Dignity, Health, and Membership: Who Counts as One of Us?

Abstract

This essay serves as an introduction to this issue of the Journal of Medicine and Philosophy. The five articles in this issue address a range of topics from the human embryo and substantial change to conceptions of disability. They engage claims of moral status, defense of our humanity, and argue for an accurate and just classification of persons of different communities within a healthcare system. I argue in this essay that though their concerns are diverse, the authors in this issue help to answer a common question: “Who counts as one of us?” Reading these articles through the lens of membership and the themes of dignity illustrates this commonality and bears fruit for further reflection on many of the challenging issues addressed in the subsequent papers.

I. INTRODUCTION

Who counts as one of us? As simplistic as this question may appear, its analysis is complex. The question is perennial. A wide variety of theorists have offered answers and explanations. For example, why does Aristotle posit a metaphysical biology, however problematic it is? Why does John Rawls take pains to articulate descriptions of persons as political and not metaphysical? Moreover, any particular answer to this question will have serious and far-reaching implications. Consider, for example, how one might explain the hypothermia experiments of the Nazis or the medical testing of children at the Willowbrook State Hospital. Were such experiments morally permissible since research subjects lacked full moral status as persons, either because they were members of the wrong ethnic group or because they lacked fully formed rational capacities? Or, more likely, were these experiments exemplars of significant wrong-doing, precisely because research subjects should have been properly protected as human persons? While the five articles comprising this issue of the Journal of Medicine and Philosophy are written from the perspectives of distinct disciplines to address various topics, they all respond to this central question: “Who counts as one of us?” This is the question of membership.

Though this question is raised more explicitly in some essays, considerations of membership are central to each author’s moral, social and political exploration. For example, Shane Wilkins (2016), Andrew McGee (2016), and David Alvargonzalez (2016) each recognize that considerations regarding membership are bound up with questions regarding the moral status of developing human beings. The boundaries of “Us” and “Them” also shape appreciation of our moral and political duties to others. Elizabeth Rata and Carlos Zubaran (2016), for example, explore the implications of the social creation of ethnic classifications, cultural concepts of disease, and political divisions for health outcomes within the Maori community of New Zealand. Jonas-Sébastien Beaudry (2016) turns our attention to the normative implications of concepts of disability. Conceptions of ourselves as members of particular groups affect what we think of as “normal” or as properly functioning.¹ In each case, the question of membership engages the recognition of status, protections, and obligations.

Medicine explicitly draws out such concerns because of our intimate regard for our own health and the health of those about whom we care most. Beings who are considered to be similarly like us are more likely to be treated in a manner consistent with how we would treat ourselves, a manner indicative of full moral status. What features must one possess in order to be considered relevantly “like us”? Aristotle thought that the limits of a proper community, a polis, were the number of persons who you could recognize. Commentators today often draw such membership distinctions in terms of what it means to be a fully rational contractor (Scanlon, 1998) or perhaps a member of a properly just society (Rawls, 1999). Here, advocates often claim that such recognition grounds arguments for just access to health care (Daniels, 2008) but permits abortion, human embryo research, and infanticide (Singer, 1993). Others urge us to recognize that such special protections (i.e., membership) should extend to human embryos, children, and the mentally disabled, as well as fully rational adults (Congregation for the Doctrine of the Faith, 2009).

My aim in this introduction is to offer a lens through which we might better appreciate the central arguments offered in the following articles. I read these articles through the lens of membership, with a brief exploration into the concept of dignity. The concept of dignity is a fitting focus for exploring the concept membership, as it exemplifies considerations of membership in the human moral community. This exploration is by no means exhaustive but is meant to assist the reader in drawing connections between the claims and arguments of these articles and to suggest further points for reflection. To this end, I begin with a conceptual geography of relevant considerations of membership and three themes of dignity, which I characterize in terms of violations.

II. MEMBERSHIP

A paramount concern for any moral theory is the set or sets of beings it holds to be relevant. Moral theories often focus on human beings as a whole or some subset of human beings, such as reasonable and rational persons.² Examination of membership in this prized class requires not only asking, “Who counts as one of us?” but also, “In virtue of what do they count?” Answers to these questions are not exclusively the concern of theorists because these answers have serious practical normative implications. For example, the qualifications for membership will affect how to understand disability and what model of it is best, as well as how to understand important distinctions within a particular population (e.g., ethnicity), their relevance, and how they should be accounted for in health policy analysis.

Notice the distinct normative implications of several possible accounts of membership. First, consider a contractualist answer that prizes “reasonable rejection” as the standard for moral evaluation. T. M. Scanlon argues, “An act is wrong if its performance under the circumstances would be disallowed by any set of principles for the general regulation of behavior that no one could reasonably reject as a basis for informed, unforced general agreement” (Scanlon, 1998, 153). Members are persons with moral standing,³ and Scanlon settles on those beings that are capable of making judgments (Scanlon, 1998, 179)⁴ as the class of creatures that should be considered because they can be wronged and because we can stand in relation to them. “Reasonable rejection” might be a fine standard, but how does one employ this notion with regard to beings that cannot yet or no longer have the ability to make judgments? Does it allow for dangerous or painful experimentation on children, for example, if proxy consent is given? Does it permit, given scarce medical resources, euthanizing the elderly with Alzheimer’s Dementia? It is not only members of the moral community that must be treated morally. Moreover, why does moving into and out of full capacities of judgment change a person’s moral status?

Consider a second example of contractualism: the position John Rawls takes in A Theory of Justice (Rawls, 1999). Rawls aims to guarantee the fair and equal consideration of all members of society. The structure and substance of Rawls’s theory needs little rehearsing, but what he claims about members is worth highlighting:

It is postulated though that the parties are moral persons, rational individuals with a coherent system of ends and a capacity for a sense of justice. Since they have the requisite defining properties, it should be superfluous to add that the parties are equally moral persons. We can say if we wish that men have equal dignity, meaning by this simply that they all satisfy the conditions of moral personality expressed by the interpretation of the initial contractual situation … (Rawls, 1999, 289)

Rawls’s answer to the membership question is that not all beings count but only those who are rational and possess certain ends and capacities. He concludes: “… to respect persons is to recognize that they possess an inviolability founded on justice that even the welfare of society as a whole cannot override” (Rawls, 1999, 513). This inviolability only applies to members, that is, to the reasonable and rational. But what of individuals that Rawls holds to be “unreasonable”? Or, those who lack the requisite rationality, such as young children? May a healthcare professional assist in the death of a patient in the event that a patient lacks rational capacities? Does justice not apply to those beings? Is experimentation on embryos permissible on this view? Is abortion? It is worth noting that Rawls often rules out religious understandings and other comprehensive doctrines as “unreasonable” on very thin grounds. For example, as Christopher Tollefsen and Mark Cherry have pointed out, Rawls concludes that any objection to abortion based on the humanity of the fetus is unreasonable:

In Political Liberalism’s brief discussion of abortion, for example, Rawls argues that agents who accept the humanity of the fetus can do so only on the basis of a ‘comprehensive doctrine,’ which, precisely because it rules out abortion, is ‘unreasonable’ from the standpoint of public reason and thus unacceptable in the public square. (Tollefsen and Cherry, 2003, 538; cf. Rawls, 1995)

Claims of rationality and reasonability are surely worth consideration, but they are neither neutral nor above the burden of proof.

In contrast, as a third example, consider how the Catholic Church’s Congregation for the Doctrine of the Faith draws the relevant criterion for membership from the fact of a shared humanity, rather than on the exercise of rational capacities. For example, they begin a recent instruction on bioethical questions as follows:

The dignity of the person must be recognized in every human being from conception to natural death. This fundamental principle expresses a great ‘yes’ to human life and must be at the center of ethical reflection on biomedical research, which has an ever greater importance in today’s world. (Congregation for the Doctrine of the Faith, 2009, 3)⁵

The relevant membership class under consideration on this view is wider than that considered by Rawls or Scanlon. This clearly affects who is treated in what manner while also informing the kind of treatment that is appropriate. Understanding ourselves to be like others who might have very different ways of actualizing human capacities changes the way we think about ourselves and forces us to think beyond certain other types of restrictions.

In order to give moral priority to one or another set of beings, we must explain why it is that this set of beings is privileged. Whether this distinction is between zygotes and embryos, human organisms and persons (Alvargonzalez, 2016; McGee, 2016; Wilkins, 2016), Maori and non-Maori [a distinction discussed in Rata and Zubaran (2016)], or the so-called “normal” and “disabled” (Beaudry, 2016), an explanation must be given.⁶ This usually involves an argument about a feature or set of features that the privileged beings have in common. For example, one might claim that all human beings possess dignity because they are biologically human. Another might claim that all beings, regardless of their “humanity,” possess dignity if and only if they meet some requisite level of rationality. These two sets of classifications create divisions for the purposes of understanding issues of membership either on the basis of biological or psychological properties.⁷

Of course, these are not the only ways to conceive of properties of membership. The aforementioned contractualist positions might best be thought of as political, whereas the position of the Congregation for the Doctrine of Faith might be categorized as theological. Such distinctions could also be described as psychological versus metaphysical. The latter has historically received much attention in moral philosophy and undergirds many accounts of dignity. The concept of dignity⁸ is often invoked in contexts where membership in the human community is under consideration. Those who employ dignity in such contexts often face criticism, as dignity is appealed to both as a ground for the equal treatment of persons and as denoting those lives which are the best kinds of human lives. These two essential roles that dignity plays, its egalitarian and meritorious roles, illustrate a tension within the different employments of the concept, and within the concept itself.⁹ Whether a patient with a possibly fatal heart condition should cease taking his medication with the hope that death will keep him from a certain decline into dementia is a fitting case to consider (Schulman, 2008).¹⁰ Does living a dignified life require avoiding undignified demented behaviors or does reflection on dignity force an understanding of all human persons as equal regardless of such behaviors? Does dignity apply to only the best human lives or to all who live human lives?

Robert George and Patrick Lee offer an account of dignity, which seeks to satisfy both considerations of humanity and of rationality.

These basic, natural capacities to reason and make free choices are possessed by every human being, even those who cannot immediately exercise them. One’s existence as a person thus derives from the kind of substantial entity one is, a human being—and this is the ground for dignity in the most important sense. Because personhood is based on the kind of being one is … one cannot lose one’s fundamental personal dignity as long as one exists as a human being. (George and Lee, 2008, 410)

A benefit of an account focused on human nature is that one can make strong claims about the necessary and sufficient conditions of membership while extending membership to beings that might satisfy the conditions to lesser degrees or in different manners. Another benefit of this account is that by tying dignity to a being’s nature, an account of dignity can do justice to the element of equality—all beings with that nature possess dignity equally because they possess that nature to the same degree—and the element of merit—beings with this nature do things which make them worthy of dignity and the treatment it entails. This benefit and the reasons for it will be addressed further in the next section.

George and Lee claim that dignity “refers to a property or properties—different ones in different circumstances—that cause one to excel, and thus elicit or merit respect from others” (George and Lee, 2008, 409–10). Because human beings have this property—insofar as they excel other beings, especially other animals, because of their rational capacities—our treatment of them is restricted in certain ways, for example, we incur commitments such as: “… (1) the obligation all of us have not to kill them, (2) the obligation to take their well-being into account when we act, and (3) even the obligation to treat them as we would have them treat us” (George and Lee, 2008, 409). Thus far, this appears to be exactly the kind of account needed to do justice to the meritorious element of dignity. Further, they posit, “all human beings, regardless of age, size, stage of development, or immediately exercisable capacities, have equal fundamental dignity” (George and Lee, 2008, 409). And so, we have the kind of account needed to do justice to the egalitarian element, as well.¹¹

The possession of certain capacities, as opposed to the exercise of those capacities, is sufficient for the possession of dignity. To emphasize that their account of dignity does justice to the meritorious requirement, George and Lee take care in contrasting the nature of human beings and the natures of other beings. They write, “The dignity of a person is that whereby a person excels other beings, especially other animals, and merits respect or consideration from other persons” (George and Lee, 2008, 410). In this issue, Alvargonzalez engages the work of George and Lee raising questions about the accidental and necessary characteristics that define us as human beings. He argues that the transformation of a human zygote into an implanted embryo involves a change in substances and has significant moral implications: somatic indivisibility is essential to implanted embryos, a feature that is not present in morulas or blastocysts. Wilkins, in turn, grapples with George and Lee’s position as such arguments relate to human embryonic stem cell research. If embryos are substantially different than zygotes, as Alvargonzalez concludes, is this sufficient to show that they are members of the moral community and thus protected from being used for medical research?¹²

Defining membership and, as a result, moral community in terms of reasonable rejection, rational personhood, or human nature will give us different answers to practical moral questions, which is why answering such questions correctly is so important. How we conceive of persons and to whom we must justify our moral claims are crucial considerations. The authors in this issue raise this key question in different ways. Consider “disability,” for example. Is it even helpful to rely on such a concept, as opposed to addressing specific concerns that particular persons find bothersome (such as the inability to walk, see, or have sexual intercourse [i.e., erectile dysfunction], which may on different accounts falls under the general heading of disability)? How should we understand various approaches to health, and what kind of justification is appropriate in decisions about resource allocation, when conceptions of health diverge? In reflecting on such arguments, it is worth keeping in mind these kinds of properties as they relate to membership. Presently, I turn to the three themes of dignity to add clarity and focus to the aforementioned lens.

III. THE THEMES OF DIGNITY

Appeals to dignity can be valuable for moral, political, and medical reflection and should not be avoided because applications of the concept are challenging or because accounts of the concept differ. In fact, in many cases, appeals to dignity allow for more accurate assessment of what is going on psychologically, conceptually, and rhetorically than other moral concepts. Consider a case of experimentation. A small child has serious learning disabilities, which create a significant care-taking challenge for her parents. They enroll her in a state school geared toward assisting children with similar disabilities. The school is over-populated and hepatitis outbreaks often occur. With the rationale that the child will probably be exposed to hepatitis anyway, a doctor injects the child with the disease in order to study its effects on healthy people. What is the correct moral assessment of this case? The child’s autonomy might have been violated. However, is this the best description of what we find to be wrong with this situation? What if her parents gave proxy consent? The child appears to have been battered, but this description does not fully explain what happened to her and why it was wrong. Describing the situation as a violation of the child’s dignity does better. Appeals to dignity require an understanding of the child as a member of a particular community, the human community. She is used as a test subject in an experiment that will not benefit her directly, and so she was treated in a manner that members of this community—given the kind of beings that they are—should not be treated. Further, this is only socially, politically, and practically feasible because of the lack of respect given to those with the child’s disability. Many instances such as this occurred at the Willowbrook State School in the 1960s.¹³ Children with significant disability were treated as less than full members of the human community.

The best way to understand disability, given competing models, and whether we should retain the concept at all, are taken up by Beaudry in this issue. Beaudry argues that there are no conceptual costs to abandoning the concept of disability all together though there are political costs (Beaudry, 2016). The umbrella term “disability” might be useful for mobilizing political support or for advocacy and activism-related reasons, but conceptually nothing is added by employing it. Consider again the child in the Willowbrook example. The failure to recognize (or respect) the humanity of the child—she is conceived of as less than what she is—gives rise to worries that her dignity has been violated. In redressing violations of dignity, it is not only the conceptual costs but also the political costs, which must be considered.

Putting to the side challenges of reconciling tensions within the concept of dignity or between different accounts of dignity, I have described dignity as a concept that is appealed to both as a ground for the equal treatment of persons but also as an idea that articulates the best kinds of lives that might be lived by human beings. Thus, dignity has both meritorious and egalitarian elements. I have also illustrated a connection between membership and dignity through, in part, a useful example of George and Lee’s human nature-focused account of dignity. I now explore three themes of dignity that help more accurately to characterize the concept. This exploration is meant to serve as a helpful illustration of the importance of considerations of membership.

First, many of us are apt to say, other things being equal, that a person’s dignity has been violated if that person is humiliated in certain ways. It might be humiliating to be thought of as the medical model directs us to think of persons with disabilities, which conceptualizes “… disability as a tragedy or problem localized in an individual body or mind, the definition and solution of which were to be provided by medical experts” (Beaudry, 2016, 210–11). However, social models of disability, as Beaudry argues, are often too suspicious of the experiences of disability and are thus similarly problematic (Beaudry, 2016). Both models, in different ways, miss the important point that human beings are the objects of their inquiry and that something goes wrong when those beings are not given the respect or deference that they deserve, or when they are not treated in a manner that conveys an accurate understanding of what they are.

Consider also the situations in which some professional guinea pigs find themselves as other possible violations of dignity: stripping for repeated prostate exams, being exposed to unnecessary amounts of radiation, or not understanding a protocol, if you are even afforded a copy, are all humiliating experiences to undergo.¹⁴ To describe such instances, for example, as acceptable merely because they were consented to, or unacceptable because consent was not properly given, misses something important. A person who moves from one medical experiment to another, consenting to one test after another, in order to feed himself and his family may not be living the best kind of human life. He may be allowing things to happen to him that are not befitting of members of his community or of the kind of being that he is.¹⁵

For clarity, consider a paradigmatic case of humiliation outside of the scope of medicine: torture. Questions about the morality of torture have engaged international attention of late. Consequentialist justifications for this treatment and careful definitional work to avoid the need for any justification has led to euphemistic terms, such as “enhanced interrogation techniques,” “walling,” and “waterboarding,” entering the common vocabulary. The almost fantastic scenarios from television shows such as “24” and films such as “Taken,” which raise questions about whether (and to what extent) this kind of treatment of another person in order to gain information about the location of a bomb or a child can be justified, are all too real. Moreover, the consequentialist rationalizations in play in these sociopolitical situations are not dissimilar from the type of reasoning often employed in justifications for humiliating medical experiments. Consider the response of the executive director of clinical pharmacology at Eli Lilly and Company when asked about the company’s use of homeless alcoholics in Phase I trials: “These individuals want to help society” (Cohen, 1996). Instances of exploitation can be missed when consequentialist claims to the greater good are the focus, especially in cases where consent was obtained. A benefit of appeals to the concept of dignity is that consent is not the final word on the matter—a person can consent to undignified treatment.

Second, other things being equal, a person’s dignity has been violated if that person is denied certain opportunities. Not having the same options as those who are relevantly like you to dress, sit where you wish, or to be heard illustrates that you are being treated as if you are not relevantly like others. Being treated in these inferior ways is to have your dignity violated, because it illustrates a misunderstanding of the kind of being that you are. Possible examples of misunderstandings of this kind are articulated well in this issue. For example, the failure to understand that some persons navigate the world differently than others affects how ‘disability’ is conceptualized (Beaudry, 2016). Similarly, classifying persons ethnically for political reasons may lead to disadvantages and lost opportunities. For example, as Rata and Zubaran argue regarding the ethnic classification of Maori and non-Maori in New Zealand’s health system: “it is in the materiality of ethnic status...that a more useful explanation of the causes of Maori health disadvantage is to be found” and not in “the political construct of ethnicity which classifies all Maori as belonging to one category with a corresponding low health status” (Rata and Zubaran, 2016, 193). Rata and Zubaran illustrate well the importance and complexity of membership. Separating such conceptual challenges from political agendas can help to clarify the issues at stake.

The violation of the dignity of persons, by not affording them opportunities that they are due, can be explained, at least in some instances, by a failure to recognize them as members of a community to which they belong. Thus, understanding the bounds of a community or the relevant qualification for membership is important. To fail to count a being as relevantly like us and so to allow for its termination is another example. The moral status of embryos is, at least in part, dependent on whether they count as one of us. In this issue, McGee continues a debate with philosopher Jeff McMahan (2002; 2007), who has argued in favor of killing human embryos for medical research. McGee concludes that Jeff McMahan “has not shown that we are not human beings in our world, and his arguments therefore cannot be used in support of the claim that, since the embryo is an organism, but we are not, we are not killed when an embryo is killed” (McGee, 2016, 166). Answering the membership question requires understanding who we are. Certain opportunities successfully to navigate the world, to acquire good health care, to live, or to thrive, when denied to human beings are plausibly understood as violations of their dignity.

The status a being possesses (see Wilkins, 2016) and whether, in fact, we are even human organisms (see McGee, 2016) are questions that demand answers. The answers to these questions are bound up with claims of membership and of dignity. For clarity, consider a paradigmatic case of denying persons’ opportunities in a way that fails to recognize them as members of the relevant class, as “one of us,” and thus is a violation of a person’s dignity, which is outside of the medical field. Places where women are denied the opportunity to engage in athletic competition, for example, to play soccer, are a particularly fitting example. The game is integral to many cultures to the point where fandom and fanaticism become inseparable. The opportunity to engage in this activity, to take part in this national pastime, is such an important good that its denial to any person is a serious offense. There are other opportunities that persons might be denied, which might also violate their dignity. For example, education allows persons to engage in more interesting projects, hold more challenging and rewarding occupations, and, in general, live lives of greater flourishing (not to mention enjoying the good of learning itself). To deny a person opportunities for education or engagement in a national pastime are a violation of that person’s dignity. Equally pressing is how we understand different levels and kinds of health care and for whom they are appropriate.

Third, many of us are apt to say that the dignity of persons has been violated, other things being equal, if they are killed in certain ways. To be murdered so that another might take what is yours suggests a failure of the robber to understand the kind of being that you are. Your membership, in this case, is misunderstood, or the terms of membership are violated. One might state that you are no longer free to engage in autonomous action or to be the beneficiary of beneficent treatment, but it is the failure to count you as one of us and to treat you accordingly which better explains the wrongness of certain killings. Consider a case in which noncombatants in a war suffer death by bombing because utilitarian calculations dictate that these deaths will destroy morale, thus bringing an end to the war and, overall, result in less death or pain or in greater satisfaction of preferences. One failure of these utilitarian calculators is that they do not consider the noncombatant as a member of their community, as similar to them in the relevant respects. This might also be the case in instances where the termination of fetuses (or even the killing of patients in a persistent vegetative state) is contemplated. This underscores again the importance of understanding who counts as one of us and the benefit of careful reflection on the arguments in the issue, in particular those from Wilkins, Alvargonzalez, and McGee. Does a developing human being possess a special moral status or the same moral status we possess? Wilkins’ (2016) critical evaluation of morally salient developmental events is especially useful here.

The paradigmatic case of killing that is a violation of dignity is murder. The killing of the innocent is surely an affront to their dignity (if anything is an affront to dignity), which is why the simple utilitarian rationalization of the killing of noncombatants is so disturbing. Situations in which killing is classified as murder are some of the most divisive within our society and pose some of the most challenging moral and political problems. Recent protests in response to situations in which citizens were killed by law enforcement agents in the United States are one such example. The paradigmatic medical cases involving killing are euthanasia and abortion. In debates over the morality and legality of abortion, who counts matters for many arguments, and for some arguments it is the pivotal consideration. Mary Ann Warren’s classic treatment of this issue is one example (Warren, 1973). If a being counts as one of us—and, as I have demonstrated, there are deep disagreements about what this means—we treat that being differently than if it does not, which obviously leads to serious consequences. Warren’s argument is a fitting illustration because the justification for abortion is dependent on whether a fetus counts as one of us; that is, whether it possesses properties sufficient for personhood. In this issue, Wilkins connects the question of moral status to morally salient developmental events and argues that appeals to moral status associated with substance ontology must invoke dispositions (Wilkins, 2016). His discussion of psychological, constitutionalist, and animalist theories is also helpful in thinking about membership. In the same vein, McGee, points out that theoretical errors drawn by McMahan, and other commentators, such as Derek Parfit, lead to problematic ethical conclusions regarding the moral status of embryos and patients in a persistent vegetative state (McGee, 2016). It is essential to recognize, as Alvargonzalez illustrates, the role that greater context and background broader theories play within such arguments (Alvargonzalez, 2016).

VI. CONCLUSION

I have argued that membership and considerations of dignity offer a useful lens through which to read the contributions to this issue of The Journal of Medicine and Philosophy. Dignity, characterized by its three themes (inappropriate humiliation, denial of opportunity, and wrongful killing), is one way to think about persons as members of a human community. Appeals to dignity often arise when we are faced with situations in which human beings are killed, humiliated, or denied opportunities. Committing murder illustrates a failure to recognize or respect the membership that we grant to those that are similar to the victim in relevant ways. That is, it illustrates incoherence in an account of membership, the qualifications for membership, or the application of membership. Murder, quite obviously, prevents someone from engaging in those worthwhile projects and pursuits that are characteristic of a good human life, a dignified life. The same might be said for certain instances of humiliation and the denials of certain opportunities, where the root of the violation of dignity is the separation of someone from a community of which they are properly a part. This is the case when some are thought of differently than others and this distinction is used to justify substandard medical care. Reflection on dignity and its three themes provides a useful lens through which to read and reflect on in the arguments in the following five papers. Each paper, in its own way, takes up the question, “Who counts as one of us?” and, in so doing, engages deep moral, political, and social issues bound up with the practice of medicine.