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Human Dignity in Healthcare: A Virtue Ethics Approach (2012)



Varieties of dignity

The word dignity, as Professor Sulmasy has ably demonstrated, is used in a variety of senses.1

2 The different senses of a word are related by analogy.

Analogical terms often have a central or fundamental meaning in relation to which other meanings are best understood, and I think Sulmasy has helpfully shown that the most fundamental meaning of human dignity is intrinsic dignity: the dignity we have inherently and in common on the basis of our human nature. Nevertheless, Thomas Aquinas pointed out that the context in which we first learn a word does not necessarily provide its most fundamental meaning (STh

The virtues of acknowledging dignity

For any sense of dignity, there will be some basis for the dignity (why it is regarded as merited), there will be some forms of behaviour that are regarded as befitting dignity(decorum, dignified behaviour by the person appropriate to rank or status), and there will be forms of behaviour by which others acknowledge dignity (show respect). A good person will possess virtues that dispose him or her to acknowledge the dignity of others.


Thomas Aquinas follows Tully in giving the name observantia observantia that those who excel in some kind of dignity (homines aliqua dignitate antecedentes) are treated with dignity (dignanturSTh II-II, q. 102, a. 2 sed contra). Observantia is a virtue related to justice (STh observantia as having two parts,dulia (STh II-II, q. 103), which I will translate as respect, which is that virtue by which we demonstrate our esteem for someone as appropriate to their status, and obedientia (STh II-II, q. 104), which is our disposition of obedience towards those who have authority.

I stated earlier that the first kind of dignity in order of learning may well be attributed dignity and it is clear from the context that this is the dignity Thomas has in mind in his discussion, and in particular the dignity of office, which is why he can so easily resolve observantia into respect for superiors and obedience to superiors. This example also provides Thomas with the basis to distinguish observantia dulia) is distinct from obedience, both in that we may find ways to show respect to someone even if we cannot specifically do what they ask, and in that doing what someone asks does not necessarily betoken respect. Indeed it is frequently possible to show, by the manner in which we do what they ask, that we do not hold someone in esteem or respect even if we are required to do what they have requested.

virtus specialis) and general virtue (virtus generalis special virtue. But in another way all acts of virtue require some strength of character or determination not to be swayed, some element of assertiveness, and in that way courage, or something like courage, is a general virtue, an aspect of all good actions (STh II-II, q. 123, a. 2). In a similar way, according to Thomas, temperateness, practical wisdom and justice are also general virtues, aspects of every good action (STh I-II, q. 61, a. 4).

Thomas explicitly says that obedience (which is a part of observantia) can be considered a general virtue if we understand it as obedience to the authority of the precepts of the moral law, in that every good action is the kind of action that could be mandated by the moral law (STh II-II, q. 104, a. 2). He does not say, but we might reasonably say, that the virtues of observantia and respect are also general virtues inasmuch as all good actions can be understood as showing respect for the dignity of human nature. This sense ofobservantia as a general virtue shows how respect for human dignity can be understood as the foundation for observing, in particular, all human rights (whether or not these rights seem directly concerned with dignity).4 All good actions display a kind of respect. Nevertheless, if there is a sense in which observantia and respect can be general virtues, they are certainly also special virtues. Observantia is the virtue that inclines us to acknowledge the particular status or dignity of a person, and within this, the virtue of respect (dulia

dulia) is something corporeal (STh

Thomas considers respect to be concerned with showing honour to someone who is superior to us in some way. This presents him with a problem in relation to the Christian injunction to show respect to everyone (STh II-II, q. 103 a. 2 obj 2 quoting 1 Peter 2.17). He answers this by saying that in everyone there is something that makes it possible to deem him or her to be better than ourselves. There is no doubt something in this, but what Thomas does not do, at least not at this point, is relate this universal duty of respect to the universal dignity common to all human beings. Nevertheless, though Thomas did not relate the two concepts himself, we can easily see how the virtue of respect can be related to intrinsic human dignity. If there is a dignity that is possessed by all human beings then observantia will incline us to acknowledge this in everyone we encounter.

The dignity of action and the shame of dependence

The focus of this paper is to reflect on how the virtue of acknowledging human dignity, observantia, which includes both respect and obedience, has application in healthcare. Healthcare presents special challenges to observantia

Not only does the delivery of healthcare restrict the kinds of behaviour through which people characteristically express their dignity or self-respect; it also restricts the ways in which respect can be shown to the person. One of Thomas’s great insights is that the virtue of respect concerns the public showing of honour or esteem (STh
I will return to ways in which healthcare professionals can meet this challenge, but because I have emphasised the relation of dignity to activity, it is necessary to say something about the place in human life of inactivity, of dependence, of receptivity, and of affliction.

Human dignity and human dependence

At a previous conference of the Centre (then known as the Linacre Centre) I was asked to deliver a paper on the meaning of suffering in the practice of medicine.5 I chose on that occasion to focus on the virtue of misericordia, the virtue of appropriate compassion or, we might say, empathy for the needs or suffering of another. In the same year that this paper was published, the virtue of misericordia was also made the focus of a major work by Alasdair MacIntyre.
In his book, entitled Dependent Rational Animals,6 MacIntyre laments the way that the philosophical tradition has neglected the importance of need or dependence as an aspect of human life. This is shown, especially since the Enlightenment, in discussion of human beings solely in terms of their freedom, rationality, or autonomy. Such one-sided anthropologies not only threaten the status of those human beings who are less able to give expression to their rational powers, but also misunderstand the common nature of all human beings, and the virtues of receiving as well as of giving help.

A saner strand of philosophy (prominent especially though not exclusively among Christian thinkers) has understood the human situation as one of dignity and dependence: a dignity that is common to all human beings but equally a neediness that is common to all. While some individuals in the prime of life may think themselves independent and even self-made or self-sufficient, we are all dependent not only physically but also culturally, and hence intellectually, on a wider community and a longer tradition. Our relative independence is in fact dependent on others in a great multitude of ways. Recognition of this reality helps show the flaw in identifying dignity too closely with ability or autonomy. All human beings are more or less dependent on one another and accounts of human dignity should not seek to obscure this fact.

The unity of the virtues

MacIntyre has done a great service in drawing attention to the virtue of misericordia, which he sees as the acknowledgement of an important aspect of our human existence: our mutual dependence. Misericordia7 misericordia, through what later writers would call solidarity. Thomas Aquinas, here as in a number of places, is closer to Augustine than he is to Aristotle, and also is closer to the reality of the human situation which is one both of dignity and of neediness.

If there is a virtue of acknowledging the dignity of a person, and indeed the common dignity of all people, this will both qualify and be qualified by the virtue of acknowledging the neediness of human existence, and in particular acknowledging the needs of the person before us. According to Thomas, the virtues do not make sense in isolation from one another but form a unity to which each makes a contribution.

Observantia and misericordia are complementary virtues. Whereas observantia keeps a respectful distance, misericordia draws us closer to the person. Whereas the object ofobservantia is the status of the person as worthy of respect, esteem or deference, the object of misericordia is need or suffering and the alleviation of that need or suffering.Observantia on its own, if such a thing were possible, could lead to a kind of neglect - respect for autonomy as a form of abandonment. Misericordia

Respecting dignity in healthcare

What then are the implications of these reflections on the virtue of observantia, as qualifying and qualified by misericorida, for the practice of healthcare?

One important implication is that virtuous healthcare professionals will be inclined to show respect to their patients, in the sense of honour or esteem, even though practical restrictions will constrain the ways in which they can do so. There will always be some ways in which respect can be shown: for example, in relation to how a person is addressed and in not presuming familiarity. In relation to making use of what measures are available to give privacy. In sitting in a chair next to a person rather than standing over him or her. In apologising for any lack of courtesy or kindness one has shown in the past. The way in which respect is shown may be culturally specific and a doctor should seek to be sensitive to this, but key to virtue in this area is the disposition to show respect - to bear witness to the dignity of the patient. A useful prompt would be to ask: in what ways would respect be shown if this were a person of especially high social status? And if this is how high social status is acknowledged, what is the decent respectful degree of public acknowledgement that every person is due?

Both patients and doctors are aware of practical restrictions on the ability to show respect, but this gives added significance to occasions where respect can be shown, for showing respect in these contexts demonstrates that the apparent indignities that the patient has to bear do not in fact betoken a lack of respect, and so do not imply a lack of respect-worthiness. If respect is not shown when it can be shown, then all that the patient has to bear from ill health and from healthcare become tokens of a lack of respect - a kind of institutional humiliation.

observantia, and this will include supplying genuine needs, addressing wishes and obeying refusals. Yet even here it will be important that acceding to patient wishes, where this is possible, is truly an expression of respect for the patient rather than, for example, mere self-protection on the part of the doctor. Furthermore, in addition to respecting the wishes of the patient, as argued above, the virtue of respect (dulia) also requires that respect is shown visibly in the way that the patient is related to and treated. When patients complain that they are not treated with respect they do not only or primarily mean that their requests have not been followed.
For the same reason healthcare professionals (and those who manage healthcare delivery) should seek to provide ways in which patients can express their own sense of self-respect, through exercising control of their immediate environment. This duty might again be thought of in relation to respect for autonomy, but to understand it properly it needs to be related not only to the dignity of being able to make choices, but to the way in which personal dignity or self-respect is typically expressed and reinforced by behaviour. Here also because the behaviour is important more for what it betokens than for the proximate aim or content of the activity, the ability to exercise control even in very limited ways can have great significance. This is not to identify human dignity with autonomy, and is certainly not to attribute dignity in proportion to capacity, but is rather to see the significance of helping a person to express their sense of dignity to whatever extent they are able.

I hope that the papers of Dr de Kermadec and Mr Bano will provide more depth and substance to our understanding of observantia: of what it is to show respect for the dignity of patients in practice. My concern has been to explore the concept of showing respect as an expression of virtue, and to show why those who fail to acknowledge the dignity of the patient do the patient an injustice.

Discussions of human dignity in relation to healthcare typically focus on whether the variety of meanings of the concept undermines its usefulness, or whether clarity and content can be given to the concept. Philosophers have rarely attempted to take with full seriousness the concerns about respect for dignity that are often voiced by patients themselves. For example, the Nuffield Council on Bioethics report Dementia: ethical issues8

Even those philosophers who defend the concept of dignity often focus on the causes or nature of intrinsic human dignity rather than on how dignity is to be honoured in practice. Too often, I think, the emphasis has been on the general virtue of respect for human dignity; that is, on human dignity as the basis of human rights, to the neglect of the special virtue of showing respect for people in practice by signs and tokens. The aim of this paper has been to encourage interest in the virtue of acknowledging human dignity, observantia, and in particular that part of observantia which consists in the virtue of respect (dulia). The paper has also argued that misericordia, a virtue that has received some attention in the last few years, should both qualify and be qualified by observantia; that is to say, that the acknowledgement of human dependence should both inform and be informed by the acknowledgement of human dignity.

1 Human Dignity and Bioethics, ed. E.D. Pellegrino, A Schulman, and T.W. Merrill (Notre Dame, IN: University of Notre Dame Press, 2009).

2 STh I, q. 13, a. 5. There is a lively controversy among Thomists as to whether the idea of analogy concerns the structure of the universe or whether it concerns the use of language; see, for example, Herbert McCabe Appendix 4 to Volume 3 of the Blackfriars edition of the Summa Theologia. Without entering into this debate it is clear at the very least that many terms in ordinary language are not predicated with a single meaning.

The Culture of Life: Foundations and Dimensions. Proceedings of the 7th Assembly of the Pontifical Academy for Life, ed. J. de Dios, V. Correa, E. Sgreccia (Vatican City: Libreria Editrice Vaticana, 2002).

4 This of course is the way that human dignity is invoked in the preamble to the Universal Declaration on Human Rights.

5 Issues for a Catholic Bioethic, ed. L. Gormally (London: The Linacre Centre, 1999).

6 A. MacIntyre, Dependent Rational Animals: Why Human Beings Need the Virtues (Peru, IL: Carus Publishing Company, 1999).

7 Nicomachean Ethics 1124b 9-10, quoted by MacIntyre p. 127.
8 Nuffield Council on Bioethics, Dementia: ethical issues (London: Nuffield Council on Bioethics, 2009), 33, paragraph 2.56.