ETHICS

 

The bifidity of dignity

 

 

WG Evans

 

 

 

CASE

The concept of Dignity may be considered as integral to the human condition.. and most observers would agree. Where there is less agreement, however, is how each observer would define Dignity.

It is intriguing to realise that despite the universal recognition of the importance of Dignity, there remains considerable debate as to what exactly is implied by the concept.

In the healthcare professions, dignity and ethics are intimately interwoven, as exemplified by Thomas Aquinas who claimed that there was a virtue in acknowledging the dignity of a person, respecting and honouring that status.¹ Aquinas called this virtue observantie, claiming that justice depended on the observation of dignity.¹

That explanation of dignity at once runs against the definitions commonly provided in dictionaries when the emphasis appears to be one of dignity being related to the individual... a type of self respect, a personal attitude.

Roget's International Thesaurus lists several characteristics together with "dignity: stateliness, portliness, courtliness, grandeur, loftiness, nobility, lordliness... etc. and even includes at the end of the list of 19 similar words... the state of sobriety! It is clear that in the healthcare professions there should be a broader understanding and application... and that it is the dignity of the patient which may be the more important.

Once again, Aquinas spells it out.. the action of obser-vantia, which already recognises the relevance of the other person. should be supported by the action of misericordia... which is the empathy shown when confronted by those suffering an affliction.¹

Consider the patient whose personal dignity may be challenged ...and even denied. There is an initial loss of dignity when it is a toothache which has brought the patient to the surgery. Then the requirement that there should be obedience to instructions ...is that why those attending for treatment are called "patients" why not "clients" or "customers"?

The first move when he/she is seated in the dental chair is the placement of a bib .redolent of infant days when drooling was the norm! Now local anaesthesia reduces the ability to control the lips.. and even the most dignified of patients ends up drooling! And has difficulty in articulating clearly! The environment imposes upon the patient and restricts his/her behaviour, resulting in a sense of loss of control, a direct challenge to personal dignity.

It is in the management of this challenging situation that the principles of professional Ethics come into play. Essentially these principles are readily expressed in Thomas Aquila's concept of misericordia. which is the empathy felt by the ethical practitioner. but to be fully effective, misericordia should be accompanied by observantia... the recognition in the first place that the patient is worthy of respect. That combination is important. Should the practitioner follow only observantia, there is the risk of according too much autonomy to the patient... whilst misericordia alone could result in the opposite... too great a dictatorship by the practitioner and a suffocating of the dignity of the patient.¹ The challenge to the discipline is finding the correct balance so there is action in unity.

 

 

Practitioners should be aware of just how easily that balance may be disturbed or disrupted. Nora Jacobson, in searching for a taxonomy of dignity, accumulated a long list of actions which were inimical to the ethical management of dignity.

In every encounter between people.. or between patient and practitioner... there is a assessment of physical and social characteristics... eye contact, dress, age, gender, responses ...and inappropriate interpretation may lead to a sense of violation of dignity.²

Amongst the disrupting behaviours listed by Jacobson are: Rudeness, Indifference, Condescension, Diminish-ment, Contempt, Dependence, Restriction, Trickery, Labelling, Vilification, Discrimination.

There are more. the ethical practitioner is alert to these behaviours and will control these reactions. Further, however, Jacobson echoes Aquinas when she observes that dignity is likely to be promoted when there is a combination of effects... the patient in a position of confidence and self assurance, expecting sound treatment, the practitioner in a position of compassion. That favourable situation (solidarity) promotes dignity supported by transparency, friendliness, calm.²

It is often in the small courtesies that the respect due to patients may be shown.. the greeting, formal but friendly, sitting down next the patient when discussing treatment and not towering over him/her, keeping the patient informed on the process, ...and of course adhering to the appointment schedule ...time is of the essence!

The last word may be that from The Shorter Oxford English Dictionary "Dignity is the quality of being worthy or honourable, worth, excellence." That is fine, we do strive for that quality. Remember however Dignity in the profession is bifid, extending also to include respecting those same qualities in the patient.

 

References

1. Jones DA. Human dignity in healthcare: a virtue ethics approach. The New Bioethics 2015; 21: 87-97.         [ Links ]

2. Jacobson N. The taxonomy of dignity: a grounded theory study. BMC International Health and Human Rights. https://bmchealthhumanrights.biomedcentral.com/articles/10.1186/1472-698X-9-3.         [ Links ]