Essay
Comment
Justice
5 min read

Dignity: why people matter

How dignity underlies our ethics and law.

Professor Charles Foster is a Fellow of Exeter College, Oxford, and a member of the Oxford Law Faculty.

A pupil in a classroom looks around and into the camera.
Indus Action

You think that you matter: that you are significant. I agree with you. I think the same about myself.

We all think we are significant, and that our significance requires us to behave and to be treated in particular ways. One of the main functions of the law (perhaps the function of the law) is to regulate this sense of significance: to protect my sense of my significance and to stop it interfering with the sense of significance that others have.

A common name given to this sense of significance is dignity. It is a defining characteristic of humans. We see it as soon as we see behaviourally modern humans – who came on the scene about 45,000 years ago. We laid our dead tenderly in the earth, clutching flowers and amulets, rather than leaving them out as food for hyenas. We carved our faces into mammoth ivory because we knew that there was something about our faces which should endure. We believed that we had souls and that other things, human and non-human did too. This made eating other ensouled things a real problem. We evolved solemn liturgies of oblation and satisfaction to solve it. Our walk through life and death was elaborately choreographed, because it wasn’t proper to stomp and blunder. Comportment mattered because we mattered.

These were astonishing assertions – so astonishing that no big society has ever taken them completely seriously.

Jumping from pre-history to history, dignity, like other precious resources, was appropriated by the rulers, who said that they and only they had a right to it. The hoi polloi never truly believed this; they knew their own worth and moral weight. But the rulers told an artful story. The gods had dignity, they said, and the gods gave it to their favoured ones – typically the royals and the heroes. The royals were the gods’ embodiments or regents, and so the thrones of Mesopotamia and Egypt were invested and affirmed by divine dignity. The capricious gods of Olympus gave dignity at particular times and for particular purposes to their particular favourites, who therefore became demi-gods for a while.

In the Hebrew world, however, a radically democratic move was afoot. God was indeed dignified, but since every human was made in his image, all humans were dignified too – and in the same way as God. The idea was picked up by St Paul: ‘There is neither Jew nor Greek’, he declared. ‘There is neither bond nor free, there is neither male nor female: for you are all one in Christ Jesus’.

These were astonishing assertions – so astonishing that no big society has ever taken them completely seriously.

The obscenity of Auschwitz relegated the hyper-spiritualised notion of dignity to the cloister, and Kant’s notion to the Academy. For whatever dignity was, it was outraged there, and the outrage extended to bodies and to the non-rationally-autonomous.

Less ambitious, and so more palatable, was Stoicism’s rather anaemic version of the Imago Dei. All humans were potentially dignified, it said, and each human had a duty to strive to realise their dignified potential. It was much less radical than the Judaeo-Christian conception, but still represented a tectonic break with the royal theocracies of Mesopotamia, Egypt and elsewhere.

This Stoical conception of dignity did useful work. It served to save the notion of dignity from two mortal threats - both, embarrassingly, from the Christian world (though Kant’s relationship with Christian orthodoxy was sometimes uneasy).

There is a strand of Platonised Christianity (drawing on the early Augustine)  that spiritualises the idea of dignity. If it prevailed dignity would have nothing to say in hospitals about bowels or bedpans, in bedrooms about sex, in plantations about slavery, in jungles about the fate of trees or toucans, or in newsrooms about anything at all.

Kant located dignity in rational autonomy, so snatching dignity from children, the demented, the unconscious, the depressed, everyone who has drunk a bottle of red wine, and more or less everyone who doesn’t have a PhD in philosophy.

The obscenity of Auschwitz relegated the hyper-spiritualised notion of dignity to the cloister, and Kant’s notion to the Academy. For whatever dignity was, it was outraged there, and the outrage extended to bodies and to the non-rationally-autonomous.

In the immediate aftermath of the Second World War dignity (almost always undefined) appeared in endless national and international laws and declarations. Fairly recently it has started to have a real legal life of its own, being invoked for many purposes, from prisoners’ rights to reproduce to the right to have your name on your tombstone in the language of your choice.

These specific invocations of dignity sometimes disguise its foundational nature – foundational to human nature itself and to the laws that seek to determine how humans should conduct themselves in society

To say that the Judaeo-Christian account of dignity gives rise to all ethics and law in the western world is a big claim. I make it unapologetically.

To see how foundational it is, ask yourself why you think it is wrong to kick a child, but not a rock. Or why it is wrong to play football with a human head, or do an intimate examination, for the purposes of teaching medical students, on a woman in a permanent vegetative state. In describing the wrongness you will certainly find yourself relying on something that looks suspiciously like human dignity.

The law is often said to be protecting interests other than dignity (such as autonomy, freedom, or bodily integrity), or promoting other values (such as beneficence or non-maleficence). Yet on close inspection, those interests and values will all turn out to be parasitic on dignity. Dignity is the first order principle: the others stem from it.

In the last forty or so years there has been a good deal of academic discussion about just what ‘dignity’ means. There is a growing consensus that it has two complementary parts. First: an inalienable element: the intrinsic dignity possessed simply and solely by reason of being human. This cannot be lost or diminished. It just is. And second, a dignity which is a consequence of the first, but denotes how, in the light of your dignified nature, you should comport yourself. If we say of someone ‘She’s let herself down’, we mean that she has failed to behave with the dignity expected of someone who has the high status of being human.

This account of dignity is derived straight from the notion of the Imago Dei, and from Paul’s gloss. The watered-down Stoical version simply gives encouragement to behave well: it has nothing akin to the inalienable element.

To say that the Judaeo-Christian account of dignity gives rise to all ethics and law in the western world is a big claim. I make it unapologetically. Perhaps you think that it is too extravagant. But it is plain enough that this account, or one of its iterations outside the sphere of Judaeo-Christian influence (there are several), accords as does no other with our intuitions about ourselves and about how we should act, and with the most fundamental axioms of the laws in all tolerable jurisdictions. The most enlightened parts of Enlightenment thinking originate in this account, though they are often embarrassed to admit it.

Whatever we mean by the Rule of Law, part of it is that no one is above or outside it: Jews and Greeks, and bond and free, and male and female are to be treated alike. We’re so used to the idea that we have forgotten its revolutionary roots.

Article
Assisted dying
Comment
Politics
7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

Markus is Professor of Moral Theology and Ethics at the University of Fribourg, Switzerland.

A single bed, wiith an unmade colourful duvet stands in the corner of a room. A hoist reaches over it from the corner.
The dying room, Dignitas Clinic, Zurich.
Dignitas.

While countries such as Germany, France or the UK are currently struggling to find a suitable regulation for assisted suicide, their peers in the Netherlands, Canada and Switzerland have years of experience with the controversial medical practice. Even if each state must explore its own ways of dealing with these ethically controversial issues, it is obvious that international experience should not be ignored as they try to find a way forward.  

In Switzerland the discussions and challenges surrounding assisted suicide are increasing rather than decreasing. Contrary to the idea that a liberalisation of assisted suicide would lead to fewer debate, tensions and difficulties are increasing.  My observation, and thesis, indicates that practices such as assisted suicide cannot be “normalised”, even in the medium and long term. 

Developments 

In recent years, one to two per cent of all deaths in Switzerland were due to assisted suicide.  From an overall perspective, this practice is therefore still a marginal phenomenon. However, a look at the total number of assisted suicides per year gives a different impression, as this has increased more than fivefold in the years between 2008 and 2020, from an initial 253 to 1,251 deaths per year, a rising trend. The cause of death statistics for Switzerland only include those cases of assisted suicide in which persons resident in Switzerland were involved and the death was reported to the authorities. According to the Swiss Federal Statistical Office, in 2020, it was mainly people over the age of 64 who made use of assisted suicide. Detailed information on the underlying illnesses of the people affected in 2018 shows that about 40 per cent were affected by cancer, just under 12 per cent by diseases of the nervous system, a further 12 per cent by cardiovascular diseases and just over a third by other illnesses, including dementia and depression. There are currently seven right-to-die organisations in Switzerland which play a leading role in a typical assisted suicide procedure. They work closely with doctors who are prepared to prescribe a lethal drug, generally Pentobarbital. The data reflects an ambivalent picture: on the one hand, the proportion of assisted suicide cases is relatively low in relation to all deaths and, for example, in comparison to the large number of people who die in Switzerland in a state of deep sedation until death; on the other hand, the number of assisted suicides in Switzerland has risen sharply in recent years.  

Perceptions and assessments 

Since the 1990s, the public perception and assessment of assisted suicide in Swiss society has changed from an initially cautious and sceptical attitude towards broad acceptance. While the debates in other countries are characterised by relatively sharp controversies between those in favour and those against, public discourse in Switzerland has been less polarised. There are indications of a certain normalisation of the situation, the strongest sign is that Switzerland has so far refrained from regulating assisted suicide in a separate law. The results of a recently-published study on the opinions of Swiss people over the age of 55 regarding assisted suicide confirm these impressions.: The survey showed that over four-fifths of respondents support legal assisted suicide, almost two-thirds can imagine asking for assisted suicide themselves at some point, and that almost one-third are considering becoming members of an right-to-die organisation in the near future, with one-twentieth of respondents already being members at the time of the survey in 2015. Among people with a higher level of education and older people aged between 65 and 74, approval of assisted suicide and corresponding practices was higher than among less educated, younger and very old people; approval was also significantly lower among religious practitioners. 

Sensitive topics  

The fact that assisted suicide enjoys broad support in Swiss society as a whole does not mean that there are not difficult and controversial aspects relating to its practice. Relevant topics include, in particular, places of death, authorisation criteria and procedures. 

Places of death: Assisted suicide is permitted also for mentally ill persons in psychiatric clinics, but the federal court recommends great caution here and requires two psychiatric expert opinions to ensure that the person willing to die is capable of judgement with regard to the desire to commit suicide. Although assisted suicide for children and adolescents has hardly been an issue in Switzerland to date, the corresponding debates are currently being held in Canada and elsewhere. The question of whether people in prison also have a right to make use of assisted suicide, has been the subject of intense debate in Switzerland for years, with a generally positive response. The question of whether right-to-die organisations should be given access to acute hospitals and nursing homes is still the subject of controversial debate, with regulations varying from hospital to hospital, nursing home to nursing home 

Authorisation criteria: With regard to the admission criteria for persons willing to die, the capacity for judgement is at the centre of attention: while the importance of the criterion is undisputed in itself, there is a struggle for reliable standards and procedures to reliably test this criterion. Since the publication of the SAMS ethical guidelines Management of Dying and Death in 2018, the criterion for end of life and, depending on this, that of unbearable suffering have received new attention due to an objection by the Swiss Medical AssociationFMH. While the guidelines are based on the criterion of unbearable suffering, the FMH wants to stick to the near end of life. It is certainly difficult to diagnose the existence of unbearable suffering, as the international debate on the significance and assessment of existential (neither physical nor psychological) suffering shows. This difficulty is illustrated by the debate that has been going on for several years in Switzerland about so-called old-age suicide and the inherent criterion of tiredness of life. At the centre of the dispute is the legally difficult question of whether a doctor is also allowed to prescribe a lethal drug to a healthy person. 

Procedures: Here the role of the medical profession and right to die organisations is by far the most important issue. In contrast to the physician-centred models in Belgium, Canada and the Netherlands, the Swiss model of assisted suicide is based on the idea that every person has the right to end their life and may call on the help of any other person to do so. Although the medical profession is usually involved in the process, the management of the procedure is normally the responsibility of a right-to-die organisation. This division of responsibilities is always up for debate when legal regulations are being considered, in which doctors should tend to take the lead in the process due to their professional background. There is also a debate about how and by whom compliance with the authorisation criteria should or could be monitored, whereby it remains to be decided whether this should be carried out before or after the death. At present, a certain amount of monitoring takes place following a suicide, insofar as the authorities investigate the cases afterwards. There is also debate as to whether Pentobarbital is a suitable means of suicide, especially if this barbiturate is not administered intravenously but taken orally; there is no knowledge of how many cases are currently administered intravenously and by whom an infusion is then set up. Last but not least, consideration has already been given to the use of lethal drugs, such as helium gas, which can be obtained over the counter. 

Attempts at regulation 

Political efforts to regulate assisted suicide in Switzerland in a more nuanced way than today have been made since the 1990s but have remain largely without consequences to date. In relevant judgements by the Federal Supreme Court or in statements by the Federal Department of Justice and Police, reference is regularly made to the ethical guidelines of the SAMS. These are classified as soft law and are therefore not legally binding, even though their content has become the subject of dispute. The National Advisory Commission on Biomedical Ethics (NCE) had already recommended more far-reaching legal regulation in 2005 as part of a detailed opinion on the subject; in the opinion of the NCE at the time, the review of authorisation criteria, a justifiable regulation of assisted suicide for the mentally ill, children and adolescents and state supervision of right-to-die organisations, should be ensured by law. The question is what form a legal regulation can take that grants the medical profession far-reaching powers but at the same time prevents medical paternalism (in favour of or against assisted suicide). From the perspective of Swiss experience, this is “a square circle”: either the doctors retain the final decision on who receives the barbiturate, or official access rules are established, the review of which does not generally require medical expertise. 

The outlook

In the short and medium term, it can be assumed that the number of assisted suicides in Switzerland will continue to rise. The coronavirus pandemic and the particular difficulties faced by nursing homes during this time are likely to exacerbate this increase. In view of these expectations and the legislative processes in other European countries, pressure is likely to increase in Switzerland to create a legal regulation. Overall, I think politically it will be important to create a legal regulation, in order to ensure legal equality and legal certainty on the one hand and prevention of abuse and expansion on the other. At the centre of social-ethical reflection is the challenge of learning to deal with the pluralism of different ideas of a good death and to develop and establish alternative models to medically assisted dying. The thesis I mentioned at the beginning is confirmed today: assisted suicide in Switzerland can hardly be normalised; new problems, challenges and demands are constantly arising. Suicide, whether with or without the help of another person, always means an existential transgression that defies normalisation.