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The concept of human dignity plays an increasing role in contemporary ethics, bioethics, and human rights. This chapter aims, ﬁrst, to present the major paradigms of dignity that have contributed over the centuries to shape the modern idea that every individual has inherent worth and accompanying rights; second, to stress that human dignity holds a prominent place as an overarching principle in the international documents relating to bioethics; and ﬁnally, to point out that the idea of dignity plays also an important guiding role as a moral standard for patient care at the bedside.
The concept of human dignity plays an increasing role in contemporary ethics and bioethics as well as in human rights instruments. Nonetheless, far from being a novel notion, it has been the subject of many centuries of philosophical inquiry. Its origins can be traced back to antiquity and is present with different nuances and in varying degree in many civilizations and cultures.
Although this brief account is focused on the special development of the notion in the Western philosophical tradition, it is noteworthy that the idea of an intrinsic human worthiness is also present in other cultural settings (UNESCO 1984; Qianfang 2000; Sachedina 2009).
This chapter aims, ﬁrst, to brieﬂy present the major paradigms of dignity that have contributed over the centuries to shape the modern idea that every individual has inherent worth and accompanying rights; second, to stress that human dignity holds a prominent position as an overarching principle in the international instruments relating to bioethics that have been adopted since the end of the 1990s, and ﬁnally, to point out that the idea of dignity plays also an important guiding role as a moral standard for patient care.
History Of The Concept Of Human Dignity
From antiquity to today, ﬁve major paradigms of dignity have contributed to shape the irreducible worth that modern societies attach to every single human being: moral dignity (antiquity), spiritual dignity (Middle Ages and Renaissance), rational dignity (seventeenth and eighteenth centuries), social dignity (nineteenth century), and human dignity stricto sensu (twentieth and twenty-ﬁrst centuries). These paradigms are neither to be understood as completely separated from one another nor representing a linear progress but rather as methodological tools that help us better understand the historical evolution of the idea of dignity. What they do have in common is that they attempt to identify speciﬁc features of human beings and to emphasize their worthiness and their social and political role.
The paradigm of moral dignity is especially prominent in antiquity. Major Greek and Roman philosophers outlined the uniqueness of human beings, differentiating human nature from the nature of other living beings and stressing its divine and superior origin. They described some qualities inherent to human nature, like free will and rationality, by means of which every individual would be able to reach and develop moral ideals and virtues (for instance goodness, prudence, and benevolence). For Plato, the human soul (psyché) has a divine origin (Timaeus, 90a-b), and its proper goal is to reach the virtues of justice and goodness through cognitive rationality and contemplation (The Republic, 353d3- 13). Aristotle also insists on the special worth of human beings, underlining rationality as the expression of a divine origin (On the Soul, 408b15). Unlike other living creatures, every human being is gifted with a complex and openended ability of language and the moral sense of good and evil, of just and unjust, qualities that made him a “political animal” (zoon politikon) (Politics, 1253a). The modern idea of universal human dignity was nevertheless not yet clearly present in ancient Greek philosophy, which justiﬁed a rigid hierarchical social order and slavery.
Roman stoic philosophers, in particular Cicero and Seneca, also contributed to shape the paradigm of moral dignity (Pele 2010). They developed a more universal understanding of this notion, taking into account “otherness” and the idea of equality among all human beings. Cicero explicitly employs the term dignity to refer to the excellence and dignity (excellentia et dignitas) that all human beings possess by the simple fact of sharing in the common rational nature (On duties, I, 105). In parallel, the concepts of dignitas and dignatio seem to have emerged in the political vocabulary of ancient Rome to describe both the highest political ofﬁces and the qualities required to achieve and perform those ofﬁces (along with foresight, provisio, and steadfastness, constantia). Cicero insists on the very speciﬁc human features and virtues such as rationality, memory, intelligence, consciousness, and foresight, which reveal that human beings are close to God by nature and are unique among living beings (On laws, I, 22; On duties, I, 11). Human virtues can be developed through a correct education (humanitas) and should be cultivated by any individual wishing to attain the highest moral and political goals (On duties, I, 73). Seneca would go a step further and defend an equal dignity of all human beings based on the understanding of a common vulnerability. With the sentence homo homini sacra res (“man is a sacred thing for man”) (“Letter XCV,” in the Moral Letters to Lucilius), the recognition of a vulnerable humanity in each individual becomes the grounding of humankind’s unity. In this ﬁrst paradigm of dignity, the worthiness of human beings is grounded on their capacity to embed the highest features of human nature within a moral framework deﬁned through speciﬁc kinds of virtues.
The paradigm of a spiritual dignity marked the Middle Ages and Renaissance. This notion emerged in the context of a dichotomy between a purely mundane life and a transcendent life in close relationship with God. Humanism embodied the main philosophical and moral background that helped shape this new pattern of dignity. The notion of dignitas hominis was created in order to defend and celebrate the excellence and greatness (excellentia ac praestantia) of human beings. It appeared as a complementary perspective and a counterpart of a more pessimistic view, the miseria hominis. This notion had been previously formulated in High Middle Ages writings, the Contemptu Mundi (contempt of the world) by Christian authors, mystics, and ecclesiastics, greatly inﬂuenced by Augustine’s theology, such as, for instance, Bernard of Cluny, Bernard of Clairvaux, and Lotario di Segni (future Pope Innocent III). In On the misery of human condition (1195), di Segni described all the miseries that accompany humans as they pass through this world. Man is presented as a dangerous and sinful creature whose salvation can be achieved only through humility and penitence and hoping for the grace of God. The humanist’s perspective and celebration of the dignitas hominis can be understood as a reaction against this spiritual and pessimistic view of human existence. Between the fourteenth and sixteenth centuries, although with precedents in the previous centuries, for instance, in Gregory of Nyssa, many humanists celebrated the dignity of human beings, coming back to the biblical sources, interpreting classical Greek and Roman philosophers, discovering and shaping new beliefs (hermeticism, Kabbalah, prisca theologia), and being inﬂuenced by the optimism of the Renaissance breakthroughs and discoveries (Copernicus’ heliocentrism, Gutenberg’s printing, fall of Constantinople, discovery of the New World). Among those thinkers, the most famous might be Giovanni Pico della Mirandola with his Oration on the Dignity of Man (1486). In this regard, it is also worthy to remember other humanist thinkers, like Francesco Petrarca, Bartolomeo Fazio, Giannozzo Manetti, Marsilio Ficino, Giordano Bruno, Erasmus of Rotterdam, and Juan Luis Vives. Beyond differences in their approaches, their writings contributed to develop the concept of dignitas hominis, deﬁning human beings as a “magnum miraculum” (a great miracle), which contains all the laws and principles of the universe in its nature (microcosmos). Pico della Mirandola claims that human beings have no clearly determined essence or nature but are gifted by God with a prodigious freedom and intelligence to shape their destiny and their very own nature; their duty is to adequately use their intellectual and moral faculties in order to be faithful to God’s trust and love. Therefore, for Renaissance philosophers, the worth of human beings is ultimately based on their ability to develop and harmonize their intellectual, moral, and bodily abilities and move toward their spiritual self-realization.
A third paradigm helps to describe the process that shaped the recognition of human beings’ worth between the seventeenth and eighteenth centuries. During the seventeenth century, two major philosophers, René Descartes and Blaise Pascal, following different paths, insisted on the dignity of human beings, highlighting their rational nature and the limits of this faculty. Simultaneously, adherents to the rationalist natural law theory redeﬁned the idea of dignitate et excellentia hominis, focusing on the rational nature of human beings, and used it as the anthropological and moral basis of natural law. According to Descartes, reason is a universal faculty shared by all individuals and constitutes the grounding of their moral equality (Discourse on the Method, I). It is also the capacity that enables human beings to be aware of their own consciousness, which is the ultimate truth: cogito ergo sum, (“I think therefore I am”) (Principles of Philosophy, I,7). Through the rational process of thinking, human beings express their dignity and uniqueness without any previous spiritual transformation as it was required by the second paradigm of dignity mentioned above. It is true that Pascal criticized some aspects of this Cartesian perspective, insisting on the limits of human reason and on the need to articulate it both with divine and with natural human intuition (“l’esprit de ﬁnesse”). However, he believed that “all the dignity of man consists in thought. Thought is therefore by its nature a wonderful and incomparable thing” (Thoughts, 186). Furthermore, for Pascal, the dignity of human beings ultimately lies in their awareness of the greatness and ﬁnitude of their nature: “the greatness of man is great in that he knows himself to be miserable” (Thoughts, 105).
In the seventeenth century, the rationalist school of natural law separated the validity of natural law from its previous theological origins. Authors like Grotius, Pufendorf, Thomasius, Burlamaqui, and Wolff made major contributions to the ﬁelds of private law, jurisprudence, and international law. Grotius and Pufendorf justiﬁed the natural law celebrating human nature and, in particular, its rational dimension. Grotius referred to the “excellence and dignity of man” whose reason enables him to progress and understand the greatest truths of mundane and social life (De jure belli ac pacis, “Preliminary Address,” § IX).
Also, Pufendorf refers to the “dignity and excellence of man (.. .), which requires that he conforms his actions to a [legal] norm.” Human soul is indeed “endued with the light of understanding, with the faculties of judging and of choosing things, and with an admirable capacity for arts and knowledge” (De jure naturae et gentium, 95). The rational nature of human beings is evoked to support their dignity and, as a consequence, to provide a foundation to modern legal systems.
The paradigm of rational dignity is also dominant in the eighteenth century and, in particular, in the perspective developed by Immanuel Kant. The German philosopher refers to the “idea of dignity of a rational being who obeys no law except that which it at the same time gives” (Groundwork for the Metaphysics of Morals, 424). This approach puts the emphasis on the freedom to conceive and follow the moral law, which is a speciﬁc capacity of human beings. Kant holds that it is only from this moral perspective and not on ontological terms that human dignity can be justiﬁed. He assumes that moral actions should be oriented by a purely formal imperative and can only consist in acting for the sake of duty alone (i.e., from respect for the moral law). This imperative must have a categorical nature, which means that it should represent certain actions as rationally required in themselves for everybody and without reference to any further goal. Kant concludes that there is only one categorical imperative and it is this: “Act only according to that maxim whereby you can, at the same time, will that it should become a universal law” (Groundwork, 421). In his view, the only way to make sense of the human will as a ground of a universal moral law is to conceive human beings as ends in themselves. This idea is expressed in the second formulation of the categorical imperative: “Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means and always at the same time as an end” (Groundwork, 429). Kant presents “dignity” as exactly the opposite of price: While “price” is the kind of value for which there can be an equivalent, “dignity” makes a person irreplaceable. Therefore, the notion of human dignity expresses a requirement of noninstrumentalization of persons.
The paradigm of social dignity appeared in the nineteenth century and was explicitly or implicitly used to discuss social and political issues and to ﬁght for a fully realized citizenship for everybody. Among other functions, it was invoked to promote the equality of men and women, as it can be read, for instance, in the Enfranchisement of Women by the feminist Harriet Taylor Mill (1851). The idea of dignity was also used to denounce the inhumane labor and social conditions of the mass of workers during the industrial revolution. In this regard, it is worth remembering the Haymarket affair of Chicago (1886), which began as a rally in support of workers striking for an 8-h workday and ended in a massacre. This event originated the International Workers’ Day, also known as Labor Day, which is today celebrated on May 1. The inhumane working conditions at the end of the nineteenth century are also well described in the social literature of that period, such as in Germinal by Émile Zola. During this same period, slavery was progressively abolished in Europe and North America, and the humanitarian movement became more articulated. In 1863, Henry Dunant founded the International Committee of the Red Cross. Two points are worthy of mention here. First, the concept of dignity was used to denounce injustices and to promote human rights. This clearly shows that dignity is not a merely empty rhetorical term but rather the source from which all the basic rights derive their substance (Habermas 2010, p. 466). Second, dignity was invoked to defend collective and social rights, which were promoted all around the world. This is a historical precedent that undermines the objection that dignity is an individualistic, liberal, and Western ideological construct.
Human Dignity Stricto Sensu
The paradigm of human dignity stricto sensu is conceived as a universal ethical and legal principle stressing that all human beings have intrinsic worthiness and inalienable rights by the mere fact of being human. This imperative has been formally recognized since the mid-twentieth century by national states and by the international community as a whole. This contemporary trend is closely related to the process of universalization of human rights that took place in the aftermath of the Second World War. The Universal Declaration of Human Rights (UDHR) (1948), which served as the cornerstone of the international human rights system, was explicitly grounded on the “recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family” (Preamble). From the very beginning, the Declaration puts forward that “all human beings are born free and equal in dignity and rights” (Article 1). In addition to the UDHR, the two major pillars of the international human rights law system, namely, the International Covenants on Civil and Political Rights (ICCPR) and on Economic, Social and Cultural Rights (ICESCR) of 1966, formally recognize that human rights “derive from the inherent dignity of the human person” (Preamble). More recently, the European Charter of Fundamental Rights (2000) refers to human dignity as a “universal value” on which the European Union is founded (Preamble). Article 1 of the Charter states that “human dignity is inviolable. It must be respected and protected.”
The particularity of this new paradigm when compared to the previous ones is that human dignity is now formally incorporated into national and international legal instruments and requires that all social, political, and scientiﬁc institutions comply with the requirement of respect for the inherent worthiness and rights of every human being. Respect for human dignity is no more a purely moral or philosophical concept but a legal and political one, which is recognized by the international community as the ground of the entire human rights system and whose promotion in all areas of social life is the proper goal of every national state.
Although international legal instruments do not give an explicit deﬁnition of human dignity, they do offer a helpful guidance for the understanding of this notion when they provide that dignity is “inherent… to all members of the human family” (UDHR, Preamble); that all human beings are “free and equal in dignity and rights” (UDHR, Article 1); and that “these rights derive from the inherent dignity of the human person” (1966 International Covenants on Civil and Political Rights, and on Economic, Social and Cultural Rights, Preambles).
The term “inherent” means “involved in the constitution, or essential character of something,” “intrinsic,” “permanent or characteristic attribute of something.” The idea expressed in this term, when it is accompanied by the adjective “human,” is that dignity is inseparable from the human condition. Thus, dignity is not an accidental quality of some human beings or a value derived from some particular personal circumstances such as the fact of being young or old, man or woman, healthy or sick, but rather something that all human beings possess by the mere fact of being human. Moreover, if human dignity is the same for all and the ground of human rights, then all human beings possess equal basic rights. Another important conclusion that can be drawn from these premises is that if basic rights are not given by authority but are preexisting values which are inherent in every human being, then they cannot be legitimately taken away by any authority (Schachter 1983, p. 853).
Human Dignity As An Overarching Bioethical Principle
The principle of respect for human dignity is not only the bedrock of international human rights law. It also holds a prominent position in the intergovernmental instruments dealing with bioethical issues that have been adopted since the end of the 1990s by intergovernmental organizations such as UNESCO and the Council of Europe. The emphasis on human dignity in international instruments on bioethics is impressive enough to lead scholars to characterize this notion as “the shaping principle” of international bioethics (Lenoir and Mathieu 2004, p. 16) or as the “overarching principle” of the global norms governing biomedical issues (Andorno 2009). This prominent place that human dignity has in global bioethical and biolegal norms is understandable. Biomedical practice is closely related to the most basic human rights, namely, the rights to life, to physical integrity, to privacy, to access to basic health care, among others. If human dignity is recognized by international law as the foundation of human rights, then it is not surprising that it is mentioned as the ultimate rationale of the legal norms governing biomedical clinical practice and research.
Interestingly, the central role of human dignity in modern biomedical ethics is closely related to the same dramatic events that led to the development of international human rights law. The drafting work of the Universal Declaration of Human Rights was largely inspired by the discovery of the horror of concentration camps, including the revelation that prisoners were used for brutal medical experiments. As George J. Annas points out, the Second World War was “the crucible in which both human rights and bioethics were forged, and they have been related by blood ever since” (Annas 2005, p. 160).
The ﬁrst impact of the idea of human dignity on biomedical ethics was related to medical research involving human subjects and embodied in the requirement of free and informed consent of research participants. Although the Nuremberg Code, which was formulated in 1947 by the trial that condemned the Nazi physicians, does not explicitly refer to human dignity, its principles are clearly inspired by this notion. The non-negotiable nature of the Code requirements for medical research shows that the idea of an unconditional human worthiness was in the mind of the judges that formulated them. According to Principle 1 of the Code, “voluntary consent of the human subject is absolutely essential,” and “the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice (.. .); and should have sufﬁcient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision.” The Code also requires that research “should be so conducted as to avoid all unnecessary physical and mental suffering and injury” (Principle 4); that it should not be conducted “where there is an a priori reason to believe that death or disabling injury will occur” (Principle 5); and that “the degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment” (Principle 6). Consistently with the focus on medical research during this period, the only provision of the International Covenant on Civil and Political Rights of 1966 which directly relates to bioethics states that “no one shall be subjected without his free consent to medical or scientiﬁc experimentation” (Article 7).
Since the end of the 1970s, the notion of human dignity began to be used beyond the domain of biomedical research to address several dilemmas raised by medical practices that operate at the edges of life, both at the very beginning (e.g., assisted reproductive technologies, preimplantation genetic diagnosis, embryo research) and at the very end (futile treatments, assisted suicide, euthanasia). The idea of human dignity as a requirement of noninstrumentalization of people is also often mentioned as an argument against practices that are regarded as new forms of commodiﬁcation of the human body, like organ selling and surrogate motherhood. In this varied context, it is not surprising that the term “dignity” is sometimes used to support different and even opposed views (such as in the debate on assisted suicide). This is why it is obviously not enough to “invoke” human dignity to respond to bioethical dilemmas. In addition, it is crucial to specify as far as possible the meaning with which the notion is employed.
The intergovernmental instruments relating to bioethics show the broader and multifaceted role that human dignity plays in this ﬁeld. Two significant documents are the Universal Declaration on the Human Genome and Human Rights (1997) and the Universal Declaration of Human Rights and Bioethics (2005), which were adopted by representatives of virtually all countries at the UNESCO General Conference. The 2005 Declaration is the best example of the multiple function of human dignity in global bioethics. The promotion of respect for human dignity is the main purpose of the Declaration (Article 2.c); the ﬁrst principle governing the whole ﬁeld of biomedicine (Article 3); the main argument against every form of discrimination, including, for instance, genetic discrimination (Article 11); the framework within which cultural diversity is to be respected (Article 12); and the highest interpretive principle of all the provisions of the Declaration (Article 28).
The Council of Europe’s Convention on Human Rights and Biomedicine (1997) is another good example of the importance attached to human dignity in bioethical and biolegal instruments. According to its explanatory report, “the concept of human dignity (.. .) constitutes the essential value to be upheld. It is at the basis of most of the values emphasized in the Convention” (Paragraph 9). The Preamble refers three times to dignity: the ﬁrst, when it recognizes “the importance of ensuring the dignity of the human being”; the second, when it recalls that “the misuse of biology and medicine may lead to acts endangering human dignity”; the third, when it underlines the need to take the necessary measures “to safeguard human dignity and the fundamental rights and freedoms of the individual with regard to the application of biology and medicine.” The purpose itself of the Convention is deﬁned by appealing to the notion of human dignity (Article 1). Although the European Biomedicine Convention is not a global but a regional instrument, its potential impact on a global scale should not be overlooked. It should be stressed that it is the only intergovernmental legally binding instrument that comprehensively addresses the linkage between human rights and biomedicine. The fact that the 2005 Universal Declaration on Bioethics and Human Rights explicitly refers to the Biomedicine Convention in its Preamble shows the importance of this European instrument, as it is unusual that UN declarations cite regional instruments among their sources.
Certainly, even with the formal recognition of human dignity as a fundamental principle, there is not always unanimity between countries and within countries about the concrete implications of this notion, especially regarding those medical practices that operate at the edges of life. Nevertheless, this does not necessarily mean that a universal conception of dignity does not exist but suggests only that a universal understanding of dignity does not exist at the margins (McCrudden 2008).
It is also important to note that although the notion of human dignity is usually used to refer to the intrinsic worthiness of every human being, it is also invoked to refer to the value attached to the integrity of the human species as such, including future generations. In this regard, human dignity aims to articulate a concern about biotechnological developments that may have a negative impact on the future of humankind such as reproductive cloning and human genetic engineering. A purely human rights approach is powerless to face these new challenges because rights are only enjoyed by existing individuals, not by humankind as a whole or by future generations. This is why the new instruments relating to bioethics directly appeal to the notion of human dignity and not to human rights when they condemn practices such as human reproductive cloning or germ-line interventions. Three examples illustrate this trend: the Universal Declaration on the Human Genome and Human Rights (1997), which emphasizes the need to preserve the human genome as a “heritage of humanity” (Article 1) and expressly labels human reproductive cloning and germ-line interventions as “contrary to human dignity” (Articles 11 and 24 respectively); the UN Declaration on Human Cloning (2005), which calls on Member States “to prohibit all forms of human cloning inasmuch as they are incompatible with human dignity and the protection of human life” (Paragraph d); the Council of Europe’s Convention on Human Rights and Biomedicine (1997), which prohibits germ-line interventions on the ground that “they may endanger not only the individual but the species itself,” (Explanatory Report to the Convention, Paragraph 89), and the 1998 Additional Protocol to the same Convention, which bans human reproductive cloning on the grounds that it is “contrary to human dignity” (Preamble).
Human Dignity As A Moral Standard For Patient Care
Human dignity is not only an overarching principle that fulﬁlls a foundational and guiding role of the norms governing biomedical issues. It is also a valuable moral standard for health care decisions at the bedside as it embodies a very concrete and context-speciﬁc vision of the patient as a “person.” While dignity as a principle refers to the inherent value that society recognizes in each of us, dignity as a moral standard for patient care relates to the inherent value that each of us recognizes in ourselves. It results from our awareness of being “subjects” and not mere “objects”; it leads us, if we are patients, to reasonably expect certain attitudes and behaviors from health care professionals (Andorno 2013).
Paying adequate attention to the dignity of each patient is crucial in health care. Patients are placed in a situation of special vulnerability; they are deeply dependent on the assistance of others, not only for the improvement of their health condition but also for meeting their most basic needs. Consequently, they are exposed to see their self-esteem affected if they ﬁnd that certain behaviors or attitudes of health care professionals disregard their intrinsic value as persons. In this regard, it is interesting to note that the etymology itself of the word “patient” shows this close relationship with vulnerability. The term “patient” comes from the Latin verb “patior,” meaning to endure, bear, or suffer, and refers to an acquired vulnerability and dependency imposed on patients by their health situation (Chochinov 2002).
The connection between dignity and vulnerability might be seen as paradoxical. As explained above, the idea of human dignity has been traditionally associated with the highest rational capacities and free will that characterize human beings. However, in the health care context, dignity becomes more visible in vulnerability and weakness than in self-sufﬁciency. In the most vulnerable patients (e.g., newborn infants, senile elderly, people with serious mental disorders, comatose individuals), human dignity is not hidden behind the ornaments of great intellectual or physical abilities or good health. In such patients, dignity is exposed in its nakedness and simplicity and results from the mere consideration that patients are humans. Health care professionals are well aware of this phenomenon as they are permanently confronted with human beings in their simple existence and are required by their profession to discover the worth of every patient in that particular situation. Doctors and nurses intuitively notice the crucial importance of keeping in mind that each patient, no matter what his or her diagnosis, is not a “case,” a “disease,” or a room number but a person with a unique character (Andorno 2013).
The patient–health care professional relationship is indeed a paradigmatic occasion for a careful and active defence of patients’ dignity. This responsibility does not only rely on health care providers but also on family members, friends, and fellow patients. Pellegrino (2008) has well described the need for a dignity promotion behavior by pointing out that patients, especially the seriously ill and dying ones, are acutely sensitive to the way others in their presence react to them:
The visitor’s look of shock on entering the patient’s room, the poorly disguised pity, the slight turning away of the eyes, the ever shorter visits, the struggle to say something meaningful, the mournful countenance, the recoil from bodily contact –those reactions all sustain the patient’s conviction that she or he is no longer a respected, needed or wanted member of their community or society (Pellegrino 2008, p. 527).
If promoting patients’ dignity has always been a crucial element of the medical profession, it has become especially urgent in the time-pressured context of modern health care. In increasingly bureaucratic, impersonal, and commercialized hospitals, the risk is high of overlooking that kindness, humanity, and respect for each individual patient are still, and will always be, core values of the practice of medicine. This is why emphasizing the notion that every human being is uniquely valuable and therefore must be esteemed highly is today more important than ever.
The Canadian psychiatrist Harvey Chochinov (2002) claims that the concept of dignity provides an overarching framework which is able to guide physicians, patients, and families in deﬁning the objectives and modalities of any medical intervention. Based on the results of an empirical study aiming to examine the understanding of the idea of dignity by patients in an advanced stage of cancer, Chochinov has proposed a new model of patient care: the “dignity-conserving care” model. This model includes three broad areas of inﬂuence of individual perceptions of dignity: illness related concerns, i.e., those things that directly result from the illness itself; the dignity conserving repertoire, i.e., those aspects of patients’ psychological and spiritual landscape that inﬂuence their sense of dignity; and the social dignity inventory, i.e., those social issues or relationship dynamics that enhance or detract from a patient’s sense of dignity.
Other studies conducted in hospital settings have shown similar results: The consideration of patients’ dignity is of crucial importance to health care, and its maintenance can contribute to the “emotional comfort” that may assist recovery (Matiti and Trorey 2008; Baillie 2009). A number of key themes that help enhance patients’ dignity have been identiﬁed: privacy; conﬁdentiality; communication and the need for information; choice, control and involvement in care; respect and decency; and forms of address (Matiti and Trorey 2008). The multifactorial nature of patient dignity is highlighted by the fact that it includes very heterogeneous elements, such as feelings (feeling comfortable, in control, and valued), physical presentation, and staff behavior (Baillie 2009).
The notion of human dignity has been the subject of many centuries of philosophical inquiry. Most of the explanations emphasize the rational capacities and the free will that characterize human beings and make of them something absolutely unique among living beings. In modern times, human dignity is understood as a universal ethical and legal principle stressing that all human beings have intrinsic worthiness and inalienable rights by the mere fact of being human.
In bioethics, the notion of human dignity plays two different and complementary roles. On the one hand, it operates as an overarching principle that fulﬁlls a foundational and guiding role of the normative framework governing biomedical issues. On the other hand, it is a valuable moral standard for concrete health care decisions at the bedside. When it operates as a general principle, the notion of dignity does not intend to determine alone the content of particular decisions but, more modestly, to show the overall aim of biomedical practice. This is why the recourse to this foundational notion is often combined with the appeal to a wide range of health-related rights, which provide a more effective and practical way forward for dealing with bioethical matters. When dignity operates as a moral standard for health care, it relates to the interaction between patients and health care professionals in the speciﬁc and varied circumstances in which they ﬁnd themselves. It requires doctors, nurses, and hospital staff to actively promote the dignity of patients in every encounter and to avoid all behaviors that can hurt patients’ self-esteem.
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