Dignity is a useless concept

Why We Can’t Dispense with “Dignity” in Health, Why We Can’t Dispense with “Dignity” in Health Care

“Remember this-that there is a proper dignity and proportion to be observed in the performance of every act of life”.
Marcus Aurelius Antoninus

Abstract
In a recent search on PubMed, the keyword “dignity” returned 3850 hits; a randomized control trial 1 reported that “dignity therapy was significantly better than client-centred care in improving spiritual wellbeing (χ2=10·35; p=0·006), and was significantly better than standard palliative care in terms of lessening sadness or depression (χ2=9·38; p=0·009)”. Health workers pick the word “dignity” to characterize their approach to patients not because it sounds nice and general, but rather for the simple fact that “dignity” is a tangible attribute of personhood that we need to attend to in caring for and treating people. Today, we seem to have forgotten about the havoc created by Ruth Macklin’s article in BMJ (2003; 327: 1419-1420) 2 with her conclusion that the concept of dignity is useless in bioethical practice. Later, the prolific Harvard psychologist Steven Pinker added fuel to it with his piece in New Republic (May 28, 2008) 3 where he claimed that dignity is a squishy concept that buttresses conservative bioethics. Even though the dust has settled, we feel that a proper response to these theorists is still in order to defuse the threats and un-easiness brought about by their polemical writings; otherwise, that individuals diligently practicing dignity therapy might think that they are being perceived as mongers of cheap sentimentality.

The oddity about the “eliminativism” of “dignity” is that while Macklin and Pinker 2 3focus on what dignity is not, neither author states what dignity is. The Merriam Webster dictionary4 defines dignity as “the quality or state of being worthy, honored, or esteemed”. Honoring and esteeming others includes being listened to in the last imprint we leave of life, the act of dying while fighting to live. Refusing the act of dignity by robbing it of a name accelerates the fear all face on the path to extinction.

Macklin 2 states “With few exceptions, these conventions (dignity) do not address medical treatment or research” To follow her logic, we are required to stop thinking about the age-old concept of dignity in medical practice as if it were an illegitimate child of modern medicine. Of course, dignity eliminativists would insist that you can’t add dignity to good evidence-based treatment and so dignity is just another way of meaning “good”. But why would dignity become the cornerstone of palliative care? Couldn’t we just give good treatment to the dying? The answer is obvious: in the face of impending demise, a patient is often acutely aware of what is dignified for himself or herself without discerning what is a good practice from the scientific point of view. It is a small kindness for us to respect the dying by cocooning them with dignity as they make the passage we all eventually undertake alone.

Macklin and Pinker can be understood as arguing “philosophically”. But as a rule of the thumb, whenever philosophers declare a commonsensical concept to be useless, misleading, squeamish or even harmful, the non-philosophical community must be wary of the special context in which philosophical polemics are pitched. Remember Lord Russell’s 5 bold assertion that “the word ‘cause’ is so inextricably bound up with misleading associations as to make its complete extrusion from the philosophical vocabulary desirable”. However, “cause” is at present still an indispensible concept in evidence-based medicine and other scientific disciplines 1. So, how useless is “dignity” as a concept for Macklin2? It is of paramount importance to state that Macklin does not mean that this concept is “useless” in a day-to-day context. Instead, she only thinks that “dignity” is not something additional to, or over-and-above, the concepts of personal autonomy and respect for persons2.

This line of argumentation is common in philosophy when a concept is reduced to more basic ones, such as when talk of colors is reduced to talk of wavelength or surface reflectance. But if the uselessness of “dignity” is only as such, there is no point to mount an attack on a straw man; for we are not guilty of using the concept as a convenient indicator of some more basic or synonymous concepts.

No one would ever dream of being labeled as abuser of language or concepts when she, for example, uses “coke” to refer to the “Coca-Cola”. On the other hand, if it happens that “dignity” has been frequently misused by people to advance their illicit political agendas (as Pinker 3alleges), it is not a problem with the concept itself. To banish a concept for the purpose of silencing the heinous users is as ridiculous as Harry Potter 6 intending to reduce the threat of Voldemort by only referring to him as “You-Know-Who”.

We contend that Macklin’s real target is the use of “dignity” in relation to death, dying and palliative care. Pinker 3 further adds the religious connotations to this. Due to space limitations, we will restrict our comment to the controversial application of the concept of dignity to the dead. Macklin 2 states: “But this situation [violating the dignity of the dead person] clearly has nothing to do with respect for autonomy since the object is no longer a person but a cadaver”. So, the problem is this: does applying the concept of dignity to a dead person involve a categorical mistake or a problem of vagueness/ambiguity? These are truly the province of philosophers’ rather than that of the health workers.

No doubt it is the wishes of the living that we respect first and foremost in planning and implementing medical interventions. However, Macklin2 has not fully given vent to philosophers’ ruminations about personal identity when she reminds us that a cadaver is an object. We agree that it is, in some contexts, a platitude to equate corpse with object; but such latitude is not available to a bioethicist who even finds the mentioning of dignity in health care offensive. Of course, we know that physical happenings to our bodies, cadavers or not, are events occurring in an object. However, Macklin 2makes a grave philosophical mistake when she writes as if the dignity of the dead body is co-extensive with the dignity of the person who is now dead. We need not have religious backgrounds or metaphysical doctrines to see the difference.

We note in passing that the Oxford philosopher Nick Bostrom7 recently mounted a defense of post-human dignity7. If Macklin2 thinks otherwise, it is likely that she would even find the health workers’ empathetic concern with life-saving another piece of sophistry in light of Epicurus’s saying 8that “when we are, death is not come, and, when death is come, we are not.”

Our conclusion is that dignity is a time-honored concept, especially in the injured and sick community. It may be well-intentioned for a philosopher to point out the abuses and pitfalls in the use of an entrenched concept; to declare it useless and harmful is more often a gesture of arrogance. In questioning our principle of scientific induction, the late Harvard philosopher Nelson Goodman9 never concludes that the entrenched concept of, say, “green” is useless in comparison to his equally robust neological concept “grue”. We advise health workers to read “dignity” as a thick concept: a value-concept imbued with significant and variable descriptive contents. Furthermore, we should agree that a patient is also a person with significant personal projects to accomplish: this much is part and parcel of Macklin’s2 task of defending the autonomy of a living patient. We are glad to see the development of dignity therapy opening channels for scientists to understand the questions of when, how, and why certain seemingly objective and effective health interventions might be perceived as compromising personal dignity. A compassionate health care service does not prosper in a sterile scientism without concomitant progress in qualitative research into the life-world of a patient and the philosophical understanding of personal identity and mortality.

References
1. Chochinov HM, Kristjanson LJ, Breitbart W, McClement S, Hack TF, Hassard T, et al. Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial. The lancet oncology 2011.
2. Macklin R. Dignity is a useless concept. Bmj 2003;327(7429):1419.
3. Steven Pinker TNRPW, May 28, 2008. The Stupidity of Dignity. The New Republic, 2008.
4. Merriam-Webster I. Merriam-Webster's collegiate dictionary: Merriam-Webster, 2003.
5. Russell B. The Collected Papers of Bertrand Russell, Volume 6: Logical and Philosophical Papers 1909–13: London: Routledge, 1992.
6. Barron D, Rowling J, Grint R, Watson E, Fiennes R, Gambon M, et al. Harry Potter and the Order of the Phoenix. Harry Potter 2007:464.
7. Bostrom N. In defense of posthuman dignity. Bioethics 2005;19(3):202-14.
8. Rosenbaum SE. How to be Dead and not Care: A Defense of Epicurus. American Philosophical Quarterly 1986;23(2):217-25.
9. Goodman N. Fact, fiction, and forecast: Harvard Univ Press, 1983.