Caplan: Dignidade

Dignity often appears in admonitions about how doctors should treat patients. “Each individual has the right to be treated with dignity […]. To repeat, individuals have a right to be treated with dignity not as an instrument of someone else’s policy” avers Sir Michael Marmot in a World Medical Association statement. The WMA’s Code of Ethics enjoins doctors to provide care “[…] with compassion and respect for human dignity”. The American Nurses Association believes that “respect for the inherent dignity, worth, unique attributes, and human rights of all individuals is a fundamental principle”.

This all sounds wonderful in the abstract. But can the concept really bear the weight that it is asked to hold in so many ethical settings, especially in health care? The noted bioethicist Ruth Macklin is one of the many who thinks not. In 2003, she declared in the British Medical Journal (BMJ) that “dignity is a useless concept in bioethics.” She went on to argue that outside of being used as a placeholder when asking for respect for persons or individual autonomy, dignity was mere window dressing in ethical argumentation.

Many disagree. They find dignity present in human beings from their embryonic state through their ending as cadavers. Others urge the bestowal of dignity on any and every patient, no matter how ornery, blameworthy, odd, obstreperous, or non-compliant they may be. And others maintain that dignity is a “natural” human state around which a package of human rights can be built. So, do those called to philosophical arms in defense of dignity succeed in blunting Macklin-like challenges? Not to any great degree.

Many of the defenders of dignity are so eager to retreat back to their conclusions that human embryos have inherent dignity or that reproductive cloning is an affront to human dignity, that they do not get far in either explicating the idea or finding persuasive grounds for positing it. Others want to cite natural law or religious tradition to support claims of human dignity. However, the invocation of a long intellectual or spiritual tradition is not an argument but only a sociological case study. And the invocation of “natural” dignity is an assertion, not an argument. What is needed are arguments that make sense of dignity and make it palatable as a key idea on persuasive and pragmatic grounds. That can be done if we recognize that dignity is intended to sometimes capture biological requirements for human flourishing, other times virtues that are valued by human beings that permit autonomy, and finally, it is often used to denote the capacities that allow such autonomy to exist. Most of us feel revulsion at what happens to people who are tortured, raped, or trafficked. Part of the reason is that we know that torture often involves humiliation or degradation of the victim. Respect for persons hardly seems sufficient for capturing the evil involved. Torture plays on cultural and social views of propriety that go beyond simply respecting the individual as a person, to the broader social realms of what makes that person feel safe, whole, and a part of larger groups. One sense of dignity, which those who invoke “natural” human dignity search for, is that in which it encapsulates a core of requirements rooted firmly in biology that permit any individual to flourish—some privacy, bodily security, adequate nutrition, housing, mobility, and the freedom to speak, think, and reproduce. Those who torture, sadly, know full well what these biologically based requirements are.

Similarly, human dignity can refer, and has since Cicero and the Stoics, to the virtues that are esteemed by a society. So, when we ask a doctor to practice medicine with dignity or speak about death with dignity we are seeking consensus on the virtues of professionalism or what constitutes a “good” death. What about finding dignity in autonomy? Making a claim of dignity about a person or even a group is more than simply acknowledging the right of individuals to act autonomously. It is to see inherent value in their ability to reflect, deliberate, value, and choose—the core elements of autonomy. There is moral pull or gravity exhibited by those who can do these things and thus are autonomous agents, have the capacity to become so, or are in the care of an autonomous agent—a disabled infant, a cadaver, or someone in a permanent coma.

Even the Christian notion of dignity that invokes both humanity’s likeness to God in the grand scheme of things to ground dignity can be secularized a bit so that dignity becomes simply acknowledging the value of a conscious, socially cooperative and reflective creature and its products which are infused with acquired dignity due to their creation by autonomous beings and their concern for them.