It seems generally to be accepted that the concept of dignity means something like being of value or worth, because of the presence of some necessary characteristics. One of the earliest references to dignity is in Aristotle's Eudemian Ethics [18
] where it appears as one of fourteen virtues or mean states of character between an excess of unaccommodatingness and of deficiency or servility [18
]. Dignity for Aristotle is thus a quality, an excellence or moral virtue of the person, a quality that contributes to human flourishing or happiness and one in which one can err in terms of excess or deficiency. If an individual has too little sense of her own worth she may be servile and if too much she may not accommodate others and may be guilty of the vice of arrogance.
A more recent account of dignity comes from the 18th
Century philosopher, Immanuel Kant, who argues that some things have a price for which they can be exchanged or for which their value can be traded, but some things are beyond price and cannot be exchanged. For Kant these have worth or dignity [19
]. As Badcott argues, Kant holds that human beings posses dignity because "they are rational, autonomous creatures with intrinsic value who can pursue and determine their own ends" [20
]. For both Aristotle and Kant dignity thus seems to be contingent upon characteristics such as rationality and autonomy: it would be difficult for someone who lacked rationality to possess the Aristotelian moral virtues, while Kant's reference to "intrinsic value" seems nonetheless to rest on the possession of autonomy.
Some contemporary philosophical accounts also emphasise individual capability or autonomy in relation to dignity. Shotton and Seedhouse [13
], for example, define dignity in relation to the interplay between capabilities and circumstances, pointing out that "we tend to lack dignity when we find ourselves in inappropriate circumstances, when we are in situations where we feel foolish, incompetent, inadequate or unusually vulnerable". They hold that dignity can be maintained where there are the capabilities to respond to potentially undignifying circumstances or where the circumstances are changed so they are not undignifying. If, for example, an older person felt that wearing an open-backed hospital gown was undignified the person could either ask for an alternative, or nurses could, as occurred in one of our local Trusts, redesign the gown so it opened at the side rather than the back. Elsewhere Seedhouse argues that "if a health worker wants to promote a person's dignity she must either expand her capabilities or improve her circumstances" [21
]. This perspective focuses on whether a person feels dignified or undignified, rather than on whether others perceive them as having dignity, thus making dignity a subjective experience rather than a moral quality subject to the judgement of others.
] distinguishes between an ethic of dignity and an ethics (sic
) of autonomy in relation to long-term care. He points out that autonomy "is crucial to certain aspects of dignity, but should not be confused with the whole of it" [22
]. This discussion supports the inadequacy of autonomy as the sole ethical focus of care, particularly in relation to those who lack autonomy. Pullman's view of an ethic of dignity does not, however, deny the importance of autonomy as a value and he states that:
each autonomous citizen assumes some paternalistic responsibilities to protect the dignity of others who may never have the capacity, are not yet capable, or who are no longer able, to care for themselves – recognises and values our mutual interdependence. It is respect for the basic dignity of humanity that elicits our care and concern for the severely demented and frail older person. In responding to their dignity we express and enhance our dignity as well.
While Pullman recognises the importance of autonomy, he emphasises its limitations as a value ("it is a value, not the value") and suggests the importance of dignity, particularly where autonomy is lacking.
Beyleveld and Brownsword [23
] develop the relationship between autonomy and dignity further and demonstrate the tension that may exist between these two concepts. They discuss dignity and the conditions in which human rights can flourish. Where a person is autonomous dignity can, they argue, be a "two-edged sword". It can either empower and support dignity or constrain it. To illustrate this, Beyleveld and Brownsword give the example of a French response to the activity of dwarf-throwing [23
]. The Council d'État affirmed that respect for human dignity was one of the components of ordre public
and, therefore, the so-called attraction of dwarf-throwing in local clubs should be banned. One of the dwarfs involved, Manuel Wackenheim, argued that he freely participated in the activity, that it secured him a monthly wage and enabled him to engage in professional life. The Council d'État responded that Wackenheim "compromised his own dignity by allowing himself to be used as a projectile, as a mere thing, and that no such concession could be allowed" [23
]. We return to this discussion of the relationship between autonomy and dignity in the concluding sections of this paper. Jacelon [24
] brings these concepts together, relating dignity to integrity. She describes personal integrity as "a dynamic intrinsic quality of the self, composed of health, autonomy and dignity".
A range of types or categories of dignity appear in the literature. Sandman [25
], for example, refers to human dignity and contingent dignity. Badcott [20
] writes of emotional dignity and distinguishes between intrinsic and extrinsic dignity: the former something that everyone has just because they are human and the latter contingent or extrinsic. Mann [26
] distinguishes between internal (how I see myself) and external (how others see me) components of dignity. Spiegelberg [27
] distinguishes between: the expression of dignity by inward and outward behaviour; dignity in general (a matter of degree); human dignity (minimum dignity which belongs to every human being qua human); intrinsic and extrinsic dignity; relational and absolute dignity; and dignity in itself (intrinsic worth) and ground for dignity and worthiness of respect.
Two theoretical accounts are particularly helpful in identifying features of dignity and indignity in relation to health and social care. The first, accommodating both intrinsic and extrinsic or contingent features, is that by Nordenfelt [28
] (for a fuller account of Nordenfelt's approach see Wainwright & Gallagher 2008). This framework provided the philosophical backdrop to the Dignity and Older Europeans Project [15
]. Nordenfelt distinguishes between intrinsic and contingent value, but he divides the latter into three, and thus distinguishes four concepts or varieties of dignity as follows:
• The dignity of Menschenwürde – Menschenwürde meaning an intrinsic dignity we all have to the same degree just because we are humans.
• Dignity of merit – People have rights on the basis of holding certain roles or office or because they have earned merit through their actions. They have rights on the basis of merit and are, therefore, treated as having a special dignity.
• The dignity of moral stature – This kind of dignity is based on their moral stature that emerges from their actions and omissions and from the kind of people they are. There are degrees of this and it is dependent on subject's action so may come and go.
• The dignity of personal identity – This kind of dignity is related to one's identity as a person and is related to self respect and concepts such as integrity, autonomy and inclusion. This kind of dignity can be taken away from people when, for example, they are humiliated, insulted or treated as objects.
The concept of Menschenwürde is of particular relevance to nursing practice as it emphasises the importance of acknowledging the worth of all human beings, regardless of their condition and is thus a counter to the criticisms of rationalist models of dignity described above. Dignity of merit and dignity of moral stature are interesting from a nursing practice perspective. Clearly, for Nordenfelt, people who attain high office or who demonstrate great moral probity deserve respect on that account and, if for no other reason than common courtesy nurses should give all patients appropriate respect. However an appeal to Menschenwürde could be said to override any claim to particular respect for merit or moral stature in so far as nursing practice is concerned. Health care professionals are generally expected to treat all patients who come before them, regardless of their moral character or civic status. Given the view of Aristotle that dignity is one of the moral virtues the moral account of dignity is clearly important. Aristotelian virtue theory also reminds us of the importance of dignity as a quality of the health care professional. Nurses, by this account, would be expected not only to respect the dignity of patients but also to exhibit dignity in their own character. Dignity of identity is also of particular interest to nurses, as it has the potential to give the clearest guidance as to how we should treat other people in practice, so as to preserve their dignity. The importance of dignity of identity provides, for example, a theoretical justification for providing individualised care.
While Nordenfelt [28
] identifies four positive types or varieties of dignity, Mann [26
] developed a provisional taxonomy of dignity violations as follows:
• Not being seen – This occurs when someone feels that they are not acknowledged or recognised and where people feel unheard or disregarded. Mann suggests that an extreme example is where prison and concentration guards were instructed not to make eye contact with inmates and to 'look only at the centre of their forehead'. An example from nursing practice might be the patient or visitor who tries to attract the attention of a nurse, only to have the nurse avoid eye contact and to ignore the attempt at engagement.
• Being seen but only as a member of a group
– In such situations people may be seen but only as a stereotypical member of a group, for example, as a woman, student, Italian, older person or a schizophrenic. As Mann [26
] points out, ''group classification can be a source of pride'' but here, as a type of dignity violation, being seen only as a group member is pejorative and depersonalising, diminishing the dignity of the individual.
• Injuries to dignity resulting from violations of personal space – There are differences in the way we perceive personal space and how we respond to people who enter our personal space. Responses will vary according to the nature of the relationship, whether permission has been gained and how dignified people feel when someone enters their personal space. There is much potential for dignity violations should permission not be sought and gained.
• Humiliation – This final type of dignity violation may occur if people are singled out, separated or distinguished from the group and subject to criticism. Mann gives the example of a child who is asked to stand in the corner at school. Although Mann refers to the conscious ''singling out'' of an individual, humiliation may equally follow from not being recognised as an individual, as in each of the previous three categories. Thus, although Mann calls this a dignity violation it might also be seen as the result of any other dignity violation. If we are not seen or seen only as a member of a group, or if our personal space is violated and we are thus treated as being of little worth, humiliation would describe our affective response to the experience and might also characterise how others would describe our situation.
Mann's provisional taxonomy was informed by discussions with students, anthropologists, sociologists and bioethicists. What becomes clear from the discussion of theoretical or philosophical perspectives on dignity is the necessary engagement of philosophy with empirical data about human experience and with the work of the social or human sciences. This is an example perhaps of Bhaskar's description of philosophy as underlabouring, a role it plays "for the sciences, and especially the human sciences, in so far as they might illuminate and empower the project of human self-emancipation" [3