After the quarrel accompanying the process of passing a law dealing with organ transplantation and several attacks questioning the concept of brain death, one could get the impression that in Germany discussions in biomedical ethics were freed more and more from ideology—it seemed that we were able to objectivise the crucial issues. The willingness to have an open and constructive dialogue between politicians, scientists and ethicists seemed to develop; and the insight seemed to gain acceptance that dogmatism isn’t helpful in this sensible area of our society.

But since the days that the ‘biopolitical‘ and bioethical debate in Germany has focussed on the early stages of human life, this rationalization of our culture of discussion is declining. The question whether research on human embryonic stem-cells should be legalised or criminalized caused emotions to run high. Footnote 1 Actually this research is possible only if human embryos are killed. Therefore the dispute escalated in such a way that some got the impression a new ‘Kulturkampf’ had begun. Footnote 2 This impression is fed by the fact that in this dispute the position of Germany concerning research and economy in comparison to other countries has been an import aspect from the very beginning. Some thought that now the freedom of research was at stake and had to be defended against anti-scientism and reactionary ideologies which tried to get back lost power in our society. In some other cases, e.g. pre-implantation genetic diagnosis (PGD), massive economic interests come into play which are regarded as being in danger if we accept far too restrictive ethical standards based on the German Grundgesetz.

1 The shared premise

In view of this trend our question must be: Why is the rationality of our discourses in biopolitics and biomedical ethics declining and why are we in danger of dissolving agreements which have already been reached? It is suspicious that at present the concept of “human dignity” is used again not to make progress in bioethical debates but to end them abruptly. This is in need of philosophical analysis. In such an examination an analysis is also needed as to how the arguments relying on the concept of human dignity run in different contexts in biomedical ethics.

My thesis is that this contemporary step back results from the fact that progress in reproductive medicine raises the question of how to deal with the beginning of human life appropriately and in such a way that persistently has been avoided in the German discussion (and the German law) or is generally regarded as being ethically inadmissible. Falling back on human dignity so quickly comes—as I see it—from the fact that an assessment of these new medical options of stem cell research or PGD forces us to think about the ethical acceptability of quality-of-life assessment (QLA) of human life.

The political solution for the issue of abortion and discussions of other problem cases like euthanasia or physician-assisted suicide in Germany have one feature in common: nearly everybody tries to avoid the question as to whether conditions or situations might arise in which a QLA is acceptable or even demanded—this is the case especially in the context concerning the option of intentionally ending human lives. Footnote 3 But both at the end of human life as well as at its very beginning, progress in biology and medicine makes it inevitable to discuss the question whether QLAs are ethically inadmissible in general.

Those who rely on the concept of human dignity, normally referring to the German Grundgesetz, to qualify PGD as ethically wrong, presuppose in their argumentation that the assessment of human life and its selection because of QLA—indisputably essential aspects of PGD—are incompatible with human dignity. Footnote 4 Some years ago Regine Kollek formulated this position with desirable clarity:

“A process in which potentially human beings are intentionally produced on a trial basis and are judged to be worthy of existence and further development by the future parents only after a genetic diagnosis is not compatible with the dignity of human life” (Kollek 1999). Footnote 5

This intuition that QLA is incompatible with human dignity—referred to here as the incompatibility-assumption (ICA)—is a widely shared premise in our debates in biomedical ethics. Even many of those who defend that PGD is ethically acceptable and should not be prohibited by law generally hold ICA. Therefore they argue that a human embryo (or even earlier stages of human life) cannot be regarded as bearers of human dignity in a strict sense. Footnote 6 Since ICA is a shared premise on both sides the debate now runs into a fruitless all-or-nothing controversy: either the human embryo (or a human embryonic stem cell) is the bearer of human dignity (in the full sense) or it is not. Footnote 7 In the heat of the moment this shared premise doesn’t come into view as something which might be questionable. But as long as ICA is taken for granted biopolitical and bioethical debates are in danger of resulting in a stalemate. Therefore in this paper I want to question this widely shared premise and ask: Is it really true that every kind of QLA is incompatible with human dignity? Or are there any good reasons to reject ICA or to restrict it in scope at least?

2 The bad dialectics of our present discussions

In cases where the prohibition to intentionally kill a human being has to be assessed ethically (e.g. active euthanasia, physician-assisted suicide or abortion) or in the context of dealing with early stages of human life (e.g. embryo research, cloning, or PGD), it is obvious to consider QLA as ethically relevant. But if you try to defend that active voluntary euthanasia or active non-voluntary euthanasia (e.g. in the case of severely disabled newborns) might be ethically justified because of the expected quality of life of those individuals whose life is under consideration, the following objection arises both immediately and vehemently:

Fundamental objection: Every account in bioethics, in which the pressing problems are answered by relying on QLA, draws a line between human lives worth living and human lives not worth living. But, firstly, this distinction is incompatible with human dignity unshakeably embodied in the German Grundgesetz. Secondly, this distinction is brought into discredit historically—the National Socialists’ crimes against humanity have shown that a social and political catastrophe is unavoidable if a society tries to solve problems of biomedical ethics relying on QLA.

As I see it, fundamental objection is untenable because of three reasons. Firstly, we are not told what the content and justifying basis of human dignity is. Secondly, no distinction is made between different accounts of QLA. Therefore, thirdly, evidence is not provided for the crucial premise of ICA. But instead of asking those questions which have to be asked if one follows my threefold criticism of the fundamental objection, many bioethicists—probably captivated by ICA themselves—counterattack in a just as fundamental way. This fundamental counterattack can take three forms (I begin with the crudest and harshest):

Counterattack I: The concept of human dignity is senseless, it has no clear meaning and it cannot be justified by rational philosophical arguments.

Counterattack II: (1) The fundamental objection relies on a notion of human dignity which is based on the theological conception of the sanctity of (human) life. Such a theological substantiation cannot, on the one hand, be convincing in a secularised society. Therefore in a pluralistic society such a notion of human dignity cannot, on the other hand, be used to justify ethical norms or even laws. (2) Human dignity cannot be applied in its philosophical sense to the early stages of human life, since these early forms of human life do not have those capacities and features necessary for being a bearer of human dignity.

Counterattack III: (1) & (2) Same as in Counterattack II. (3) We can define human dignity in a weak philosophical sense which is connected only to weaker claims of ethical and legal protection (and, in fact, our social praxis dealing with the early stages of human life shows that we rely on such a weak philosophical sense of human dignity).

As far as I can see, Counterattacks II and III are the only ways out if you want both to block the fundamental objection and accept ICA. Footnote 8 They agree that a human embryo cannot be the bearer of human dignity in the strong philosophical sense while human persons can be, and that the theological reading of human dignity cannot be used in a secularised and pluralistic society. But while in Counterattack II the philosophical notion of human dignity is not refined but used in one philosophical sense, it is only in Counterattack III that we find the suggestion to distinguish a strong and a weak philosophical notion of human dignity (Birnbacher 1996).

This overall constellation of arguments leads to two debates which partly overlap. On the one hand supporters of the fundamental objection criticise those who want to distinguish a weak and a strong philosophical sense of human dignity (against followers of Counterattack III and partly in agreement with followers of Counterattack II); and they argue against the attempts to remove the beginning of human life from the scope of the strong notion of human dignity (against followers of Counterattacks II and III). On the other hand, followers of Counterattacks II and III agree on two fundamental issues: firstly, a theological interpretation of human dignity is not acceptable, and secondly, the strong philosophical notion of human dignity cannot reasonably be applied to the early stages of human life.

As long as all accept ICA the whole discussion is marked by an all-or-nothing stalemate which leaves no room for compromise and mediation. If we want to overcome this annoying result of the current debate’s bad dialectics without undermining the principle of human dignity and without eliminating the beginning of human life from the scope of human dignity altogether, we have to scrutinize ICA. This is especially justified if we accept the fact that in many contexts of bioethics and everyday ethical judgements, QLAs are in use and that this is an ethically unavoidable and legitimate way to deal with the pressing questions in biomedical ethics and biopolitics. To overcome this stalemate, I will defend the three following theses:

Thesis 1

QLAs and ethical judgements relying on them are ethically acceptable if we base our arguments on a proper understanding of quality of life.

Thesis 2

QLAs based on such a proper understanding of quality of life are compatible with human dignity (in the strong sense), if we too rely on a proper understanding of human dignity, i.e. an understanding of human dignity which takes into account the fact that we live in a secular and pluralistic society.

Thesis 3

Taken together, QLA and human dignity, both interpreted in an appropriate way, can be used to justify a reasonable pluralism ethically suitable for the society we live in.

3 Four accounts of QLA

To clear up the debate it is useful to distinguish four accounts of QLA by means of the standards of assessment they call on:

  • The naturalistic standard

  • The social standard

  • The interpersonal standard

  • The personal standard

The naturalistic standard pretends to deliver a concept of QLA—the famous quality adjusted life years—which is based only on biological and medical facts, free from any evaluations and norms. But since the quality of life cannot be grasped free of evaluations, such a concept of QLA is implausible. Footnote 9 Nevertheless this standard is an underlying feature of our current bioethical or biopolitical debates since many adherents of the fundamental objection allege that the defenders of QLA do have the naturalistic standard in mind, that they adhere to ‘biologism’ (to say the least).

The social standard consists of those evaluative and normative judgements (or preferences) which in fact dominate our society (it might be that those who hold these judgements and preferences cannot even articulate them explicitly). Although nobody in the current debate seriously wants to rely on it, the social standard is operative in the arguments of those defending the fundamental objection. Either they insinuate that the recommended criteria for QLA are de facto products of our societies’ ideology. Or they argue that—maybe against the intentions of their defenders—QLAs will automatically end in using the social standard, since our evaluative praxis will be influenced by social modes and cultural prejudices. Footnote 10

The interpersonal standard is explicitly normative. It consists of those features, which rational subjects would choose rationally because of their being human beings (e.g. embodiment, sensitivity, social needs, capacity to develop personal autonomy). Footnote 11 This standard is relevant in all contexts of QLA, since it is complementary to the personal standard, and it is dominant in all cases in which the life of a human being is assessed which actually cannot lead its life as a person. Footnote 12 One of the central questions in the following will be whether ICA is valid if we have the interpersonal standard in mind.

The essential capacity of human beings to lead their lives as persons is the core of the personal standard. It takes into account that persons do stand in an irreducible evaluative relation towards their own existence (in the sense of “identifying with” their present and future existence) in developing life plans, trying to realise their own interests in actions, or making evaluative judgements. The capacity to develop and realise such an individual plan as one’s own biography is an essential part of the human life adjusted to personal autonomy. Footnote 13

The personal standard recognises this essential feature of human persons and is an articulation of personal autonomy since here the quality of one person’s life is understood as the extent to which this human being ascribes such quality to her own life (understood as auto-biography). Since personhood and personality are constituted in mutual relations of recognition the personal standard is not based on something private (e.g. the famous qualia so prominent in the philosophy of mind or the even more famous private language Wittgenstein discusses) or something which cannot be understood by other persons (at least in a high degree). Footnote 14 Therefore, the interpersonal and personal standards are complementary aspects of QLA which cannot be separated completely (although it depends on the context and the case under discussion how these standards are adjusted to each other).

The disciples of the fundamental objection often have the naturalistic and the social standard in mind; defenders of QLA normally refer to the interpersonal and the personal standard. Thus we have to ask whether or not ICA holds for all these accounts of QLA. But before we can answer this question we have to have a closer look at the notion of human dignity. As already noted in formulating the three counterattacks against the fundamental objection it might be the case that we have to distinguish different accounts of human dignity, too, before we are able to examine ICA.

4 Human dignity and personal autonomy

A thorough examination of ICA not only requires discussion of the four standards for QLA distinguished separately, but we also have to clear up the notion of human dignity (its content and the basis on which it can be justified). In a secularised and pluralistic society committed to pluralism, human dignity, too, must be given an interpretation compatible with the self-image of such a society. Footnote 15 The normative force of the principle of human dignity depends a lot on the grade of its coherence with our remaining web of evaluative and normative beliefs. If inconsistencies in this web become manifest because some of our central ethical principles and our fundamental and widely shared ethical intuitions don’t match (e.g. concerning the question of how to deal with the beginning of human life in the context of reproduction techniques and human genetics), all ethical intuitions, beliefs and principles are under close scrutiny—even our concept of human dignity.

Before we reject this principle stock and barrel claiming that it is no longer suitable for us or antiquated because of recent developments in our society, and before we limit it in strength or scope we should ask whether we can deliver an interpretation of the principle of human dignity giving it a content appropriate to our modern evaluative self-image. In this paragraph I will suggest such a conception of human dignity which—at least to my mind—still has its place in a secularised and pluralistic society.

4.1 Human dignity: two traditions

In one tradition “human dignity” is interpreted within the doctrine of “sanctity of human life”. Footnote 16 The special moral status of human life is justified by the ‘fact’ that god has given human life this special ethical value. The theological impact of this is made obvious by the term “sanctity”. Since in a pluralistic and secular society a theological justification of moral claims and even more of legal rights is problematic (to say the least), many authors have tried to give an analysis of “sanctity” in non-theological terms. Footnote 17 And the main candidate is the notion of “absolute value”. In another tradition the special ethical status of human beings marked by “human dignity” is justified by special capacities of normal Footnote 18 human beings. Most prominent here is the following feature: Human beings are able to lead their lives autonomously in the sense that they can decide and judge in the light of self-given moral rules. As I understand it this interpretation of human dignity can be freed from theological assumptions (although it might not be possible to free it from all metaphysical assumptions). The basic idea is that human beings can lead their lives as persons. Included therein is the idea that human beings have a sense of meaning and worth of their own existence. It is this outstanding capacity to lead an autonomous life as a person which demands and justifies that we owe respect to each other. And it is this respect which is the central aspect of the absolute value of human life which is expressed by “human dignity”.

There are three crucial differences between both conceptions of “human dignity”. Firstly, they are based on different kinds of justification (theological versus philosophical), none of which is self-evident, purely empirical or value-free. Secondly, the source of human dignity according to the theological reading is external (its source is god) and the internal structure of a human beings’ mental life is of no importance. Within the philosophical account the source of human dignity is internal, i.e. a special capacity or feature of human beings (which I have named personal autonomy above and which might consist itself in a set of capacities and features). As a consequence of this, thirdly, the theological version of human dignity doesn’t take the perspective of individual human beings into account since “human dignity” doesn’t reflect the internal structure of a person’s mind, while the autonomy-based conception is based in a constitutive and essential way on the self-relation human beings enter into qua leading a life as a person (this means that “human dignity” reflects the internal structure).

4.2 Human dignity: absolute or intrinsic?

Additionally we can distinguish now between different interpretations of the intended strength of the value of human life indicated by “human dignity”. I want to discuss only two of them: the absolute-reading and the intrinsic-reading.

In the absolute-reading there are two crucial features of human dignity and the value of human life:

The special value of human life is: (1) not derived from something else (e.g. human interests)—except probably god; Footnote 19 (2) it cannot be given up; and (3) it is not allowed to be weighed up against other ethical values.

This absolute-reading is an essential part of human dignity in the strong philosophical and theological senses.

This is not the case with the intrinsic-reading where:

The special value of human life: (1) is not derived from something else (e.g. human interests); (2) it cannot be given up; but (3) it is allowed to be weighed up against other high-ranking ethical values.

This intrinsic-reading is suggested in Counterattack III as “human dignity” in the weak philosophical sense (and has no counterpart in the theological reading or in Counterattack II).

As should be clear, the official understanding of “human dignity” in the German Grundgesetz is of the absolute kind. Although the right to life may be weighed up against other very important ethical values human dignity may not. The intrinsic-reading would be a serious revision of our meaning of “human dignity”. Such a revision might be necessary and ethically justified if our notion of human dignity causes ethical problems in the new contexts created by new technical developments like PGD. But before we reach such a revisionary conclusion we should first try to make our ethical intuitions in these contexts cohere with the absolute-reading of human dignity. As I will show now it is possible to find such a reflective equilibrium if we combine the absolute-reading of human dignity with the conception of human dignity based on personal autonomy. This is good news since every society devoted to pluralism is well-advised to protect the capacity to develop a personality and to lead a life autonomously by accepting human dignity—in the strong philosophical sense—as an essential element of our ethical praxis not to be weighed up.

5 Human dignity, QLA and pluralism

5.1 Against ICA

If we give human dignity the interpretation just outlined it is easy to see that neither the naturalistic nor the social standard of QLA is compatible with human dignity. This incompatibility is due to the fact that these standards don’t take the actual (or counterfactually ascribed) evaluative self-understanding of human persons as a starting point but instead override it in the name of some external standard of assessment (be it ‘scientific’ or ‘social’ acceptance). Beyond that it is not hard to realise that ICA cannot be correct in general. It is an essential feature of being a person to develop an evaluative stance towards one’s own life and its quality. Therefore there cannot be a general incompatibility between QLA and human dignity if the latter is based on personal autonomy.

Thus the personal standard must—in principle—be ethically acceptable (this is not to say that it must be the dominant standard or can be applied in all cases) since this standard explicitly takes the individual’s evaluative stance towards its own life as a starting point. Footnote 20 Furthermore we have to bear in mind that a human being’s personality can’t develop and exist without processes of social interaction and recognition which are possible only on the basis of shared biological, anthropological and cultural starting conditions. Acknowledging this fact is not only sufficient to block the objection that QLAs based on the personal standard are hopelessly ‘private’, it also makes clear that the interpersonal standard is a necessary complementary component of QLA, since relations of recognition and criticism are constitutive for becoming a person, too. Personal autonomy requires critical examination and acknowledgement; a person’s autonomous decisions are open to rational evaluation and criticism—they have to be measured against not only internal coherence (much of which fits into a person’s biography) but also against objective standards of rationality and plausibility. Besides that, the empirical research on QLA shows that we de facto are provided with good instruments to determine an individual’s quality of life (Schumacher et al. 2003). Footnote 21

The personal and the interpersonal standards go hand in hand. The more a human being has realised personal autonomy or has developed the features necessary for exercising personal autonomy the more the personal standard becomes dominant (this can be seen, e.g. in the case of voluntary active euthanasia). The less a human being has realised or is able to realise personal autonomy in articulating an evaluative stance towards its own existence the more important will the interpersonal standard become (this can, for example, be seen in cases of non-voluntary euthanasia).

5.2 Conclusion

Since the personal and interpersonal standards of QLA are compatible with human dignity (a plausible and philosophically attractive interpretation), ICA is wrong. Therefore the fundamental objection must be rejected since it fails to distinguish different standards of QLA, ascribing to their opponents always those standards (like the naturalistic or the social one) which really are incompatible with human dignity (in any sense). Furthermore, defenders of ICA often rely on an understanding of human dignity which cannot lay the foundations for our secular and pluralistic society.

In fact we find an irreducible plurality of conceptions of the good and the individually succeeding life in our society. The interpretation of human dignity, suggested above, accepts that we are in need of a non-theological foundation of human dignity which at the same time takes into account that our society not only is pluralistic de facto but that pluralism is an important value. Acknowledging and welcoming pluralism allows us to make the principle of respect for personal autonomy the basis for our ethical praxis (not only in bioethics or biopolitics). So the interpretation of human dignity I have argued for in this paper not only shows how QLA and human dignity might be compatible, it also makes clear in which sense human dignity and respect for human dignity can and must be an essential element of every pluralistic society. Footnote 22

Having reconciled human dignity, with QLA and pluralism as suggested in this paper we are in a position to develop an ethical theory and, in practice, an ethical stance in which neither personal autonomy is overridden by absolute values nor are intrinsic values generally given away in favour of actual preferences of individuals in our society. We can overcome the bad dialectics of current bioethical and biopolitical discussions in Germany and regain room for an open and constructive dialogue. Doing this we regain leeway for argumentation which has to be shaped with ethical, social and political content in a responsible manner. As I see things this can only be done if we openly discuss what quality of life means for us, and if—in an open dialogue—we find out what we want to understand by leading a life in human dignity. As long as we do not accept that accounts of quality of life guide our ethical intuitions in many contexts of biomedical ethics, we will not be able to quarrel rationally about those aspects of our ethical self-images which are dominating our ethical praxis. Overcoming ICA is the first and a necessary step towards such a debate—but it cannot replace it.