Dignity Reevaluated: A Theological Examination of Human Dignity and the Role of the Church in Bioethics and End-of-Life Care

Introduction

In 1995, then-Pope John Paul II wrote the encyclical letter Evangelium vitae to, among other things, affirm, explain, and defend the Church's staunch pro-life stance in opposition of assisted suicide, abortion, and euthanasia. Within this encyclical, he centrally proclaimed his earnest belief that “society as a whole must respect, defend, and promote the dignity of every human person, at every moment and in every condition of that person's life” (John Paul II 1995, n. 81). Evangelium vitae, along with a great deal of John Paul's other work, ¹ appeals powerfully and often to the vital importance of human dignity.

Three years after John Paul's letter was published, the Swiss “assisted-dying” organization Dignitas was founded. Dignitas provides individuals with the means to end their own lives, and advocates within the broader community for the supposed right of an individual to choose the manner and time of their death. Although Dignitas's beliefs and practices regarding death are diametrically opposed to those of the Catholic Church, its motto, “to live with dignity, to die with dignity,” appears, prima facie, to be astonishingly congruent with John Paul's thought (Dignitas 2014). Of course true similarity between these two parties runs incredibly shallow; congruency is limited simply to common appeal to some notion of dignity as a positive end for humanity. This example serves to show what could easily be discovered through a brief perusal of academic or popular writing on the subject of medical ethics: individuals with prodigious diversity of opinion are appealing to the notion of dignity without an agreed-upon definition for the term itself.

In the face of such terminological confusion, it is necessary to engage various contemporary understandings of dignity for the purpose of promoting clarity, both within the Church and the broader community. Such clarity will allow members of the Christian community to better engage with secular viewpoints and to see more plainly the tangible role of the Church, a body that unfailingly believes in God-given human value. I contend that the concept of human dignity represents an absolute characteristic that is donated graciously and creatively to all bearers of imago Dei. Human dignity must thus be affirmed as inviolable and independent of autonomy, rationality, or capability. In this paper I advance this thesis through the consideration of two alternative understandings: dignity as redundant and dignity as capacity-dependent. I then propose—via consideration of Mark 5:1–20—a framework for how the Church might think about dignity, and conclude with brief contemplation of the specific dignity-recognizing task of the Church.

Dignity as Redundant

It has been antecedently shown that recent appeals to dignity within the medical-ethical dialog may be rhetorically powerful but inevitably suffer from a lack of definitional consensus. Confusion is further exacerbated when the term “dignity” is utilized as a proxy for other ideas that may be less rhetorically appealing to some members in the dialog. For example, we shall see below that John Paul II uses dignity when he intends to communicate something specifically theological: “imago Dei.” Similarly, it is easy to see that when Dignitas uses the term “dignity,” the intended meaning is “autonomy:” likely defined, as in Beauchamp and Childress, as “self-rule that is free from both controlling interference and from limitations” (2001, 58). Dignitas's approach silently equates deprivation of the supposed right to self-determine the time and manner of death with deprivation of dignity. Where such an association is taken as axiomatic, dignity becomes redundant. Upon seeing dignity used as a proxy term for a wide range of ideas, some have come to see it as mere rhetorical tool, devoid of any substantive meaning in itself.

Many thinkers have thus argued for the redundancy and ultimate irrelevancy of dignity within the academic medical-ethical dialog. Schopenhauer proclaimed that the phrase “dignity of man” has become “the shibboleth of all the perplexed and empty-headed moralists who concealed behind that imposing expression their lack of any real basis of morals, or, at any rate, of one that had any meaning. They cunningly counted on the fact that their readers would be glad to see themselves invested with such a dignity and would accordingly be quite satisfied with it” (Schopenhauer 1995, 100). Similarly, many contemporary scholars lament the “stupidity” (Pinker 2008, 28) of what is taken to be a “useless concept in medical ethics [that] can be eliminated without any loss of content” (Macklin 2003, 1419–1420). James Griffin, perhaps phrasing this approach most clearly, writes: “autonomy is a major part of rational agency, and rational agency constitutes what philosophers have often called, with unnecessary obscurity, the ‘dignity’ of the person” (2002, 131).

Full engagement with this view, aptly labeled “dignity fatigue” by Mahlmann (2013, 593) is challenging, given that it is polemical against dignity-based accounts of human value without offering a substantive alternative understanding. It is sufficient here to note that, although the difficulties and ambiguities that attend recent discourse surrounding dignity are apparent, medical ethics cannot simply do without accounts of human value. It is undoubtedly true that, given ambiguity and competing definitions, recent discussion of dignity has accomplished little by way of dealing with actual ethical conundrums. Furthermore, where groups seek to defend what they see as a more fundamental value, they should do so with clarity instead of employing dignity as a proxy term for the sake of rhetorical power. Perhaps Dignitas's motto should read, “To live with autonomy, to die with autonomy.” But surely autonomy itself is dependent on some notion of human value. What is it that makes a human being worthy of honor and respect? Why does their agency matter? “Dignity” gives us language to engage these questions, and surely it is no mere redundancy. Any medical-ethical consideration demands some account of why we ought to respect, honor, and value each other. Although much clarification is needed, we must not grow so fatigued of “dignity” rhetoric that we become cynical and dismissive of the very question of human value. I have no specific loyalty to the word “dignity” itself, but we must not be quick to abandon a term which gives us a way of approaching questions that are foundational to any medical-ethical discussion.

Dignity as Capability-Dependent

There are a great many thinkers who affirm the vital importance of dignity while still believing it to be dependent on some more fundamental characteristic or ability. I have distinguished this approach from the simple belief in the redundancy of dignity, although it might be argued that these approaches exist in continuum with each other, given their common assertion of the relative nature of dignity. The difference lies centrally in the value each approach places upon dignity. As we have seen, there are those who see dignity as essentially superfluous within the medical-ethical discussion because it is viewed as ultimately contingent. There are others, such as Dignitas, who see dignity as central while simultaneously believing it to be relative. I will now take up consideration of this approach, for the purpose of contrasting it with an approach that views dignity as absolute or inviolable.

The Universal Declaration of Human Rights, published initially by the United Nations in 1948, begins with the following supposition: “Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world…” (United Nations 2012). The first sentence of Article 1 of this significant document similarly reads: “All human beings are born free and equal in dignity and rights” (Art. 1). Here we see dignity established as a legal and constitutional term, tied to language of rights. This text also illustrates the close historical and logical association between “personhood” and “dignity.” In medieval times the two terms became practically synonymous; such an association is even assumed by Christian thinkers including Aquinas. ² Thus we can understand, especially after the great post-WWII human-rights documents were published, how thinkers in ethics come to unconsciously assume the interdependence and interwoven-ness of rights, dignity, and personhood.

Such an approach does not become problematic, or even controversial at all, until theories of ethics attempt to define personhood in such a way that excludes certain humans. The question of personhood, which is now inseparable from dignity, is manifestly vital to contemporary medical ethics, and there is great debate over how to define it. The assertion that we can define personhood by one or more characteristics or capabilities is commonplace. Fletcher, for example, would have us standardize personhood, and therefore dignity, by means of an IQ test (Fletcher 1972, 2012, 334–337). Tooley, in his disturbing article “Abortion and Infanticide,” argues that the necessary criterion for personhood, protection of rights, and dignity is self-consciousness (1972). Others have offered alternative criterion. Although the variability of competing criteria reveals the preposterous difficulty that attends the attempt to reduce human personhood to a single, all-encompassing, scientifically objective, and intrinsic characteristic, what we note principally here is not the definitions themselves. Rather, it is sufficient to understand that much recent thought regarding dignity sees it as ultimately relative, dependent upon physical characteristics that may or may not be present in various stages of human life.

This approach can be broadly critiqued from a variety of perspectives. First, all proposed criteria have implied, morally significant exceptions. This leads medical ethics to a predictable exchange of examples involving infants, comas, trisomies, Siamese twins, aliens, and so on. Next, the point of distinction between the human person, imbued with dignity and legal rights and the human non-person, devoid of dignity or legal rights, will always seem arbitrary. What makes a human with an IQ of 41 that different from a human with an IQ of 39? Finally, we might consider the potent critique of Hauerwas:

where dignity and personhood are seen as contingent upon some type of capability, they themselves become mere rhetorical “nicety.” (2012, 378)

Dignity as Immutably Given

Each of the accounts of dignity described thus far positions dignity as contingent and relative: it is dependent on some more fundamental characteristic, and dignity can be gained and lost, depending on circumstance and capability. I concur with the view that dignity is dependent upon some, more foundational principle or causation; but, I contend that, since the dignity-granting force is the creative act of the Christian God, dignity cannot be lost. It is, therefore, contingent and absolute. Dignity is a term that allows us to speak of the honor and respect due to the creation of a loving God. It is ultimately contingent upon the creative act of God, and, post-creation, it pervades the being of the creature immutably. To use the words of John Paul II: “not even a murderer loses his personal dignity, and God himself pledges to guarantee this” (John Paul II 1995, n. 9). We will note a few features of this analysis and then focus specifically upon Mark 5.

It is first imperative to note that, by this account, dignity can be best understood within a Christian narrative. Christian thinkers have long used this term, tied as it has become to language of “rights” and “personhood,” as a way of communicating specifically Christian themes without being dismissed by their secular conversation-partners. Undoubtedly some positive results have come from this, notably the deeply Christian assumptions underlying documents such as the Universal Declaration of Human Rights. We have seen, however, that this rhetorical tactic inevitably confuses the dialog as it throws into question the meaning of the word itself, and even leads to disillusionment with the very notion of dignity. We might therefore consider putting down the project of communicating Christian claims on universal terms and again take up the task of communicating universal claims on Christian terms. Such a task is doubtlessly unfashionable within a post-modern ethos; however, we must prefer a definition that is unintelligible without God to one that is wholly unintelligible.

Second, dignity is not a foundational Christian notion. As noted previously, dignity simply gives us a way of discussing the implications of a more foundational truth: human life has immeasurably great value because it is created, sustained, redeemed, and destined for glory by a loving God. “When man in faith in God's Word and promise realizes how God from eternity has maintained and loved him in his little life, and what He has done for him in time, in this knowledge of human life, he is faced by a majestic, dignified, and holy fact. In human life itself he meets something superior” (Barth 2012, 724). In other words, we may use dignity as synonymous with the phrase “the respect and honor due to the immeasurably valuable and image-bearing creation of an infinite and loving God,” but dignity is unintelligible apart from this association. This further supports my previous contention regarding the centrality of Christian thought to the notion of dignity.

This consideration also sheds light on how human dignity relates to the important theological notion of the “imago Dei.” Schwobel clearly summarizes this association: “human dignity can be interpreted as an implication of the fact that humans are created in the image of God…It is not dependent on the existence of a quality which humans possess. Rather, it is the presupposition for all the qualities humans possess and the criterion of their exercise” (Schwobel 2006, 51). Such an association can also be seen in Evangelium vitae, within which John Paul II affirms imago Dei—donated graciously in the act of creation, persisting in spite of sin, and destining human life for fellowship with God—as the theological concept undergirding respect for dignity as an a ethical imperative. “Here the Christian truth about life becomes most sublime. The dignity of life is linked not only to its beginning, to the fact that it comes from God, but also to its final end, to its destiny of fellowship with God in knowledge of love of him” (John Paul II 1995, n. 38).

Finally, I note that this approach is generous, not limiting dignity to certain human beings. As noted above, the dark implication of Dignitas's motto is that one without legal autonomy is without dignity—“as if we were most fully human when we acted on our own, chose the course of our ‘life plan,’ or were capable and powerful enough to burden no one” (Meilaender 2013, 3). By contrast, an absolute definition is generous, affirming the value of life at all stages and in all forms. The dignity of a human being may be categorically ignored or denied, but it cannot be destroyed. It is independent of age, awareness, IQ, relational-capacity, or any other characteristic. Dignity is immutably donated by God. This truly has enormous implications for medical ethics.

With these themes in mind, let us consider Mark's account of Jesus' healing of the Gerasene demoniac. As noted previously, here we encounter a man who is chained, violent, incapable of human relationship, alone, enslaved, and certainly without autonomy. Here we encounter, paradigmatically, someone who is living as if he had no dignity. In response to this tragically disturbing sight, Dignitas pauses to ponder if the man has autonomy, and perhaps approaches him to ask what ends he desires; Tooley attempts to determine if the demoniac is self-aware; and Fletcher pulls out his IQ questionnaire. Jesus, on the other hand, has compassion. He treats the suffering, cowering man as if he has great value, great dignity.

We again meet the Gerasene man later in the passage, and he can clearly be recognized as a dignified person. He is “clothed and in his right mind,” he is capable of rational discussion, and he is blessed by Jesus with a new missionary vocation (Mark 5:15). Indeed, this is the only place in the book of Mark where the so-called “Messianic secret” of Jesus is not protected. Where Jesus usually orders silence, he gives to the Gerasene man an apostolic-like task: “Go home to your friends, and tell them how much the Lord has done for you, and what mercy he has shown you” (Mark 5:19 NRSV). In Mark, the Gerasene man is the beginning of the Gentile mission. Surely, by the end of the story, he is clearly recognizable as dignified.

The story of the Gerasene man implies a great truth about Jesus and a concrete task for His Church. Jesus, encountering a man who lives as if he has no dignity, treats the man as one with immense value. I argue that Mark 5 does not describe a granting of dignity where there formerly was none. Rather, Jesus recognizes and proclaims the anteceding God-posited value and dignity of the man, even if his dignity had long been ignored and desecrated. What we see here is restoration, rooted in Jesus' great affirmation that the Gerasene man was not made for slavery but for freedom—destined to “life in its fullness, to ‘eternal life’” (John Paul II 1995, n. 80). This proclamation extends to all humankind and affirms the absolute nature of human dignity. Although Jesus does not explain the meaning of his actions using the language of dignity (or at all, in this case), the freeing of the Gerasene demoniac clearly reveals the Christian task of asserting and believing in the value and dignity of all people, especially those whose dignity is not immediately recognizable by intuitive or contemporary philosophical standards. This task orients us to the difficult, yet truly redemptive role of the Church.

Writ large through the biblical narrative is the same great imperative for God's people that we have heard in Mark 5: recognize and assert the God-given value and dignity of all people, especially those whose dignity is difficult to perceive. Calls to defend and advocate for the fatherless, for widows and orphans, and for the poor and destitute permeate Old Testament Scripture. These themes occur repeatedly in the Deuteronomic code and in Job, the Psalms, Isaiah, Jeremiah, and Zechariah. ³ The clearest example, perhaps, comes from Psalm 82: “Give justice to the weak and the orphan; maintain the rights of the lowly and the destitute. Rescue the weak and the needy” (Ps 82:3). These same value-recognizing themes are central to the mission of Christ and to many of the epistles of the New Testament. This is perhaps most clearly stated in James: “Religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world” (Jas 1:27). This theme finds fulfillment in the paradox of the cross: we ultimately recognize dignity in others and in ourselves only because we have perceived, in the form of a naked, dying man, what dignity actually is.

Conclusion

In the final analysis, a theological definition of dignity presents a task to the Church. For we, like Jesus, regularly come across human beings who may seem, by contemporary standards or by our prima facie intuition, as if they have no dignity. In our time, these individuals may not resemble the Gerasene man. They may take the form of unborn children, Alzheimer's patients, those with physical or mental disabilities, or stroke victims. One of them takes the form of my grandfather. But we must resist the urge to define these creations by what they lack, or what they have lost. We must resist the urge to pull out the IQ questionnaire. Instead, as the infinitely beloved creation of God, each human possesses immeasurably significant value that demands that we treat him or her as a creature possessing human dignity. And it is the task of the Church to recognize and protect this dignity, especially where it is difficult to see.