Volume 3, Issue 01 - March 2000

Digging Beneath our Dignity: Cultivating Ethics' Fundamental Value

"Dignity" has several meanings and usages. Dignity is an emotive word that draws upon, and draws out, our feelings. We hear phrases like, "He lived with dignity", "She carried herself with dignity", "There is a price to pay for dignity", "The disease took away her dignity", "They were treated with dignity", and so on. Some health care organizations identify dignity as one of their core values (2). The Canadian Association of Social Workers mentions the "intrinsic worth and dignity of every human being" in their code of ethics (3). The United Nations Universal Declaration of Human Rights' first article includes, "All human beings are born free and equal in dignity and rights" (4).

What follows is an argument for cultivating the more informed use of the word "dignity" as it relates to our identity as a moral community. (For a far more in-depth analysis of dignity, I highly recommend Daryl Pullman's article (1).) I will also claim that the commonly accepted principles of health care ethics, autonomy, beneficence, non-maleficence, and justice, are all derivative of the value dignity. Dignity is the trunk and root system from which the branches of autonomy, beneficence, non-maleficence, and justice develop and spread. Respect for dignity determines the health of these four branches within a moral community, which in turn determines the health of the moral community.

Dignity Defined

Human conduct can be within the sphere to which moral judgements apply (morally good or bad, right or wrong) or outside the sphere of moral judgements (neither moral nor immoral but amoral). I want to distinguish between two ways the word "dignity" is used: (a) the moral worth/moral status usage and (b) the amoral worth/non-moral status usage.

Additionally, within (a) (the moral worth/status usage) I would distinguish two uses of the term: (i) an intrinsic/inherent usage ("intrinsic", meaning belonging to a thing by its very nature and "inherent", meaning existing in someone as a permanent and inseparable quality or attribute); and (ii) a merit usage. The intrinsic/inherent usage is what is intended by the above-cited organizations. Intrinsic dignity is that moral worth/moral status we all hold by virtue of being human beings. It is not conditional, not contingent, not a function of any worldly factor other than being human.

Merited dignity is the dignity we earn and accumulate by conducting ourselves in a manner that actively respects the intrinsic/inherent dignity of other human beings. Neither intrinsic nor merited dignity can be reduced or taken away from an individual under any human circumstances. When others do not respect our intrinsic dignity or merited dignity, our dignity is not affected; rather, they have lost an opportunity to add to their own merited dignity.

Take for example two identical twins, Goodright and Badwrong, who are on vacation in Hawaii. They are racing to shore from a swim to catch their favorite soap opera. They swim past a four-year old child about to drown. Badwrong is first to hear the bright child say, "Please save me, I can't swim. Please respect my intrinsic/inherent dignity, my moral worth." Badwrong responds, "I recognize no one's moral worth and certainly no one's intrinsic/inherent dignity. I'm late for my soap opera."

Here, Badwrong lived up to his name. Not only was his conduct morally bad/wrong, but he also lost the opportunity to accumulate his own merited dignity. Fortunately, Goodright lived up to his name and saved the child saying, "I recognize your intrinsic/inherent moral worth as equal to all human beings." Goodright's conduct in this context is an example of merited dignity. Imagine further that later that night the child is being honored at a banquet for his excellence at playing the piano. Both brothers are in the audience and Badwrong remarks to Goodright, "Well I still refuse to recognize the child's intrinsic/inherent dignity but I must say he plays that piano in a most dignified manner, what with his custom-made tuxedo and all." The child's dignified skill and appearance do not fall within the sphere of moral judgment. They are, in this context, morally neutral or amoral.

Curiously, the Canadian Oxford Dictionary focuses on the amoral use of the term. It defines dignity as: "(i.) a composed and serious manner or style, (ii.) the state of being worthy of honour or respect, (iii.) worthiness, excellence, (iv.) a high or honorable rank or position, (v.) high regard or estimation" (5). None of these definitions make specific reference to the moral worth/status definition. Yet, a world class athlete, musician, scientist, etc., can be afforded honour, respect, worthiness, excellence, high regard or estimation without there being any corresponding reflection on their individual moral worth/status. Although, "worthy" in definition (ii) can have multiple meanings, one of which is "having some moral worth", it is striking that the moral worth definition is not more specific. Given the profound significance of the word "dignity" in the UN's Universal Declaration of Human Rights, in professional codes of ethics, and in core value statements of health organizations, we need to promote a clearer understanding and proper profile of the moral worth definition of the term.

Inherent Dignity

As a part of a Family Day weekend celebration of the 35th anniversary of Canada's flag this February, citizenship judge G. Bhatia said, "the Universal Declaration of Human Rights should be required learning for every child in the world" (6). The Declaration begins, "WHEREAS recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world." I support Bhatia's claim and would expand it to all adults, with an emphasis on a fuller understanding of the use of the phrase, "inherent dignity". Inherent/intrinsic dignity is not earned, compromised, increased or decreased by one's conduct or the conduct of others. This also means that no disease, disability, or suffering, of any kind, can reduce or compromise our inherent dignity (even if it reduces our quality of life). Inherent dignity remains equally in all humans from their beginning to their death and, in some senses, beyond their death.

The distinctions drawn so far are valuable in that when we use the term "dignity", it is very important to be clear on what we are saying. For if we accept the above, then in a real way it does not make sense to say something like, "the disease took away her dignity" or "her dignity was preserved" because that is not possible. What is possible is that we can fail to recognize in her the inherent dignity that remained with her in her last days. It is also possible to say that, "she no longer was able to respect, or disrespect, the dignity of others, because her condition deprived her of that capacity".

Some Implications

Amoral types of dignity (high regard, status, position, honors) are not always deserved and are often short-lived, and contingent upon the unpredictable fashions of the day. Merited dignity can accumulate throughout a lifetime of actively respecting the intrinsic dignity of all human beings. However, no matter how much merited dignity one acquires in life, I would argue that it could never surpass the value of our intrinsic dignity. This should not be interpreted as diminishing the value of merited dignity, but rather to emphasize the value of intrinsic dignity, from which all else in ethics draws meaning and moral force.

People in the severest stages of dementia, who may have lost all measurable autonomy, independence, and self-determination still have intact the identical intrinsic dignity they have had throughout their lives. These same people still have intact the accumulated merited dignity they have acquired throughout their lives through actively respecting the dignity of all other human beings. What they have lost is the capacity to continue adding to their combination of intrinsic dignity and merited dignity. They have not lost any dignity (moral worth), however undesirable their state of affairs. They may lose amoral (non-moral) dignity, such as some of the high regard, status, position they held prior to the severe dementia, but this form of dignity, though not unimportant, is often overrated.

I believe that for us not to see that undesirable diseases, disability, and suffering cannot reduce our intrinsic/inherent dignity (for if they could, then dignity could not have been truly intrinsic/inherent in the first place) and cannot reduce our merited dignity, is to unwittingly assault respect for dignity, resulting in trauma to the branches of autonomy, beneficence, non-maleficence, and justice. In a mature moral community, death is always with dignity, for the intrinsic dignity and the merited dignity of those dying are untouched by dying and death.

Closing Thoughts

Intrinsic dignity and merited dignity do not need preserving, they need respecting. Caregivers, in the act of caring with respect for those near death, add to their own merited dignity and to the merited dignity of their communities. Mature moral communities will not flourish without widespread education about intrinsic dignity and an active distribution of merited dignity.

References

1. Pullman, Daryl. (1999). The Ethics of Autonomy and Dignity in Long-Term Care. Canadian Journal on Aging, 18:1, pp. 26-46.
2. Catholic Health Association of Canada. (1991), Health Care Ethics Guide, pp. 29-30.
3. Canadian Association of Social Workers Code of Ethics (1983).
4. United Nations. (1948), Universal Declaration of Human Rights.
5. The Canadian Oxford Dictionary. (1999). Oxford University Press.
6. The Edmonton Journal. February 20, 2000.

Board Member Election!

At the AGM on May 5, 2000, the PHEN membership will be electing a representative to the Board to fill one vacant position. For more information or for nomination forms, please contact Colette Mooney at PHEN's Northern Alberta Office.

Announcements

• The Provincial Health Ethics Network and the Alberta Heritage Foundation for Medical Research (AHFMR) are pleased to announce an agreement regarding the adminisitration of the Community Health Research Ethics Review Committee (CHRERC). The CHRERC will be administered and funded by AHFMR for two years henceforth, with PHEN playing a monitoring role through the appointment of a representative to the Committee. The CHRERC was established to conduct, on request, ethics review of human research from the perspective of its impact on communities & collectivities. The CHRERC will review any research conducted in the province which does not fall under the jurisdiction of an existing REB, or for which a parallel review is specifically requested. For more information, please contact Sarah Hayward, SEARCH Manager, AHFMR, (780) 423-5727.

• Campbell Miller, Mary Lou Cranston (PHEN Board) and Al-Noor Nathoo (PHEN Staff) met this month with Lynne Duncan, Deputy Minister, and Neil MacDonald, Population Health, Alberta Health and Wellness. The Ministry expressed its continued strong support for, and ongoing interest in, PHEN's activities, and recognized the challenges inherent in meeting its mandate. For more information, please contact one of the aforementioned.

• Discussion sessions held by PHEN to discuss draft Accreditation Standards for Comprehensive health Services have now been completed. A summary document from the sessions has been submitted to the Canadian Council on Health Services Accreditation and is available at www.phen.ab.ca/pcons/main.html.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.