As the world population is aging and becoming frail, there is an increased demand on healthcare globally. Geriatric patients that are frail older individuals (often with dementia) require enormous amounts of resources both in terms of workforce and funding. Also, many western countries, such as Belgium, the Netherland and Canada are legalizing euthanasia not only for suffering patients, but also for patient deemed to have lost their dignity. Dementia and old age are being often presented as reasons to lose dignity, and require euthanasia.
However, the invocations of dignity in bioethical debates are controversial, even though the value of dignity is set to be the foundation of the Universal Declaration of Human Rights. Many believe that dignity is essentially a useless concept, devoid of meaning or a fundamentally flawed concept (Singer 2000, Macklin 2004, Cochrane 2010). Because of the various interpretations, dignity has been used in so many opposing senses that the concept could be too slippery to help tackle difficult problems in bioethics (Kuhse 2000). It is used to justify the legalization of euthanasia for suffering patients, but it is also mentioned as a reason to care for a patient and avoid euthanasia for the most vulnerable of them (Pageau 2020). Others have accused dignity of a rhetorical gesture used in the absence of good argument to stall biomedical progress (Pinker 2008). Moreover, some suspect that dignity is redundant, a term that simply restates other ethical principles such as respect for autonomy (Macklin 2014).
Despite the philosophical controversy, the concept of dignity is pervasive in biomedical practice and it is unlikely that we will no longer need it. Mostly because the patient experience of dignity is a growing area of research in healthcare fields like palliative care (Barclay 2018; Chochinov 2012; Pageau 2020). Dignity is also a relevant concept in the day-to-day experience of the elderly (Nordenfelt 2003, 2004; Franklin et al. 2006; Ternestedt 2009). We still have much to learn from the concrete patient experiences, how is dignity conferred on elderly people when they are treated as having equal status, and what factors contribute to the denial of dignity of the sick and frail (Barclay 2016). Healthcare professionals often have only a vague idea of what it means to respect dignity when providing care, especially for the elderly. There are profound ethical challenges in the daily care of persons with impaired autonomy (Rejno et al. 2019). The ethic of care, as defended by Tronto (2009), asks for more empathy. Caring is central for most geriatricians as frail vulnerable patients need more care than cures, dementia and other illnesses of old age being incurable. Hence, vulnerability has to be met with compassion and empathy or with “love” (Fiasse 2015).
The proposed panel session aims to explore the topic of the dignity of the elderly and try to determine what aspects of dignity apply to the elderly, how dignity relates to caring for fragility and what are the implications for geriatric care. In doing so, we aim to connect the philosophical discussion of dignity with the existing qualitative research on day-to-day experience of patients and healthcare professionals in elderly care.
Dignity and Older Europeans
Prof. Lennart Nordenfelt | Ersta Sköndal Bräcke University College
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Prof. Lennart Nordenfelt | Ersta Sköndal Bräcke University College
I shall provide an analysis of four salient concepts of dignity. The text is a development of a work which was initiated in the year 2000, when I was affiliated to an international research programme supported by the European Union, called Dignity and Older Europeans (DOE) (Nordenfelt 2009). In the theoretical part of the study there emerged four different concepts of dignity: human dignity, dignity of merit, dignity of moral standing, and dignity of identity. I will take this analysis a step further, being particularly influenced by Sulmasy (2013). I propose an improvement and clarification of my earlier classification of dignities. The concepts to be analysed in the article are: human dignity which is an intrinsic worth of the natural kind of humans. This dignity is grounded in the constitutive properties of humans; attributive dignity which is the result of an attribution, typically an explicit nomination, for example of high officials; dignity of excellence, that is the dignity that is grounded on the possession of a highly valued property, such as intelligence, moral standing, strength or beauty, and dignity of identity, that is the dignity that pertains to individual humans as autonomous and integrated persons, having a history and a prospective future.
Paternalism and Respecting Dignity in Dementia
Senior Lecturer Linda Barclay
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Senior Lecturer Linda Barclay
Treating people with dignity demands that we avoid belittling or infantilising them. Acting paternalistically toward people with dementia is sometimes unavoidable, particularly as the disease progresses. While paternalism is usually discussed in contrast to personal autonomy, it is also a potential threat to dignity. In this presentation I will discuss the tension between dignity and paternalism as well as propose a framework for avoiding infantilization when exercising paternalism is unavoidable.
Fragility, self-esteem and dignity
Associate Professor Gaëlle Fiasse
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Associate Professor Gaëlle Fiasse
In light of Paul Ricœur's philosophy and my research on fragility, I will pinpoint some of the ethical attitudes towards patients who are suffering. Pain and suffering can decrease self-esteem, capacities, the relation to one's world and to others. I will thus highlight how people who accompany the elderly can help them to nurture their self-esteem and what kind of presence can be developed. Against affective fusion, I will show nonetheless that a certain sollicitude is required to consider the other person as another person with human dignity who calls for responsibility, care and presence.
A clinical perspective on dignity in geriatric care
Associate Professor Felix Pageau | Laval University Faculty of Medicine
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Associate Professor Felix Pageau | Laval University Faculty of Medicine
Caring often trump curing in geriatrics, since dementia and other forms of neurodegenerative disease afflict more frequently the elderly. Frailty and reduced life expectancy call for adapted care which aims at comfort rather than prolonged survival. We know that an older adult with multiple diseases does not need to be aggressively treated but rather requires a secure environment with compassionate healthcare professionals. As the body and mind age, having meaningful and thoughtful relationships help to respect one’s dignity. In Western society, however, ageism, ableism and mental health stigma tend to depreciate the elderly suffering with dementia. In my talk, I will explain how this is the case. Also, I will demonstrate that human rights, dignity and ethic of care defend the elderly with dementia against any form of discrimination in care. As it is essential to geriatric care, we will show that one should always be fairly treated irrespectively of age, mental health problems and/or handicaps.
Respect for dignity without shame
Senior Lecturer Emilian Mihailov | University of Bucharest
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Senior Lecturer Emilian Mihailov | University of Bucharest
Is dignity a useless concept in medical ethics and, thus, be eliminated without any loss of content? It is true that dignity has been used in so many opposing senses that the concept could not be trusted, but the growing area of research in geriatric care shows how important is dignity the day-to-day experience of the elderly (Nordenfelt 2003, 2004; Franklin et al. 2006; Ternestedt 2009; Barclay 2018; Pageau 2020). My intervention will highlight the need to focus on how dignity is conferred on elderly people through attitudes of respect, rather than avoiding shame. Caring environments are sometimes inherently shameful (for example, cleaning and toileting), but that does not mean that dignity is threatened. Respecting dignity could be a moral framework that helps us to value the elderly as equally important even if they are less autonomous.