O'Mathúna, Dónal P.
This comment by Jonathan Mann (as cited in Horton, 2004, p. 1084), a tireless advocate for justice and human rights, especially for people with AIDS in developing countries, reveals a very practical dimension to ethics. Mann's comment suggests that overall health is linked to the promotion of dignity and human rights.
Nurses understand that how we interact with others can deeply impact their sense of dignity (and their health). Ignoring or making a dismissive comment to an irritating patient can put her down, leading to emotional pain, increased muscle tension, and physical pain. Angry frustration thrown at a student who doesn't get it can stab deeply. A cutting remark directed at a colleague can reverse months of collaborative team-building. On the other hand, a caring smile or an understanding comment can give a weak patient or a struggling colleague the strength to cope with undignifying circumstances.
Ethics often is viewed as focused on life-and-death situations. Is euthanasia right or wrong? Do certain types of research violate human dignity? Bioethics is a broader term that includes medical and nursing ethics along with the ethics of high-tech biomedical advances; cloning, reproductive healthcare, and advanced technology. Such issues are important, but most people do not confront them daily. However, when ethics examines the rights and wrongs of human behavior, many everyday situations have ethical components. A fuller exploration of human dignity demonstrates why.
Human dignity captures the notion that humans are uniquely valuable and therefore ought to be esteemed highly. If this is accepted, ethics will be helped by identifying whether actions and attitudes affirm or deny human dignity. This makes dignity and ethics very relevant for everyday settings.
Patients' illnesses and vulnerability can leave them asking whether they still have dignity. How we respond to patients can reinforce a sense that they have lost their dignity, or can counteract that experience and support dignity. The potential impact of our responses to everyday situations places a responsibility on all of us who interact with patients. These responsibilities exist whether sought out or acknowledged. They are part of the consequences of being personal, relational, and spiritual beings. They point to the importance of acting with dignity. More generally, our interactions with others—patients, colleagues, and students—can remind them of their inherent dignity or suggest that their dignity must be earned in some way.
DIGNITY AND INDIGNITY
The idea of human dignity has a long and significant role in ethics. The United Nations' Universal Declaration of Human Rights (1948) begins with a focus on human dignity: "Whereas recognition of the inherent dignity and of the equal and inalienable rights of the human family is the foundation of freedom, justice, and peace in the world..." The declaration points out two important features in understanding and applying the notion of human dignity. One is that dignity is inherent. It is not granted or bestowed by others, but is part of who we are as members of the human family. By implication, this dignity and its resulting rights cannot be taken away by anyone. The second is that dignity is tied to an equality within the human family. Dignity is thereby foundational to our experience of the greatest goods, the things that make life meaningful and valuable.
Dignity is a difficult concept to define, and sometimes it takes great indignity to recognize human dignity. The Universal Declaration was published in the aftermath of the atrocities committed during World War II. It took the horrors of the Holocaust and widespread civilian deaths for humanity to issue an affirmation of the importance of human dignity. We may struggle to define dignity, but when we look at how people treated others in Nazi concentration camps, we know human dignity was violated. Sometimes abstract concepts come into clearer focus during our interactions, good or bad, with others (Pellegrino, 2008).
What it means to act with dignity or indignity in healthcare can likewise be difficult to define. Similarly, greater clarity can be revealed in undignified circumstances. Illness, disease, and disability can diminish dignity. Such conditions make us vulnerable to situations where dignity can be more easily affirmed or violated. Edmund Pellegrino is a physician and ethicist who was chairman of the President's Council on Bioethics when it produced its work on dignity. Pellegrino noted, "Humans become most acutely aware of their own dignity and that of others when it is threatened by the acts and opinions of their fellow humans or by the circumstances of one's life" (2008, p. 521.)
Illness and disease force us to think about the basis of our dignity and what makes life dignified. This points to how illness, disease, aging, and disability impact our sense of dignity and that of others. It also points to the significant impact our choices can have when we interact with those who are ill or disabled. Put positively, healthcare settings create opportunities for undignified situations to be transformed into ones where dignity is upheld and promoted.
Although most would agree with the importance of upholding human dignity, there is controversy over a number of points. Within healthcare ethics, and bioethics more generally, questions are raised about whether human dignity really provides practical guidance. Some claim dignity is only applicable to humans after birth. This allows them to accept abortion and embryo-destroying research as ethical and supportive of human dignity. Others see these same acts as violations of human dignity. Likewise, at the end of life, some claim that promoting human dignity requires the legalization of euthanasia and assisted suicide; others claim that euthanasia and assisted suicide are violations of human dignity. Given that dignity can be used to support such divergent views, some question whether it provides any practical help at all.
Nurses involved in everyday patient care will have practical questions about what it means to live with dignity. It can be challenging to describe what makes life dignified, especially in the face of pain and suffering. Some claim that external circumstances dictate the type of dignity people have. In some parts of the world, people feel they need large houses and newer cars to live with dignity, while in other parts of the world people have next to nothing in the way of material wealth. How do external circumstances and material possessions impact our dignity?
Such fundamental questions about dignity have practical implications. On the one hand, we want to believe we have inherent dignity regardless of our circumstances. But the circumstances of illness and vulnerability appear to tear away dignity. How can these paradoxical notions be reconciled?
Ethicist Gilbert Meilaender (2009) recently provided a helpful distinction that resolves some of this tension. He shows that many of the challenges raised against the notion of dignity can be resolved when two core aspects are distinguished. Human dignity has a dimension that describes the unique characteristics of our species. As such, we are a unique "in-between" sort of species: "lower than the gods, higher than the beasts" (p. 4). This uniqueness is marked by the integration of body and spirit, and our distinctive physical, rational, emotional, relational, and spiritual capabilities. The combination sets us apart from other beings. However, these characteristics change and are present to varying degrees in different humans, and change over the course of our lives. In this sense, dignity represents the fullness of our humanity, something some of us come closer to in some areas, but none of us achieves completely.
But dignity also encompasses an unchanging dimension. The term dignity has been used to express our affirmation of human worth and equality. Regardless of individuals' varying powers and abilities, all humans are entitled to be viewed and treated with equal dignity. In spite of how undignified patients may feel because of an illness, their inherent dignity as humans remains intact and should be respected. In spite of how undignified a coworker has been to us, certain responses would violate their and our dignity, making the responses unethical. Keeping these two dimensions of dignity in mind (what is changeable and what is unchanging) can help resolve many of the criticisms of dignity in ethics.
DIGNITY AND RELIGION
Critics of human dignity raise an even deeper issue: Why should humans be given a unique status? A traditional answer has been because humans are made in the image of God. However, putting dignity on such foundations does not sit well with some bioethicists. Ethics in recent times has sought to become more secular, understood as independent of traditional and cultural roots, especially religious roots. In doing this, ethics has sought to divorce itself from beliefs about why concepts like dignity are so important and accepted. This is seen in the current emphasis on autonomy in healthcare ethics. In many settings it is not what a patient chooses that is viewed as ethical, but only whether the patient was free to make his or her individual choice. Then, rational arguments are provided to support contradictory choices. It seems that ethics can offer little help in resolving whether any one choice is more ethical than another.
Part of this problem arises because some vision of what human life is all about must underlie every attempt to develop ethical positions. However, such deeper worldview issues often are ignored by modern bioethics. If ideas have an origin in religious beliefs, such ideas are dismissed. For example, Ruth Macklin is Professor of Bioethics at the Albert Einstein College of Medicine in New York. She claims that, "Dignity is a useless concept in medical ethics and can be eliminated without any loss of content" (Macklin, 2003, pp. 1419–1420). Part of her problem with dignity arises because "Dignity has its origins in religious and human rights writings" (pp. 1419–1420), leading her to dismiss the concept and seek other ways to address related ethical issues. Another critic claims that interest in dignity within medicine is a movement "fed by fervent religious impulses" (Pinker, 2008), and therefore rejects the idea.
However, most ethical concepts have roots in religious writings, including central issues such as love and justice. Macklin also thinks that because there is no agreement on the definition of dignity, we should discard it. But there is similar ongoing debate over the definitions of terms such as harm or competence. That should not lead us to discard those notions. Some concepts are hard to define, but we know them when we see them.
Even though it may be difficult to define dignity, the term points to important assumptions in our broader ethical foundations. These beliefs need to be examined carefully. Some will claim that all humans are not endowed with equal dignity or that some humans have lost their dignity. We need to look at where these notions have come from and contrast them with the underlying beliefs that support dignity being inherent.
ORIGINS OF DIGNITY
Human dignity does have its origin in religious ideas, but that should not lead to its dismissal. The term "human dignity" is a more recent way of expressing the belief that humans are made in the image of God, an idea developed in theology, philosophy, and literature. In the Bible, all humans are declared to be made in the image of God (Genesis 1:26). This is the source of the inherent dimension of dignity. All humans, regardless of our varying capacities or moral behavior, have this status (Genesis 9:6; James 3:9). Our dignity is a gift from God and not something we have to earn or achieve. It leads us to being designated as "a little lower than angels" (Psalm 8:5). Reflection on the giftedness of our dignity should eliminate arrogance in how we view or treat others. Every human has been endowed with the same dignity, so we should treat others with the same dignity with which we want to be treated (Matthew 7:12). This radical equality that we are urged to promote can best be based in our common dependence on God for all that is good in us.
At the same time, being made in the image of God does not mean we are identical in abilities and gifts. We bear the image of God, but at the same time we are broken images. Only Jesus is the complete image of God (2 Corinthians 4:4; Colossians 1:15). Christians should be allowing God to transform them into people whose lives more fully reflect the character of God (Colossians 3:10), but no one will attain this completely in this life. We vary relative to one another in how well we live up to our full dignity, but we are equally distant from the perfection of God.
Looking back at what the image of God meant in biblical times helps us understand its relevance for ethics. The Hebrew word for "image" used in Genesis refers to the statues a ruling king would erect in his domain to remind people of their ruler (O'Mathúna, 1995). We see something similar today in countries where rulers erect large photographs of themselves. Humans, as bearers of God's image, should remind others of our Creator. We can do this with our words, but our lives and actions typically speak much louder. Bearing God's image encompasses remarkable responsibility and should lead us to reflect on whether someone would be drawn to the One I call God after viewing my thoughts, words, and deeds. As I get ready to speak or act, I should question whether I am about to image God as he would want.
At the same time, I should treat others in accordance with their dignity and value as images of God. The toppling of Saddam Hussein's statue in Bagdad in 2003 was more than just knocking a statue; this represented the rejection of the one the statue imaged. How we treat images of God should reflect the respect we would show God himself if he was in our presence. Viewed that way, every human should be highly esteemed and treated accordingly. C.S. Lewis reflected on this and concluded that "the dullest and most uninteresting person you can talk to may one day be a creature which, if you saw it now, you would be strongly tempted to worship." Therefore, he continued, "There are no ordinary people. You have never talked to a mere mortal" (Lewis, 1942, p. 9). Reflecting on this should help us to treat people with dignity.
THE PLACE OF NARRATIVE
The stories we tell can help us to make this more practical. Several theories of ethics have been developed, one being virtue ethics. This approach looks to stories to help us understand ethical issues. Narratives allow us to see people's character traits in the context of their lives and relationships. They show us ethics rather than tell us what to do. We sometimes feel compassion for characters, sometimes anger. We connect with them, and see who we would like to emulate and who not. Narrators also help us to see the implications of their beliefs and ethical systems.
A well-known story that shows dignity in action is the Parable of the Good Samaritan (Luke 10:25–37). This story has had a significant impact on Western healthcare as reflected in hospital names and Good Samaritan laws. The story asks the question who is my neighbor—equivalent to today's questions over who is a person or which humans have dignity. The lawyer who came to Jesus asking "who is my neighbor?" was not expecting the answer he received.
Briefly, the story tells of a Jewish man who is walking down the road, attacked by robbers, and left to die. His own people, a priest and Levite, pass him by. Along comes a Samaritan, a sworn enemy of the Jews. The Samaritan man had compassion on the injured Jewish man and took care of him by bandaging his wounds, putting him on his donkey, bringing him to an inn, and paying for his care. He also promised to return and check on him.
At the conclusion of the story, Jesus did not give criteria for determining who are neighbors. He gave no guidelines for determining who is entitled to be treated with dignity or exactly what this implies. Instead, he asks which of the characters in his story acted like a neighbor. The lawyer answered it was the one who had mercy; Jesus encouraged him to do likewise. We see the right thing to do as we watch others do the right thing.
Acting with dignity is challenging because it engages all aspects of our being. Although ethics has often been viewed and taught as a purely rational exercise, it is much more (O'Mathúna, 2009). As seen above, narratives help bring out the emotional, spiritual, and relational dimensions of ethics that should accompany ethical reflection. Figure 1 illustrates a Christian holistic approach to ethics that is exemplified by the Good Samaritan. Jesus' initial engagement with the injured man was emotional: he felt compassion. Moral perception is about how we become alert to an ethical issue, which often happens when we engage emotionally with novels, movies, or songs (O'Mathúna, 2008). The original audience for Jesus' parable was Jewish, and they probably empathized easily with the injured man. They would have expected their religious leaders to care for him, and would have been shocked that the story had them pass the man. Then a sworn enemy becomes the hero! Good stories jolt us out of our moral slumber and engage us emotionally.
Figure 1: A Christia...Image Tools
But the Samaritan did not just feel. He thought about the needs of the injured man and this led him to act. And his reflection did not stop there. His actions got him to the inn and then he thought about future expenses. The diagram shows how feeling, thinking, and acting are interwoven. The multidimensional nature of ethics acknowledges the two general principles Jesus declared before telling his parable: "‘Love the Lord your God with all your heart and with all your soul and with all your strength and with all your mind’; and, ‘Love your neighbor as yourself’" (Luke 10:27, NIV). As Christians we should not forget that the Holy Spirit seeks to guide us in our ethical decision-making processes. We will return to this dimension later.
Reflecting on the parable of the Good Samaritan, we can creatively imagine how this narrative provides concrete guidance for upholding the dignity of patients, colleagues, and students. As mentioned earlier, we can learn about dignity by seeing where it has been ignored or violated. The human rights advocate, Jonathan Mann, elaborated four general ways that dignity is commonly violated:
* by ignoring one another or insufficiently acknowledging the other;
* by seeing others only as members of a group and not as individual persons;
* by transgressing another's personal space;
* by humiliating another (Mann, 1998, pp. 30–38).
All four ways are illustrated in the characters in the Good Samaritan account and in contemporary healthcare. First, the attacked man was ignored as he lay injured on the ground. In what ways might we ignore patients as we make our rounds or sit at our desks? Is it easier to keep looking ahead even though out of the corner of our eye we know someone is trying to get our attention? When engaged with patients or students, do we ignore some of their questions? A psychiatrist recently confessed to having an unwritten rule in his practice: don't ask, don't tell (Carlat, 2010). He found it more productive to not ask his patients certain questions because he knew those would lead to extended discussions that he did not want to take the time to have.
The first listeners to the parable of the Good Samaritan would have probably assumed that the Samaritan was going to ignore, if not further hurt the injured Jew. They would have recoiled, if not rebelled, at the idea of a Samaritan being the hero. They would have judged him, not as an individual, but as one of those Samaritans. How might we prejudge people because of the group to which they belong? He's just a nurse? She's a doctor! He's an alcoholic ... overweight ... noncompliant ... a smoker ... HIV positive. She's just one of those...
The injured man's private space was violated during his attack. We are unlikely to condone or experience such direct violations, yet how might common practices be unnecessary intrusions on patients' personal space? Are examinations carried out as modestly as possible? Are discussions about personal details and decisions conducted as privately as possible? Are students given feedback in ways that thoughtlessly expose them to embarrassment, or in ways that are thoughtfully constructive?
Humiliation is threaded throughout the Good Samaritan story and raises questions about where arrogance and pride might be involved in healthcare. Edmund Pellegrino points out that humiliation is widely experienced in modern healthcare. He says, "‘Humiliation’; is the word I hear most often from patients describing the experience of being ill and seeking help" (Pellegrino, 2008, p. 524). What a tragedy that when people in need come for help they may end up feeling humiliated and their dignity violated.
The challenge for nurses, especially Christian nurses, is to become aware of ways that we can violate others' dignity and imagine how we could do better. The task may appear daunting if not overwhelming. To continually relate to others in dignity-promoting ways requires extraordinary capabilities. To avoid all the possible ways of diminishing another's dignity may appear impossible. It is impossible.
THE SPIRITUAL DIMENSION
This is why the spiritual dimension of ethics is so important. In this world, we are broken images of God. We are called to love others as God would, but we in ourselves cannot love perfectly. We need God's grace and forgiveness on a daily basis. As we seek to treat others with the dignity they deserve, we see our own inability to do so. This drives us to Christ in humility and dependence, reducing the pride and arrogance that leads us to think that we are better than anyone else, or that serving some people is beneath our dignity. It reminds us of our dependence on God to do anything that truly matters (John 15:4–5). As we depend on God, we will be led and empowered to serve others in better ways.
Remembering that we bear the image of God, and that we fall short of being true images, we can see the dignity in others in spite of how undignified their circumstances may be. We may struggle to treat others with dignity when they refuse to affirm our dignity. Yet we are called to be kind and compassionate, forgiving others, because of what Christ has done for us, not what anyone else has done to us (Ephesians 4:32). We are to sacrificially bear the burdens of others (Galatians 6:2) because this is what Christ did for us. We can only do this if we are firmly grounded in the grace and power of God. In this way, dignity is a religious idea.
ACT JUSTLY, LOVE MERCY, WALK HUMBLY
Thinking ethically about situations has many dimensions. We need to take into account our feelings and our interactions with people. Emotions can be elicited by a movie, novel, or song that touches us and reminds us of human dignity or vulnerability. These feelings can alert our conscience to something ethical or unethical in a situation. Christians also receive spiritual input through the Holy Spirit, the Bible, and fellowship with other Christians. But we cannot leave all this at the level of feelings. We must move on to thinking about the situation, and then to action. As we act, further thoughts and feelings will arise about whether dignity is being promoted or diminished. This gives a larger loop where all aspects are interacting with one another.
Such a holistic approach to healthcare is being recognized more widely. In a modern narrative, actor William Hurt plays a surgeon in the movie The Doctor (1991) where he tells his students that in surgery, "I'd rather cut straight and care less." In real life, the advice is very different. "It is ironic to think that the advice doctors and surgeons once received of ‘not getting emotionally involved with our patients’ is exactly the opposite of what we are so rightly being recommended to practice today. It is as if somebody is saying, ‘Be a good surgeon, be a good technician, and above all, be a kind and generous human being. Be a compassionate surgeon’" (Toledo-Pereyra, 2005, p. 159).
We cannot continue to act in ways that diminish another's dignity without those actions impacting who we are. It affects us when we treat people with dignity or when we diminish their dignity. Sometimes it takes a well-constructed narrative to emotionally jar us into realizing this. This happened to the surgeon in The Doctor when he became a cancer patient. Seeing the hospital through the eyes of a patient opened the eyes of his heart to the indignity of the system in which he had been blindly immersed. In a similar way, in the movie Wit (2001) Emma Thompson plays an English professor diagnosed with terminal cancer. Through the indignities she suffers as a research subject she realizes how she violated her students' dignity over the years. Engaging with a narrative and realizing where we fall short in affirming others' dignity is easier than waiting for life's pain to crash in on us and teach us these lessons.
Nurses have many opportunities to promote the dignity of those they care for. These opportunities arise in spite of, or because of, patients' needs and disabilities. Patients can be helped physically, but affirming dignity helps in deeper ways. The dignity of Emma Thompson's character primarily is helped by her nurse in simple ways such as touching, talking, and eating a Popsicle together. To act with dignity is to find ways to promote the inherent dignity of whomever we find facing us: a patient, colleague, student, or any other person. The challenge, and the opportunity, is to find ways to do this with everyone around us. Such a task requires insight and power available only from a Divine Source. The Old Testament prophet Micah declared that God has shown us what it means to be good: "To act justly and to love mercy and to walk humbly with your God," (Micah 6:8, NIV). That is what it means to act with dignity.