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Human Dignity and Assisted DeathReview - Human Dignity and Assisted Death
by Sebastian Muders (Editor)
Oxford University Press, 2017
Review by Prashant Kumar
May 29th 2018 (Volume 22, Issue 22)

In recent years, Ruth Macklin's assertion that dignity is a "useless concept" [1] and Stephen Pinker's discussion of the "stupidity of dignity"[2] are claims which display skepticism about the notion of dignity (p. 2). In response to such claims, this book explains that, despite the skeptical treatment, the notion of dignity has not yet received a treatment that a) assembles all important perspectives and positions, b) examines the arguments that may be enhanced by it, and c) enriches the yet undertheorized role it currently holds in the literature.

In order to give a proper account of the notion of dignity, this book promises to offer 1) an in-depth explanation of the "widely shared intuitions about human dignity in the medical context of terminal illness" (p. 4), 2) to take a step forward towards reconsideration of the arguments in favor of extending the notion of dignity to other issues, i.e. autonomy, self and others, and 3) a clarification of the notion of dignity in general "which might lead to its application in the other contexts as well" (p. 4). The first chapter serves the purpose of an elaborate introduction where Dr. Muders puts forward the promises of the book.

2.    Human Dignity, Suicide, and Assisting Others to Die (Jeff Mcmahan)

The central aim of this chapter is to explore what "human dignity" refers to and whether it has any claim on deciding whether suicide or assisted death is permissible. Mcmahan takes help of philosophers like Kant, Cherles Beitz, Rosen, Waldran, Habermas, and Avishai Margalit, to understand the notion of human dignity, but he focuses especially on Kant to establish an argument that he calls "the Lexical Priority Argument" (pp. 21-28). This position is based on two principles; the universal nature of human beings which considers human dignity as an inner worth and higher than other values, and the categorical imperative. Treating human beings as instruments in the case of suicide and assisted death is a violation of these two rules, hence, it is not permissible.

The author shows that in the case of suicide and assisted death, the agent is not used as an instrument but as an end to herself. Therefore, Kant's invocation to "human dignity provides no better ground for objecting to the permissibility of suicide and assisted death" (p. 29). The main argument runs around the term "rational", but in the both cases, i.e. Kant's and in Mcmahan's, we find no explication of what they actually mean by "rational" which, despite the convincing argument in favor of the proposed objective of the chapter, casts doubt on the whole project.

3.    Dignity and the Case in Favor of Assisted Death (Ralf Stoecker)

Stoecker begins by asking a simple question – "why should we consider a legal prohibition of assisted suicide as a threat to human dignity?" (p. 30) He considers two answers to the question, a) self-determination and b) to avoid living an undignified life. He largely focuses on the second answer and explicates the relationship between human dignity and assisted death. Towards this end, he takes recourse to historical facts, three examples of suicide cases happened in different parts of the world, empirical data, and empirical research on terminally ill patients. Explaining each point lucidly, analyzing and pointing out the flaws in the arguments of the opponents, he concludes that there is no necessary connection between one's dignity and one's decision to commit suicide. So, one "should not regard suicide as a demand of dignity" (p. 45). Nevertheless, Stoecker defends the right to self-determination, and suggests that the best we can do is to "persuade her but must not interfere" (p. 45).

4.    Dignity through Thick and Thin (L. W. Sumner)

Sumner has already published a book, Assisted Death: A Study in Ethics and Law, in which he dealt with "the ethical and legal status of physician-assisted death with scarcely a mention of dignity" (p. 49). This paper, in one sense, advocates the same objective of that book by accommodating the notion of dignity. In his treatment of this notion, he makes a distinction between thin and thick conception of dignity and argues for the thick conception of dignity. In order to defend this position, he leans on empirical research (Linda Ganzini and her colleagues' findings and Harvey Chochinov and his colleagues' results) and Luban and Waldron's analysis of dignity. He provides two reasons in favor of the thick conception of dignity, viz. 1) it is empirically loaded and more informative contra Macklin's claim that dignity is an empty concept, and 2) it "looks not to the content of the speech, but to the speakers" (p. 65). Prof. Sumner's thesis espouses the relational aspect of dignity and takes particular cases of patients. So, if a patient does think that he is being humiliated in his medical observation, but others don't think so (or the visa-versa), should he still be granted medical assistance for his death?

5.    Death with Dignity: A Dangerous Euphemism (Christopher Kaczor & Robert P. George)

The authors argue that dignity can be understood in four senses – dignity as flourishing, dignity as attributed, dignity as intrinsic worth [3], and dignity as autonomy[1], and none provide sound arguments in favor of euthanasia. Interestingly, he rejects euphemisms such as "death with dignity" and "right to die with dignity" by showing that it is not about death or dying, but it is precisely about intentional killing. Though each sense of dignity in relation to euthanasia is dealt separately, the authors nevertheless try to boil it down to the sense of dignity as intrinsic worth. With the arguments provided in the chapter, it seems to me that they should have explained more about why human beings have intrinsic value and, therefore, must be treated as ends rather than means.

6.    Physical Disability, Dignity, and Physician-Assisted Death (David Wasserman)

Wasserman argues that physical disability provides no stronger dignity-based reason than other kinds of loss for permitting physician assistance in dying (PAD). In showing this, he talks about three senses of dignity, 1) narrative dignity, 2) personal, social, and human dignity, and 3) dignity as basic human functioning. In most cases, it is argued that indignity in physical disability is self-imposed and lacks a social support. Therefore, none of the above-mentioned sense of dignity provides a basis for treating physical disability differently than other sources of perceived dignity. Even the arguments which consider the condition of physical disable person as undignified, can also take their living with these conditions as an extreme act of dignity. So, Wasserman concludes, undermining this line of argumentation and permitting PAD on a special ground will do nothing but will reinforce the stigma.

7.    Dementia, Dignity, and Physician Assisted Death (Rebecca Dresser) 

Dresser argues that dignity-based arguments are not the sufficient reasons for PAD for dementia patients in early or advanced stages. He sees dementia not only as a medical problem, but also as a cultural problem. Therefore, the public conversation also needs to "consider the social factors that influence conceptions of personal dignity" (p. 121) in addition to "well-reasoned" request, the better understanding of personal dignity, and a possibility for a revision to earlier narrative of patient's life. Dresser argues that the change in environment and social conditions will reduce the indignities associated with dementia but does not specify too clearly how such a change is likely to be effected.

8.    Autonomy and the Value of Life as Elements of Human Dignity (Sebastian Muders)

Muders offers a combined approach to explicate dignity in terms of specific interpretations of both autonomy and value of life and argues that both concepts are compatible with each other. The fundamental point of these two concepts is that human beings are free and rational beings. "The argument from autonomy states that we ought to respect a person's dignity by giving due weight to her authority" (p. 141) and on the other hand, the argument from value of life states that we should "act in accordance with the intrinsic worth we have" (p. 142) as human beings in matters of suicide and assisted death. Despite the fact that Muders provides compelling arguments to support his claim, the connection between Darwall's understanding of Kantian theory of dignity and argument from autonomy is not explained at all. The chapter includes other errors, for e.g. the acronym of New Natural Lawyers is misstated as NLL which at the end of chapter is correctly written as NNL.

9.    Dignity and Assisted Dying: What Kant got Right (and Wrong) (Michael Cholbi)

Cholbi sets the aim of the chapter to explicate "what Kant's understanding of dignity implies about assisted death" (p.144). He defines Kantian notion of dignity as universal, unified, equal, and inalienable that, in turn, advocates dignity as a source of duties to one self. In this sense, dignity is not a price but is a worth which every human possesses by the very fact that they are human being. He argues at the core that if Kantian position is plausible, then "although death with dignity remains incoherent in Kant's eyes, some instances (that Cholbi calls hopeless cases) of assisted death at least count as deaths not at odds with dignity" (p. 158).

10. Two Competing Conceptions of Human Dignity (Luke Gormally)

Gormally discusses the two competing conceptions of human dignity (autonomy-based conception and egalitarian conception of intrinsic dignity) with relation to assisted death in order to show whether one or the other conception provides the sound reasoning to legalization of assisted suicide or not. He argues against the autonomy-based conception because of its arbitrariness, and advocates that "doctor should rely on an entirely defensible egalitarian conception of intrinsic dignity" (p. 174). Though he thinks that the egalitarian conception is defensible, however, he opposes any legalization of assistance in death because the legal prohibition of assistance in suicide saves patients and preserves the integrity of doctors. 

11. The Value of Life and the Dignity of Persons (Willaim J. Fitzpatrick)

Fitzpatrick argues that the notion of human dignity is more fundamental than the value of life. He explicates that the idea of value of human life (sanctity of life) gets its meaning and normative significance when the whole idea is viewed the point of view of human dignity. In this sense, the value of life has no independent force. He further argues that "human dignity is importantly person-focused and is best understood as that special form of value that is given appropriate recognition through an irreducibly personal engagement that incorporate loving concern and respect for the person in question" (p. 177). As the author himself points out that the main aim is not to show straightforward answers to end-of-life quandaries, but to point out and advocate a framework for discerning human dignity and the value of human life.

12. Could Suicide Really Be a Fundamental Human Right?: A Triple Threat (Margaret P. Battin)

Battin begins with a question – Can we really consider suicide as a fundamental human right? This particular chapter is a reconsideration of what he had already advocated earlier in a paper published almost three and a half decades ago. He defended suicide as a fundamental human right. He develops argument from the notion of dignity and shows a linguistic triple threat in this notion. He further demonstrates various cases – historical, cross cultural, current, and direct experience, and shows that even this will not help us as it provides many intuitions to deal with. We will not come to a final solution, but at the same time, it hints that "the problem is too complex, more fractured, but therefore also more interesting than we might have realized in advance" (p. 217).

13. Human Dignity and the Right to Assisted Suicide (Holger Baumann & Peter Schaber)

The authors of this chapter argue in favor of the moral permissibility of assisted suicide. "If a person competently requests another person to assist her in dying, she thereby exercises how normative power to make the act permissible" (p. 218). In defence of this claim, they develop a version of status-based conception in contrast with value-based conception in that they have a deontic rather than axiological basis. From this particular account of dignity, consent becomes the crucial factor. So, if a person gives a consent to assist in her dying, it will be morally permissible. Though the conclusion strongly follows from their account of dignity, but the grounds on which a competent person gives her consent is not very clear. When can we claim that a person is "competent" enough to give consent? And on what ground?

As far as I have discerned from this book, it encompasses a detailed analysis of the notion of dignity not only with relation to assisted death, but with relation to value of life, autonomy/self-determination, and human rights. This book is not only for philosophers, students of philosophy, medical students, or people who are working on bio-ethics, but it opens doors for each one of us who demands a dignified life. I hope this book will definitely enrich their understanding of dignity.

To summarize, this book is a valuable contribution to the field of ethics in general and medical ethics in particular, and it deserves a careful study. "As Marcus Aurelius says: 'In short, know this: Human lives are brief and trivial. Yesterday a blob of semen; tomorrow embalming fluid, ash.' We will all die but we don't need to treat death like the enemy and we must not let our fear of becoming ash lead us into prolonging our lives beyond any meaning, purpose or pleasure"[1], or in one word, without dignity.

 

[1] Macklin, Ruth. "Dignity is a Useless Concept," British Medical Journal 327 (2003): 1419-1420.

[2] Pinker, Stephen. "The stupidity of dignity", The New Republic, May 28, 2008. https://newrepublic.com/article/64674/the-stupidity-dignity

[3] Sulmasy, P. Daniel. "Dignity and Bioethics: History Theory, and Selected Applications," in Human Dignity and Bioethics: Essays Commissioned by the President's Council on Bioethics, ed. By Adam Schulman and others, 469 – 501.

[4] Cathy Rentzenbrink, A fate worse than death. March 16, 2018.  https://www.prospectmagazine.co.uk/magazine/a-fate-worse-than-death

 

© 2018 Prashant Kumar

 

Prashant Kumar, Jawaharlal Nehru University, New Delhi, Delhi, India


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