Journal of Palliative Care

The basic tenets of palliative care are frequently subsumed under the goal of helping patients to die with dignity. Our research group has studied the issue of dignity, with dying patients serving as the primary informants. This paper reviews some of our findings, including an overview of the Dignity Model that derives from our empirical work. Furthermore, this paper summarizes various psychotherapeutic approaches which have been considered for this vulnerable patient population. Finally, we provide the rationale based on the Dignity Model for a psychotherapeutic intervention we have coined Dignity Therapy. This brief, individualized therapeutic approach has been informed by our dignity work, and specifically designed for application in patients nearing death.

In this paper, I review Canadian law in relation to the unilateral withholding or withdrawal of Potentially life-sustaining treatment, and I look at such questions as whether physicians are legally permitted to unilaterally put a do-not-resuscitate (DNR) order on a patient's chart. I explore who has the legal authority in Canada to decide on withholding and withdrawal of potentially life-sustaining treatment, and I conclude that unilateral withholding and withdrawal is a violation of the strong social commitment to dignity as it is understood and reflected in the law by the Supreme Court of Canada. I then offer a concrete proposal for institutional policy with respect to unilateral withholding and withdrawal of treatment in light of the law.

After a diagnosis of life-threatening illness, decisions must be made regarding various treatment options including life-sustaining interventions. The preservation of dignity is commonly invoked in these discussions with patients, their substitute decision makers, and health care providers. Current thoughts on dignity explore two main ideas: dignity as intrinsic worth and dignity as worth judged according to extrinsic socially based constructs. For the most part, both notions of dignity are appealed to in discussions of continuing or withholding/withdrawing treatments and in debates on the legalization of assisted death. These conceptions of dignity are value-laden and frequently biased, and therefore should be used with caution, if at all, in discussions with patients and their substitute decision makers. The fundamental issues in discussion with all patients diagnosed with a life-threatening illness are ones of respect for persons, acceptance, caring, and the value of interpersonal relationships.

The achievements of modern medicine are manifold and impressive. However, there is a broad recognition of the fact that continuing medical treatment is not always beneficial to the patient, nor is it always what the patient wants. This has led to a debate about the way physicians may or may not be involved in the end of life of patients. Could there be a justification for the active ending of a patient's life? This debate has a global character. In this article we will explore this debate for developing countries; we will focus on physician-assisted death (PAD) in Latin American countries. At stake is the moral relevance of differences, not the moral justification of PAD per se. We argue that arguments for PAD apply equally in affluent and in developing countries. Some of the counterarguments, however, would seem to hold more in developing countries than in affluent countries. Yet, under certain conditions, a Policy tolerating PAD would be as acceptable in developing countries as in developed countries.

The desire to be treated with dignity, particularly at the end of one's life, is a fairly universal preference found in most cultures. Such treatment requires positive actions of respect in the behaviour of others toward the dying and the dead. It also involves negative actions, particularly refraining from doing “dignatory harms” to the dead and the dying. Yet it is not always easy for clinicians and researchers who deal with the dying and dead to decide on appropriate action or inaction. I suggest that such decision making can be helped by locating the dying person along three dimensions: the personal, the familial, and the cultural. These elements are interrelated in complex ways that need to be unpacked in context. Thus, one person may locate herself within a familial context while a sibling may locate himself against that context. While locating individuals along the three dimensions suggested does not “solve” ethical problems, it should help clinicians in understanding and dealing more compassionately with the dead, the dying, their families, and their communities.

Although the concept of human dignity is widely invoked in discussions regarding end-of-life decision making, the content of the notion is ambiguous. Such ambiguity has led some to conclude that human dignity is a redundant or even useless concept that we would be better off without. This paper argues, to the contrary, that the concept of human dignity is indispensable to moral discourse. Far from dispensing with human dignity, we must work to clarify the concept. The paper outlines two distinct but related conceptions of dignity that are often conflated in contemporary moral discourse. These conceptions are labelled “basic dignity” and “personal dignity”, respectively. It is argued that basic dignity functions as a universal meaning constraint on moral discourse in general. Hence, to dispense with the notion could reduce us to speaking moral nonsense. Throughout the discussion, some implications for our understanding of end-of-life decision making are explored.

The concept of dignity is often invoked in relation to ideas about a “good” death and, indeed, a “good” life. In this article, I discuss the question of dignity in relation to the rights of the individual in the modern world. This world is one where the relationship of individuals to society is contested in the context of medicine, with all its technologies of treatment and uncertainties of prognosis. For patients who criticize or oppose medicine in order to recover their dignity, it is necessary to articulate or to portray their suffering. In this way, they are able to show not only that they live in spite of illness, but that they also live by virtue of it. From this perspective, dignity is shown to be part of a collective response to a medicalized world in which ideas about illness and health are also being transformed.

Dignity is an expansive ideal, figuring in international covenants, codes of research involving human participants, and debates about decision making at the end of life. One result of this expansiveness is that human dignity can be appropriated by proponents on both sides of many issues, thereby appearing more as a rhetorical flourish than as a serious element in argumentation. However, an appreciation of narrative inquiry shows that opposing representations of dignity constitute alternative assessments of responsible action, both of which can be morally reasonable. One implication is that normative disagreements, as between deathbed decisions about palliative care or euthanasia, can be expected to occur, so that the ideal of dignity should be legally expressed in a practice of supportive laissez-faire in preference to any undue regulation of dying.

Considerations of human dignity figure prominently in discussions of health care, and are central in the debate with regard to end-of-life care and the issue of physician-assisted suicide. In this paper I reflect on my experience as a person living with multiple sclerosis in order to explore ways in which prevailing cultural values contribute to the loss of dignity that accompanies incurable illness and disability. I suggest that authentic Christian community may offer an alternative culture with a radically different value system, one that enhances human dignity.