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At the end of the “Dignitarian Medical Ethics” reading, you will notice several “References” for the text that are somewhat dated. Using Google Scholar and/or the Brenau Trustee Library website find three scholarly books and/or articles that relate to social media in business that are dated within the past five years (as this is only March of 2020 they will be from 2015-2020).
Cite them in proper APA form and give a short summary of the research for each.

62 Barclay L. J Med Ethics 2018;44:62–67. doi:10.1136/medethics-2017-104467

AbstrAct
Philosophers and bioethicists are typically sceptical
about invocations of dignity in ethical debates. Many
believe that dignity is essentially devoid of meaning:
either a mere rhetorical gesture used in the absence of
good argument or a faddish term for existing values like
autonomy and respect. On the other hand, the patient
experience of dignity is a substantial area of research
in healthcare fields like nursing and palliative care. In
this paper, it is argued that philosophers have much to
learn from the concrete patient experiences described
in healthcare literature. Dignity is conferred on people
when they are treated as having equal status, something
the sick and frail are often denied in healthcare settings.
The importance of equal status as a unique value has
been forcefully argued and widely recognised in political
philosophy in the last 15 years. This paper brings medical
ethics up to date with philosophical discussion about
the value of equal status by developing an equal status
conception of dignity.

IntroductIon
The field of medical ethics is already saturated
with ethical terms and phrases—the right to life,
autonomy, respect, informed consent and benevo-
lence, to name just a few. ‘Dignity’ has never really
taken hold to the same extent. Although many
commentators in the field of medical ethics use the
term, it does not enjoy the philosophical respect-
ability of other key terms. It has not been subject to
the same kind of extensive philosophical analysis,
and there is an absence of agreement as to what it
really means.

When Ruth Macklin declared that ‘dignity is a
useless concept,’ she almost certainly stated explic-
itly what many philosophers already believed.1
‘Dignity’, she argued, is either just a rhetorical
device used when one has run out of good argu-
ments, or else nothing other than a fashionable new
term for existing values like autonomy or respect
for persons. There is certainly no evidence that
appeals to dignity have done anything to advance
intractable debates around the right to life, eutha-
nasia and abortion.

There are further reasons to be sceptical about
dignity. The other main area in which the phrase is
repeatedly used is human rights law. References to
dignity are scattered throughout international and
domestic human rights declarations and conven-
tions. Yet here too there is no real attempt to
explain what it means, or why the supposed dignity
of every human being should endow them with
human rights, or how human rights protect that
dignity. Indeed, in the field of human rights law
we have quite explicit reasons to be sceptical about
dignity. The historical record shows that those
charged with drafting the Universal Declaration of

Human Rights could not agree on the foundations
for those rights, that is, what it is about human
beings that justifies them. As Jacques Maritain said,
‘Yes, we agree about the rights on condition that no
one asks us why’: quoted in ref 2, ‘Dignity’ was, and
remains, a convenient term to cover over that lack
of agreement. What does ‘dignity’ mean? Whatever
you want it to mean!

At direct odds with this weighty scepticism, the
fields of nursing ethics, nursing home care, palli-
ative care and research broadly concerned with
the ‘patient experience’ are awash with research
on dignity.3–6 Much of this literature is a response
to patients’ persistent complaints that healthcare
institutions rob them of their dignity. Hospital
websites and broader public policy have increas-
ingly committed to improving the quality of care
for patients, nursing home residents and the dying,
by improving respect for their dignity.

How do we make sense of this apparent discon-
nect between philosophical scepticism about
dignity on the one hand, and the enormous prac-
tical concern for dignity in healthcare settings on
the other? One easy response is to declare that
patients and healthcare researchers are also guilty
of using a term devoid of unique content, or for
purely rhetorical purposes. Indeed, Macklin’s scep-
ticism about dignity could apply to healthcare liter-
ature with some force. I have argued elsewhere that
the methodologies used in that field are somewhat
problematic.7 The rich qualitative data based on the
responses of various patient groups and healthcare
practitioners report on the experiences of these
groups by presenting long lists of items or categories
without any attempt to explain what unifies them
specifically under the value of dignity. More impor-
tantly, patients and healthcare practitioners are no
more likely to have a clear sense of what ‘dignity’
means than do philosophers. As such, simply asking
them directly to talk about dignity risks conflating
dignity with everything that contributes to good
quality healthcare, including autonomy, compas-
sion, benevolence, and so on. I have argued that this
is exactly what happens in much of the qualitative
healthcare literature.

Despite these reservations, I don’t doubt that
patients and healthcare practitioners, and the liter-
ature that represents their experiences, identify a
unique and important value, which is indeed the
value of dignity. Moreover, the value of dignity
is not captured by existing values like autonomy,
respect, benevolence, and so on.

I will show that careful analysis of the ‘patient-ex-
perience’ reveals that what patients rail against is
their routine relegation to an inferior social rank in
healthcare settings. In developing this concern into
a conception of dignity, and applying it to health-
care, this paper will bring medical ethics up to date

Dignitarian medical ethics
Linda Barclay

Extended essay

to cite: Barclay L.
J Med Ethics 2018;44:62–67.

correspondence to
Dr Linda Barclay, Department of
Philosophy, Monash University,
Clayton, VIC 3800, Australia;
linda. [email protected] monash. edu

Received 6 July 2017
Revised 14 August 2017
Accepted 24 September 2017
Published Online First
13 October 2017

Inside the ICU

http://jme.bmj.com

http://crossmark.crossref.org

63Barclay L. J Med Ethics 2018;44:62–67. doi:10.1136/medethics-2017-104467

Extended essay

with developments in political philosophy, where the impor-
tance of equal status has been forcefully recognised in the last
20 years or so.8–12

WhAt Is dIgnIty?
Michael Rosen13 and Jeremy Waldron14 have analysed the
various meanings or ‘strands’ of dignity throughout the history
of political and legal thought.15 ‘Dignity’ can and has been used
to mean many different things, which contributes to its very
deconstructed state in healthcare literature and policy, as well
as to its multiple meanings in legal contexts.16 Given the multi-
faceted meaning of ‘dignity’ in all of these areas, I see no reason
to try and corral this diversity into a single conception. Rather,
I want to develop one specific conception of dignity and show
why it is important, including in healthcare settings. The concep-
tion of dignity I develop in this paper is not incompatible with
other notions of dignity, and will often compliment them.

One distinction is particularly important for my purposes.
We can think of dignity as something inherent in persons, or
alternatively as something conferred upon them. It is the latter
idea that I develop. This is the kind of conception of dignity
which falls under Waldron’s broad description of dignity as
status.14 It is different from dignity as worth, which conceives of
a person’s dignity as inherent in them, by virtue of their posses-
sion of a valuable nature or valuable capacities. It is the status
conception that best seems to capture the idea that dignity in not
(only) inherent in people ‘but is also at least partly constituted
by distinctive forms of interpersonal interaction in which it is
expressed’ (p 160).17

There are potentially numerous ways to expand on the idea
of dignity as status. Historically, dignity as status has been
connected to social hierarchies. Rosen suggests that dignity
‘originated as a concept that denoted high social status and the
honors and respectful treatment that are due to someone who
occupied that position’ (p 11).13 The respectful treatment due
to a social superior might have included tugging at the forelock,
curtseying and bowing, and particular forms of deferential or
obsequious address.

Waldron argues in favour of what Rosen dubs a more recent
‘expanding circle’ narrative of status dignity that includes most
human beings.14 According to Waldron, the prevailing concep-
tion of status dignity for us is equal status, for the ‘modern
notion of human dignity involves an upwards equalization of
rank, so that we now try to accord every human being something
of the dignity, rank, and expectation of respect that was formerly
accorded to nobility’ (p 33).14

On my conception of dignity, dignity is conferred in social
relations where we follow social norms for treating people as
sharing equal status. When we do so, we communicate to others
that we consider them our social equals. To enjoy dignity is to
reliably be treated in accordance with such norms. Conversely,
people do not enjoy dignity when they are routinely treated in
a way that relegates them to a lower social status. Such routine
behaviour communicates both to its victims (and to others) that
they are believed to be social inferiors.

This is somewhat abstract. What we want to know is how
dignity is conferred on patients in their concrete interactions
with healthcare providers. How should such providers conduct
their exchanges to ensure that they treat those for whom they
care as social equals? Dignity as status in general is always much
easier to describe in the breach. It is intuitively clear that tugging
at the forelock, and bowing and scrapping, are at odds with
equal status. It is more challenging to describe those positive

social relations that constitute it. So let us begin in the breach,
and describe some common examples.

Nola has dementia, and has recently moved into a nursing
home. Nola needs some assistance with personal care, medica-
tions and decision-making. Nola and her children are unhappy
with some of the behaviour of healthcare staff. She does not
always get a daily shower, and is sometimes forced to wear soiled
and dishevelled clothing. She has been placed on the toilet with
the door left open so staff can keep an eye on her while they tidy
her bed. Some staff are rude and dismissive when they perceive
her as asking too much of them, whereas others have a tendency
to speak to her as though she is a small child. The manager of
the facility enrols Nola in a range of social activities without
consulting with her.

Ahmed has been diagnosed with leukaemia and has spent
3 months in hospital. He shares a room and a bathroom with
three other men. The room is noisy, with constant sounds of
other patients’ televisions, radios and visitors. The ward is also
noisy at night, as nurses go about their duties with little regard
for sleeping patients. Despite keeping his curtain closed for
privacy, it is constantly opened without warning by nurses,
doctors, allied health professionals, cleaners and meal deliverers.
The shared bathroom often becomes soiled during the course of
the day. When he complains about his inability to rest, and the
lack of privacy and cleanliness, Ahmed is told he is ungrateful.

Glenda has been admitted to a mixed-sex ward with an acute
bowel obstruction. She is mortified to find herself sharing a
ward with three men, especially given her frequent use of the
bathroom and the nature of the conversations she has with
healthcare staff. One of the men on the ward ceaselessly engages
Glenda in conversation that she finds intrusive and unsettling.
She has requested a move to a women’s ward, but has been told
there are no such beds available.

Something is clearly not quite right about the care that Nola,
Ahmed and Glenda each receive. Most of us can readily appre-
ciate their distress. As I have indicated, the qualitative literature
is full of examples of this kind, which are provided by patients
in response to questions about their experience (or lack thereof)
of dignity.

Suzy Killmister has offered one analysis of cases such as
these18 which I will show has considerable appeal but is none-
theless insufficient. She argues that in these kinds of examples
patients are unable to uphold their standards and values, which
can cause significant humiliation. Nola, Ahmed and Glenda
have basic standards around privacy that are routinely violated
by healthcare providers, as are Nola and Ahmed’s standards
of cleanliness. Glenda’s standards of privacy and decorum
concerning interactions with the opposite sex are also violated.
Many of Nola’s standards and values are likely violated when
she is spoken to as though she is a small child, and enrolled in
all manner of activities in which she finds no purpose or value.
Accordingly, Killmister argues that healthcare practitioners
respect a patient’s dignity when they refrain from transgressing
the patient’s standards and values, or refrain from forcing the
patient to transgress his or her own standards and values.18
Thus, ‘part of the trauma of undergoing medical procedures
is the shame we experience in having our bodies exposed, the
public nature of otherwise deeply private bodily functions, and
the child-like dependence to which we are reduced. The reason
why, for example, being left semi-naked on a hospital trolley is
experienced as humiliation, and thus as a violation of dignity, is
that the patient has standards of public decency that they strive
to maintain in their daily lives and which they are here being
forced to abandon’ (p 162).18

64 Barclay L. J Med Ethics 2018;44:62–67. doi:10.1136/medethics-2017-104467

Extended essay

One benefit of Killmister’s analysis is that it can also make
sense of the felt loss of dignity that people report even without
the intervening behaviour of others. Patients feel a loss of dignity
just by virtue of increasing levels of dependence, or uncontrolled
pain, or loss of bowel function, for example.5 6 19 The failing
body can itself jeopardise a patient’s ability to uphold, and
continue to live in accordance with, her standards and values.

Killmister’s analysis is intuitively compelling. It captures
something important at stake when patients complain of the loss
of dignity. That patients are often shamed and humiliated in such
situations further supports her analysis, for the most common
view about shame is ‘…that it is an intensely negative emotion
directed at the self as a result of having failed to live up to some
standard, ideal, or norm’ (p 568).20 While there is dispute about
whether or not a person has to accept the standards in order to
feel shamed for falling short of them, there is no dispute that
feelings of shame and humiliation are provoked by failing to live
up to one’s standards and ideals.

I suggest that Killmister’s view is best understood as an
account of dignity as bearing. We recognise dignity in upholding
the demands of morality, in spite of our countervailing natural
inclinations or challenging circumstances.13 21 Killmister herself
does not conceive of the standards and values at stake as
necessarily moral. Moreover, she strongly implies they can be
entirely individual or subjective, by referring to them as ‘one’s
own’ standards and values. Nevertheless, the intuitive appeal of
her analysis rests on the widely recognised value of dignified
bearing or comportment in upholding the demands of standards
and values.22 We admire those people who maintain a digni-
fied bearing under even extreme conditions, such as Nelson
Mandela. Many of us are disgusted by Donald Trump’s conduct,
which is frequently characterised as undignified (for any adult,
whatever their formal role). In short, most of us tend to describe
as undignified failure to live up to standards and values due to
weak will, poor character, cowardice or wantonness.

Nevertheless, Killmister’s analysis, and any account of dignity
as bearing, does not sufficiently describe the importance of what
is at stake in these cases. There is broader conception of dignity
at play in most of these examples, of which loss of dignity as
bearing is but one part. Violating a person’s standards and
values, or placing her in a situation where she is forced to trans-
gress them, is one of the ways in which we can treat a person as a
social inferior. But it is just one such way, and should not deflect
attention from the arguably more important ideal of dignity
conferred by social relations where all enjoy equal status.

Others not only violate Nola, Ahmed and Glenda’s values
and standards. They speak to them rudely, or with condescen-
sion; nurses fail to keep their voices down and allow them to
rest; they are spoken to impatiently and made to feel like they
are nuisances. In these cases, healthcare staff display a general
tendency to disregard Nola, Ahmed and Glenda, which includes,
but goes beyond, violating their standards and values. They fail
to treat them as though they have equal status. They treat them
as social inferiors. Part of treating them as social inferiors is to
disregard standards and values around privacy, decorum and
respect that are not only held by Nola, Ahmed and Glenda, but
by most of us who appreciate the force of these examples.

Consider similar qualitative research in other areas. Based
on extensive interviews, Nora Jacobson documents how the
day-to-day exchanges of the sick, homeless and poor are char-
acterised by rudeness, indifference, condescension, contempt,
exclusion and vilification. Her research participants had a vast
range of phrases to describe how it felt to be subject to such
social exchanges: ‘like a child’, ‘like you are an inch high’, ‘like

an animal’, ‘like a dog’, ‘like a bum’, ‘like a criminal’, ‘like a
second-class citizen’, ‘like dirt’, ‘like garbage’, ‘like scum’, ‘like
a piece of shit’, ‘like nothing’. Jacobson says of her participants
that ‘their language is replete with denotations of (lesser) size or
position’ (p 87).23

If we want to move from the breach to say something more
concrete, we need to know what forms of social exchange treat
people with equal status, and thus confer dignity. I argue that
dignity is secured when our exchanges with each other conform
to whatever our social norms are for treating one another as
social equals. Whether any given token of social exchange is
dignity conferring or not depends on the social norms in place.
Just as social norms determine that tugging at the forelock and
bowing and scrapping are behaviours for treating royalty as social
superiors, so too our social norms determine that other forms of
social exchange are ways to treat others as social equals. Earlier
defenders of dignity lauded obsequious behaviour befitting social
inferiority. There was dignity in knowing and accepting one’s
place in the social hierarchy, and conducting oneself accord-
ingly.13 The modern attachment to dignity as equal status largely
rejects behaviour connected to status hierarchies. We are often
repelled by people who expect us to treat them as though they
have higher status, and pity those who are content with displays
of their low social status.

Cheshire Calhoun argues that behaviour in accordance with
social norms plays an important communicative role.24 While
Calhoun’s interest is with civility, with respect to dignity we can
say that it communicates to its recipients that they are consid-
ered social equals by those who engage with them. Successfully
communicating this moral attitude is contingent on following
shared social norms which express equal status. It is only because
there are widely shared norms, which are ‘often codified, social
rules’ for what counts as treating other as social equals, that we
can successfully communicate an attitude of regard for others as
our social equals (p 260).24

In the interpersonal realm, actually treating people with equal
status amounts to just the same thing as following social norms
that communicate equal status. Equal status is largely constituted
by nothing other than such norm-governed behaviour. Whether
or not a person has greater worth or value than the rest of us is
independent of how we treat her. Her status, however, is not.
We can readily appreciate that a judge is of no greater worth
than you or I, but she still enjoys a different status, at least in the
context of her professional role, by virtue of norms governing
how we treat her: we stand up when she enters to room, we
refer to her as ‘Your Honour’, and so on. Dignity as status is
distinct from dignity as worth because status does not exist
independently of the particular forms of norm-governed social
relations that constitute it. In the interpersonal realm, treating
people as social equals is to follow social norms that express or
communicate equal status.

It is common to suspend social norms for treating others as
one’s social equal in healthcare settings. Just being a patient, as
with being homeless, or poor, is a stigma, a feature that is taken
to be discrediting, something at odds with what we take a worthy
and valued person to be.25 Why being sick or frail is a stigma is
beyond the scope of this paper. But one of the key consequences
of stigma is that norms for treating people as having equal status
are violated. Especially in institutional care settings, doctors
and nurses often do not interact with their patients as they do
with their neighbours, or their colleagues or with shopkeepers.
They are sometimes rude, impolite and take themselves to be
justified in suspending all manner of widely shared social norms
around privacy, respect, decorum, and so on. As such they treat

65Barclay L. J Med Ethics 2018;44:62–67. doi:10.1136/medethics-2017-104467

Extended essay

their patients as social inferiors. The qualitative literature tells
us that this is communicated effectively to patients, and keenly
felt. Patients consistently identify being patronised, spoken to
rudely, or made to feel as though they are an inconvenience, as
among the factors that threaten their dignity.26–29 As Killmister
notes, they feel humiliation and shame when their privacy is not
respected, or when norms of decorum are ignored.27 30 31 But this
is not only because they are prevented from upholding their own
standards and values, which is indeed felt as shameful. They are
also humiliated by the clear message that healthcare providers
do not regard them as their social equals, and as such do not
perceive that respecting such shared norms should govern their
exchanges.

On my conception of dignity, it is something conferred in
social relations where we follow social norms for treating
people as having equal status. When we do so, we communi-
cate to others that we consider them our social equals. To enjoy
dignity is to reliably be treated in accordance with such norms.
Conversely, people do not enjoy dignity when they are routinely
treated in a way that relegates them to a lower social status. Such
behaviour communicates both to its victims (and to others) that
they are believed to be of lower social status. One way to be
so treated is when others do not uphold norms around polite-
ness, respect, privacy, decorum, and so on, which are among our
norms that govern exchanges between equals. These are among
the key social norms which, when followed, constitute dignity
as equal status.

thE morAl ImportAncE of dIgnIty
We are now in a position to see that Macklin is wrong to
claim that dignity is a useless concept. Respecting persons and
respecting their autonomy are not coextensive with treating
them with dignity.

While Macklin is not particularly forthcoming about what
she means by respect for persons, she apparently has in mind
something like the Kantian notion of treating people always as
ends: she refers to examples of discrimination and abuse, and
the need for voluntary, informed consent to medical treatment
and research. However, a very broad range of interpersonal
exchanges can fail to treat people as social equals but have
nothing to do with discrimination and abuse, or more generally
not being treated as an end in the Kantian sense. Patients can be
treated with scrupulous care in regard to their legal entitlements,
with respect to discrimination law, with respect to informed
consent, and so on: but when others shun and exclude, when
they are rude, contemptuous, condescending and hostile, when
they ignore basic etiquette around privacy, cleanliness and norms
of decorum, then such patients do not enjoy dignity. They are
relegated to an inferior social status.

It might be argued that dignity is coextensive with a less Kantian
notion of respect. I have no objection to the claim that treating
people as social equals is a way of treating them with respect. To
that extent, dignity is connected to respect for persons. But it is
hardly synonymous with it. Respect is a very expansive concept,
far exceeding displays of equal status. Indeed, in a wide range
of contexts we treat people with respect precisely by following
norms that express their higher status, as when we defer to our
elders or stand for a judge. So rather vague appeals to respect
for persons fail to mark out the more specific concept of dignity
conferred in social relations in which all enjoy equal status.

Similarly, failure to respect a person’s autonomy can certainly
be an effective way to lower his status. This is a common experi-
ence for people in institutional care, especially when others treat

them as though they are children by failing to involve them in
key decisions about their healthcare. But there are many social
exchanges that fail to confer dignity which have nothing to do
with respect for autonomy. Being treated with contempt, conde-
scension, rudeness, hostility and vilification does not necessarily
interfere with self-direction or the pursuit of one’s freely chosen
ends.

The conception of dignity I have identified is not equivalent to
other moral values in healthcare, although it can certainly overlap
with some of them (just as respect can overlap with autonomy,
or benevolence with compassion). It marks out a specific area of
concern spoken of over and again by patients, namely the failure
to be treated as a social equal in their exchanges with those who
provide their care.

There is one final way to support Macklin’s scepticism about
dignity. It might be argued that dignity as equal status is just not
of great moral importance. In contrast with life and death issues
like abortion and euthanasia, or with issues like organ sales or
genetic enhancement, being treated as having equal status might
look like a fairly trivial issue.

Scepticism about the importance of dignity as equal status is
mistaken, perhaps dangerously so. Not only can the failure to be
treated as a social equal cause significant humiliation and shame,
it is plausible to suggest it is also bound up with maltreatment
and abuse. I shall develop each of these arguments in turn.

Killmister identifies avoidance of shame and humiliation as
one compelling reason to treat people with dignity. Part of the
value of dignity is that the social relations which confer it avoid
humiliating people and inflicting blows to their self-esteem and
self-worth.16 Indeed, it has been suggested that non-humiliation
is the paradigm meaning of dignity: Avishai Margalit boldly
claims that ‘if there is no concept of human dignity, then there is
no concept of humiliation either’ (p 149).32 33 34

Human beings are highly attuned to the regard which others
have for us.34 It is common therefore to feel humiliated when
treated as a social inferior. Furthermore, additional harms
tend to follow from humiliation and the damaged self-worth
and self-esteem it can cause, namely, diminished agency. Joel
Anderson and Axel Honneth argue that being able to trust our
own feelings and intuitions, to stand up for what we believe
in, and to consider our projects and accomplishments worth-
while, are all central to autonomous agency. But such self-trust,
self-esteem and self-worth only develop within social relations
that nurture and sustain them. Social relations characterised
by disrespect and humiliation are at odds with the robust
capacity for effective agency.35 Thus, it is not uncommon to
notice that people who are institutionalised, and subject to
negative stereotypes, become less responsible for their own
decision-making and increasingly willing to rely on others to
fulfil their needs.36 37

Although of great moral importance, I do not believe that
avoidance of humiliation and reduced agency …

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