all the subject of fierce debate about whether they merit the actions and restrictions inherent in the notion of dignity. Some would have us confer moral standing on forests, works of art and sites of great natural beauty. These battles do not debunk the concept of dignity. They merely show it is highly contested-- a fate endured by many moral concepts. So I would agree with Professor Macklin that the proponents of dignity be it in debates about human rights or over the moral status of a cloned embryo use the term to suit their purposes and ideologies more than anything else. What I think Professor Macklin misses is that dignity is conferred not generated by a particular property or capacity. Those who use the term thus are obligated to show why something or someone ought be treated in certain ways and to spell out what those ways are. Competing interests: None declared |
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Idris Baker, Specialist Registrar in Palliative Medicine Leicestershire & Rutland Hospice, Groby Road, Leicester LE3 9QE
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Editor, Macklin (1) takes too narrow a view. Certainly dignity is often referred to without clarity or explanation, and in some of these references it may be redundant. It is misused in driving consideration of advance directives and active voluntary euthanasia. But Macklin's "close inspection of leading examples" cannot lead to conclusions about dignity itself. Dignity is a characteristic of persons, and one which our actions can enhance or diminish. It is related to autonomy but it goes further. Respect for it is a distinct component of what is meant by respect for persons, and it resonates strongly in the care of the dying, especially those who no longer retain any autonomy but should still be treated with respect. When we toilet and wash dying people rather than leaving them dirty, when we moisten their mouths rather than leaving them dry, when we lay them out carefully after death, it is their dignity that we are respecting. Study of nurses' treatment of the dying shows us that social identity, and dignity, live on in part after death (2). We should not let the abuses of this concept render it useless. We should instead use its clarified definition to guide decisions with those whose dignity is most threatened. 1. Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-1420 2. Waterhouse E (2001). Personal Communication. Competing interests: None declared |
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Anthony Staines, Senior Lecturer in Epidemiology UCD, Dublin, Ireland
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Dignity, which derives from the Latin word dignus, meaning worthy, is not a superfluous concept, in bioethics, or anywhere else. It has a well defined meaning, which explains many of the uses of the term to which Ruth Macklin objects in her challenging editorial [1]. Professor Macklin finds the idea of dignity quite problematic, and I have some difficulty in seeing why. All societies that I know anything about treat humans, alive or dead, differently from other large dangerous animals. This is true even for societies which have practiced mass murder, and those which have practiced cannibalism. The Germans, Russians and Chinese all developed elaborate systems to demonise and cast out their enemies, before they slaughtered them. They also had elaborate bureaucratic systems for the killers [3,4,5]. Even in those societies in which eating the dead was customary, people did not eat other humans for food in the same way that they ate chickens, for example. Dignity is precisely, an inherent moral characteristic of human beings, or to use Lewis's suggestive term, 'hnau' [6]. It does not depend, unlike many other characteristics, on the status, actions, capacity, or position of the human being. It is that characteristic, as a result of which all humans are deserving of, or due, respect. Like many other terms in ethics and philosophy, dignity can be used as an empty slogan, or a cover for intellectual undress, but this does not invalidate the idea. ‘Rights’ is another useful term, which is often used sloppily and inadequately, but which remains useful nonetheless. The Nuffield Council on Bioethics [7], pace Professor Macklin, have in fact hit at least part of the nail on the head, in defining dignity in terms of “the presumption that one is a person whose actions, thoughts and concerns are worthy of intrinsic respect”. For me, the essential word here is intrinsic. I disagree vehemently with Professor Macklin’s ideas, but I respect them and her, because she has an inalienable right to my respect, as a fellow human being (or indeed as a fellow “hnau”). From this perspective it seems to be vacuous to use ‘dignity’ as a synonym for respect, since respect is a consequence of dignity, and simply incorrect to use it as a synonym for autonomy. Finally, in dismissing all documents which do not treat directly of bioethics and medical research, Professor Macklin has dismissed the whole conceptual background against which the social meanings of dignity can be located and understood. I agree, that if one were willing to dismember ethics from human society in this novel way dignity would mean little, but autonomy would mean less. A Happy, Dignified, and Respectful Christmas to you all, Anthony Staines [1] Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-1420. [2] Goldhagen DJ. Hitler’s Willing Executioners. 1997. [3] Applebaum A. Gulag, A History. 2003. [4] Laogai Research Foundation. http://www.laogai.org/ (Accessed 25/12/2003) [5] Lewis CS. Perelandra. (Voyage to Venus). 1943. [6] Nuffield Council on Bioethics. Genetics and human behaviour. Chapter 12 Paragraph 2 http://www.nuffieldbioethics.org/publications/geneticsandhb/rep0000001049.asp (Accessed 25/12/2003) Competing interests: None declared |
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Stanley M. Giannet, Affiliate Assistant Professor of Psychiatry and Behavioral Medicine University of South Florida College of Medicine, 33613
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The term "dignity" may indeed be cliche, but it is a fundamental necessity in the practice of effective and caring medicine. Dignity, like religion, does not have to be operationalized or empirically studied. This construct transcends the hypothetico-deductive analysis of the experimental method and provides powerful meaning to both the clinician and the patient. Dignity is a core value and a core clinical competency; it is a necessary ethical obligation that provides the foundation for medical practice, healing and successful palliation. Dignity is more that an affirmation of one's autonomy. It consists of a psychospiritual connection with the patient: a connection that involves empathy, presence and compassion. I submit that this connection can and should remain even after the patient dies. Cadavers are no less human because they are devoid of life. On the contrary, cadavers remind us of the finality of life - the existential reality- that we are mortal creatures temporarily existing and experiencing the world. The cadaver was the vehicle in which the patient experienced the awe and wonder of life. Certainly, this vehicle, replete with a history and identity, should be respected. The empathic clinician actively appreciates the patient's suffering and attempts to experience the world from the unique prism of the patient with sensitivity and compassion. Clinicians provide presence when they are authentic, deeply aware of the fragility of life and affirm the human essence of the person they are treating. Moreover, they treat the patient with regard and respect. Dignity, I believe, is correlated - anecdotally at the very least - with greater patient comfort and responsiveness to treatment. The shocking reality is that without dignity, clinicians often develop a sterile stoicism towards the suffering and a needless aloofness or alienation from those they serve. Even worse, the absence of dignity as a core value in medical practice can lead to depersonalization where the patient's identity and personhood are reduced to an insurance account number, hospital room number or a diagnosis. For instance, one of the most shocking examples of this is when I overheard a nurse refer to a patient as "The urinary tract infection in room 306." Perhaps, instead of eliminating this construct, the medical profession can remove the vagueness of the concept by revisiting palliative care theory and developing universally accepted standards of dignity-based practices. Stanley M. Giannet, Ph.D. Affiliate Assistant Professor of Psychiatry and Behavioral Medicine, University of South Florida College of Medicine, Florida, USA. Second Vice President, Board of Directors, Gulfside Regional Hospice, Florida, USA Associate Dean of Arts, Letters & Social Sciences, Pasco-Hernando Community College, Florida, USA President, Giannet Consulting Services, Inc. Florida, USA Competing interests: None declared |
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William G Notcutt, Consultant in Anaesthesia and Pain Management James Paget Hospital, Great Yarmouth, NR31 6LA, UK
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I have been very interested in this discussion. However, I believe that there is a missing element to it. I am no wordsmith but the way the word dignity is used has troubled me for a long time. It is much used by various crusaders or aggrieved relatives (particularly in the media) to reinforce their statements or arguments and thereby make them unchallengeable. I go back to the dictionary (Chambers) where I find that dignity is the state of being dignified. The verb " to dignify" is transitive and here is the crux of the matter. You are only dignified if I dignify you (care for you, love you, hold you worthy or in esteem, etc.). Therefore the use of the word reflects how I treat you. If I clean up your faecal incontinence, spend time with you, wash your body after your death, then these are all examples of me dignifying you. Therefore, you are "dignified". Dignity is a meaningless concept if you are alone on a desert island (one for the philosophers). Dignity is not intrinsic to you, something you own or possess. Yet it is commonly used in this way and often hijacked to reflect a "lack of mess", "absence of unpleasant bodily fluids", "being in full control", "having a stiff-upper-lip", “being smartly dressed”. Hence "he was a dignified old boy" or “I felt so undignified having a baby/ having my bottom wiped/ having to be fed etc. etc.”. Maybe we need to change or expand the definition of the word as language moves on. Maybe we just need to reflect on the true meaning and thereby clarify the debate. Yours sincerely, Competing interests: Founder member of local Clinical Ethics Advisory Group (now retired from it) |
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8. 16037 Riva Trigoso (Genoa) Italy.
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In my opinion, Ruth Macklin in his intriguing editorial (1) fails to remember a paramount paradigm of lack of dignity and respect for persons or for their autonomy, regarding really both doctor’s and patient’s dignity, although in opposite sense. What I mean is that now-a-days, in this technologized world, at least apparently, all HNS provide people with primary prevention – on more or less large scale – against the most common human diseases, such as malignancy, diabetes, arterial hypertension, rheumatic disorders, osteoporosis, a.s.o., which represent accordingly today’s epidemics, so that a large amount of (people’s) money is spent on preventive measures every year. According to the concept, all physicians agree with, that prevention is surely better than treatment, such as procedure seemingly respects all human rights documents. However, not “all” individuals can be involved, e.g., by type 2 diabetes (2), malignancy (3), hypertension (4), osteoporosis (5) a.s.o. (See HONCode web site 233736, www.semeioticabiofisica.it, Constitutions). As a matter of fact, although overlooked or ignored by HNS authorities around the world, for reasons very easy to understand, both Biophisical Semeiotics and biophysical-semeiotic constitutions do really exists (6). At the bed side, doctor is now fortunately able to recognize and assess in a quantitative, and not expensive, way, the diverse constitutions, selecting rationally people to undergo “real and efficacious” primary prevention, without creating anxiety, easily avoidable, not causing loss of work houers, and particularly not spending large amount of financial resources, which could be more useful if consumed in other fields of the medicine. 1) Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-1420 (20 December), doi:10.1136/bmj.327.7429.1419 2) Stagnaro S., Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. letter [PubMed –indexed for MEDLINE]. 3) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, in stampa. 4) Stagnaro-Neri M., Stagnaro S., Stadio pre-ipertensivo e monitoraggio terapeutico della ipertensione arteriosa. Omnia Medica Therapeutica. Archivio, 1-13, 1989-90, 1990 5) Stagnaro-Neri M., Stagnaro S., Diagnosi Clinica Precoce dell’Osteoporosi con la Percussione Ascoltata. Clin.Ter. 137, 21-27 [Pub- Med indexed for MEDLINE] 1991 6) Stagnaro S. Primary Prevention based on detecting Biophysical-Semeiotic Constitution. BMJ.com. Rapid Response. 8 January 2002. Competing interests: None declared |
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Peter R. J. Cheyne, Lecturer Fukuoka University
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Ruth Macklin's paper, 'Dignity: A Useless Concept' deserves little comment. 'Dignity' cannot be eliminated and replaced with 'autonomy' without semantic residue. The dignity from within is a calm and serious manner. This dignity can not always be ascribed to patients, but its facilitation during hospitalisation should be fostered and is not the same thing as respecting autonomy. The dignity from without is the honour and esteem held for a person. This dignity must include a respect for autonomy. On the other hand, respect for a person's autonomy does not entail honouring or well esteeming him or her. Macklin's paper provides an example of impatiently rushed thinking, exactly the kind of error of which patients too often complain when they say they aren't treated with dignity. The concept of dignity names something human. If it were to be eliminated, something human could become commonly overlooked. Ruth Macklin has confused dignity for autonomy just as a busy hospital consultant might confuse Mrs. White for Ms. Smith. I suggest Dr. Macklin get on better first name terms with her concepts before she operates on them. Competing interests: None declared |
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Idris Baker, Specialist Registrar in Palliative Medicine Leicestershire and Rutland Hospice, Groby Road, Leicester LE3 9TD
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Editor, Dr Notcutt in his rapid response correctly points out that a person has dignity because he has been the object of dignification by others. But I do not think that this means that a person must have something done directly to them in order to be dignified. Part of what it is to be human is that we are, inherently, in relation to each other. Although dignity is not strictly intrinsic, we are characterised by a dignity conferred on us by our common humanity - even when moribund or when on Notcutt's desert island. Respecting dignity, seeking to enhance rather than diminish it, reflects this. This does not of course justify the common use of the word dignity to mask invalid arguments or claims, and it does not excuse us from the requirement clearly to show what we mean when we refer to people's dignity. But we should recognise that some form and degree of dignity is a universal (if not intrinsic) human characteristic. Competing interests: None declared |
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Kirk C. Allison, Associate Director, Program in Human Rights and Medicine University of Minnesota , Mayo Mail Code 164, Minneapolis, MN 55455
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Ruth Macklin argues that pruning a multivalenced term from the ethical lexicon, namely ‘dignity’, will result in no loss of content or substance ethically or, ultimately, culturally: perhaps clarity will be gained thereby. One may instead equate dignity with "respect for persons or their autonomy" [1]. However, is ‘person’ for which one is to have respect less rich or conflicted a concept, or less excisable for example when equated with autonomous moral agent (excluding those who not yet, no longer, or may never fully actualize this human potential)? Autonomy is a good that is a precondition for engaging in a broad range of human actions (healing or injurious), but it is not the only good – and as a concept it may be that it is called upon to do too much work in ethical consideration. (In particular this applies where ethics is limited to the articulation of the implications of autonomy - the potentials and powers and interests of autonomous agents, defined in terms of a capacity to conceptualize, articulate and pursue explicit goals – in extremis denying all else.) With greatly limited autonomy, a person (say with mental retardation) can live a life ‘of dignity.’ Yet does such a one have a claim upon us in this regard whether or not they can articulate it (that is without autonomy and before cultural ‘concessions’)? A recognition (rather than mere assigning [2]) of dignity in the absence of autonomy is requisite to call culture to account towards providing conditions for such a life ‘of dignity’. Recognition implies that there is something present that a culture may acknowledge, be blind to, see but ignore for reasons of immediate utility, or perhaps have come into focus and gain force through a process of reflection. One with mental retardation may not be able to articulate a personal let alone generic vision of dignity or defend their ‘interest’ in it, yet culture is wrong not to respond to it or infirm not to see it. Moreover, dignity’s interests (inhering in particulars) apply to the dead as well as to the living (as painfully clear in the Georgia undertaking scandal of 2002) [3]. Certainly any recognition of dignity takes place in cultural context and has constructive elements in expression which may vary widely. But dignity reduced to social construct (performatively assigned) cannot do the work of challenging ‘culture’ to provide conditions supportive of a ‘life of dignity’ when such conditions are or become seriously inconvenient. If assignable, dignity may be rescinded when it does not serve the interest of ‘culture.’ (This is quite different from a culture - a shorthand for individuals and institutions - unable to fulfill recognized duties to either the living or the dead, say in the event of famine or epidemic. One would say it is possible they did not receive their due given a tragedy of circumstance, but without culpability.) In recognition dignity is responded to duly or perhaps ignored, but is not assigned. In the ‘performative model’ (where dignity exists if assigned, or evaporates if rescinded), there can be no ‘truth of dignity’ from which to ‘speak truth to power’. Here, flexible to changing fiat (or calculus), ‘dignity’ may tend to serve a very specific interest of culture – namely the prevailing powers in culture (perhaps the elite of culture), or of a local prevailing power where the interests of power are not limited by a compelling reason not to actualize all potentials and goals (admitting here goals pursued for seeming majority interest may be for woe as well as weal). Without ascribing ill motives, denying dignity or making it contingent may serve the interests of the powerful contra the vulnerable. (But where ill motives are obvious, extreme but instructive examples, such as in the rhetorical history of ethnic cleansing, reveal the psychological advantages of unassigning dignity for endeavors considered justified or useful yet outside the previous cultural norm.) In curcumstances of increasing burden, the vulnerable are unlikely to gain purchase on utilitarian grounds where the effective powers that assign or rescind dignity also define the implicit utility function and unit of utility. An ‘only social construct’ account of dignity finally hobbles under the same 'scope problem' found in behaviorist reductions (all human activity as 'only behavior'): While describing an aspect, the reduction cannot engage distinctions that are most vital [4]. An alternative to deleting or reducing dignity to contingent cultural assignment, without denying context, is understandng dignity as recognizable in human life because it names something tacitly present – also when its bearer is not autonomous.[5] If tacit it may be “implied or indicated yet not actually expressed” by its bearer[6]. The intuition of a dignity present and implicit in human life underlies coherence in the claim of human rights beyond local convention, and to right treatment - continuing even after death. Statutes follow (or may not follow) recognition. Its violation can be sensed in experience - whether articulable or not - most acutely by those exploited, but also in observer and even violator - at least until numbed by repetition. Kirk Allison, Ph.D. Associate Director, Program in Human Rights and Medicine, University of Minnesota [1] Macklin R. Dignity is a useless concept. BMJ 2003; 327: 1419- 1420. bmj.bmjjournals.com/cgi/content/full/327/7429/1419 (accessed 12/30/03; simul sub.). [2] Specifically, “Dignity reflects a moral status that moral agents assign to others. It is conferred on a human being by other human beings.” Caplan AL. Dignity is a social construct. BMJ 2003; 327 re. [1] (24 December 2003) http://bmj.bmjjournals.com/cgi/eletters/327/7429/1419#44646 [3] Cole, TR. We have a sacred covenant with the dead. Los Angeles Times; Mar 8, 2002; B.17 [4] It should be clear that a person pursuing behavioristly focused research is not necessarily a reductionist. [5] Recognition of dignity may extend beyond what is human – more than one species of dignity may be recognized. [6] “Tacit.” Webster’s Ninth New Collegiate Dictionary (1985): 1200. The Oxford English Dictionary (2nd, 1989; online edition) includes the senses ‘unspoken,’ ‘unvoiced,’ ‘still,’ as well as “Not openly expressed or stated, but implied; understood, inferred." http://dictionary.oed.com/cgi/entry /00245989?single=1&query_type= word&queryword=tacit& edition=2e&first=1&max_to_show=10 Competing interests: None declared |
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Alexander M. Capron, Director, Ethics, Trade, Human Rights and Health Law World Health Organization, 1211 Geneva 27, Switzerland
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Ruth Macklin’s recent British Medical Journal editorial, “Dignity is a useless concept,”(1) has touched off a lively debate in bioethics. Simply put, she argues that this oft-invoked term is like the emperor’s new clothes: there’s nothing there—or, more precisely, nothing that isn’t more clearly conveyed by the widely accepted principle of respect for persons. Prof. Macklin is surely correct that in most cases, such as in the protections afforded for individuals to make their own choices about medical care or participation in research, dignity is simply a term to recognize that “one is a person whose actions, thoughts and concerns are worthy of intrinsic respect,” as the Nuffield Council on Bioethics has put it.(2) The vehemence with which Macklin’s argument has been rejected by many of those who wrote “rapid responses” to the on-line BMJ demonstrates that, especially for persons working in health care, dismissing dignity risks disregarding a basic tenet of the respect owed to patients as human beings. I think it is possible to agree with them and still think Macklin is right because they are talking about different things: the former are concerned with dignity in the particular sense of treating individuals in a dignified fashion, while Macklin is criticizing the use of the term in a general fashion, as is conveyed by calls to safeguard human dignity from scientific changes. In the particular sense, dignity is invoked to enjoin people in power from subjecting others to humiliating or degrading acts. For example, it is right for hospitals, nursing homes, and similar facilities to ensure that patients are not wheeled about in flimsy and revealing hospital gowns, treated demeaningly, gossiped about by staff, or the like. That such behavior is usually proscribed by more specific rules does not make it wrong to sum them up as protections of patients’ dignity. Moreover, comparable strictures also apply to dead bodies, not because they would suffer directly but because treating individual—particularly, recently deceased—cadavers with respect provides security for all of us (as the future dead) and reduces the risks of a slide toward undignified conduct toward the demented (“they won’t notice”), the infirm (“they can’t object”), the poor (“they have no power”), and so forth. Thinking about how individuals’ rights to respectful treatment are violated makes clear the difference from the general sense of dignity criticized by Macklin. Examples of the types of uses to which she objects include assertions that human cloning or the patenting of human genes violates human dignity. Such claims are not based on any showing of harm to particular persons but to humanity in general, although, as she shows, once the august but ill-defined concept of human dignity has been invoked, no further justification for the claim is typically provided. This vagueness contrasts with the reality that is conveyed by Macklin’s argument that what lies behind dignity is simply the principle of respect for persons. As spelled out in The Belmont Report, an early and still highly regarded elaboration of bioethics principles, respect for persons encompasses “two basic ethical convictions: first, that individuals should be treated as autonomous agents, and second, that persons with diminished autonomy are entitled to protection.”(3) Attending to the latter facet helps to round out the picture painted by Prof. Macklin. While it is difficult to know what violating human dignity might mean, it is not difficult to specify conduct that would fail to treat persons as autonomous agents. Indeed, over the past thirty years, bioethics has been greatly concerned with helping to show why (and how) healthcare professionals should have clear and candid conversations with patients that will enable them to be informed decisionmakers and, having done so, respect the decisions these patients make. Saying that the failure to respect autonomy violates human dignity may not provide any added illumination, as Macklin points out, but at least equating dignity with autonomy clarifies the contours of the former. Likewise, specifying the ways in which persons with diminished autonomy should be respected—in sum, not treated as objects or unconsenting means to others’ ends, but rather as persons whose own well- being must be enhanced—is a fairly straightforward task. But if the term “human dignity” is cut free of being a less precise way of expressing these two facets of respect for persons, how then could one tell when it is violated? The answer provided in Arthur L. Caplan’s response to Prof. Macklin that dignity “reflects a moral status that moral agents assign to others”(4) tells us nothing about which acts amount to indignities or why, much less why it is important that the imputation of status be made by “moral agents” or itself be labelled “moral.” Most of the human rights now associated with the broad concept of human dignity have been set forth in treaties negotiated by sovereign states, not moral agents. Indeed, Caplan’s response seems to mirror the prevailing use of the term human dignity in bioethics documents: it is violated whenever someone finds something troubling or offensive, without the need to specify what the harm is. Let me provide an example: I think the world will be a better place if human reproductive cloning is never developed, but I feel obligated to explain that conclusion by trying to weigh the possible benefits and harms of the procedure. Suppose that a talented but unscrupulous fertility specialist secretly developed a safe method of reproductive cloning and used it on an unwitting couple. Certainly their rights to be informed decisionmakers about their own reproductive healthcare would thus have been violated, but would the existence of a cloned child violate human dignity? Assuming that neither the parents nor the child ever knew her origins, I can imagine some practical risks, but no assault on human dignity. Those who invoke that concept against reproductive cloning seem to be bundling in it our sense that many reasons given by people wanting to use cloning rather than sexual reproduction (such as a desire to replicate a dead child, to create copies of themselves, or to have a duplicate of an admired person) involve substantial risks of unhappiness or worse for the child (as well as disappointed expectations for the parents), and that allowing such individual uses would push forward a process in which children (and people in general) are measured by the extent to which they possess particular genetic features. Whether particular harms of this sort, which would be inconsistent with human flourishing and which tend to treat human beings as objects, would actually follow from reproductive cloning is a matter of speculation; making such predictions in a reliable would plainly depend on getting quite specific about the harms, a task that is not advanced by invoking the concept of human dignity, without more. Therefore, let’s continue to ensure that patients are treated “with dignity” and protected against humiliations and thoughtless treatment that undermine the respect they are owed as persons, while at the same time insisting that those who would invoke “human dignity” as a fundamental principle in bioethics and as a guide to public policy must clarify the content of the concept beyond respect for persons. 1. Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-1420. 2. Genetics and human behavior (2002), www.nuffieldbioethics.org/publications/pp_0000000015.asp (accessed 29 Dec. 2003). 3. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (U.S.), The Belmont Report (30 Sept. 1978), U.S. Govt Printing Office, p.4. 4. Caplan, AL Dignity is a social construct. 24 Dec. 2003 http://bmj.bmjjournals.com/cgi/eletters/327/7429/1419#44646 (accessed 29 Dec. 2003). Competing interests: None declared |
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Mark Struthers, GP Her Majesty's Prison, Bedford, UK
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'The holidays' are a traditional time for celebration and the New Year a time for hope and optimism. It was worrying then to see Ruth Macklin’s chilling little homily slip in under cover of the BMJ’s festive and frivolous issue. America stands on its dignity but has been careless with it. In a year when America has forcefully confirmed its autonomy and ditched any respect for persons of other nations, it is a little unsettling to see an American, a prominent medical ethicist, mount such a contemptuous assault on the concept of human dignity. The ‘many’ international human rights instruments and international conventions do little to address ‘medical treatment or research’ and are haughtily dismissed by Macklin as of little importance to medical activity. Americans will wish to ignore it but Article 1 of the United Nations Universal Declaration of Human Rights states that: “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.” For a country that aspires to be a world leader in human rights, the death penalty has defined the rogue state and become America’s Achilles’ heel. Article 5 of the Universal Declaration states that: “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” American exceptionalism is pre-eminent; it is beneath American dignity to abide by it. America has also ignored the 1989 United Nations Convention on the Rights of the Child and continues to execute juvenile offenders. In 1999 the only country other than America, to execute a child offender was Iran: an axis of evil indeed. Ruth Macklin considers dignity a useless concept in medical ethics. With the medicalisation of judicial killing, I wonder if she might offer an ethical analysis of this medical activity in America. Although the aetiology may remain a mystery, the diagnosis is clear. America exhibits a chronic inability to engage constructively with the outside world and with international instruments and conventions. When Americans come to engage with some respect for other nations, the world may yet dignify, may yet perhaps confer some dignity on America. Competing interests: A profound contempt for the human indignity of the American death penalty |
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Larry Culliford, Consultant Psychiatrist Brighton CMHC, 79 Buckingham Road, BN1 3RJ
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A latecomer to this discussion, I tend to side with Prof Stanley Giannet. I am wondering if it might help to consider dignity as a spiritual concept, where 'spirituality' refers to that which connects the one with the whole, thereby linking the deeply personal with the universal. Suggesting that each person is connected spiritually with everyone else, living, dead or to come, is to agree with the sentiments of many responders to Ruth Macklin's editorial. Dignity is served by adherence to that view, as are kindness, compassion, tolerance, wisdom and many other highly valued human attributes. Why is the literature of medical ethics, as Prof Macklin describes it, so determinedly secular? As I wrote in a BMJ editorial at Christmas a year ago(1), differing religious beliefs and practices can be divisive, but spirituality by this definition is essentially unifying. Is it not time therefore to re-introduce this forgotten dimension more broadly into our thinking about medicine, medical ethics and health care generally? It seems to me to unlock many conundrums. Reference: Culliford L. Spirituality and Clinical Care. BMJ 2002;325:1434-5 Competing interests: Dr Culliford writes spiritually orientated self-help books under a pen-name. See www.happinesssite.com |
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Ann Gallagher, lecturer in mental health The Open University
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Some of what Ruth Macklin says about dignity is uncontentious: appeals to dignity are often vague; the concept is interpreted variously; references to it sometimes appear sloganistic; and it is often reduced to respect for autonomy or for persons. What is contentious is that dignity is useless and could be eliminated without any loss of content to medical ethics. Dignity cannot and should not be reduced to respect for autonomy or for persons. Rather it constitutes an otherwise missing value which enables practitioners and theorists to discuss aspects of medical practice which other values do not address. Criticisms of dignity apply also to other values in medical ethics. ‘Autonomy’ and ‘respect for persons’ are good examples. They also appear as vague, ill-defined and sometimes sloganistic in codes, reports and in legislation. Whilst theorists make laudable attempts to clarify these concepts, such clarification may fail to make its way into professional documents. This is also the case with dignity. There is now a good deal of theoretical and empirical work to draw on which makes vague references to dignity inexcusable. The rapid responses here are likely to advance thinking on this topic, most significantly, the response of Arthur Caplan. Fairly extensive previous work also deserves attention. See, for example, the work of Spiegelberg in Gotesky and Laszlo 1970; Mairis 1994; Haddock 1996; Moody 1998; Mann 1998; Pullman 1999; Seedhouse and Gallagher 2002; and Nordenfelt 2003. In response to Professor Macklin’s question ‘Why, then, do so many articles and reports appeal to human dignity, as it if means something over and above respect for persons or for their autonomy?’ it might be asserted ‘Because it does mean something over and above respect for persons and autonomy’. More, of course, needs to be said. Just as vague and sloganistic references to dignity will not do so, too, with respect for autonomy and for persons and these values need to be elucidated. Autonomy has a range of meanings (See, for example, Husted in Chadwick et al 1997) and what is meant by respect for persons is not always clear. A Lockean view of respect for persons, for example, focuses on rational capacity. If, as is generally held, respect for autonomy and for persons emphasise and focus on the rational and decision-making capacity of patients then these values seem insufficient in discussions about the treatment or non-treatment of those who are incompetent, of body parts or of the dead. Another value is necessary. That value is dignity. A value which acknowledges the worth of humans qua human regardless of competence, sentience or body form. Without dignity, it seems, there can be little (if any) meaningful discussion about the rights and wrongs of the treatment of those deemed non-autonomous or non-persons. Dignity is not only a useful value it is, in fact, an essential one. What Professor’s Macklin’s provocative piece urges us to do is not to throw dignity out but rather to reclaim it, embrace it, draw on and develop existing theoretical and empirical work and not refer to it glibly, vaguely or thoughtlessly. References Haddock J. (1996) ‘Towards further clarification of the concept ‘dignity’’ Journal of Advanced Nursing 24, pp.924-931 Husted J. ‘Autonomy and a right not to know’ in Chadwick R., Levitt M. and Shickle D. (eds.) (1997) The Right to Know and the Right Not to Know Avebury, Aldershot Mairis E.D. (1994) ‘Concept clarification in professional practice: dignity’ Journal of Advanced Nursing Vol. 3, pp. 947-953 Mann J. (1998) ‘Dignity and Health: The UDHR’s Revolutionary First Article’ Health and Human Rights Vol. 3, No. 2, pp. 31-38 Moody H.R. (1998) ‘Why Dignity in Old Age Matters’ Journal of Gerontological Social Work Vol. 29, No. 2/3, pp.26-36 Nordenfelt L. (2003) ‘Dignity of the elderly: An Introduction’ Medicine, Health Care and Philosophy 6, pp.99-101 Seedhouse D. and Gallagher A. (2002) ‘Undignifying Institutions’ Journal of Medical Ethics 28, pp.368-372 Spiegelberg H. ‘Human Dignity: A Challenge to Contemporary Philosophy’ in Gotesky R. and Laszlo (eds) (1970) Human Dignity: This Century and the Next Gordon and Breach, Science Publishers, New York Competing interests: None declared |
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Mary Catherine Beach, Assistant Professor Johns Hopkins University, Baltimore, Maryland 21205, USA, Patrick Duggan and Gail Geller
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To the Editor: Ruth Macklin examines the use of the term ‘dignity’ in medical ethics, finds that appeals to human dignity are vague, and thus concludes that dignity is a useless concept [1]. We disagree on several counts. While we agree with Macklin’s primary assertion that ‘dignity’ is often used vaguely or merely as a slogan to make sweeping claims that might otherwise be questionable, we feel that dignity is far too important a concept to be dismissed out of hand. As a point of clarification, ‘dignity’ is no more or less vague than many other terms employed in medical ethics: It can be defined as ‘the quality or state of being worthy of respect or honor,’ derived from the Latin ‘dignitas’ meaning ‘worth’ or ‘worthiness,’ and its use can be quite deliberate and serious. Macklin also believes that dignity means no more than respect for persons or their autonomy. We disagree with this interpretation for several reasons. First, although dignity is often attributed to persons, in which case it does imply a duty to respect persons, dignity can apply more broadly than respect for persons. Dignity may also characterize non- persons, as Macklin’s example of practicing medical procedures on the newly dead nicely illustrates. The newly dead, who are not persons (although they are human), certainly can be thought of as worthy of respect—respect that presumably cannot be owed to them as ‘persons,’ since most theoretical accounts of personhood are not inclusive of the dead. Second, even when dignity is used to describe persons, there remains a fundamental difference in the moral focus of dignity versus respect for persons. The idea of ‘dignity’ is primarily concerned with the person-who -should-be-respected, whereas the duty of ‘respect’ is centered on a moral agent, the person-who-respects. People have dignity regardless of whether they are respected by others. To say that a person has dignity is to imply that that person has value and is worthy of respect, which is different than saying that someone else has a duty to respect that person. Dignity is not merely a more vague formulation of respect for persons; it is the fundamental underpinning of respect for persons. Mary Catherine Beach, MD, MPH
Phoebe R. Berman Reference: 1. Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-1420. Competing interests: None declared |
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Stephen J Fletcher, Consultant, Intensive Care Unit Bradford Teaching Hospitals, Bradford, BD9 6RJ
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Editor I read Professor Macklin’s editorial on the concept of dignity with interest. [1] I agree that in strict legal-ethical terms the word has little utility but it is a term that patients and relatives understand and place value in. As with ‘obscenity’ dignity is hard to define but instinctively understood. When explaining to relatives the condition and likely outcome of their loved one who is a patient in intensive care, it is difficult to convey the suffering that the patient experiences. This is particularly true when death appears inevitable and the suffering in vain. In this situation, relatives readily appreciate that prolonging intensive care support is preventing a ‘dignified’ death and may not be in the patient’s best interest. They frequently volunteer that the patient him- or herself would want to ‘die with dignity’. I would submit therefore, that the word is of value to the clinician if not to the ethicist. Yours faithfully, Dr Stephen J Fletcher
[1] Macklin R. Dignity is a useless concept. BMJ 2003;327:1419-20 Competing interests: None declared |
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Francis P. Crawley, Secretary General & Ethics Officer European Forum for Good Clinical Practice, 1040 Brussels, Belgium, Amin Kashmeery and Chifumbe Chintu
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That Ruth Macklin’s dismissal of dignity from health research ethics has aroused deep indignation reflects the fact that, however cloaked, the assault is not simply an interesting philosophical polemic. Indeed, there is little in the way of either philosophy or ethics to recommend the essay. The provocations of this Christmas missive with its deliberate secular and political aims are not lost on the victims of callous medical research and other structured aggressions supported by such wrongful apologies. The failure of individual engagements and cultural expressions to provide due care for the dignity of others in word and deed should not be passed over lightly by society. There is nothing commendable in the ill -conceived assault on religion, ethics, and human rights. Such fanfare promotes the use of double standards in the assertions of the powerful over the vulnerable. Past and present abhorrent events testify well to the overwhelming suffering caused by the failure to think and act in a humane manner. It is not the dignity of the person that requires explanation or apology, but rather the decision not to recognise the dignity of others in personal, scientific, political, and economic pursuits. Even still, for the act once committed, explanations and apologies arrive too late to forestall injury, and they are seldom sincere in their recognition of the moral suffering inflicted. Francis P. Crawley, Secretary General & Ethics Officer, European Forum for Good Clinical Practice, Brussels, Belgium Chifumbe Chintu, Chairman, Pan-African Bioethics Initiative (PABIN, Lusaka, Zambia Amin Kashmeery, Director, Centre for Biomedical Ethics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Competing interests: None declared |
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Lydia E. Mayer, Asst, Professor Obstetrics and Gynecology, TUSM 96 Westchester Rd, Boston, MA 02130
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In “Dignity is a useless concept,” Macklin’s argument ignores an important historical fact, commits the naturalistic fallacy and would, based on these oversights, risk the competent, caring practice of medicine. First, if one looks at the history of the use of the word “dignity,” it is clear that each philosophical age has changed its meaning. For example, dignity referred to external, formal honor in Aristotle’s time, while Cicero associates it with character.1 Pico della Mirandola2 links dignity theologically to free choice. Dignity was a first principle, which Kant3 used to develop the concepts of respect for persons and autonomy. Hermeneutics would suggest that like other fundamental concepts, dignity requires contemporary philosophical interpretation. Second, I agree with Macklin’s point that currently dignity is most often invoked as a slogan. However, it would be wrong to allow such inappropriate and confused use to lead to the conclusion that dignity ought to or only can be used this way. As others have noted, dignity is a word in need of a taxonomy.4 Third, the most important reason that respect for dignity needs to be a bioethical principle is that, as a premise, it has founded contemporary standards of medical care. Clinicians’ moral stances influence medical processes and outcomes. While space precludes argument of the following,5 reflection shows that respecting dignity enables clinicians to create clinical contexts that allow them to become more deeply familiar with the genuine patient and her circumstances than they are under conditions of autonomy. Respect for dignity is thereby a requisite for high quality medical assessment, treatment, and good patient outcomes. In other words, branding dignity a useless concept abolishes the profound respect most associate with persons and endorses a medicine that could accept patients as physiological entities and only if they commanded respect on evaluative bases of characteristics such as demographic descriptors or social mores. Indeed, as shown elsewhere,5 if “dignity is a useless concept” then medicine must be prepared to forfeit care, justice, and its current standards for quality. 1 Cicero. De Officiis. Book 1,XX - XXI Passage 69. Trans. Walter Miller. Harvard Univ. Press: Cambridge, MA; 1913, p.71 2 Pico Della Mirandola, Giovanni. Oration on the Dignity of Man. trans. A. Robert Caponigri. Regnery Publishing, Inc.; Washington, D.C.: 1956 3 Kant, Immanuel II:71 (435 –436) Groundwork of the Metaphysics of Morals. trans. H.D. Paton. Harper and Row; New York: 1964. 4 Mann JM, Gostin L, Gruskin S, Brennan T, Lazzarini Z, Fineberg H. “Health and Human Rights.” Chap. 1 in. Mann JM, Gruskin S, Grodin MA, Annas GJ, Eds. Health and Human Rights: A Reader. Routledge: New York City; 1999, p 15. 5 Mayer, L. Respect for Dignity and Medicine. Article currently submitted for publication. Competing interests: None declared |
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Miles R Bore, Associate Lecturer and Researcher University of Newcastle, Australia, 2308
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Concepts can be slippery things. We believe we understand what ‘happiness’ means, but ask people to clearly define ‘happiness’ and you might get as many definitions as the number of people asked. More concrete concepts are easier to define. The concept ‘chair’ might be less of a cognitive stretch than more abstract concepts such as ‘morality’. So it would seem with the concept of ‘dignity’. In 1936 Allport and Odbert set about creating a list of all the words in Webster’s Dictionary that described the psychological traits of humans. Their resulting list included some 4,500 words and the basis of their research became known as the lexical approach to the study of personality. Simply, if a word exists then it exists for a reason. It describes something of note, of states, of tendencies, of differences within (I feel happier today than I did yesterday) and between (Fred is always happier than Jan) people. Dignity is a word representing an abstract state or feeling. If I fall over in the street, I experience a loss of dignity. Furthermore, this loss can be felt whether the fall occurs in view of others or not. When a person visits their doctor, or a hospital, or participates in medical research, the treatment they receive and the manner in which they are treated impinges on their sense of dignity. It seems quite possible for a person’s autonomy to be respected yet their dignity upset. While the person might voluntarily agree to a medical procedure, be well informed of the procedure, have their records of the procedure kept in strict confidence, be unharmed by the procedure and actually benefit from the procedure, they might still incur and feel a loss of dignity. Even the humble hospital gown might be seen as a challenge to many a patient’s dignity. And this is my point of argument with Professor Macklin’s article. I disagree with the statement that dignity “is no more than respect for persons or their autonomy”. You can highly respect a person and their autonomy by your actions, words and thoughts, and as a doctor you will also be striving for their well-being, but you cannot guarantee that this will not ‘mess’ with their sense of dignity. It is quite imaginable that respected, autonomous patients endure indignities for the sake of a hoped- for cure. The concept of dignity seems to stretch beyond a person’s life and into death. Most, if not all cultures, have rites, ceremonies and rituals honouring a person who has ceased to live. There are procedures and an expectation of reverence for the handling of bodies. To give an extreme example, the WWII scenes captured on film of Jewish bodies being tossed, shoved or bulldozed into mass graves produces a sense of shock and repulsion in most people. It seems we humans consider that a dead body should be treated with dignity: we do not just see a cadaver. The thought of dying without dignity seems frightening to many people, or at the very least, a dignified death is seen as highly preferable. The question raised by Professor Macklin’s article is: does the concept of dignity add anything to medical ethics? I think it does. Yes, the concept is not well defined, but it clearly exists and seems very human. It cannot be fully accounted for by other concepts such as respect and autonomy (or beneficence, non-maleficence or justice) if a person is given respect, allowed full autonomy, yet still feels a loss of dignity. This is not only deeply psychological, but highly relevant to medical ethics. The onus, it would seem, is to develop a greater understanding and appreciation of this highly abstract concept we call ‘dignity’. Medical ethics, and those it serves, might well benefit. Reference: Allport, G., W., and Odbert, H., S. (1936). Trait names: A psycho-lexical study. Psychological monographs, 47, 1-171. Competing interests: None declared |
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Jamie S J Wilson, Final Year Medical Student Ninewells Hospital
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To have dignity is: To be outwardly of right mind and body so as to have self respect (whether privately felt or endowed by virtue of onlookers). Competing interests: None declared |
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Ronald F Ingle, Honorary Senior Lecturer Medical University of Southern Africa, PO Medunsa, 0204
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Jamie Wilson's definition comes closest to what I want, even belatedly, to add to the responses. Assuming that "medical ethics" and "ethical analysis" are rooted in reality, I find no other word deals so necessarily, through its derivative indignity, with being chronically incontinent of urine and faeces, slobbery, and smelly; with uncontrollable laughing or crying, with being unable to remember loved ones and friends, with being imbecilic; with losing ones hard-won personage, by which you achieved some sort of lovable identity. Competing interests: None declared |
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