Theor Med Bioeth (2016) 37:173–192

DOI 10.1007/s11017-016-9368-6

The value of dignity in and for bioethics: rethinking

the terms of the debate

Clair Morrissey1

Published online: 15 June 2016

 Springer Science+Business Media Dordrecht 2016

Abstract The discussion of the nature and value of dignity in and for bioethics
concerns not only the importance of the concept but also the aims of bioethics itself.
Here, I challenge the claim that the concept of dignity is useless by challenging the
implicit conception of usefulness involved. I argue that the conception of usefulness
that both opponents and proponents of dignity in bioethics adopt is rooted in a
narrow understanding of the role of normative theory in practical ethical thinking. I
then offer an alternate understanding of the nature and value of dignity. I begin by
recognizing that claims that one’s dignity has been violated point to an important
difference between ‘‘respect for autonomy’’ and ‘‘respect for persons.’’ I then
suggest three different conceptions of how dignity can be normatively guiding for
bioethics, and conclude that, ultimately, understanding dignity as the cornerstone of
a reflective perspective that frames moral reflection and deliberation is valuable for
doing bioethics well.

Keywords Human dignity
Method in bioethics
Respect for persons

Introduction

The concept of dignity is ubiquitous in discussions of human rights and global

health. It plays a central role in evaluating the quality of elder care and care for the
cognitively impaired. The concept is pervasive in clinical contexts more generally,
and it is frequently appealed to in public and political discussions of both actual and
possible advances in biotechnology. Debate about the meaning of dignity, a long-

& Clair Morrissey

cmorrissey@oxy.edu
1
Department of Philosophy, Occidental College, 1600 Campus Road, Los Angeles, CA 90041,
USA

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standing philosophical problem, has gained even greater attention due to the
concept’s inclusion in transnational rights documents and national constitutions that
refer to it in the context of the rights they articulate.1 Explicit reliance on dignity in
the 2008 revision of the Helsinki Declaration, the Council of Europe’s Convention
on Human Rights and Biomedicine, and UNESCO’s Universal Declaration of the
Human Genome and Human Rights has brought this more general philosophical
question to the fore in bioethics. Moreover, the concept of dignity took center stage
for the President’s Council on Bioethics in the 2000s, as it was given a prominent
role in discussions of advances in biotechnology. The Council commissioned both a
reader of primary texts about human nature and human value, and a collection of
essays from leading scholars on the nature and importance of the concept of human
dignity for bioethics [5, 6]. At the same time, Leon Kass’s tenure as chairman of the
Council (2001–2005) explicitly politicized this discussion, as his work employs the
concept of dignity to argue for socially conservative policies on human cloning and
aid-in-dying [7, 8].
Despite, and in part because of, this widespread use, there is a great deal of
skepticism about the value or importance of the concept of dignity. As is well
known, in a 2003 editorial in BMJ, Ruth Macklin argues that bioethicists’
appeals to dignity ‘‘are either vague restatements of other, more precise, notions
or mere slogans that add nothing to an understanding of the topic.’’ She
concludes: ‘‘dignity is a useless concept’’ [9]. Notice that Macklin’s criticism of
dignity is specific to its role in contemporary bioethics. Although her piece can
be read as posing a larger challenge, it is addressed to bioethicists in particular,
and it is the more narrowly focused discussion in which it participates that I term
‘‘the dignity debate in bioethics.’’ This debate is best characterized as a
disagreement about whether there is a conception of dignity that can be used to
do meaningful work in bioethics. In this way, it is as much about the nature and
aims of contemporary bioethics as about the content of ‘‘dignity’’ as a particular
moral concept.
Here, I aim to challenge the conclusion that dignity is useless for bioethics. My
challenge begins by reflecting on the terms of the debate itself, specifically on
implicit assumptions regarding the conditions for being ‘‘useful.’’ I argue that the
conception of usefulness underwriting a significant aspect of the dignity debates is
problematic, and rooted in an overly narrow understanding of the role of normative
theory in practical ethical contexts. Instead, I propose that considerations of dignity
point to recognizing an important difference between ‘‘respect for autonomy’’ and
‘‘respect for persons,’’ and suggest three alternative conceptions of how dignity can
be normatively guiding for bioethics. Ultimately, I contend that understanding
dignity as the cornerstone of a reflective perspective that frames moral reflection
and deliberation is valuable for doing bioethics well.

1
The role of human dignity in grounding human rights has also received a great deal of philosophical
attention beyond bioethics in recent years, especially in the context of the foundation of human rights
[1–4].

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The dignity debate in bioethics

The charges

As a starting point, within the debate, the concept of dignity can be understood as a
special, foundational kind of moral value or worth of human beings or persons as
such, which explains special moral concern for, or the equal moral status of, human
beings or persons.2 Macklin’s concise and forceful argument against the use of
dignity in bioethics is a useful framework for presenting the position of those who
oppose the use of the concept in bioethics.3 Macklin begins her argument by
recognizing a (seemingly) strange feature of a host of bioethical discussions: both
‘‘sides’’ use the language of dignity to support their respective positions. Debates
between people who disagree about the proper policies regarding abortion, aid-in-
dying, embryonic stem cell research, and genetic engineering and enhancement all
cite dignity as a point in favor of their respective positions. In light of this rather
widespread phenomenon, Macklin claims that the concept of dignity is indetermi-
nate and empty.
The charge that dignity is indeterminate is best understood as a set of related
criticisms of how people use the concept in contemporary scholarly and public
discussion. The first is the criticism that bioethicists’ appeals to dignity often fail to
clearly define or articulate the meaning of the term. Sometimes, the concept is left
undefined because its meaning is (wrongly) assumed to be self-evident, and
therefore without need of specification. Other times, the term is used as a
placeholder of sorts, pointing to some value or property but not, itself, explained.
When theorists do specify the meaning of dignity, skeptics claim, they do so in a
number of different and competing or contradictory ways. From the point of view of
doing bioethics well, indeterminate concepts get us nowhere, as they provide no
clear or definite meaning that can be used to illuminate or motivate ethical claims or
arguments.
Furthermore, Macklin and others argue, the most plausible conceptions or
specifications of the concept render it redundant. They provide no further moral
content than the more precise notion of ‘‘respect for autonomy’’ which generates
relatively concrete and precise obligations or prescriptions for actions, such as
‘‘obtain voluntary, informed consent’’ and ‘‘protect confidentiality.’’ Thus, appeals
to dignity in argument rely either on an unspecified vague notion or an idiosyncratic
conception of the concept, or else, needlessly complicate the discussion by
introducing a redundant concept instead of focusing on the more precisely
understood ‘‘respect for autonomy’’ [12].

2
Discussions of dignity are often bound up with debates about moral status, most notably, attempts to
distinguish ‘‘persons’’ from ‘‘human beings.’’ Below, I contest one aspect of the tight connection between
these two discussions by arguing that the ‘‘metaphysical framing’’ of the dignity debate, which sets out to
identify particular status conferring properties, is misguided. In this section, I use the phrase ‘‘human
being or person’’ to indicate that my characterization of the dignity debate in bioethics includes those who
understand members of either or both categories as at issue.
3
Although Macklin’s view is arguably the best known in this skeptical camp, many theorists make
similar arguments, or maintain aspects of the argument Macklin gives here [10, 11].

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Underlying these criticisms regarding the concept’s indeterminacy is the stronger

charge that the concept of dignity is empty. That is, reference to dignity in argument
is mere noise without substance, or rhetoric without a referent. When people appeal
to dignity, they are merely declaring themselves aligned with a certain outcome of a
policy debate or are otherwise attempting to end, rather than further, discussion of
the issue. Appealing to dignity is, then, mere sloganeering or an attempt to play a
kind of moral trump card [13]. The suspicion is that appeal to dignity in argument is
question-begging, as it is merely trotted out to justify what one is already committed
to for political reasons, not to get the answer ‘‘right’’ or to make a good argument to
determine what course of action or policy is justified.

Two characteristics of the dignity debate in bioethics

Proponents of the importance of dignity in bioethics have responded to the charges

by carving out ‘‘useful’’ conceptions of the term. Given the framing of the charges
against the concept, dignity can be redeemed by identifying a conception of it that
illuminates how or why human beings or persons have this unique value, and how
recognizing or attributing it to individuals can do unique, meaningful, normative
work in bioethics. Taking heed of the worry that everyone seems to mean something
different by the term, and recognizing the breadth and diversity of contexts in which
it is employed, a number of theorists have responded by generating taxonomies of
its use, disambiguating its many meanings, and providing arguments for the value of
particular conceptions over others [14–16].4 Rather than entering directly into this
fray by attempting to sort out and locate each of these different uses and the
different contexts in which the concept is deployed, I am interested in first reflecting
on and characterizing two foundational features of the debate itself.
The first feature of interest, the metaphysical framing of the debate, is the
assumption that a satisfactory account of dignity needs to identify a unique feature
or property of human beings or human existence that can ground or explain the
existence of a foundational moral value of human beings or persons as such. The
second feature of interest is the standard for usefulness—that in order for the
concept of dignity to be useful for doing bioethics well, its meaning must be
articulated in such a way that the definition can be a straightforward aspect of
practical deliberation, or otherwise, lead to straightforward normative guidance. I
discuss each of these implicit assumptions in more detail before turning to reasons
to resist each of them.
The metaphysical framing of the dignity debate involves at least two
methodological commitments. First, the concept of dignity must be properly
‘‘grounded.’’ It assumes that for talk of dignity to be justified, one must be able to
give a sufficiently foundational reason to believe that those things really have this
kind of special moral value or status. Second, it assumes that this grounding is
4
Human Dignity and Bioethics: Essays Commissioned by the President’s Council on Bioethics [6] is
helpful as an overview of the debate and its history, especially the taxonomy with which the collection
begins [17] and those discussions found under the headings ‘‘Human Nature and the Future of Man,’’
‘‘The Source and Meaning of Dignity,’’ and ‘‘Theories of Human Dignity,’’ which itself focuses on ‘‘The
Nature and Basis of Human Dignity.’’

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sufficiently accomplished only by specifying a unique and weighty property or

feature of humanity or human experience. Consider the opponents’ charges of
emptiness: dignity, or what would justify talk of it, is not really ‘‘out there’’ at all.
Thus, philosophical claims appealing to this foundational value are sloppy, merely
hand-waving, or trading on ambiguities. An adequate analysis of dignity must
clearly and precisely give a definition of the concept that can be justified by appeal
to what there are good empirical or moral reason to believe is true of human beings.
Consider also internal disagreement between different camps on the proponents’
side of the debate that primarily concerns which particular property, or perhaps what
kind of property (i.e., natural capacities, natural vulnerability, or non-natural
properties), is taken as the source of this foundational moral worth.5
The second characteristic of the dignity debate is the assumption that a
satisfactory account of dignity yields a conception that can be used straightfor-
wardly for specific or definite normative guidance. That is, one of the conditions of a
satisfactory account of the concept of dignity is being able to demonstrate how one’s
particular conception can be used in practical argument. This is accomplished by
demonstrating that when one refers to dignity in argument, one reaches discrete,
clear prescriptions that either cannot be reached or cannot be reached as directly or
easily as by employing other basic normative principles or concepts.
Consider the starting point for Macklin’s argument and her charge of
redundancy. First, her suspicion about the concept of dignity is motivated and
funded by the ubiquity of its use. That is, she begins by noting, as cause for
suspicion, that people who have different positions on the permissibility or value of
particular policies all cite dignity as a point in favor of their respective views, most
famously in discussion of aid-in-dying and abortion. Taking this feature of the
discussion as evidence for concern about the concept implies that the aim of
referring to a particular normative concept should be to reach a clear, discrete,
normative conclusion. The charge of redundancy takes this assumption one step
further by insisting that not only should a moral concept be able to be used in
argument to reach particular normative conclusions, but it should also have
something to say by way of normative guidance that other principles or concepts do
not say.
The shared assumption on both sides of the debate is that the concept of dignity is
valuable to have in doing bioethics insofar as it can be directly and transparently
appealed to in explanation and practical argument, can provide straightforward
answers to important practical questions, and does so for practical questions that
other moral concepts or principles do not. These assumptions about the terms of the
debate are underwritten by a particular way of understanding the aim of bioethics
and the role played by normative theory or ethics in reaching this aim: that a central
(perhaps the central) aim of bioethical reflection, deliberation, and debate is to
definitively settle such questions, and that the role of normative theory in this

5
This metaphysical framing of dignity discussions is in no way unique to bioethics. The foundation of
human rights discussion has much the same character, so much so that Joel Feinberg beat me to this
observation and characterization of the parties to the discussion by at least 30 years [18].

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context is to offer moral rules or decision-procedures to apply to different practical

moral problems.
Together, the metaphysical framing of the debate and the assumed conception of
usefulness express a particular understanding of how moral argument works and
what it is for in the context of bioethics. More specifically, they assume that the
central goal of ethical discussion is to rationally compel or convince someone else
to accept some particular normative conclusion. In the context of arguments
appealing to the concept of dignity, this amounts to the goal of rationally compelling
the audience (1) to believe that some creatures in the world really have this special
value, and (2) on the basis of this recognition, to agree with some specific normative
(usually policy) conclusion. The first task is thought to be best accomplished, given
the internal logic of this conception of moral discussion, by pointing to a feature or
property of human nature or human experience, and demonstrating that this property
is both morally important and unique to those creatures that are the proper objects of
the kind of attitudes and behaviors that the recognition of dignity justifies. The
second task is thought best accomplished by showing how the particular property, or
feature-based conception of dignity, can be used as something like a premise in a
practical argument to reach a unique normative conclusion about a central bioethical
problem.
This view of the role of moral discussion in doing bioethics is both attractive and
pervasive. If dignity is a property of human nature, or grounded in a feature of
human experience, there is a solid reason to believe in it. This possibility is
especially compelling in contexts characterized by at least some degree of cultural
or moral pluralism, where, nevertheless, a common course of action must be chosen.
In these contexts, it may be especially important to justify conclusions in terms that
everyone can reasonably accept, or cannot reasonably reject. Moreover, as the
concept of human dignity concerns the basic equal moral worth of individuals, one
may reasonably care about the ability to rationally compel people to assent to its
existence. As Derek Beyleveld and Roger Brownsword explain, ‘‘If we have no
reason, there is a serious (epistemological) contingency at the base of this
conception’’ [19, p. 22]. This epistemological contingency may be thought
dangerous for a number of reasons, but most centrally, if a (good, strong) reason
to believe in the existence of dignity cannot be provided, one could choose not to
believe in its existence. Notice that the failure to be able to give a reason to believe
in its existence is another way of saying exactly what the opponents of dignity in
bioethics assert: proponents of dignity in bioethics are unable to identify something
sufficiently weighty and universal, and which is not already captured or accounted
for by other more firmly entrenched values, that can compel people to believe in
dignity.

Challenging the terms of the dignity debate in bioethics

One attractive feature of the metaphysical approach to dignity is that it promises to

provide an answer to the justification question: why believe in the moral worth of
human beings or persons, as such? If a foundational property or feature of

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individuals cannot be identified, it can justify basic egalitarian commitments to the

moral worth of all individuals. As Jean Hampton writes, the ability to answer this
justification question is often thought of as ‘‘the holy grail of normative ethics’’ [20,
p. 45]. Despite the temptation of embarking on this quest, I believe there is reason to
resist answering this question in the terms in which it is put.
An important drawback of the metaphysical framing of the debate is that it shifts
the theoretical focus away from understanding moral obligations and toward
providing sophisticated definitions that can escape counterexamples. Moreover, it
argumentatively privileges a willingness to commit oneself to extreme views for the
sake of principle. As an example, this frustration with property-based arguments or
metaphysically framed arguments about moral status can be found in the literature
engaging Peter Singer’s infamous disabled infant cases. Criticism of Singer’s
reasoning often focuses on his strategy of arguing from ‘‘marginal cases,’’ which
some regard as obtuse and others as relying on false dichotomies between which
cases are taken to be interstitial [21, 22].
Moving beyond this initial methodological drawback, I contend above that the
importance placed on securing dignity on a firm foundation is related to a concern
that the prescriptions that follow from use of the concept are only truly binding if
the concept is rooted in something substantial, preferably a verifiable property or
feature of human life or human beings. If the concept is not appropriately moored,
one might worry that a reason (of the right kind) cannot be provided to accept that
dignity exists or to comply with the norms or obligations that follow from its
recognition. Although often expressed in urgency, this worry is overstated. If the
worry is about convincing real people to act well with respect to one another, having
ready to hand a ‘‘rational’’ foundational justification is not particularly pressing, and
the lack of one not a particularly compelling problem. There are many ways to bring
about social harmony, most of which centrally involve cultivating empathy and
imagination rather than providing rational arguments. I see no reason to believe that
everyday compliance with moral obligations is enhanced by being able to justify
that they are binding by appeal to dignity, as opposed to by helping individuals
cultivate or develop a particular attitude or perspective about the moral value of
others.
This reflection highlights the extent to which the dignity debate in bioethics
assumes a particular kind of context of discussion—one in which moral arguments
are addressed to otherwise amoral rational agents, who must be convinced of first
principles in order to move forward or make any kind of progress. In contrast,
bioethics, both as an academic discipline and as a practice in health institutions,
often begins with the recognition that there are difficult, multifaceted moral
questions raised by or in the context of complex institutions that must be resolved. I
suggest, following Thomas E. Hill, Jr. and Hampton, that bioethicists should take
their interlocutors to be reflective, conscientious people, who have a wide range of
experiences that need to be made sense of and a need to resolve practical questions,
instead of amoral rational agents who need to be convinced that people and moral
problems are worth caring about at all [20, 23]. Hill makes this suggestion in the
context of discussing the nature of Kantian moral rules and normative theory more
generally, but I believe it is all the more important to recognize in discussing

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practical ethical questions and concerns which require public or collective practical
moral deliberation.
If, instead, the worry about grounding moral obligations is not about compliance
but about the justified authority of those who enforce or issue the obligations, more
needs to be said by those who adopt this metaphysical framing about why this kind
of rational assent to the foundational principles or values is required for legitimacy.
It could be that they cannot be justified in coercing compliance with policies unless
everyone can reasonably accept or (at least) not reasonably reject them. It does not
follow from this that a reductive account of dignity is necessary to assure that this is
true. There are many conceptions of legitimate authority, and a plethora of accounts
of the kind of justification needed to exercise it. Rational assent to a foundational
account of the moral value grounded in the nature of individuals is only one such
account, and quite extreme among them. Moreover, contemporary liberal democ-
racies of the kind that significantly constitute the context for the dignity debate have
increasingly come to embrace more pluralist accounts of the values that citizens
bring to the political context with respect to which legitimacy would need to be
determined.
Finally, some may worry about what is meant by ‘‘normative guidance’’ in the
conception of usefulness at play in the dignity debates. Drawing on insights from
those adopting a host of non-traditional approaches to bioethics, there is good
reason to question whether normative guidance should be understood as the ability
of a concept or value to be used as a premise in practical argument or to be
articulated as a principle or rule for general application. Virtue ethicists, casuists,
feminist theorists, and narrative ethicists, among others, have made important
contributions to discussion of the problems with this applied theory approach
[24–27]. They have argued not only against particular attempts to identify the right
set of moral rules and procedures but also against the view that having such a set
would be attractive in the first place.
I will not rehearse this discussion in full here, but two basic worries can serve as
umbrella considerations for the various concerns. The first can be expressed using
the common adage: if all one has is a hammer, everything looks like a nail. Seeing
every situation as something that can be fixed with the instrument one has ready to
hand can lead to an inappropriate (not to mention indiscriminate) hammering away.
If one is committed to the idea that the contribution of an ethical concept must be
rooted in its contribution to practical reasoning of the kind discussed above, then
one’s ethical theorizing will be solely directed to this end. The second worry is the
danger of viewing ethics as a toolbox—as providing a sundry set of instruments one
can pull out as different needs arise. Seeing ethics this way risks prioritizing
reaching an answer (either any answer or some particular answer) over
understanding the situation at hand.
Not only might this conception of moral decision-making be undesirable, it may
not be possible for any moral concept or moral theory to play such a role in practical
deliberation—either for individuals or for scholars and stakeholders engaged in
more public or collective ethical deliberation. Even the strongest proponents of a
principle-based approach to moral decision-making recognize that values, rules, and
ideals must be specified to a particular context, and weighed and balanced against

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other similarly specified values [28]. That is, principles are not the kinds of things
that can be straightforwardly applied to actual institutions and cases. Thus, the
conception of normative guidance that holds as a mark against the concept of
dignity appealed to by those who reach contradictory normative conclusions is not
rooted in a realistic picture of moral reasoning.

A different kind of account of dignity for bioethics

In what follows, I take up the suggestion that bioethicists give up our quest for the
grail and, instead, adopt a new way of thinking about the nature and importance of
the concept of dignity for bioethics. The considerations offered in the section just
above do not necessarily tell in favor of skepticism about the value of dignity for
bioethics, but instead, they tell against giving an account of the concept in the terms
set out by the debate. Here, I begin the project of articulating an alternative
conception.

Dignity and appeal to respect for persons

It is helpful to start with a case in which an intuitive way of explaining a moral

wrong is as a violation of dignity: the practice of shackling incarcerated women
during childbirth. Although estimates are somewhat difficult to make accurately,
roughly 6 % of incarcerated women are pregnant, most of whom give birth while in
prison. These women are regularly transported to hospitals to give birth not only
handcuffed but also with their feet bound together and with a chain around their
bellies. While in labor, they are often not only handcuffed to the hospital bed but
their feet are often also cuffed. When they give birth, their feet are often released,
but they frequently remain handcuffed to the bed. In 2008, the federal government
passed an anti-shackling policy for women in federal custody, and in 2014, extended
this protection to women held in immigration detention centers. However, more
than 86 % of prisoners in the United States are in state institutions, beyond the
scope of these protections. Currently, 32 states have no law against shackling
pregnant women prisoners during labor and delivery, and the law is not fully
enforced in many of the 18 states that do legally prohibit it [29].
Some who defend the practice cite concern for the welfare of the community—
they believe the practice is justified because the restraints are necessary to prevent
women from harming others or themselves. But others argue—seemingly as an
explanation of the practice rather than a justification of it—that the practice was
caused by and persists merely as a bureaucratic oversight. It is an unintended
consequence of failing to think through how the policies that articulate standard
protocols governing medical treatment for prisoners should apply differently to men
and women. As incarcerated people have been overwhelmingly male, the rules
governing the treatment of prisoners have, for the most part, developed for that
population and have not been rethought for the increasing female prisoner
population.

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The practice and the justifications for it fail to respect incarcerated women as
persons, not merely their autonomy.6 It misses the point to locate the morally
troubling aspect of shackling incarcerated women during childbirth in the fact that
the women would not have chosen to be chained or that they did not, or would not,
consent to wearing the cuffs while they give birth. Even with a more robust notion
of autonomy, the moral wrong is not fully explained in terms of lack of self-
determination, even though being shackled during childbirth is likely a deep
violation of the women’s ability to lead their lives according to their own values and
principles. Moreover, the wrong-making feature of this practice is not best or solely
described in terms of paternalism or failing to respect the autonomy of incarcerated
women as patients. It also misses the point to locate the moral wrongs only or
primarily in the potential physical harm to the woman or the child. Merely citing
empirical evidence regarding the significant negative health outcomes for the
woman and her child does not fully explain what is morally troubling about this
practice, thus principles of non-maleficence similarly do not exhaust the moral
problems. This practice is morally troubling because the women are regarded in
solely instrumental terms. This can be seen clearly both in the justification that sees
the women only as potential threats to the community (and not as patients, or
pregnant bodies, or women) and in the explanation that writes the practice off as
bureaucratic oversight, as they indicate that the women do not even rise to the level
of consideration as people, as subjects of lives, in the eyes of those enforcing the
policies.
Elizabeth Spelman makes a helpful distinction between two senses of treating
someone as a person [31].7 In the first, and more pervasive sense in moral
philosophy, treating someone as a person involves recognizing her as a bearer of
rights, and as such, as owed particular treatment. The second sense, perhaps more
familiar from everyday interaction, can be thought of treating and recognizing
someone as ‘‘the person one is.’’ Respecting and treating someone as the person she
is involves making an effort to understand her self-conception, over which she has a
kind of practical authority.
Recognizing an individual as a bearer of rights risks ignoring ‘‘the person she is,’’
as recognizing her as a rights-bearer may require abstracting away from the
particular features of the individual and her circumstances in order to classify her as
6
Recognition of the need for a notion of respect for persons or respect for autonomy that is better able to
capture and attend to the value of particular selves (embodied, and historically and socially situated) is not
novel. The notion of relational autonomy has been central to the development of such an account, and
bioethicists who employ and develop the notion are a valuable source of insight in this area. See
Mackenzie and Stoljar’s volume for such contributions [30]. As such, the notion of relational autonomy
suggests a similar value to the value of dignity I hope to point to here. At the same time, I believe the
discussion of relational autonomy does not exhaust the content of the notion of dignity at play in these
examples, as relational autonomy tends to privilege particularity and the construction of selves through
relationships and in the context of institutions and practices. Here, appeal to dignity is pointing to how we
share particularity. Asserting dignity, or recognizing that dignity has been violated, involves recognition
that we are all individuals who lead particular lives and occupy particular social roles (whatever those
may be) from the inside.
7
I have focused my attention on the notion of respect for persons, which departs, in some ways, from the
broader dignity debate’s discussion of both human beings and persons. Below, I consider how the view I
suggest here may be useful for thinking about moral obligations with respect to non-person human beings.

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a certain kind of thing. For example, and resonant with the metaphysical framing of
the dignity debate above, to recognize and respect someone as a rights-bearer may
be to identify her as having or manifesting a particular property, say, rationality, and
on that basis, as subject to particular rules or obligations. To do so, one ignores the
particular things about her that make her who she is rather than someone else.
Moreover, it is often the idiosyncratic, incidental, or particular features that make
her who she is from her own point of view. Her demand to be treated as a person,
then, may be a demand that others recognize who she is (in her full complexity), and
not merely what she is (a creature with a particular property).
In reflecting on these two notions of respect for persons, one may first be struck
by how the particular properties and features often appealed to in the first sense are
or can be problematically androcentric, racist, heteronormative, and ableist. This is
an important and familiar concern from feminist theory and critical race theory
about who is excluded and who is included by conceptions of properties that confer
moral worth and status. Beyond this concern, Spelman’s discussion illuminates that
regardless of which property is identified, there is a worry that this way of
understanding respect for persons involves organizing one’s treatment of others
according to and on the basis of general properties they happen to have, rather than
according to the particular features and details of their individual identities, which
often are the things that someone most identifies with about who they are (again in
contrast to something like, say, being a rational agent).
At the same time, recognition of the person one is as a standard for ‘‘respect for
persons’’ is an overwhelming obligation in practice. As Spelman highlights,
attending to individuals as the persons they are can be incredibly demanding, to the
point that doing so would make it impossible to navigate our everyday interactions.
If buying a coffee required attending to the this-person specificity of each barista,
how could you make it through morning coffee, let alone the rest of the day? [31]
Given our interest here in a notion of dignity that can be useful for bioethics, an
account that embraces the second sense of respect for persons may, then, seem like a
non-starter—as the kind of attention, concern, and insight one would need in order
to do so for everyone with which one interacts is not possible.
However, recognition of individuality, specificity, and particularity as the core of
something like respect for persons (or self-respect) is taken up and developed by
many.8 Following this line of inquiry, my suggestion is that calls for concern for
dignity in policy-making or protests and demands that one be recognized as having
dignity, call for recognition of a certain kind of equal status (akin to ‘‘rights-bearer’’
in the discussion above), but not merely to be recognized as instantiating a particular
property in virtue of which one has this status. Rather, concern for dignity can be
understood as concern to recognize individuals as subjects of lives or selves. In this
sense, concern for dignity is concern for individuals as beings that have particular
bodies, histories, values, desires, beliefs, social contexts, and worldviews. Recog-
nition of dignity need not require, in every context, full understanding of the
particularities of each particular person’s identity, but only that the individuals at
issue are selves rather than bare particulars or ideal rational natures. My aim is not

8
My discussion here is informed most directly by Robin Dillon and Seyla Benhabib [32, 33].

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184 C. Morrissey

to claim that ‘‘individuality’’ is the property that confers the value of dignity (as if to
replace ‘‘rationality’’ with ‘‘individuality’’). Instead, I suggest that concern for
dignity involves calling on people to adopt a particular point of view on others—as
concrete particular selves who are subjects of a life.
Returning to the example above, the claim ‘‘shackling the pregnant prisoners is
wrong because it violates their dignity,’’ may be saying that the policy, or perhaps
particular actions of shackling, are wrong because they express or manifest
blindness to the women as selves or subjects of lives. It reduces them to bare
particulars (i.e., as threats to the community because they are criminals) and refuses
to recognize relevant features of them as individuals who are experiencing a
significant life event, from the inside (i.e., they are giving birth while incarcerated,
they may not have an opportunity to see or interact with the child after giving birth,
and they will experience the childbirth in a way fundamentally different than other
women in the same community experience childbirth, which likely threatens or
undermines their conception of themselves as women and as mothers).
Notice that this kind of violation is something that both individuals and
institutions can commit. We can also, as individuals, fail to recognize that someone
we are interacting with is some particular person, in addition to failing to recognize
the particular person that they are. When one criticizes a person, practice, or policy
for violating dignity in this way, one is calling on the individual or institution to
recognize that individuals are selves, not bare particulars or loci of rationality, by
behaving consistently with that recognition or by designing policies or practices that
are consistent with that recognition.

Attitudes, commitments, and perspectives

Appeals to dignity that indicate the need to see others (and ourselves) as selves
rather than as bare particulars or as ideal rational natures raises an important
question: what does the claim or judgment ‘‘dignity has been violated’’ amount to if
not a claim about a property from which one can derive rules or principles for
appropriate treatment? There are at least three alternative conceptions of the nature
of such judgments or claims that may prove fruitful for doing bioethics. Below, I
explore each of these alternatives, which I will refer to as (1) the attitude view, (2)
the commitment view, and (3) the reflective perspective view, respectively. I
understand all three approaches as genuine alternatives that avoid the metaphysical
morass discussed in the first part of this paper and, at the same time, can provide
relevant normative guidance. As such, they are each potentially valuable for doing
bioethics well. That said, below, I provide some reasons in favor of the third, the
reflective perspective view, as the most promising on the grounds that it encourages
us to think more broadly and richly about what doing bioethics means.
Beginning with the attitude view, one approach to rethinking dignity—or more
precisely, rethinking the nature of judgments that dignity is violated or respected in
a particular case—is to manifest an attitude of a particular kind. Both Joel Feinberg,
in discussion of the foundation of human rights, and Bernard Williams, in ‘‘The Idea
of Equality,’’ offer conceptions of dignity of this kind [18, 34]. Feinberg refers to
respect for humanity, or dignity, or belief in the equal moral worth of individuals, as

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The value of dignity in and for bioethics: rethinking the… 185

an ultimate attitude, not justifiable in more fundamental terms. To explain the sense
in which it is an ultimate attitude, he gives an analogy to parents’ love for their
children. The attitude is natural in the sense that most normal people ‘‘fall into it.’’ It
is something one finds oneself with, and that one gives as a reason for one’s actions,
but which stands in no need of grounding or justification in something more
foundational. When one asks a parent, ‘‘why do you love your child?’’ one might
expect a somewhat befuddled response on the parent’s part. ‘‘Because she is my
child’’ seems to be the right answer, and one can expect the request for further
reasons to be met with confusion. This kind of ultimate attitude can justify behavior,
and it can make it the case that certain kinds of actions of individuals are
appropriate, or not. Asking ‘‘why did you give her a hug when she was sad?’’ can
similarly be sufficiently answered by ‘‘she’s my kid.’’ In this way, the attitude can
serve as a reason that we recognize in acting and in our evaluations of what is
appropriate. The attitude is, thus, normatively guiding for those who have or adopt
it.
From the point of view of identifying an account of dignity that helps one do
bioethics well, one may worry both about an account that relies on the supposed
naturalness of the attitude, and the merely causal path to the belief about the nature
of others as selves. We want to do something with the judgment that dignity has
been violated. The attitude account of what it means to believe in dignity seems to
end the discussion by simply explaining the fact of having the attitude rather than
providing resources for doing normative work or making normative claims. People
may be advised to adopt this attitude, or institutions may be forced to manifest the
attitude, but neither opens up a great deal of room for theoretical or moral discussion
and deliberation. One either has the attitude or one does not, and the idea that it is
obtained through a causal process does not invite significant discussion or
deliberation about whether to adopt the attitude or whether the recommendations
on its basis are worth taking up or even taking seriously.
On the second alternative understanding of the nature of dignity judgments, the
commitment view, belief in dignity is a kind of fundamental commitment of
institutions or individual members of particular groups. This view begins by taking
seriously the important role that the attribution or ascription of dignity seems to play
in the political arena, especially foundational rights documents that begin from the
recognition of dignity. It draws from this observed practical role that upholding or
protecting dignity is a commitment a particular community or group of people, or
their institutions, have made. In this sense, it is either a promise that one will govern
the relevant institution or behavior according to the value of the equal moral worth
of individuals as such, or the adoption of an ideal according to which policy,
regulations, or practices are to be evaluated. The commitment to dignity would be
best thought of as a social convention. It would be a concept used to evaluate actions
and policies because one is a member of the relevant community or organization, or
perhaps because one is an individual who has adopted this ideal for oneself. One
may endorse this social convention out of a sense of solidarity either to other
members of one’s present community who have also committed to so doing or as an
obligation to those in past generations to uphold and protect things of value they

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have built or created, out of a recognition of the benefits, individual or collective,

received from them.
As with the attitude view, I think the commitment view is a potentially promising
approach to answering the question of how we come to believe in dignity. However,
it also has shortcomings, most obviously, the worry that it does not adequately
capture the context, strength, and force of demands to be treated as a person. People
often appeal to dignity in order to move institutions or individuals to commit to
governing their actions according to the equal moral worth of individuals. This
implies that there is some force to the claim ‘‘I have dignity’’ that is not merely a
reminder that one already values something or that the institution has misapplied a
rule it already endorses.
Moreover, from the point of view of a concern to identify a notion of dignity that
can help in the doing of bioethics, this commitment view appears to have only
descriptive potential. One may take the commitment, promise, or tradition as an
adequate initial description of, or hypothesis about, how the concept functions in
some contexts (for example, perhaps, a Catholic healthcare institution that refers to
human dignity in its mission), but this approach fails to give the concept a properly
prescriptive or normative role to play. This account does not indicate whether or not
taking dignity as an ideal is a good thing to do. Instead, doing bioethics with this
conception of dignity directs attention to concerns with consistency and fidelity to
the mission of institutions that do have this as a foundation. This is non-trivial: the
role of interpretation is far from easy, straightforward, or conceptually unsophis-
ticated. But it is also limited and inherently conservative.
The third way of thinking about dignity takes as the cornerstone or foundation
what Hill calls a ‘‘basic moral attitude,’’ although I will refer instead to a reflective
perspective to avoid confusion with the attitude view discussed above [23].9 By ‘‘a
reflective perspective,’’ I mean a particular way of framing or guiding moral
reflection and deliberation about practical questions. To take dignity as a
cornerstone or foundational aspect of such a framework is to say that the moral
worth of selves may be thought of as fundamental content for a lens through which
one makes sense of the moral landscape. It highlights or causes one to attend to
certain kinds of considerations, to see some values or reasons as pressing or
important, and to prioritize concern for particular aspects of the situation or context.
One can think of such perspectives as providing a starting articulation of what is
valuable, or what is to be valued or prioritized, and what constrains the kinds of
reasons that are relevant to the question asked. It is in this sense that it serves as a
moral lens, or a way of seeing the world. By explicitly emphasizing the notion of
reflection, I mean to indicate, following Hill, how this perspective is not presented
as a self-evident truth, or even the result of moral calculus or proof. Rather, it is a
starting point and context for decision-making, which is itself open to moral
evaluation, revision, and development, and which stands in need of articulation and
specification in context.

9
Gerhold Becker also suggests and begins to develop an account of dignity that takes it as a foundation
or cornerstone of a basic moral attitude [35].

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The value of dignity in and for bioethics: rethinking the… 187

Reflective perspectives, understood this way, provide normative guidance.

However, such guidance is not direct normative prescription. Instead, it assumes
that particular questions of policy, practice, or procedure require thought and
deliberation. The approach emphasizes discussion and reflection rather than action.
Thus, it calls for promoting and valuing contexts in which people—both theorists
who are reflecting on practices and institutions, and individuals who more directly
participate in them—can ‘‘figure things out,’’ so to speak. This suggests that the role
of bioethicists is to be facilitators of robust and meaningful deliberation and debate
rather than experts who provide answers to questions already on the table.
As my aim here is to suggest the potential of this approach, examples can be
helpful for explaining what it would mean to adopt this reflective perspective. In
The Upstream Doctors, Rishi Manchanda recounts the story of his patient Veronica,
a woman who suffered for years from headaches [36]. Manchanda’s practice
includes, as part of standard ‘‘in-take,’’ a short series of questions aimed at gathering
information about the broader environment and living conditions of their patients (a
non-standard practice). By asking Veronica not just about where her head hurt and
for how long but also about what her apartment and work place were like,
Manchanda was able to diagnose her condition as chronic nasal allergies and
congestion, made worse by the mold, dampness, roaches, and other features of her
substandard housing. Veronica was then connected with two community organi-
zations—a tenants’ rights advocacy organization and a community development
agency that works to create affordable housing in part by training residents to
become community health workers. As a follow-up, rather than having Veronica
come back to the clinic, a community health worker went to her home to teach her
strategies for controlling dampness and to help her write a letter to her landlords
explaining their legal obligations with respect to these aspects of the property.
Manchanda’s practice has developed creative interventions for addressing their
patients’ health concerns, revising what information they seek from their patients
during routine appointments, rethinking the nature of ‘‘medical treatment’’ and the
purview of physicians located ‘‘in the clinic,’’ and partnering with community
organizations relevant to interventions aimed at the social determinants of health.
This creativity comes in part, I suggest, from instituting practices that require seeing
their patients as the persons they are. In this case, their patients are not merely
bodies with sets of symptoms, although they are that. Their patients are also
individuals who live particular lives, in particular places, characterized by certain
kinds of social and economic conditions, and with particular mechanisms for access
to information and the development of strategies for addressing and controlling
those conditions. The creativity of this approach is born not from the application of
rules derived from the concept of dignity but from the different kinds of questions
one asks, and the concerns that one prioritizes, when adopting a moral framework
that takes as its foundational concern patients as individual selves.
I turn now to what it would mean to adopt such a perspective as a bioethicist
rather than as a clinician or direct-care provider. At the most basic level, adopting
this perspective in the context of theoretical discussion and reflection would turn
attention to the ways in which institutions relevant to bioethics—healthcare,
scientific research, public health, environmental protection—construct selves, or

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otherwise communicate or manifest views about the nature or worth of individuals.

This would not only change the kinds of concerns raised in the context of traditional
and long-standing topics in bioethics (i.e., the nature and importance of informed
consent) but also reprioritize as central, rather than peripheral or incidental, a host of
topics or concerns: health inequities and the social determinants of health, the social
bases of self-respect or self-worth, obligations with respect to children, and the
claims of children and the elderly.
For example, in discussions of patients in persistent vegetative states, the
reflective perspective approach would not necessarily privilege or make central
concern for the current cognitive capacities of the individual or any other particular
property they may or may not have. Instead, it encourages thinking about them as
selves who lived lives with certain histories, concerns, values, beliefs, and
relationships with others. Doing so may lead to discussion of many different moral
issues beyond the content of particular advanced directives, to the nature of
advanced directives themselves and the relationship between patient and physician
they manifest.10 Or, such a perspective may draw attention to the nature of and
potential for humiliation, which is intimately tied to recognition of the individual as
a self [38].
One may object that my account cannot do all that proponents of dignity in
bioethics have called on the concept to do. Namely, it will not be able to capture
direct moral concern for non-person human beings, for example, anencephalic
infants. This is an important worry, and in responding to it, I hope to highlight the
important features of the view I am advocating.
Against a view that makes respect for persons central, the objection is raised that
concern for non-person human beings is merely ‘‘indirect’’ (for example, they are
understood merely as the object of love or concern for a human person, or merely as
an object with respect to which one should manifest certain traits of character). The
worry is often that non-person human beings are being taken as less morally
valuable than human persons or as morally equivalent to non-human animals or
mere things. However, within a reflective perspective, the importance of whether or
not the moral concern for non-person human beings is ‘‘direct’’ is already somewhat
mitigated, for moral obligations are not understood to derive directly from a
recognition of moral status or particular moral properties that confer this status. So,
in advocating this view, I am suggesting that whether someone is a ‘‘person’’ need
not be the first or primary moral question, and the kind of view I am suggesting
makes no commitment to claims about moral status derived from or dependent on
this categorization.
Merely recognizing that this kind of account is not in the business of providing a
test for moral status does not show that it can adequately or fully address this
concern about non-person human beings. Instead, the objection calls for some
indication of how someone adopting this reflective perspective would understand
and approach these ethical issues. To that end, it is important to return to the heart of
my suggestion: that bioethics embrace the importance of recognizing individuals as

10
See Adrienne Asch’s discussion of revising the current approach to advanced directives in the context
of the disability rights critique of end of life movement as a model of this kind of analysis [37].

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particular selves, as subjects of lives. Anencephalic infants do not appear to be

subjects of lives in any robust sense. However, we can see in each of these children
a particular, concrete, human creature with a life (no matter how short), and
recognize in them the loss or absence of this subjectivity valued in ourselves and
others, including the loss of a future in which they become particular ‘‘selves’’ of the
kind discussed above. This recognition can call on us to attend to and honor the grief
of their parents and families, and can help us re-center discussions about the dead
donor rule and the potential use of these children for organ donation away from
necessary and sufficient conditions for ‘‘brain death’’ and toward a useful notion of
‘‘loss’’ in this context.11 It may also prompt calls to extend and enrich the
conception and nature of the palliative care such infants receive (including required
training for the health professional involved) to include care for grieving parents and
family.
Having used particular cases to indicate the usefulness of this reflective
perspective for bioethics, I want to conclude this discussion by reflecting more
generally on why adopting it in bioethical deliberation, including scholarly
discussion, may be especially important in order to temper the way in which the
contexts central to bioethics are currently framed. The nature of the institutions at
issue (i.e., medicine, public health, environmental protection, research funding,
human and nonhuman animal subjects research, etc.) invites and incentivizes
adopting what may be called an ‘‘efficiency-privileging perspective.’’ These
institutions are large and often anonymous. They serve, govern, and employ a
number of different people at different levels of accountability. Such systems need
rules and policies to make clear who is responsible for what kinds of decisions, and
to make decision-making consistent across different levels and domains as well as
responsive to the values and aims of the institutions. This requires specified, clear-
cut procedures for decision-making (i.e., the UNOS organ allocation procedure), the
operationalization of certain moral values (i.e., a hospital’s standard informed
consent document for any invasive procedure as a mechanism for meeting the
requirement to respect patient autonomy), and reliance on metrics for measuring
procedures and outcomes suited to (relatively) quick, consistent, transparent
decision-making (i.e., the Medicare Physician Fee Schedule).
Such an efficiency-privileging perspective is, perhaps, essential to the basic
functioning of the kinds of large-scale bureaucracies central to bioethics. However,
it is not the only apt lens through which to evaluate or prescribe actions and policies
within these contexts. Moreover, as a framework, it too is open to reflection and
revision, which may be best accomplished in conversation with a framework that
privileges the value of individuals as the selves they are.12 A reflective perspective
that takes dignity as a cornerstone would be especially concerned with evaluating
instrumental attitudes towards individuals, and the adequacy of the metrics utilized
for capturing it, and should be valued and promoted within these various
11
Jay Rosenberg introduces a distinction between ‘‘death’’ and ‘‘loss’’ in the Preface to the second
edition of his Thinking Clearly about Death. It is his notion of loss that I have in mind here [39].
12
See Erik Parens’s discussion of the value of a ‘‘binocular habit of thinking’’ for a richer defense of the
value of being able to occupy potentially conflicting stances, perspectives, or ways of understanding a
problem or issue [40].

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190 C. Morrissey

institutions. Furthermore, there are likely many reflective perspectives valuable in

doing bioethics. A moral perspective, for example, that takes as foundational and
thereby highlights and articulates the value of community, group membership, and
collective goods, aims, and projects may also be important.

Conclusion

I hope to have advanced the discussion of the usefulness of the concept of dignity in
and for bioethics in two ways. First, I have relied on insights from methodological
critiques of traditional bioethics to organize, highlight, and ultimately undermine
two features of the dignity debate in bioethics. Second, I have suggested that
bioethics can benefit from thinking about concern for dignity as calling for respect
for persons as the individuals they are, and as a central aspect of a reflective
perspective or basic moral attitude.
Understanding concern for dignity as a cornerstone of a reflective perspective of
this kind emphasizes the importance of deliberation rather than efficient decision-
making about discrete moral questions. In this way, this approach (not only the
substance of this particular perspective) challenges the dominant decision-making
mode of the institutions central to bioethics. Although it is not possible to engage in
the kind of reflection encouraged by this approach in every interaction, it suggests
the importance of one of bioethics’ roles as a field.
My approach understands moral or ethical theory as centrally concerned with the
framing of moral considerations and guiding moral attention. In this, it is
importantly different from the metaphysical approach to dignity. Insofar as the latter
privileges the way in which the concept can be used to arrive at unique answers, it
seems to presuppose that bioethicists already know what the questions are, and
which are most important. Understood in this way, moral theory is normatively
guiding because it can be used to determine answers to questions that can be readily
identified as the important or pressing ones to ask. In contrast, the reflective
perspective approach holds that moral theory provides normative guidance by
helping bioethicists identify and ask new questions, to see and attend to what is
morally important about the situations faced, and by providing terms in which to
figure out, through discussion and reflection, how to navigate those situations.

Acknowledgments I had the good fortune to present this work in many different venues. I would like to
thank audiences at the Feminist Association of Bioethics 2014 World Congress and the ASBH 2014
Philosophy Affinity Group Meeting. I am especially grateful to Josephine Johnston, Gregory Kaebnick,
Erik Parens, Dylan Sabo, Daniel Sulmasy, Kristi Upson-Saia, and the anonymous reviewers for this
journal for their insightful and helpful feedback on earlier versions of this argument.

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