The Ethics Page

ETHICAL CASE ANALYSIS: DIGNITY-CONSERVING PALLIATIVE CARE

PAULINA TABOADA, MD, PhD

CASE HISTORY

This is a 68 years-old man with advanced adenocarcinoma of the esophagus who had metastasis to the mediastinal lymph nodes, lungs and liver. During a follow-up appointment, he looks extremely cachectic and sad. Nevertheless, criteria for the diagnosis of clinical depression were not fulfilled.

He complains of a severe lack of energy, anorexia and progressive dysphagia. He does not complain of pain or other physical symptoms, but describes his perception of a “lack of dignity” as even worse than any physical symptom -- “it is always there and cannot be suppressed with drugs.”

ETHICAL ANALYSIS

What can health care professionals do in relation to a patient’s perception of “lack of dignity” at the end of life?

Several surveys have revealed that the patient’s subjective perception of “lack of dignity” is one of the main reasons underlying their euthanasia requests. Preservation of a patient’s “dignity” at the end of life is considered to be a central goal of palliative medicine. Nevertheless, health care professionals do not always have a clear understanding of the patient’s subjective perceptions of dignity, nor of the practical implications of this notion for the implementation of therapy. Moreover, the very philosophical concept of “dignity” seems to be in need of further clarification. Indeed, “considerations of dignity are frequently invoked as the ultimate justification for various, even diametrically opposite, approaches to the care of dying patients, whether in reference to euthanasia and assisted suicide, hydration, nutrition, terminal sedation, or basic symptom management. In many circles, the term ‘death with dignity’ has become synonymous with the right to assisted suicide and euthanasia thus removing it from its place as a principle of bedside care for patients nearing death.” (Chochinov, 2002, pp. 2253-4).

In the history of Western philosophy, at least three different meanings of human dignity have been distinguished. Sullivan & Heng (2010) summarize the philosophical content of these three senses of human dignity as follows:

• “Intrinsic human dignity is the value that human beings have simply by virtue of the fact that they are human beings, i.e., their ontological value. Intrinsic dignity is not based on any social standing, ability to evoke admiration, or any particular set of talents, skills, or powers.
• Attributed human dignity is the value that human beings confer upon others by choice and convention.
• Inflorescent human dignity is the value of human excellence or virtues. Inflorescent dignity presupposes the intrinsic dignity of all human beings but refers to the value of the habits and conditions that lead human beings to blossom, flourish or thrive as human beings.”

Sulmasy (2008) stresses the importance of distinguishing between these three dimensions of human dignity and of understanding their respective philosophical foundations, as they often get confused in ethical discussions. In fact, to conceive human dignity exclusively as a person’s capacity of self-determination and the respect for dignity as the mere respect for autonomous decision-makings may engender the false impression that “dignity” is a useless concept in medical ethics, as Ruth Macklin has recently argued (2008). Contrarily, being able to distinguish the different dimensions and sources of human dignity has enormous practical implications, especially in ethical decision-makings at the end of life.

Palliative care has been rooted in an acknowledgement of the inherent dignity of each person. Chochinov argues (2002, p. 2254) that “if the preservation of dignity is to be a targeted goal of palliation, the patient’s sense of dignity must be thoroughly understood.” Consequently, this author has developed an interesting line of clinical research to explore the patient’s understanding and perception of dignity. (Chochinov 1999, 2002, 2005, 2006, 2007, 2008, 2010) Based on the results gathered after the application of the so-called patient dignity inventory (2008) he proposes a dignity conserving model of care that can be summarized in the following four areas:

A: attitudes

B: behaviors

C: compassion

D: dialogue

Health care professionals working in the field of palliative care are encouraged to reflect on specific questions related to each of these four dimensions of care. Through successive carefully conducted surveys, Chochinov has shown that dying patients often derive self-respect and a sense of dignity from the sense that others value them, for example, for who they are and what they have done. Hence, his line of research provides interesting material to help answer my initial question. Concrete attitudes and behaviors of health care professionals and family members can have a real impact on the patient´s subjective perception of their dignity at the end of life.

REFERENCES:

• Chochinov, HM: Dignity conserving care: a new model for palliative care. JAMA 2002; 287:2253-2260.
• Sulmasy, D: “Dignity and Bioethics: History, Theory, and Selected Applications,” in The President’s Council on Bioethics, Human Dignity and Bioethics: Essays Commissioned by the President’s Council on Bioethics (Washington, D.C.: The President’s Council on Bioethics, 2008).
• Sullivan F & Heng, J: Caring and Giving Hope to Persons Living with Progressive Cognitive Impairments and Those Who Care for Them. National Catholic Bioethics Quarterly, Summer 2010.

PaulinaTaboada,MD, PhD is a former member of the IAHPC Board and long time contributor to this Ethics Page. She is the Director of the Center for Bioethics, Pontificia Universidad Catolica de Chile Santiago, Chile