Abstract
The UK Commission on Dignity in Care for Older People published a report for consultation entitled ‘Delivering Dignity’ in February 2012 (see http://www.nhsconfed.org/Documents/dignity.pdf). The rationale for the setting up of the Commission and for this consultation process relates to the ‘many reports highlighting the undignified care of older people in our hospitals and care homes’ (p. 2). I hope that other readers of Nursing Ethics will access this report and give the report some consideration in relation to their own practice.
In this comment piece, I discuss some of the challenges that are raised by the report. First, the report acknowledges (p. 30) that it avoids defining its key term. It seems to me that assertions of dignity are claims to recognition, respect, honour and deference. Even if they are appeals to a dignity that is shared equally by all, they are essentially concerned with the management of counter claims to status, hierarchy and the exercise of power in relationships.
In making one reference to human rights (Recommendation 21) and several to the notion of the ‘person’ and ‘person-centred care’, the report makes clear reference to some essential concepts for thinking about dignity. The account of the ‘six senses’ framework given on pages 22 and 23 also gives what I think is a very good indication of how dignity is to be achieved. Nonetheless, the lack of a clear definition of the concept is likely to lead to some confusion between the concepts of ‘dignity’ and ‘respect’, and there is a lack of clarity about what the relationship of ‘kindness’ and ‘compassion’ to dignity might be.
This could lead to important misunderstandings by staff and organisations about what dignity requires of them, and how older people might maintain and develop their sense of dignity when being cared for and, where they have lost some aspect of what they see as their dignity, regain it.
At other points, notably in the title of the report, dignity is presented not as what I think it is – a quality of one’s social identity (one’s personhood) that is developed and maintained by participating in a particular network of relationships – but as a commodity that can be measured and ‘delivered’.
It may be possible to say quite specifically in tools and checklists what we should not do if we want to preserve dignity or not offend it. But it is much harder to specify anything very specific about what we should do in order to maintain and develop it. In periods of institutional care, the sense that we have of our own personhood and dignity will depend not just on the memory of the life we had outside that setting, and may yet return to, but also on the status and value that we are offered in the network of relationships that forms around us, and we are able to engage with.
What this requires is not just acts of imaginative respect by individual workers, but the development of an entire culture in which those cared for are offered not just care, but the opportunity to participate in and develop that culture and to develop as much of a life of their own as they both can and want. Without offering the opportunity to be more than a passive recipient of acts of care that care, however well intentioned it is, will never be dignifying.
To achieve this, workers will need not only respect, kindness and compassion. Interest, creativity and liveliness could provide a much stronger focus on the positive possibilities of a person’s life. Kindness and compassion alone may draw attention primarily to deficits.
On page 10, the report says that for older people it is important that their care is shaped not just by their illness or frailty but by the wider context of their life and relationships. They should be treated with respect and supported to maintain their dignity, and their identity should not be lost when they enter the care system.
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