Dependence and a Kantian conception of dignity as a value

Abstract

Kantian moral concepts concerning respect for human dignity have played a central role in articulating ethical guidelines for medical practice and research, and for articulating some central positions within bioethical debates more generally. The most common of these Kantian moral concepts is the obligation to respect the dignity of patients and of human research subjects as autonomous, self-determining individuals. This article describes Kant’s conceptual distinction between dignity and autonomy as values, and draws on the work of several contemporary Kantian philosophers who employ the distinction to make sense of some common moral intuitions, feelings, and norms. Drawing on this work, the article argues that the conceptual distinction between dignity and autonomy as values is indispensable in the context of considering our obligations to those who are dependent and vulnerable.

Introduction

Kantian moral concepts concerning respect for human dignity play a central role within medical ethics, medical research, and bioethical debate, most notably the Kantian-inspired view that respect for a person’s dignity is owed on the grounds of a person’s autonomy. Here a person’s autonomy, as a rational, self-legislating being, is typically regarded as the distinguishing feature of a person’s dignity. Kantian moral philosophy is also drawn on within arguments stating that respect for dignity is owed to one’s self no less than others, due to the shared humanity of persons, each of whom must always be treated as an end and never as a mere means. Here, the shared humanity of persons as rational beings with a capacity to set their own purposes and ends is the source of dignity. An obvious link in both cases is that dignity connotes a special kind of worth.

However, the fact that Kant employs autonomy and shared humanity as playing key roles in elaborating the nature of this special worth raises the prospect that Kant bequeaths two separate, and sometimes competing, debating positions. For example, arguments in support of a right to medical assistance to die at a time of one’s choosing often appeal to autonomy and self-determination. At the same time, arguments against the right sometimes appeal to Kant’s view of shared humanity and his argument against suicide.¹ This is the argument that suicide constitutes the use of humanity in one’s person as merely a means rather than an end.

This article does not step directly into these practical arguments. Instead, it describes a conceptual distinction between the value of dignity and the value of autonomy in Kant’s moral philosophy.² Drawing on the work of several contemporary Kantians, the article then shows how the conceptual distinction makes sense of moral feelings and intuitions in contexts where dependence on others, and a resulting vulnerability, is inevitable. Here, I refer to the dependence that can result from incapacitation and illness, frailty in advanced old age, and either periodic or irreversible limitations upon rational capacities due to cognitive decline or mental illness. The argument proposed is that Kant’s conceptual distinction between dignity and other values, including autonomy, provides the ground for an indispensable safety net for dependent individuals.

Dignity as worth

As is well known, Kant’s moral philosophy is a morality of duty in accordance with moral law. This law is the famous Categorical Imperative, which, in the first of several formulations, says ‘[a]ct only in accordance with that maxim through which you can at the same time will that it become a universal law’ [4, p. 31].³ Despite the priority of this formal framework of duty, it would be wrong to think that Kant is only concerned with duty as a formal, governing rule. Kant’s moral philosophy also provides an account of how and why our goals and purposes have value. In brief, the value of our goals and purposes comes from our dignity.

Kant thinks that insofar as we are rational beings who set goals, purposes, and ends to which we give a value (for Kant this is a necessary feature of rational agency), we are, by the very fact of setting ends, affirming our own value. This value is our dignity, and it is this value or worth that gives our various purposes and goals their value.⁴ Put simply, the value of our goals and purposes is conditional upon the value we affirm in ourselves as we set goals and purposes. This means that our own value—our dignity—does not depend on the value of our goals or purposes. Their value depends on dignity’s value, which is why Kant regards dignity as having an unconditional value.

In Kant’s view, a human person has a dignity merely by the fact of existing as a being with a capacity to set ends. This is what Kant means by a dignity of ‘humanity as an existent end’.⁵ Kant takes the idea of an ‘existent’ dignity of human persons and applies it in a formulation of the Categorical Imperative. This is the Formula of Humanity, which says, ‘[s]o act that you use humanity, whether in your own person or that of another, always at the same time as an end, never merely as a means’ [4, p. 38].⁶ The formula says that persons should never be treated as mere means, that is, for purposes that do not befit them as ends. Treating a person as an end requires treating a person as having a dignity or worth that is beyond the worth of one’s own purposes. To put this another way, a person’s value must never be set beneath the value a person accords to his or her own goals and purposes.

The formula contains a prohibition, which states what must not be done, or what must be included as a limit on any maxim for action, and arguably, it is this feature of the formulation that receives the most attention, particularly in bioethical debates. However, what should be noted is that dignity grounds the prohibition on the use of persons as mere means. It is the value of dignity that gives the rule its point. And this idea of dignity as a source of value can be extended to all Kantian duties and moral conceptions.

Autonomy is valuable, and central to human life and identity. However, there is a conceptual distinction between dignity and autonomy as values. Dignity is our own value. In contrast, our rational autonomy (in the varying ways and extents to which we have it) is our capacity for setting goals and purposes, to which we assign a value, and our capacity for realizing our goals and purposes. The value of our goals and purposes depends on our value as having a dignity, not the other way around. In this sense, the value of dignity is conceptually prior to, and thus distinct from, the value of our autonomy.

An opponent of this interpretation may note that Kant says persons have a dignity as end-setting beings, and extrapolate this to mean that persons have a dignity only insofar as they are autonomous. An opponent may also argue that in cases where autonomy is compromised or absent, so too is the personhood to which respect is owed. In contrast, I suggest that this kind of position overlooks the conceptual priority Kant gives to dignity, as a ground or basis for any other kind of value, and as providing the point of prohibitions, such as the one stated in the Formula of Humanity. Our rationality and autonomy are potentialities and powers we exercise, and we affirm our own dignity in their exercise. These potentialities and powers have a value, but it is not the same value as our dignity. Dignity is not a power or capacity we exercise, it is a value that is affirmed in the exercise of our rationality and autonomy. An increase in a person’s rational powers and capacities produces no increase in their dignity. Relatedly, there is no particular standard of rationality and autonomy a person could fail to meet that would render them as lacking the worth their dignity accords them, which is not to say that lacking or losing autonomy is neither harmful nor lamentable.⁷

Of course, many argue against precisely this point, asserting that beyond a certain point of autonomy loss, say when there is advanced dementia, a person or perhaps a person’s life lacks worth.⁸ This familiar position places autonomy and dignity on the same level as values, asserting that autonomy loss produces a loss of dignity and a loss of value. The loss of value stems from the loss of autonomy. The point I am making is that although Kant is a pre-eminent philosopher of autonomy, this is not his position. Dignity has a sui generis value, which thus is separate from autonomy.

A consequence of this Kantian view of dignity as a sui generis value is that a person’s dignity cannot be accorded a low status, neither with respect to oneself nor with respect to others. Dignity is not subject to individual choice, nor is it diminished by the decline of a person’s autonomy and choice-making capacities. There is a different kind of link between autonomy and choice. An autonomous person can choose to behave in ways that are appropriate or inappropriate to their dignity, a person can also be treated in ways that are disrespectful of their dignity. However, a person is unable to choose not to have the worth their dignity accords them, and although it is morally repugnant, disrespectful treatment does not take away a person’s actual worth.

None of the above entails under-valuing or under-rating autonomy. Nor does the view that dignity and autonomy are distinct, as values, deny that unless human beings are capable of rationality and autonomy some of the time, the kind of worth our dignity affords us would not arise. The position asserted here is that dignity is a kind of ‘something’ that is different from autonomy because its value is distinct from the value of autonomy. This proposal appears not to address the question of what dignity is, other than to say that dignity is the existent value a person has, and that this value is sui generis, which sidesteps the question of the metaphysical status of dignity. This is justified for the following reason. Even if it were possible to precisely ‘locate’ dignity in a place, capacity, or set of features (which I doubt), the question of why the ‘location’, capacity, or set of features have value would still require an answer. As I hope to make clear, Kant’s conception of existent dignity addresses just this kind of redress. To repeat, the problem with defining dignity with reference to something else, such as autonomy, individuality, a certain quality or capacity, or an inner kernel is that any such definition leaves open the question of why these kinds of things matter. The answer to this question is the same answer that Kant provides to the question of why our ends matter. A person’s ends, individuality, autonomy, and so on matter because the person matters. This ‘mattering’ is a person’s value, or his or her dignity.

While dignity is a value or worth an individual has, it is also a value or worth that human beings share in. We have a share in each others’ dignity, but not a share in each others’ autonomy or individuality. In addition, while dignity is a person’s own value, it nevertheless has a public, normative dimension. This is because dignity is a value that establishes a standard that behaviour and attitudes can fail to meet, both toward oneself and toward others.⁹

In what follows, I will describe how this view of dignity as a value and normative standard is taken up in the work of several contemporary Kantians, and describe how it makes sense of some common moral feelings and intuitions that have a particular bearing in the context of dependent and vulnerable individuals.

Velleman and Rosen on worth

David Velleman develops a Kantian argument to describe a conception of human worth that he laments is often missing in practical debates. He does so in the context of arguing against the right to a medically assisted death, when asserted as ‘a person’s right to end his life on the grounds that it is no longer worth living’ [9, p. 608]. In Velleman’s view, it is a mistake to suggest that a person’s life is worth more or less to the extent it affords that person more or less harms and benefits, or to the extent that a person values his or her life as going well or not. He argues that this mistake arises from a failure to grant that a person’s dignity is distinct from the value of the choices or ends a person adopts.

Drawing on the Kantian conception of dignity described above, Velleman argues that a person is valuable or worthy in a way that is fundamentally different from the value of the harms and benefits her life affords her or to the value she herself places on her life as going well or not. This value or worth is a person’s dignity, which he says is held in common, as a one of us kind of worth. He says ‘the dignity of a person isn’t something that he can accept or decline, since it isn’t a value for him; it’s a value in him, which he can only violate or respect’ [9, p. 613].¹⁰ Velleman’s quarrel with others, concerning end of life decision-making, centres on the failure on their part to grant that dignity is a condition of anything else of human value. He suggests that this is the point of Kant’s argument against suicide, where Kant employs the Formula of Humanity.

In a recent book on dignity, Michael Rosen provides an overview of historical, theological, and legal concepts of dignity, and provides a critique of moral theories that he describes as humanistic, by which he means theories proposing that the moral value of an action lies in the human benefit the action produces [10]. Rosen outlines a Kantian conception of dignity, as both a value in itself and a condition of other values that is close to Velleman’s view. Both Rosen and Velleman argue that dignity is the foundational worth or value that is the ground or basis for the worth of any kind of human benefit or value.

I mentioned above that dignity cannot be accorded a low status, as it is not a matter of individual choice. Rosen puts it this way. He says that for Kant, ‘there must be at least one thing whose value does not come from the choice of a rational being’ [10, p. 151]. Values would lose their point if all of them were a matter of choice. We affirm our own value in choosing ends to which we assign a value. So choosing ends assigns value, but the value assigned comes from the value that human beings possess in having a dignity, and this value is not chosen.¹¹

Velleman and Rosen both think that dignity, as a condition of any other value, grounds the prohibition contained in Kant’s Formula of Humanity. It is the value of dignity that grounds, or provides the point of, the prohibition on the use of persons as mere means. In this vein, Rosen argues that a Kantian duty of respectfulness (for one’s own dignity and the dignity of others) is more fundamental than the Kantian duty to universalise one’s maxims. He says that ‘instead of starting from the question what maxims can be universalised without contradiction, it would be better to understand Kant as asking first how we have to act in order to treat our dignity (our inner kernel of intrinsic value) with the proper respect’ [10, p. 147].¹²

Both authors are of the view that a Kantian conception of dignity as a value, distinguished from autonomy, makes sense of certain moral feelings, intuitions, and norms. For example, Velleman suggests the conception helps explain a distinctive form of moral affront. He describes stifling a feeling of rage and affront at a conference dinner when another conference participant claimed that the prospect of premature death mattered less to him than the pleasure of smoking [9, p. 607]. Velleman interpreted the smoker’s claim as placing the value of his life on a relative scale with something quite trivial by comparison. For Velleman, this type of claim reduces, at least by way of representation, the dignity of persons, which is a dignity we share.

Rosen believes that only a Kantian conception of dignity plausibly explains the widespread moral norm of treating the body of a dead person respectfully. He suggests this moral norm is simply an expressive duty of respectfulness for a person’s worth. The expressive duty is a duty ‘to perform acts that are expressive of our respect’ [10, p. 140]. He argues that the moral significance of the duty is not fully explained as a product of cultural, social, historical, or prudential factors. Instead, the norm is an expressive moral duty that can be embodied in widely differing burial and cremation practices. He notes: ‘[t]he precise content of such rituals vary widely … but their existence and, as it seems, symbolic force, is strikingly general’ [10, p. 129].

Rosen asks us to imagine the case of the last surviving person on earth feeling a duty to treat the dead body of the second to last person respectfully, although there would be no one to look on approvingly and no one to benefit by it. In Rosen’s view, a person who feels a duty of respectful treatment, in this imagined case, would be responding to the norm embodied in varying practices of respectful treatment. The fact that the norm is an expressive duty explains why, in the imagined case, the absence of onlookers makes no difference.

Rosen suggests his Kantian view of respectfulness as an expressive duty—a duty to respect a person’s dignity independently of benefits and beneficiaries—is out of step with the view of many contemporary moral theorists for whom it is just obvious that there must be a connection between a moral norm and a human benefit, as the benefit explains the moral purpose of the norm. Though there may be some overstatement here, his choice of example successfully captures respectfulness as a moral feeling or attitude that is directly prompted by a conception of a person’s dignity, irrespective of the fact that a person concerned may not be aware of, nor be benefitted in any way by, the expression of respect. The norm is thoroughly non-consequentialist in the sense that the duty is prompted only by respect for a person’s dignity. There is no purpose, other than that of paying respect, from the perspective of a person who feels the duty.

Disrespect, respect, and dependence

Both authors examine negative feelings that stem from the Kantian conception of dignity as worth. Rosen’s example of a non-consequentialist expressive duty to respect the body of a person who has died raises the issue of ill-feeling and disgust as a response to disrespect. Velleman, however, believes the Kantian conception makes sense of a moral feeling of affront. There is an obvious, but illustrative difference between the two examples.

In Velleman’s case of feeling affronted by a smoker’s dinner party remarks, there are no appreciable differences in the powers and capacities of someone whose words and actions cause affront, intentionally or otherwise, and the powers and capacities of an affronted person. In contrast, disgust is a visceral form of affront provoked by witnessing, or even finding out about, an exercise of power over a physically powerless other. A dead person is powerless in a literal way. Nonetheless the powerlessness is neither mundane nor morally insignificant from the perspective of a disgusted onlooker.

I venture that our disgust in response to acts of contempt and disrespect toward a person’s body, including the powerless body of a dead person who is beyond the reach of harm, are emotive responses to expressions of contempt for dignity in a practical sense. This is the sense that respecting a person requires an appropriate comportment toward, and treatment of, his or her body. An emotive response such as disgust, prompted by contemptuous treatment, indicates that disrespectful treatment of a person’s body is indistinguishable from disrespect for a person. This is one of the reasons why disrespectful treatment of a person’s dead body has such symbolic force.

While it is entirely possible to respect a person without also respecting their views and opinions, it is hard to see how respecting a person does not require respectful treatment of his or her body, should a person be in the care of, or dependent on, others. One’s comportment toward and treatment of a person’s body either expresses respect or expresses disrespect.¹³ There is no middle ground between the two, as even indifference is a failure of respect. This simple point emphasizes that respectful treatment of a person’s body is a non-negotiable feature of any kind of care, and that respectfulness is arguably a more fundamental basis for good care than beneficence.

These observations can be connected to a heightened sense or feeling that respectfulness toward a person is owed in contexts of dependency. In a case of disgust at the disrespectful treatment of someone who is powerless, the literal asymmetry between a person who expresses disrespect and the target of the disrespect contributes to our sense that the disrespect is morally appalling. Likewise, the asymmetry that exists when a person is dependent due to illness, incapacitation, or advanced old age, and thus needing care, has the same implication: not only is there a sense that respectfulness is owed, but a failure of respect toward a dependent individual is viewed as particularly appalling.

These observations also suggest a direct practical implication of a Kantian conception of dignity as a distinct value. While respecting a person is not limited to respectful treatment of his or her body, respectful treatment of a person’s body is a basic or non-negotiable dimension of respectfulness. The common feeling that respect is owed in a context of dependency also reveals a standing recognition that the asymmetries mentioned above are not morally neutral. In circumstances in which a person, or a person’s dead body, is in the care of others, the treatment a person receives, or to which their dead body is subject, is never morally neutral. The treatment either expresses or fails to express respect for a person’s dignity.

Conclusion

These practical examples of moral affront, respectfulness, and disgust invoke a bare conception of dignity as a value. The conception of dignity is bare in the sense that the worth belonging to a person, even after death, need not be particularised. No knowledge of a person’s powers, capacities, or their life story is required in order to invoke it. Nor is any intimacy, familiarity, or attachment to a person involved in grasping that a person has the worth their dignity accords them. Yet, what I hope to have illustrated is that even though there is a theoretical Kantian argument for such a bare conception of dignity as worth, no complicated argument is needed to see that such a conception is already motivating, and certainly needs to be, in a context of dependency due to illness, incapacitation, or advanced old age.

If I am correct in suggesting that respect for a person’s worth is owed in contexts of dependency, then the respect owed is a rational duty. Rosen’s characterisation of a norm of respectfulness highlights a deeply felt and widely-recognized moral duty to treat the bodies of those who have died respectfully, out of respect for a person’s worth. We tend not to question the moral basis for this rational duty as it is tied to social customs and practices, and the customs and practices generally require little in the way of shared resources. A duty of respectfulness toward those who are dependent, and thus need care, involves recognising that autonomy and independence, on their own, are not variables that connote a person’s worth. This position can come into question when the value of dignity and the value of autonomy are not distinguished from one another, as this article has argued they should be. Otherwise, a person’s value can be seen as diminished when his or her autonomy is compromised. This questioning can seem legitimated by the fact that the resources required to care for dependent individuals are considerable. A Kantian conception of dignity as a value, distinct from the value of autonomy, is a safety net for those who are dependent and, thus, are vulnerable to being viewed as diminished or lesser than others, and potentially less deserving of our shared resources.