The purpose of this article is to develop a conception of death with dignity and to examine whether it is vulnerable to the sort of criticisms that have been made of other conceptions. In this conception “death” is taken to apply to the process of dying; “dignity” is taken to be something that attaches to people because of their personal qualities. In particular, someone lives with dignity if they live well (in accordance with reason, as Aristotle would see it). It follows that health care professionals cannot confer on patients either dignity or death with dignity. They can, however, attempt to ensure that the patient dies without indignity. Indignities are affronts to human dignity, and include such things as serious pain and the exclusion of patients from involvement in decisions about their lives and deaths. This fairly modest conception of death with dignity avoids the traps of being overly subjective or of viewing the sick and helpless as “undignified”.
- palliative care
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It is commonly said that health care professionals should seek to ensure that terminally ill people in their care should die with dignity. This seems to involve two claims. The first is that lives without dignity should be ended. This might be by the withdrawal or withholding of life-preserving treatment, or by the direct administration of some life-ending treatment. Those who advocate non-voluntary euthanasia for the severely handicapped may endorse such a view, although it is unclear how death, either induced or natural, adds dignity to an “undignified” life. The second claim is that people should be allowed to make the choices necessary to procure a death with dignity. This second claim is the one more commonly used, often by those advocating assisted suicide or voluntary euthanasia. The idea seems to be that certain conditions are such that palliative treatment is insufficient to ensure a death with dignity and that therefore euthanasia should be used.
The phrase is not a transparent one, however, and its use has been attacked. Perhaps death itself is by definition undignified; or perhaps the word “dignity” is not one that can possibly apply to death. The main purpose of this article is to defend a conception of death with dignity. I begin with an examination of the words “dignity” and “death” and of the phrase “death with dignity”. I then turn to criticisms made of the application of this phrase in health care. Finally, I set out a conception of death with dignity that attempts to capture the meaning people give to it whilst avoiding some of the problems. The key element of this conception is that dignity is largely something that someone brings to death; it is not something that health care professionals can confer.
DEATH, DIGNITY, AND DEATH WITH DIGNITY
The word “dignity” is derived from the Latin, dignitas, meaning worthiness and nobility. It may be attributed to a broad range of things. In the first place, it may be attributed to humans, animals and, even, objects; hence one might speak of the dignity of a ballet dancer, or an old soldier, of a swan, and of a work of art. The term may also be attributed to actions; hence one might speak of someone conducting herself in a dignified way (often in the face of indignities, as I hope to show). The dignity of some people seems all-pervasive. For example, we might think of Jesus, Gandhi, and Mandela as possessing a dignity that belongs to them as a whole, rather than to them in a specific role, as it does to a ballet dancer or soldier.
“Dignity” appears to have two words that function as opposites, “undignified” and “indignity”. One important aspect in these two words, neither of which seem to function as a pure antonym, is the sense that they can convey of some type of insult or affront. This is true particularly of the latter term; we speak of “indignities” being inflicted on people or things. Such an affront will usually be imposed by another, such as when a swan is put into human clothes for an advertisement, or when Christ had the ironic term “INRI” nailed above his head on the cross.1 You might affront your own dignity, however, where that dignity attaches to you as part of a role, rather than to you as a person. For example, a ballet dancer who uses her skills to make money as a lap-dancer might be said to affront her own dignity.
Let us turn now to the term “death” and then the phrase “death with dignity”. Kass suggests that the discussion of death with dignity conceals four senses of the term “death”.2
Non-being—the rather mysterious state of being dead;
Transition—the point at which one moves from being to non-being;
Process—the period leading to death. This is not entirely straightforward as we are in this process from the moment of conception. In practice it usually means a period in which there is an awareness of what will end a particular person’s life and, roughly, when.
The fact of mortality—death as a universal truth that attaches to us all.
“Dignity” is not a term that would apply to the first sense. One would hardly talk of the indignity heaped upon Shakespeare each year he carries on being dead, for example. The term might apply to the fourth sense if one were to say (in a quasi-existentialist way) that death is the indignity that makes life absurd, for example. But it is not clear what this would mean and it is obviously not the sense in which the term is usually applied in health care. Thus it would seem that the more common use of the phrase “death with dignity” attaches to the second and third senses of death. If this is so then we appear to mean dying with dignity when we use the phrase. This will be assumed in the rest of my discussion.
CRITICISMS OF “DEATH WITH DIGNITY”
The application of the phrase “death with dignity” in health care has been attacked. Ramsey suggests that death is an indignity, an affront to life, and that the phrase is, therefore, an oxymoron.3 His argument, however, makes two errors. The first is that it confuses the different senses of “death”. Ramsey moves from the quasi-existentialist belief that death is an indignity for all people, to the view that every person’s process of dying is undignified. This is not a justified move. The second error is that it mistakenly assumes that being subject to an indignity undermines one’s dignity. This is also unjustified, as I shall argue presently.
Coope has a far more robust critique.4 He suggests that it is not clear that the notion makes any sense at all. One can die in undignified circumstances (such as with trousers down in a brothel), but he questions whether one can die with dignity any more than one can be born or breathe with dignity.
He considers a common reply to this question: that dying with dignity is whatever the dying person thinks it is. Hence—for example, if someone thinks it is undignified to die in a confused state, or incontinent, or heavily dependent on others, then it is undignified for him. Coope suggests that the problem with this is that:
if no one understands the phrase “death with dignity” we likewise do not understand the sentence: “Smith thinks that this is a death without dignity”.5
This is slightly cryptic. The point seems to be, however, that this subjective notion of dignity cannot do any useful work in discussions about dignified death. For example, if we were to say that assisted suicide should be an option for all people to ensure they had (subjectively) dignified deaths, we would have to provide that option to anyone who felt their current situation required it to maintain their dignity. Hence, someone who felt that impotence, or hay fever, undermined their dignity would have the same right to assisted suicide as someone who felt that way about a terminal, wasting disease.
Coope goes on to ask whether there may be any more objective notion of death with dignity. He suggests that, in so far as there is, it is a disturbing one. In particular, it seems to be thought that being “ministered to as helpless” is undignified. Hence, the weak and the injured are subject to Nietzchian contempt for living lives beneath or without human dignity. He concludes that, whilst it might be possible to construct a satisfactory notion of death with dignity along these lines there seems to be no good reason to do so. Talk of death with dignity adds nothing to the discussion of how best to treat people who are dying, or living lives of poor quality.
DEATH WITHOUT INDIGNITY AND DEATH WITH DIGNITY
Coope’s criticism is a powerful one. None the less, the phrase “death with dignity” is in common currency; it has meaning for many people, most of whom would agree on the necessity of avoiding both the overly subjective and the Nietzchian objective interpretations. Is it possible to construct a conception of death with dignity that captures the sort of views people have whilst avoiding these two, unacceptable, polar positions?
When working as a care assistant I once looked after someone dying of lung cancer. He was on, what we called at the time, the “danger list”. This was an odd phrase as death in the short term was a certainty, not a danger. The quality of care on this particular ward was poor; in particular, pain control was badly managed. The routine was that the staff would wait for the pain to begin before giving inadequate amounts of morphine. Therefore, the man was frequently in severe pain. I recall him screaming. But each time the morphine took the edge off his pain he would make a great effort to get up, walk round, talk to other patients and staff, and eat at the dinner table with everyone else. Perhaps he should have been more angry (as I should have been)—but my memory is of someone fighting hard to maintain his dignity all the way to his death. What is interesting is that the events in this man’s death bear few hallmarks of what many think of as a dignified death—and yet it seems to me to have been so. I think that, in order to understand this, it is useful to draw a distinction between death without indignity and death with dignity.
1. Death without indignity
We have seen that “indignity” conveys the idea of an affront. Hence, a death without indignity would be one in which no such affronts occur. What would such affronts be? In the first place, there may be specific affronts, such as playing loud rap music to someone who loves only classical music, or jeering at someone who is incontinent, or using “baby names” to an old General. But there may be things that affront all people, in the way that lap-dancing affronts all ballet dancers, and dressing up, all swans. To understand this one would need to ask whether there is a dignity that all humans possess simply because of being human and, if so, how is it affronted?
A potential answer to this draws on an Aristotelian idea.6 The unique and essential feature distinguishing humans from other animals is rationality, the ability to reason and to act upon reasons. Human dignity would, therefore, arise from this feature. We would affront such dignity by failing to acknowledge this in an individual; instead treating them as an object or an animal. For example, if one were to engage in euthanasia without consent (“involuntary euthanasia”) then this would look like an affront to someone’s dignity (even if he would have chosen that option had it been offered); it looks as though one has “put someone down” like a dog. Another example of an affront to human dignity would be failing to tell someone of his terminal diagnosis in order to avoid upsetting him. This is an affront because it removes the ability for him to make choices about his own life. In more Kantian terms, we would be failing to recognise this person as an end in his or her own right. Not all affronts to human dignity will be imposed by human agents, however; disease processes that take away an individual’s ability to reason might also be seen in this way. A death without indignity will be one in which these types of affront do not occur.
On this account, dignity may be seen as a continuum. There is a basic level of dignity that all humans possess simply by virtue of being a member of a rational species. Some people, however, exercise their reason in better ways than others. They can be said to be living good lives. It is these people who possess the greatest degree of dignity; these are the people we admire and view as possessing dignity (or dignity to a high degree). What, then, can this account make of the notion of “death with dignity”?
2. Death with dignity
Whilst inflicting indignity on others is a moral failure, a failure to recognise their human dignity, it does not remove their dignity either in its minimal or fullest sense. If someone is subject to involuntary euthanasia, or lied to about his diagnosis, then he is wronged, affronted; but he may still live his life, and die his death, with (greater or lesser) dignity in the face of that indignity. Christ (and other martyrs) suffered great indignities but, none the less, died with dignity. Mohammed Ali is sometimes praised for the dignity with which he faces his Parkinson’s disease. People die with dignity because of their personal qualities, their virtues, whatever the circumstances in which they die: indignity is suffered; dignity is earned.
It follows that a dignified death will be something earned. Someone who lives a good life, lives virtuously, will die in that way. For the rest of us, death with dignity will be, like life with dignity, something to aim for but only partially to achieve. The potential for dying with dignity may also be lost in those who lose their reasoning capacities—for example, through dementia-inducing illnesses. Similarly, unbearable (and uncontrollable) pain or other suffering may undermine someone’s ability to reason and to choose and, hence, to die with dignity.
It seems, then, that health care professionals cannot ensure that someone dies with dignity. They can, on the other hand, contribute to a death without indignity. This will involve ensuring that, as far as possible, they respect people’s autonomy and use of human reason. It will also involve removing barriers to dignity that can be removed, such as (controllable) pain. On these occasions, health care professionals are making an indirect contribution to death with dignity. To return to my earlier example of the man dying in great pain, health care professionals could and should have removed indignities; in doing so they would have helped him to die without indignity. In the end, however, his strength of character was such that he had a dignified death; in other words, he had a death with dignity in the face of indignity. Indeed, perversely the indignities enabled him to demonstrate his dignity (J Gilbert, personal communication, 2001).
Does this account of death with dignity capture the sense people have of it? And does it do so whilst overcoming Coope’s criticisms? As to the first question, a recent “discourse analysis” (which included interviews with terminally ill patients and their relatives) showed that for them “death with dignity” does often signify simply a death without indignity.7 Even such things as dying in a decrepit room were of relevance here. But deeper notions of dignity were also a factor in people’s ideas of death with dignity. Self determination was a major theme; so was the idea that dignity was something that developed through one’s life through interpersonal relationships. The Aristotelian conception I have offered here seems to capture both the importance of minimising indignity, and the deeper sense in which dignity is something that belongs to someone and has developed with him or her.
Turning to the second question, it seems clear that the conception avoids being overly subjective. On an Aristotelian account, if someone is still capable of living an active reasoned life then he is capable of living with dignity. Therefore, someone who claimed that impotence or hay fever undermined his dignity would be in error. Contrariwise, it might be reasonable to claim that someone suffering uncontrollable pain, or depression, has had his dignity undermined to some extent.
However, this takes us onto the question of whether the conception could be guilty of Nietzchian contempt for the sick and injured. I do not think it could; the reason is that any “contempt” or criticism of people that is compatible with this conception of death with dignity is only for what is in their control. People will often not die with dignity. In many of these cases the lack of dignity arises from within; it is a character fault. In other cases it arises externally, as with dementia inducing illnesses. Only the former are to be criticised; they could have died with dignity but did not. (Perhaps also it is possible for someone who has not lived well to die with some dignity. The death of James Cagney’s gangster character, Rocky Sullivan, in the film, Angels with Dirty Faces, offers a fictional example of this. Rocky Sullivan acts like a coward in the face of the electric chair in order to prevent his becoming a role model to local youths.)
Whatever the case, health care professionals cannot ensure that people die with dignity. They can, on the other hand, try to ensure people die without indignity, in two ways. The first is by not imposing indignities—for example, taking choices away from people at the end of their lives. The second is by acting so as to minimise indignities, such as pain. But there would never be cause to criticise people who suffer such indignities, nor hold them in “contempt”, because they are not in control of whether or not they suffer them.
In the conception of death with dignity outlined, the term “death” has been taken to apply to the process of dying, and the term “dignity” has been taken to apply roughly to someone who lives well (in the Aristotelian sense of living in accordance with reason). It follows from this that dignity is a function of someone’s personal qualities and that a death with dignity is a personal achievement; it is not something that can be conferred by others, such as health care professionals. By contrast, indignities are affronts to personal dignity. They are things that prevent or impede someone from living with dignity, mainly because they prevent him from taking an active, reasoned part in his own life. Health care professionals have a twin role here; the first is not to impose such indignities, the second is to minimise them, wherever possible
Does this conception imply anything for the euthanasia debate (where the phrase is so often used)? It would seem to offer prima facie support for voluntary euthanasia. For example, someone might choose to end his life now whilst he is still capable of living and dying with dignity rather than suffer an illness that removes that possibility. But this support for euthanasia is fairly weak. It is clear that no matter how good someone’s character is, bad luck can remove his dignity. If this happens, it is far from obvious that suicide or euthanasia will rescue it. Furthermore, opting for euthanasia without good reason could presumably itself constitute an affront to human dignity.
This paper has benefited from the comments of the two JME reviewers.