Why would people want to use a notoriously vague concept like dignity (Macklin 2003; Horton 2004)? Obviously because they think it is a useful and perhaps even powerful way to achieve something. If one looks at the use of dignity in contemporary discussions from this perspective, it clearly is a language tool that is always used with a certain agenda (Wittgenstein 1953). This is not new. Concepts and words have always been used in order to achieve things: sometimes rhetorically, at other times more philosophically or legally, but always within a specific setting and with the intention to organize the world, creating order and establishing boundaries so as to live in it.

The concept of dignity has been used in an infinite number of settings during the last two thousand years. Perhaps the main reason why the concept is considered to be vague is that the permanence of the use of the concept suggests a continuity of its illocutionary content that seems to get lost the more one focuses on the details of dignity talk. The main interest of this paper is not a detailed discussion of the sophisticated ways in which dignity has been discussed recently in political (Margalit 1996), philosophical (Korsgaard 1996), bioethical (Beyleveld and Brownsword 2001) or legal (McCrudden 2008) debates. This contribution to the debate seeks to abstract from the more detailed discussions and search for a unity underlying the various approaches of dignity.

The paper is structured as follows. First a short impression of the history of the concept of dignity is presented in order to show how from Roman Antiquity the concept has been referring to either a practice or an idea. Subsequently, a third version of dignity will be introduced according to which the concept refers to a feeling of experience. It will be argued that although the three versions of dignity hang together, they should also be clearly distinguished, because each one of the versions are only partially effective. We will demonstrate this by taking the discussion about voluntary ‘dying with dignity’ as an example. Inspired by both Paul Ricoeur’s concept of ethics and the ethics of care a model will be proposed in order to show how the three versions of dignity may sustain each other and help achieve what neither one of the concepts can do on its own.

A very short history of the concept of dignity

Searching for the roots of the way the concept of dignity is used in our day, the works of Cicero (106–43 BC) seem to be an important starting point. In his writings the concept of dignity is used in two meanings (Cicero 1991). The first one is a social one and refers to the public recognition of one’s social position. This is not only a very old meaning of the word, but also a very permanent one, as is shown by the use of the word dignity in many European languages up till today. It is important to notice that in this first sense, dignity is something which cannot be established by oneself. As public recognition, dignity depends on a group of other people. And because it depends on a collective, there is not one subject or a clearly defined group of subjects that can be held responsible for acknowledging or refusing public recognition. Dignity as public recognition is not stable or permanent. The social position may be more or less connected with power, but the recognition of this position is dependent upon a group of other people.

The reason why we focus on the foundations of what upholds dignity is related to the way we look at concepts: as tools that are used with a certain agenda. In this first meaning, the concept of dignity is used in order to establish a practice that sustains a certain social order. Dignity is used in order to distinguish human beings from one another and to place them in a certain order or ranking. This first meaning of dignity can be called the social meaning of dignity, and as such it is based on a practice.

Cicero, however, uses the concept of dignity in another way as well: as the intrinsic and characteristic quality by which human beings are distinct from other beings. According to the philosophy of the Stoa, this intrinsic and characteristic quality is reason (ratio) and the fact that human beings are endowed with reason distinguishes them from animals and plants.

In this second meaning, the concept of dignity has a different function. It is used in order to distinguish human beings from other beings that surround them. This distinction is based upon a certain concept of rationality and a valuation of this concept. Rationality is seen as something possessed by human beings exclusively, and because it is considered to be intrinsic it defines the species as such (animal rationale).

At first sight, this notion of intrinsic dignity seems to be a very stable and perennial one. What is more stable than a notion that cannot be taken away from human beings because it is intrinsic to their nature? On second thoughts however, the notion of intrinsic dignity does not refer to a practice but to an idea. The stability of this idea is as strong as the authority or plausibility of the philosophy that proposes this view. And many philosophers, theologians and institutions in history have proposed and sustained the idea of intrinsic dignity up to this day (Sulmasy 2008).

Christianity

A very influential combination of Stoic philosophy and Christian theology was achieved by the Fathers of the Church. Augustine (354–430 AD) e.g., connected the stoic idea of rationality as the basis of the dignity of human beings with the notion that human beings are created in the image of God (Genesis 1). Giving Stoic philosophy a biblical foundation, the idea of intrinsic dignity was rooted firmly in Christian theology and still is so until today.

Interestingly, in Christian theology the strong connection between dignity and rationality resulted in the idea that not only human beings, but also other rational creatures like angels, were endowed with intrinsic dignity. The reason for this is a theological one. In the writings of Thomas Aquinas (1224/5–1274), building on Augustine and voicing a Western Christian tradition that had not yet been split by the Reformation, we find this thought spelled out clearly: rationality is the basis of morality and the knowledge of God, which is the ultimate goal (finis ultimus) of life. In Aquinas’ view, acting against or below the standards of one’s rational nature, is acting against or below one’s dignity. Besides, next to the idea of intrinsic dignity, also in Augustine and Aquinas we find the concept of dignity used in connection with the first meaning of Cicero, as referring to an ecclesiastical or public office which is asks for respect and recognition.

This theological foundation of human dignity is so deeply rooted in Christian thought that we continue to find it through the ages after the Reformation both in the Roman Catholic and Protestant tradition. In the writings of Luther e.g. the essential importance of human dignity is that it keeps human depravity and sanctity in balance (Kraynak and Tinder 2004). In the influential letter Rerum Novarum (1891) pope Leo XXIII criticizes the situation of the industrial laborers of his day, saying: ‘The dignity of man, who is treated with great respect by God Himself, may not be damaged without punishment.’ Leo XIII connects his statements with the idea of natural rights of human beings (private ownership, land, life, labour, marriage, food, etc.), using a language of rights that would also be used by the Universal Declarations of Human Rights of the United Nations in 1948.

Renaissance and enlightenment

But long before this universal declaration, the idea of intrinsic dignity had been taken up in various ways outside or apart from the Christian tradition. The Renaissance philosopher Pica della Mirandola (1463–1493) in his Oratio de Homine Dignitate made an important step by breaking free from the Christian theological foundation of dignity as he proclaimed the freedom of man as his dignity. After Renaissance thought had put man at the centre of the universe, however, the concept of dignity would be developed further in different directions.

On the one hand thinkers like Thomas Hobbes (1588–1679) would define dignity as the simply as ‘the public worth of a man, which is the value set on him by the common wealth.’ (Hobbes 2010). According to this notion, dignity can be compared with one’s price on the market: not an absolute value but ‘a thing dependent on the need and judgement of another.’ In fact here we see a variation on the first meaning of dignity that Cicero used: a form of social dignity, no longer attached to or derived from a public office, but determined by the market.

On the other hand an influential thinker as Immanuel Kant (1724–1804) defines human dignity as a worth that has no price. In his Grounding for the Metaphysics of Morals he writes: ‘That which constitutes the condition under which alone something can be an end in itself has not merely a relative worth, i.e., a price, but has intrinsic worth, i.e., dignity.’ (Kant 1981) In Kant’s philosophy this idea of intrinsic worth is directly related to the foundations of morality as expressed in his second categorical imperative: ‘Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end.’

Kant’s influence on contemporary thinking can hardly be underestimated. Nevertheless, again we see here a variation of the old idea of intrinsic dignity: no longer dependent on a Christian worldview, but still dependent on the plausibility or authority of an idea, a certain way of thinking. In that sense Kant’s rational foundation of his ethical thinking, brilliant and influential as it is, is not different from that of Cicero or Aquinas. In the end dignity refers to an idea that is not based on a practice, but on other ideas about reality and the way we should live in it.

Present day

There is, however, a third meaning of dignity that has become topical in bioethical debates. With this third version is not meant what Daniel Sulmasy calls ‘inflorescent dignity’ and which is, in his words: “the value of a process that is conducive to human excellence or the value of a state of affairs by which an individual expresses human excellence.” (Sulmasy 2008). Although Sulmasy’s argument to formally distinguish this version of dignity in bioethical debates is helpful, he considers it expressive of the intrinsic dignity of human beings. That means that is it based on or derived from intrinsic dignity. For that reason, it cannot stand on its own and it can be considered as a further refinement of the intrinsic version of dignity.

This third version of dignity that differs from what has been discussed so far is a fairly recent invention: dignity as something that people experience of themselves. In the Netherlands e.g., it was observed in the last few years that the term dignity was appearing with increasing frequency in the reports of the regional review committees that investigate whether euthanasia has been performed according to the official rules and regulations. Research has shown that of the 123 euthanasia requests reported by physicians in 2002 no less than 63 % were inspired by a perceived loss of dignity (Rietjens et al. 2006). Right to Die-NL (NVVE—Nederlandse Vereniging voor Vrijwillig Levenseinde)-an association numbering more than 104,000 members that plays a major role in the public debate-has started a research project in order to find out whether irreversible loss of dignity can be a criterion for those who suffer from unbearable suffering. The content of this concept of dignity is a completely subjective one, and can be described as ‘whatever people say that it is’. Some people experience loss of their dignity when they no longer are able to live in their homes. Other people feel they are losing their dignity when they experience a decline of their cognitive capacities. And a third group of people feels deprived of their dignity when they discover they cannot lead what they consider to be a meaningful life. In fact preliminary analyses have shown that the spectrum of what people experience as compromising their dignity covers the entire range of human existence, from physical and psycho-social to existential issues.

This third version of dignity, subjective or experienced dignity, is completely different from the other two, because it rests entirely on what individuals say they feel. In fact it is a very formal notion, an empty vessel to be filled with whatever people feel that it should be filled with. As such is seems not to be dependent of the opinion of other people, as the first meaning of dignity, or a certain philosophy as goes for the second meaning we discerned. Or is it more complex than this, and are the different versions of dignity somehow related, although often unnoticed? How are the different aspects of the three versions of dignity to be valued, what are their pro’s and con’s and to what extent do they need to be brought into play with each other in order to be plausible?

Three versions of dignity

People recur to problematic concepts like dignity because they have an agenda. They think it is helpful to use the concept in order to describe and organize the world in a certain way. This holds for all three of the versions we have met so far. In the case of experienced or subjective dignity, it is clear that the concept serves to be heard as a unique individual. When someone asks for assisted suicide because she experiences a loss of dignity related to suffering from Alzheimer’s disease, someone makes clear that cognitive capacities are so central to her life that the loss of it directly affects her self-respect and what she considers to be a life worth living. Saying that one has lost one’s dignity is an existential utterance. But how does this relate to those who claim that life is always worth living because human beings have an intrinsic dignity that can never be taken away?

Subjective dignity

The experience of one’s own dignity can be a great source for enduring pain, whether this is caused by diseases or accidents on the one hand or moral actors in the case of torture on the other. The loss of one’s self respect can be a very painful and weakening experience that makes it very hard if not almost impossible to endure suffering. But that alone is not enough to put all cards on a subjectivist version of dignity. The reason is twofold.

In the first place, people can have an opinion about themselves that is false or not shared by their surrounding world. Normally this will lead to attempts by the society to correct this self interpretation. A girl suffering from anorexia may have a strong feeling that she is too heavy, even if she has lost so much weight that according to her medical records her life is at risk. A successful physician may be depressed because she feels that she hasn’t achieved anything in life, although she is a highly respected member of the community. Someone may think he is Napoleon and complain that he does not receive the respect and honor he deserves. In these cases subjective appraisal is never taken for granted, however much people may ‘authentically’ feel it is their reality.

The second reason is–and this is about the content of the concept of dignity–because when one speaks of subjectively experienced dignity, automatically the two other versions of dignity come into play. Every judgment about oneself is possible only against the background of a cultural horizon in which one interprets oneself. One’s understanding of the very notion of dignity is acquired during a life time in a number of different situations. It makes a big difference for one’s understanding of the concept whether one is raised in a culture where the notion of intrinsic dignity is self evident or considered to be metaphysical nonsense. And the appreciation of one’s own dignity is often largely co-determined by one’s environment (Vanlaere 2006).

Subjectively experienced dignity is existentially important, because it refers to one’s self esteem and self respect, but too narrow and unstable a fundament to build one’s moral decisions on. What then about Cicero’s original notion of social dignity? Might this be a helpful notion?

Social and relational dignity

If we take social dignity in the narrow sense of recognition based on a public office, the concept does not seem very helpful and stable. As we have noticed before, the concept is used as a tool to distinguish human beings from one another and to place them in a certain social order or ranking Thus public dignity is only the pregorative of a minority of people who have a special position in society. If, however, we expand the social nature of this version of dignity to what some call ‘relational dignity’, we might have a more promising road laying ahead of us (van Heijst 2006). Discussing the first interpretation of dignity we have seen that the experience of self respect is an important basis for enduring suffering. We have also seen that it is based on a social context. It is this insight that is at the basis of the dignity therapy developed by the Canadian psychiatrist Harvey Chochinov (Chochinov 2002). According to this approach the experience of dignity can be enhanced by a short intervention consisting in hearing the life story of the patient.

Chochinov discovered a strong association between undermining of dignity on the one hand and depression, anxiety, desire for death, hopelessness, feeling of being a burden on others and overall poorer quality of life on the other (Chochinov et al. 2005). He designed a therapeutic intervention consisting of three therapeutic sessions of 30–60 min. In the first session the intervention is proposed, explained, informed consent is obtained and psychometric battery is done. The second session is taped and starts with the open question: ‘Tell me about your life and what you consider to be the most important.’ After the session the taped story is reshaped and edited into a narrative. In a third session the document is read to the patient and the patient has the opportunity to reflect on his or her life.

In fact, Chochinov’s dignity therapy is a combination of two forms of dignity that we have described. Dignity therapy aims at a stronger sense of experienced dignity and does so by approaching people in a way that makes them feel respected (relational dignity). But however much powerful this combination of two forms of dignity may be, there always is a problem with the stability and continuity of both. The problem with social and relational dignity is that they are dependent on cultural practices that can change. As we know in many cultures the dignity of women and minorities is systematically undermined or denied in more or less explicit ways. The more the experience of one’s own dignity is undermined by one’s social context the harder it is to sustain a notion of dignity. What is needed in those cases is a counterstory, or a counterfactual notion that is not dependent on social arrangements but can stand on its own and help to keep alive the notion of dignity in a situation where there are no empirical signs of it.

Intrinsic dignity

Providing a counter story, a powerful moral vision that can be guiding when culture lets down is precisely the importance of the notion of intrinsic dignity. The notion of intrinsic dignity provides a powerful idea, independent from empirical reality, which helps sustain a morality according to which a fundamental equality among human beings is held up. Whether one recurs to the Christian notion of human beings made in the image of God, the Kantian idea of intrinsic worth or the Universal Declaration of Human Rights is of secondary importance. All three are theoretical conceptions that can work as a strong counterfactual notion. At the same time, however, we have seen that notions like these are as vulnerable as their authority or plausibility is.

But there are more problems related to the intrinsic notion of dignity as proclaimed by these three sources. As we have seen, the concept of dignity is used in order to organize the world. In the case of intrinsic dignity both in Stoic, Christian and Kantian philosophy intrinsic dignity was used to divide the world into those rational and non rational beings. Obviously this clarity has a price to be paid by both human beings whose rationality is compromised and higher mammals who display forms of social and rational behavior that we are still trying to understand (Walker 2011).

A second problem, put forward by those who advocate a strong emphasis on experienced dignity, is that the idea of intrinsic dignity can work as an intellectual prison that may deny the experiences of people. If I feel that because of a fatal disease my dignity as a human person is compromised to such a degree that I see the continuation of my life as a hell but I live in a cultural context that forbids the termination of my life because of my dignity as a human being, I may feel held captive in life against my own will.

A third problem focusing on intrinsic dignity alone is that paradoxically it may contribute to cleaning the consciousness of people and abstaining from moral action when it is urgent. If the intrinsic dignity of people cannot be taken away it may become an excuse for not helping them in need, e.g. when they are considered to be far away and not part of our own culture. Whatever famine or poverty people may suffer, their dignity can never be taken away from them.

Ethics of care: an integrated view on dignity

Our analysis of dignity departed from the idea that people use concepts like dignity with a certain agenda. We have seen that each of the three versions of dignity plays a role in the contemporary ethical discussions, and rightly so because they bring elements to the fore that are relevant and cannot be advocated by one of the other versions. We have also seen that each of the three versions of dignity has its own problems and none of them alone is sufficient as a strong basis for a balanced view on dignity. What is needed for the sake of the quality of the discussion and a real exchange of perspectives, is a model in which the three perspectives are integrated and in which their interrelation is determined and clarified. This model for integration will be proposed in two steps. In the first step the three foundations of dignity will be reconsidered against the background of the philosophy of Paul Ricoeur that may function as an integrative framework. In a second step the position put forward in this paper will be worked out with the help of the ethics of care because this theory offers a help in critically articulating the ethical requirements of the social practice that presents itself as underlying all other versions of dignity.

Paul ricoeur

According to the philosophy of Paul Ricoeur, the ethical intention can be formulated as ‘leading a good life, with and for others, in just institutions.’ This sentence can be read as the program of Ricoeur’s ‘little ethics’ in a nutshell (Ricoeur 1992). In his ethics Ricoeur claims to present a well balanced integration of Aristotelian teleology (‘aiming at the good life’), Kantian deontology (‘with and for others’), taking into account the institutional setting in which the moral life of human beings develops and by which it is determined to a large extent.

Ricoeur’s enterprise is helpful in understanding how different philosophical traditions and perspectives may articulate elements that need to be brought together in order to forge an account of a concept like dignity that can counter the various objections that have been listed above. If Ricoeur’s little ethics is taken as a framework for putting into perspective the three versions of dignity that have been discerned, it becomes clear how the three may hang together.

The subjective experience of one’s own dignity may be placed in the Aristotelian line of ‘aiming at a good life’. It is strongly connected to what Ricoeur would call ‘self-esteem’. Although very important as a basis of both happiness and moral action, self-esteem is an emotionally informed self appreciation that is largely made possible because of the appreciation and recognition by other people. This can be founded both psychologically and philosophically (Ricoeur 1992).

This means that the second version of dignity, the social or relational one, is more basic in two respects: genealogically in terms of the genesis of subjective dignity, and systematically because the subjective experience of dignity is based upon recognition by other people. Here we enter the more Kantian line in Ricoeur’s thinking in which he stresses that the good life cannot be achieved unless it is ‘with and for others’. Social or relational dignity is thus strongly connected with notions like ‘respect’ and ‘solicitude’. They are based on social practices by which communities are held together and individuals may flourish.

By introducing the community, Ricoeur stresses that a new dimension should be taken into account, surpassing the interrelation dimension of persons who hang together. Communities–like social practices–are more stable and permanent than the emotional ties of individual persons. After some time they produce institutions that safeguard the continuity and stability of communities and their members. Institutions like language, education, care, justice have a great impact on both one’s self-appreciation and one’s moral life. It is here, on the institutional level, that the third version of dignity can be situated. Unlike subjective dignity that is based in one’s self appreciation, and social and relational dignity that rest on practices, the idea of intrinsic dignity is nothing more than an idea which can only survive as long as it continues to be proclaimed. It may be strong because of its counterfactual potential, but when it disappears from the intellectual heritage of the institutions that sustain our cultural horizon (whether these are represented by the United Nations, religions or philosophical theories), it is lost and reduced to the personal opinions of individuals.

Ricoeur’s philosophy provides a framework that helps us appreciate the connection between the three versions of dignity and their mutual dependence and interrelatedness. Of these three the social or relational dignity seems to be the most fundamental one, both genealogically and systematically. But social practices may be organized in various ways and not all social practices are morally good. The argument in this paper therefore needs one more step so that the threefold account of dignity avoids the problems that have been discussed in the second paragraph of this paper. The last step will be taken departing from the ethics of care.

Ethics of care

Concepts like dignity are powerful tools to organize the world we live in. But tools can both be helpful and useful when they help achieving what one wants to express, or damaging when they are misused or their use has side-effects. In order to understand the working of concepts like dignity, and be able to appreciate their moral achievements one will have to study the practices from which they originate (Leget et al. 2009).

One tradition of thinking that seems to be helpful in rethinking dignity and working towards an integration of the three versions of dignity distinguished so far is the ethics of care. Originating in the feminist thinking of the early 1980 s, during the last three decades the ethics of care has developed into a ‘mosaic of insights’ with critical potential and a great sensitivity to contextual nuance (Held 2006).

The ethics of care is built on the fundamental idea that moral understandings are framed by social practices (Walker 2007). In the argument established so far we have seen that social practices are foundational to relational dignity and this version of dignity is both genealogically and systematically prior to the two other versions of dignity. Since caring is a universal human activity promoting the wellbeing and flourishing of human beings and the world around them, the ethics of care seems to be a good candidate for offering a moral basis for further reflection.

The ethics of care tries to be sensitive to the particularity of situations rather than the features that can be generalized. It is more interested in the way people try to pursue the good life in complex webs of personal relations than advocating for maximal autonomy of self supporting individuals. The ethics of care is sensitive to the way our moral life is informed by the context in which we live, our emotional attachments and the vulnerability we experience because of the fact that we have mortal bodies (van Heijst 2011). But, thanks to its feminist roots, it is also highly sensitive to the more or less subtle ways in which people are excluded, marginalized, disrespected or disvalued (Tronto 1993). Asymmetry in relations of power is an important theme in the political awareness of the ethics of care.

The ethics of care is relevant for a field broader than healthcare. In fact, according to Berenice Fischer and Joan Tronto’s definition, care includes “everything that we do to maintain, continue and repair our ‘world’ so that we can live in it as well as possible”. In this paper, however, the reflection on dignity focuses on end of life issues, as an example. Concluding of this paper it will be asked what ‘dying with dignity’ could mean from the perspective of the ethic of care and how the different versions of dignity discussed so far relate to each other in such an account. Because moral understandings are framed by social practices this paper concludes in a practical way by formulating general critical questions that may help reflecting on the practices in which dying with dignity is at stake, and which help constituting experiences and ideas of dignity.

  1. 1.

    What is the meaning of the concept of dignity as used by patients who express their subjective experience? This first questions aligns with accounts of dignity as a feeling or experience and focuses at the lived experience of vulnerable people. An ethics of care sympathizes with those who are in a vulnerable and dependent position and is interested in understanding their perspective. In order to answer this first question a phenomenological and hermeneutical approach is needed: phenomenological because one will have to understand the life world of the patient, including the existential constituents temporality, spatiality, intersubjectivity, embodiment and moods (Todres et al. 2007); hermeneutical because one will have to interpret the patient’s dignity talk within the larger framework of the patient’s lived experiences, beings sensitive to the many layers of meaning and possible inconsistencies that may be discovered in those narratives.

    A reconstruction of the patient’s lived experience of dignity asks for an open minded approach in which one abstains from using predefined categories. One of the very subtle uses of power in healthcare is precisely this interpretation of patient experiences in categories that stem from the professional’s framework (Baart and Vosman 2011). In fact, by showing interest to the patients experience and interpretation of dignity one enters the life world of a patient.

    Listening open minded to what vulnerable people have to tell is a social practice and an expression of solicitude and respect. Here we encounter the interrelation of subjective and relational dignity that we also discovered in the work of Harvey Chochinov. This leads to the second critical question:

  2. 2.

    What is the quality of the caring relations in which the patient is involved? This second question aligns with social or relational dignity. It is formulated in plural because with focusing on caring relations we are interested in a web of relations that helps to make meaningful the world in which patients live. Three caring relations are central here:

    1. (a)

      The caring relations with professionals A caring relation is a social practice in which two people are involved. In the contexts where end of life issues are at stake, this social practice is hallmarked by vulnerability and intimacy on the one hand and various kinds of subtle power and possible pressure on the other. Operating at the margins of life one is confronted with one’s own vulnerability which may evoke various reactions of self preservation. One of the temptations of end of life care is total control and preservation of the illusion that death can be well organized and even neat to a certain extent. Here we touch upon one of the paradoxes of palliative care analyzed so well by Julia Lawton according to whom hospices play the double role of being places of great care on the one hand, and hiding death and decay from society and continuing the false image of controlled death on the other (Lawton 2000). Here we also see the paradoxical interrelation between palliative care on the one hand and euthanasia and physician assisted suicide on the other: both aim at a controlled death which is seen as comfortable. By focusing on the caring relations with professionals, of importance is not only the quality of the relationship in terms of attention and confidence, but also how both patient and professional are affected by this relation. Advocates of physician assisted suicide may be put all cards on the subjective experience of patient’s dignity in order to ask for the termination of life, forgetting what this means for the experienced dignity of the caregiver. Because both caregiver and patient constitute a caring relationship, the experience of both subjects need to be taken into account.

    2. (b)

      The personal web of reciprocal relations between a patient and his close family, friends, relatives neighbors, etc. Self esteem and the experience of dignity are the result of social practices. Vulnerable people who are socially marginalized or neglected have a higher risk of suicide and depression (Vanlaere 2006). This means that dignity should be seen as part of an open ended process and not as a given or an indication that a life is no longer worth living. What dignity is, and how it affects both subjects involved in a relationship is constituted and discovered by caring for someone.

    3. (c)

      The caring relations in which a patient is actively involved Various research has shown that caring is an important source of meaningfulness and self esteem for people. Patients are often seen as object which only task is to receive care, whereas the possibility to care–be it other human beings, pets or plants–contributes to the experience of being needed and meaningful. It directly contributes to experiences of autonomy and self esteem because one remains socially embedded.

  3. 3.

    What is the social position of the patient? This question focuses on social dignity as another dimension of the practices on which the social account of dignity is based. By focusing on the social position of the patient we focus on his or her position in society in the broad sense: not only the individual position in society, but also the collective position by the fact that the patient belongs to a certain group of people like the elderly or cancer patients. Different cultures have different appreciations of those people who are sick, vulnerable, old or dying. This cultural horizon codetermines in many ways how people experience themselves. In North-Atlantic culture e.g. there is a strong tendency to push sickness, vulnerability and mortality to the margins and focus on health, youth and stories of repair. In other cultures old age may be associated with dignity and respect. As we discussed above, the cultural horizon of meaning should be taken into account in order to discover how both the dignity established in interpersonal relations and the experienced dignity are influenced or determined by this relation.

By formulating these three critical questions a tool is available for analyzing how dignity plays a role in social practices that deal with the end of life. When this social practice is analyzed through the lens of care, one might say that dying with dignity should refer to a situation in which both the dying person is supported in his or her self esteem and those surrounding the dying person act out of solicitude upholding an attitude of respect towards the vulnerable human being that is about to die. Dignity appears as an intersubjective category which is constituted and upheld by people who are interrelated in caring relationships. Does that mean that the idea of intrinsic dignity is no longer needed? From the argument in this paper it is clear that this version of dignity is still an important element in moral discussions as a moral compass because of its counterfactual hermeneutic power. The question, however, to what creatures and on what grounds this intrinsic dignity can be attributed is a different one, and opens a discussion that asks for a next paper. It is clear however that from the perspective of an ethics of care rationality alone-whether in actuality of potentiality-is a criterion far too narrow.