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Death and Human Dignity

Daniel P. Sulmasy

To cite this article: Daniel P. Sulmasy (1994) Death and Human Dignity, The Linacre Quarterly,
61:4, 27-36, DOI: 10.1080/20508549.1999.11878278

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Published online: 01 Jun 2017.

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l .

Death and Human Dignity

by
l~
l Daniel P. Sulmasy, O.F.M., M.D.
Georgetown University Medical Center
Washington, DC
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"Death with dignity," has often been invoked in arguments regarding

euthanasia and assisted suicide. i ,2,3,4 Only a few authors have reflected seriously
about what this phrase actually means. S,6,7 Yet, an understanding of death with
dignity seems critical to an understanding of the ethics of caring for the dying.
Differences in the positions various authors hold regarding the morality of
euthanasia and assisted suicide are almost always traceable to deep differences in
the moral presuppositions which lie just beneath phrases like "death with
dignity."
But fruitful debate cannot begin with an unexamined slogan. And small errors
at the beginning of an argument lead to grave errors in the conclusions.8 Just as an
understanding of the theory of the molecular biology of cystic fibrosis will
ultimately lead to better patient care, so an understanding ofthe theory of human
dignity and its relationship to the morality of human illness and death will
ultimately lead to better patient care. The stakes are high. The medical profession
cannot afford to ignore critical discussion of the fundamentals in the debate about
euthanasia and assisted suicide.
In this paper, I will examine and criticize several theories about human dignity.
I will suggest an alternative interpretation. I will then show what it means for
doctors and patients to apply that interpretation to end of life decisions.
What Is Human Dignity?
Dignity is defined in the dictionary as "the quality or state of being worthy,
honored, or esteemed.''9 It is something one may have, or something one may
perceive in another, or in oneself. Dignity, therefore, has both an essential and a
perceptual aspect. To be perceived to have less than the esteem of which one is
worthy is to suffer an indignity. To treat oneself or others with less than the proper
esteem is to behave in an undignified manner.
Since morality concerns right and wrong behavior towards others, dignity is
fundamental to morality. In asking why one should treat other human beings as
worthy, honored, or esteemed, one is really asking a variant of the question, why

November, 1994 27
 be moral? Almost everyone accepts the idea that the word "dignity" has
enormous moral importance, and it is often invoked in the euthanasia debate. But
people seem to differ in their views about what gives other people worth, honor,
and esteem. Space considerations obviously preclude a full discussion of what
gives a person dignity. But one simple way to examine the suitability of any
particular theory about dignity would be to perform a thought experiment: to
assess the morality ofthe logical consequences of adopting one or another theory.
I will therefore sketch an outline of what sort of moral world would follow
logically from accepting each of four common conceptions of human dignity
-conceptions that are often prominent in arguments about death and human
dignity. I do this in order to indicate, in a preliminary way, why each of these four
views is inadequate.
Arguments about the most appropriate ethical system abound. Yet, it would
seem that consistency is a minimal requirement of any system worth
considering. 1o Therefore, dignity ought to mean the same thing whether one is
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dealing with the ethics of race relations, child abuse, or euthanasia. A moral
argument based upon a concept of dignity that cannot be consistently applied in
~ I
all areas of morality is not an acceptable argument. ..,
1. Social worth - Some might suggest that human dignity depends upon social
worth. Hobbes wrote that "the public worth of a man, which is the value set on
him by the Common-wealth, is that which men commonly call DIGNITY."l1
But it follows from such a Hobbesian conception of human dignity that the
unemployed, the severely handicapped, the mentally ill, and all others who
cannot contribute to the economic well-being of society have lost their dignity, if
they ever had it. This conception stands in obvious opposition to the increasing
tendency of our society to recognize the dignity of such persons, and would not
seem to be what most people mean by the term. If human dignity is not lost when
one loses one's economic value to society, then this Hobbesian conception must
be rejected.
2. Freedom - Some might suggest that human dignity depends upon freedom.
But human dignity cannot be derived solely from the fact that human beings have
free choice. Human freedom is respected because human beings have dignity, and
not the other way around. To believe otherwise is to suggest that those who have
lost control of certain human functions or have lost or never had the freedom to
make choices, have no dignity. This would mean that infants, the retarded, the
severely mentally ill, prisoners, the comatose, and perhaps even the sleeping have
no human dignity. This seems to be a false basic moral intuition.
In reply, some might suggest that what counts is the capacity for control and
freedom, and not the exercise of control and freedom. It has been suggested that
some individuals without full control and freedom nevertheless deserve to be
treated with dignity either because they have a potential for such a capacity (so
that children, for instance, come to be regarded as placeholders for actual
persons), or they have a history of having exercised such a capacity (so that the
demented, for instance, come to be regarded as remnants of persons).12 But these
arguments seem based upon quite tenuous stretches of the concept of dignity

28 Linacre Quarterly
 based on freedom. Who would feel dignified and secure as a placeholder or a
remnant? Further, these arguments still cannot answer why those with neither a
history nor a potential for free, rational choice (such as the severely mentally
retarded) are worthy of human dignity. In contrast, consider why it is that
although suicidally psychotic patients have lost the freedom to choose between
life and death, other human beings intervene to save them. This is done precisely
because in losing their freedom, these patients have not lost their dignity. Human
dignity is not to be equated with human freedom and control. The famous
photograph of the Rev. Martin Luther King, Jr. sitting in an Alabama prison cell
l ," is a portrait of human dignity in the face of lost freedom and control.
3. Pleasure and Pain - Some might suggest that human dignity depends upon
the amount of pleasure and pain in a human life. Certainly, however, most people
are able to tell stories of the extraordinary lessons in human dignity they have
learned from persons whose lives have been racked by pain, and most people
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could also tell stories of the undignified lives of human beings who have spent all
their human energy solely in the pursuit of pleasure. Basing morality squarely on
a balance between pleasure and pain inevitably leads one to accept the morality
of certain acts of euthanasia, 13 but this seems to be an anemic account of human
dignity, and not one that most persons would hold among the basic underlying
assumptions of a moral system.
4. A Subjective Account - Some might suggest that human dignity is
something individuals are free to define as they wish. But this assertion leads to
numerous philosophical problems. First, the concept of a moral term implies that
it has universal meaning. 14 Human dignity either means the same thing for all
human beings or it has no moral meaning at all. If moral terms were to mean
whatever anyone wants them to mean, all meaningful moral conversation would
stop. Second, to say that morality is not objective is performatively self-refuting.
It is self-contradictory to make an objective claim about a subject that one asserts
is not objective. Third, to say that human dignity is subjective is to claim that one
person can never reliably recognize the dignity of another person, because the
other person's dignity depends upon that person's subjective mental states, which
are potentially subject to constant flux. Finally, under this conception, those who
are incapable of excercising subjectivity would have no dignity - the severely
retarded and the comatose, for example. And this does not seem to sit well with
our considered judgments about morality. Thus, human dignity cannot be a
purely subjective concept.
An Alternative Basis for Dignity
Almost everyone agrees that human beings have dignity. But what is it? Every
one of the above attempts to say that human dignity consists of "x" - whether of
social worth, or of freedom, or of pleasure, or of our individual subjectivity is, to
some extent, a pre-logical assumption. Each requires a leap of moral belief. None
can be proven. Yet this does not mean that they cannot be argued for. One can
show that each attempt to say that human dignity consists ofthis human power or
that human characteristic leads to an awkward set moral conclusions.
Thus, one ought to reject the above conceptions of human dignity. I propose

November, 1994 29
 instead the following alternative: Human dignity has its basis in the moral
proposition that every human life has intrinsic meaning and value. In other
I
words, human beings have dignity simply because they are human beings. To say - ...J
that human dignity consists of something else, of some characteristic that some of
us have and some of us don't, or that some of us have in greater abundance than
others, leads to unacceptable conclusions.
If human beings have dignity simply because they are human, the following
are also true:
a) Everyone, by definition, has dignity. Dignity is thus supremely
democratic.
b) Dignity is truly inalienable. No person and no circumstance can take
dignity away from any human being.
c) Dignity is also truly qualitative. It does not admit of degrees. It is the
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same for everyone.

~ I
One also should note that it does not follow from this conception that human I

lives have infinite value. The fact of human mortality precludes the possibility
that human lives are infinitely valuable. Human dignity then depends on the
recognition that human lives are neither infinitely meaningful and valuable, nor
ever devoid of meaning and value. As Shakespeare has put it, a human being is
"the beauty of the world; the paragon of animals; and yet to me, what is this
quintessence of dust?"lS
It also follows that no one can claim the right to declare that any human life is
devoid of meaning and value. One may act in opposition to human dignity, but to
freely choose to assault human dignity is to act immorally. A person may be
treated in an undignified manner, even enslaved, but human dignity is not
destroyed by human immorality. Pleasure does not increase human dignity, and
pain does not diminish it. One may be deprived of happiness, and not of one's
essential human dignity.
To respect human dignity is to come to terms with what it means, honestly, to
be human. Honorable human action is the fruit of a correct perception of the
essence of human dignity - one's own, as well as that of others. Perceptions can
be more or less correct. Actions can be more or less honorable. But the essence of
human dignity is nothing more or less than the esteem and honor human beings
deserve simply because they are human.
Human Death and Human Dignity
Therefore, those who suggest that one can never allow a person to die, and that
one must continuously strive to maintain mere biological life at all cost, no matter
how much the patient is suffering, are acting against human dignity and therefore,
acting immorally. Such actions amount to a denial of the truth of human mortality
and therefore a denial of the truth about the value and meaning of human life - a
denial of human dignity. Whether an inevitable death is avoided out offear, or out

30 Linacre Quarterly
 of a bizarre interpretation of "the sanctity of life," holding biological life to be a

l. supreme moral value, such deaths are undignified. To continue to fight when
overmastered by disease, when there is no goal except living itself, can be mere
hubris. It is not death with dignity.
On the other hand, to kill a patient, even if that patient is dying, is to suggest
that the patient's life has lost all meaning and value, and is therefore also to act
against human dignity - to act immorally. Since human dignity is not dependent
upon social worth, or freedom, or pleasure, matter how much these may be
diminished by the circumstances in which a dying person may be found, human
dignity is not lost. And since human dignity is not subjective, no one is capable of
deciding idiosyncratically that his or her own life has no more dignity. It is
immoral for a person to decide that any life, including one's own, has no meaning
or value. It is only possible to wilfully act with the intention of causing a person's
death by a mechanism that originates in one's own actions if one has decided that
the person's life either has no meaning and value or has merely instrumental, not
.
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intrinsic, meaning and value. To do so is to act immorally - to act against human

. dignity.
If one does not believe in human dignity, if one believes that human beings are
meaningless chemical events in the evolution of the universe, then further
discussion is pointless. But if one does believe in human dignity, one also
recognizes that there are many forces, originating in nature and in human choice,
that conspire to assault human dignity. Death itself is the pre-eminent assault.
The fact of human mortality is perhaps the ultimate question about human
dignity. If human beings have such meaning and value, why do human beings
"
die?
The answers to this question are many. Some answers are religious. Others
refer to the greater good of humankind or the ecological good of the planet. But
the fact that human mortality is so troubling a question, troubling enough to be
raised at all, implies deeply held beliefs about the essence of human dignity. If no
one held such beliefs, no one would bother to ask the question.
One must remember that human dignity has both an essential and a perceptual
aspect. Dignity means both the esteem in which one is held and the esteem of
which one is worthy. Sickness certainly mounts an assault upon human dignity.
One may perceive that one has lost one's dignity, or may be perceived as having
lost one's dignity, when one is forced to strip naked before a doctor, forced to
reach for a bedpan, covered with vomitus, bleeding, incontinent, demented, or
otherwise needy. Disease humiliates us. Death humiliates us. But these assaults
are disturbing precisely because they raise the question of whether human life
ultimately has any meaning or value, any dignity.
Medicine and Human Dignity
Medicine exists precisely to serve the dignity of persons whose dignity is called
into question by disease and injury. To heal is to remind persons that sickness and
limitation do not destroy their essential dignity; that their lives continue, in spite
of it all, to have meaning and value. When it is possible to eliminate the assault on
dignity wrought by disease, doctors cure. When it is possible to mitigate the

November, 1994 31
 assault wrought by disease, doctors palliate and help patients maintain function.
When the assault can neither be eliminated nor mitigated, healing does not cease.
Doctors continue to heal by reminding the sick of their essential meaning and
value even when the pills and needles and machines no longer have a function.
Hence the medieval aphorism: to cure sometimes, to relieve often, and to comfort
always, remains an apt description of the essential goals of the medical enterprise.
It is not easy to remind the dying of their dignity. But that is precisely what it
means to comfort the dying.
From the perspective of the patient, to choose death in the face of assaults on
human dignity is to believe the falsehood that one's life has lost all meaning and
value. This premise is necessary in order to justify killing oneself, or to justify
asking to be killed. Some may respond by suggesting that euthanasia is justified
whenever one determines that one's life no longer has enough dignity, but to do
so, such persons would need to measure dignity in terms of either pleasure, or
freedom, or control, or social worth or claim that dignity is purely subjective. But
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as argued above, to use any such measure is to suggest that the essence of human
dignity consists in something other than simply being human, and this leads to
morally awkward conclusions. Euthanasia and assisted suicide are freely chosen,
willful assaults upon human dignity, based upon the premise that a human life
has no meaning or value.
On the other hand, to accept one's own death (once it has become inevitable) is
to accept the truth that one's life is not of infinite value. It is supremely honorable
to face one's mortality. To face one's mortality is to act with, and not against,
human dignity. To resist death or to accept death for the sake of something
greater than one's own life is also supremely honorable, because it is also a
recognition that one's life is not of infinite value. To die with dignity is to die
honorably, announcing and not renouncing one's own essential dignity.
Medicine, as a truly human profession, must also recognize its own dignity. To
fail to ever allow patients to die, for example, is to fail to recognize the limits of
medicine. Medicine does not grant immortality. Oil the other hand, to kill
patients is to make an undignified and false move beyond the limits of medicine.
The goal of the physician is to make the right and just healing act for a particular
patient in his or her particular circumstances. 16 Killing patients is neither right,
nor just, nor an act of healing. It is outside the bounds of medicine. 17
Death and Dignity - A Personal Account
Like most physicians, I have had patients die under my care. Not one has ever
asked me for euthanasia or assisted suicide. I would like to think that this is
because I have struggled to never let my patients believe the falsehood that they
had somehow lost their human dignity because they were suffering or dying or
had diminished control over one or another of their bodily functions. I have
sensed their suffering in such circumstances, and I have reached out in acts of
compassion. I have seen many patients die prolonged yet dignified deaths, full of
the knowledge both that their lives had value, and that their lives were not of
infinite value. These patients faced their mortality with courage, hope, and love.
Watching them and their families confront the mystery of death has been a

32 Linacre Quarterly
 deeply transformative experience for me as a physician. I was not always able to
control all of their pain, despite my best efforts. Some died after a few days in
coma. Some died incontinent. Some died demented. With their consent, I
withheld and withdrew therapies that would have needlessly prolonged their
dying. But I have never killed a patient, nor aided a patient in suicide.
In contrast to these truly "good" deaths, I have had some patients who have
approached their deaths in despair and fear. I struggled with these patients,
acknowledging but never ratifying their emotions. I worked to let them know
I that they were not dying alone. I made sure they knew that even if no one else
would be there, I would be there for them. I struggled to let them know that they
I. had not lost all dignity; that they remained connected to the human community
l by the bonds of love even as they were leaving. Sometimes my efforts were
successful, and they died in peace. Sometimes I was not successful, and these
patients remained fearful and despairing to the end. I have mourned their deaths
most of all. But I never once gave up trying to heal the aspects of their suffering
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that morphine can never touch - their need to believe in their own value and
meaning - their own dignity. This is a daunting task - to heal the
misperceptions of the dying about their own value; to remind them that they are
.. not grotesque creatures who have ceased to have importance because they are
naked, covered in feces and blood. But this is what medicine does at its limit. This
is what it means to heal the dying. There could have been no greater assault on
their human dignity, and ultimately no greater suffering, than ifI had looked even
one of them in the eye and said, "Yes, you're right. Your life has no meaning or
. value. I'll kill you now if you'd like me to do so."
Is Suffering Ever Unbearable?
Some may argue that I am proposing a supererogatory standard, demanding of
patients more than they can bear. But this sort of counterargument cannot
withstand careful scrutiny.
First, I have argued that my account of human dignity is more defensible than
the alternatives, and that my position regarding euthanasia and assisted suicide
follows from my account of human dignity. Moral words are universalizable and
[Link] This means that if I am correct, my account of dignity applies in all
situations. The task for the proponents of euthanasia and assisted suicide is to
prove that human dignity means something other than what I have suggested, not
) ,
just with respect to euthanasia and assisted suicide, but with respect to all moral
questions.
Second, despite the fact that doctors have been able to kill for much longer
than they have been able to cure, the overwhelming majority of persons who
have died in the last 2,500 years have neither killed themselves nor have they
been killed by their physicians. This suggests that the burden of proof is on the
proponents of euthanasia and assisted suicide to show, despite the development
r of morphine, non-steroidal anti-inflammatory drugs, anti-depressants, patient-
controlled analgesia, nerve-blocks, epidural analgesia, biofeedback, and other
contemporary techniques, coupled with the account of human dignity that I
propose (which is perfectly compatible with the withholding and withdrawing of any

November, 1994 33
 and every modern life-sustaining therapy in the dying), that people today are
forced to suffer more than their ancestors. The only other alternative, if one
suggests that death without access to euthanasia or assisted suicide is r )
supererogatory, is to argue that every patient who has died a natural death during
the past 2,500 years without being offered these options has acted
supererogatively. Both of these options seem false. Declaring euthanasia and
assisted suicide immoral is not demanding of patients more than they can bear.

Is This a Purely Religious Argument?

Some might object that because this argument is compatible with traditional
Jewish and Christian conceptions of human dignity, it is essentially a religious
claim and is therefore irrelevant as a public argument. But this is fallacious. First,
many arguments in the public arena are compatible with religious beliefs, and are
not eliminated from public debate solely for this reason. The concept of human
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I
rights, for instance, is compatible with Jewish and Christian belief. There is no
"proof' that human rights exist. We all accept this as a matter of common moral
"faith." The fact that this unprovable concept is compatible with religious belief is
not a reason to eliminate arguments based on human rights from the public
forum. Likewise, an argument based upon the unprovable concept of human
dignity proposed in this paper ought not be dismissed simply because it is
compatible with religious beliefs about human dignity.
Second, the argument in this paper stands independent of religious conviction.
One can hold the concept of human dignity proposed in this paper without ,.
adherence to any credal confession. This argument does not depend upon
scripture, doctrine, or the opinions of any pope, priest, rabbi, or minister. The fact
is that arguments must start somewhere, and if dignity is to figure in arguments
regarding euthanasia it must have a meaning. I have argued that the conception of
human dignity presented here is better than any of the alternatives. The burden of
proof now lies with those who propose other concepts of human dignity to show
that their concepts can be consistently applied throughout a moral system "
without leading to contradiciton and without clashing with our considered moral
judgments.
Conclusion
Many arguments against euthanasia and assisted suicide have been based upon
considerations of the social consequences. 19,20 Many of the counterarguments
have been attempts to show that safeguards can be constructed to place wedges
along the "slippery SIOpe."21,22 This paper has presented arguments about why
euthanasia and assisted suicide are intrinsically immoral acts. Euthanasia and
assisted suicide are immoral because these actions directly attack the bedrock
human value which makes all other human values possible - the inherent
dignity of human life.
The demand for euthanasia and assisted suicide is, in some ways, an ironic
demand for a quick technological solution to the problems technology itself has
created. But this amounts to a form of denial. It is a stubborn refusal to accept the

34 Linacre Quarterly
 truth about medicine - its value, its meaning, and its limits. It is at the same time
a stubborn refusal to accept the truth about being human - its value, its meaning,
and its limits. It is absolutely true that physicians must be more affectively
responsive and sympathetic to the needs of the dying and absolutely true that
physicians need to muster more compassion for the dying. But affect without
truth is not mercy. It is mere sentimentalism. The dying need healing from their
doctors. The dying must always be assured by doctors that they have not lost their
human dignity - that they continue to have worth, honor, and esteem. The
dying need doctors who recognize that their lives have a measure of meaning and
value which is far from infinite, but never nil. The dying do not need to suffer the
final indignity of a sensitive but unthinking doctor wielding a syringe filled with
100 mEq of Kel, or a prescription for 100 secobarbital capsules which reads,
"Take these when you need them, and if you wake up in the morning, call me."
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1307-1311.

November, 1994 35
 20. Peter A. Singer and Mark Siegler, "Euthanasia: A Critique," New England Journal of
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36 Linacre Quarterly