Dignity is a useless concept
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7429.1419 (Published 18 December 2003) Cite this as: BMJ 2003;327:1419
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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
Competing interests: No competing interests
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being withdrawn from bioethical debate.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.
adj. prof. gerontology, Simon Fraser University.
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Dignity is A Social Construct
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
Competing interests: No competing interests