The concept of dignity is foundational to Catholic Christian ethics today. Yet it has not always been so. I will begin by outlining the historical roots of the Christian theology of dignity. Second, I will set forth three uses of the word, ‘dignity’: the attributed, the intrinsic, and the inflorescent. Third, I will argue for the centrality of the intrinsic meaning of dignity as the foundational notion for ethics. Fourth, I will discuss how moral norms follow from a duty to respect intrinsic dignity. Fifth, I will show how the notion of intrinsic dignity can be understood as a robustly Christian theological claim. Finally, I will delineate what a Christian understanding of respect for intrinsic dignity means for dying persons and those who care for them.Footnote 1

A very brief history of dignity

Space limitations and the more theological focus of this essay make it necessary to cover this material in a manner that does not even approach doing justice to its depth and complexity. Yet it is important for readers to understand something of the intellectual history of the concept of dignity if they are to understand its current use in theological discourse about care at the end of life.

The word ‘dignity’ has an interesting history in Western thought (see Sulmasy 1997). While it is often argued that the idea of dignity is essentially religious, dignity is not based directly on the Jewish or Christian Scriptures. The word in the Hebrew Scriptures that is translated as ‘dignity’, Gedula, occurs rarely and means something more like nobility of character or personal standing in the community. The Hebrew phrase Kavod HaBriyot (honor of God’s creation), presently translated as dignity when used in reference to human beings, is a Talmudic phrase not found in Torah, the Psalms, or the Prophets. The Greek word most accurately translated today as dignity, αξιοπρέπεια (axioprepia) is not used in the New Testament. The phrase το αξίομα, (to axioma), which is closer to worthiness, is also not found, although the related word, axios—worth or desert (as in “the worker is worth his wage”)—is frequent. Another Greek word, σεμvoτης (semnotes) is sometimes translated as dignity, but it occurs only three times in the Christian Scriptures and is best translated as ‘seriousness.’

Aquinas uses dignitas and its cognates frequently in the Summa Theologiae. It tends, however, to indicate the value something has by virtue of its place in the great chain of being. For example, plants have more dignity than rocks; angels more dignity than human beings. In a nutshell, while Christians may have always had some concept of human dignity, until very recently “it had not been developed into either a clearly defined literary form or an internally consistent set of ideas” (Trinkaus 1973). The notion may have preceded its articulation, but an unarticulated notion is not yet a concept.

Aristotle, likewise, does not use the word axioprepia. He uses semnotes only three times, and not at all in the Nichomachean Ethics. In the Eudemian Ethics he defines dignity (semnotes) as a virtue, “the mean between servility and unaccomodatingness.” (Aristotle 1991). This hardly seems the way we use the word ‘dignity’ today.

Roman stoics, particularly Cicero and Seneca, made copious use of the word. For the Romans, this Latin word literally meant “worthiness” and that in its common political meaning, it meant a person’s “reputation or standing” (Griffin and Atkins, 1991).

Renaissance writer Giovanni Pico della Mirandola is credited with being the first to make a connection between human freedom and human dignity. In his oration “On the Dignity of Man,” he argues that human dignity consists in the capacity to choose to become what one wants to be (Pico della Mirandola 1948).

By contrast, Hobbes tied dignity to power. He wrote that “The value or worth of a man, is as of all other things, his Price; that is to say so much as he would be given for the use of his power” (Hobbes, Leviathan X, 1991). In turn, Hobbes offered this definition of dignity: “The publique worth of a man, which is the value set on him by the Commonwealth, is that which men commonly call DIGNITY” (Hobbes, Leviathan X, 1991).

Kant’s notion of dignity can be understood as a response to Hobbes. Kant writes, “The respect I bear others or which another can claim from me (osservantia aliis praestanda) is the acknowledgement of the dignity (dignitas) of another man, i.e., a worth which has no price, no equivalent for which the object of valuation (aestimii) could be exchanged” (Kant, Metaphysical Principles of Virtue, Ak462, 1983). Kant connects this to the capacity for free moral agency that is intrinsic to the nature of human beings (Kant, Metaphysical Principles of Virtue, Ak419-420, 1983). He insists elsewhere that “Humanity itself is a dignity” (Kant, Metaphysical Principles of Virtue, Ak462, 1983).

This Kantian idea of dignity was eventually married to the notion of human beings having been created in the image and likeness of God by a Kantian theologian named Antonio Rosmini (See Sulmasy 1997 and also Franck 2006). A speculative and theologically suspect notion at first, this conceptual use of the word ‘dignity’ subsequently made its way into formal Catholic theology, and was first explicitly used in this way by the Church in the social encyclical Rerum Novarum, in which Pope Leo XIII defended the dignity of workers in the late nineteenth century (Leo XIII 1891). Thus, it was through the retroactive baptism of a basically Kantian idea that dignity became an important word in Catholic Christian thought.

Three uses of the word ‘dignity’

Given this history, it is clear that the word ‘dignity’ is used in several different ways. One convenient classification of these uses is to distinguish between attributed, intrinsic, and inflorescent conceptions of human dignity (Sulmasy 2008).

By attributed dignity, I mean that worth or value one confers upon others by acts of attribution. The act of conferring this worth or value may be accomplished individually or communally, but it always involves a choice. Attributed dignity is a conventional form of value. Thus, we attribute worth or value to those we consider to be dignitaries, those we admire, those who carry themselves in a particular way, or those who have certain talents, skills, or powers. We can even attribute worth or value to ourselves using this word. The Hobbesian notion of dignity is attributed.

By intrinsic dignity, I mean that worth or value that people have simply because they are human, not by virtue of any social standing, popular admiration, or any particular set of talents, skills, or powers. Intrinsic value is the value something has by virtue of being the kind of thing that it is. Intrinsic dignity is the name we give to the value that human beings have by virtue of the fact that they are human beings. This value is thus not conferred or created by human choices, but is prior to human attribution. Kant’s notion of dignity is intrinsic.

By inflorescent dignity, I mean the way people use the word to describe 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. In other words, inflorescent dignity is used to refer to individuals who are flourishing as human beings—living lives that are consistent with and expressive of the intrinsic dignity of the human. Thus, dignity is sometimes used to refer to a virtue — a state of affairs in which a human being habitually acts in a way that expresses the intrinsic value of the human. The inflorescent use of the word is not merely attributed, since it depends upon some objective conception of the human and the value of the human. Nonetheless the value itself to which this use of the word refers is not intrinsic, since it derives from the intrinsic value of the human. Aristotle’s use of the word is inflorescent, as are some of the Stoic usages.

These conceptions of human dignity are by no means mutually exclusive. Attributed, intrinsic, and inflorescent conceptions of dignity can often be invoked simultaneously. It is extremely important, however, to be able to parse out the various ways the word is used in order to understand ethical arguments invoking “dignity.”

Intrinsic dignity as the foundational meaning of the word

I would argue that the notion of intrinsic dignity is foundational. To be consistent in our use of moral words, to do the kind of moral work we want the word ‘dignity’ to do; from any perspective, but particularly from a Christian perspective, the central notion of dignity is the intrinsic.

First, it is necessary to postulate intrinsic dignity in order to make sense of the notions of attributed and inflorescent dignity. By what basis might one attribute dignity to something or say that the thing has inflorescent dignity? It must be because something about the entity makes it appropriate to use the word ‘dignity’ in attributing value to that entity or in describing its flourishing.

What both the attributed and the inflorescent concepts of dignity assume is that the entity has intrinsic dignity (Sulmasy 2013). It would be very odd to say that a snail’s attributed dignity had been violated. It would be very odd to say that a snail was behaving in either a dignified or an undignified manner. The attributed and inflorescent uses of the word ‘dignity’ depend upon a crucial assumption about the value of the entity under consideration—that the entity has intrinsic dignity. This implies that intrinsic dignity is the central notion.

Second, if there are such things as intrinsic values, then what I have called intrinsic dignity simply means the value that human beings have by virtue of being the kinds of things that they are. This is true by the definition of the word ‘intrinsic’. Whatever is intrinsically valuable is valuable independent of any valuer’s purposes, beliefs, desires, interests, or expectations. Truly intrinsic values, according to environmental ethicist Holmes Rolston, III, “are objectively there—discovered, not generated by the valuer” (Rolston 1988).

Accordingly, if there are intrinsic values in the world, the recognition of the intrinsic value of something depends upon one’s ability to discern what kind of thing it is. This leads one to the notion of natural kinds, a relatively new concept in analytic philosophy.Footnote 2 The fundamental idea behind natural kinds is that to pick something out from the rest of the universe, one must pick it out as a something.

This “somethingness” implies what Wiggins calls a “modest essentialism.” The essence of something is that by which one picks it out from the rest of reality as anything at all—its being a member of a kind. It would be incomprehensible to suggest that there really are no actual kinds of things in the world independent of human classification—no such things, de re, as planets, mosquitoes, or human beings. Thus, the intrinsic value of a natural entity—the value it has by virtue of being the kind of thing that it is—depends upon one’s ability to pick that entity out as a member of a natural kind.

I would then define intrinsic dignity as the intrinsic value of entities that are members of a natural kind that is, as a kind, capable of language, rationality, love, free will, moral agency, creativity, humor, aesthetic sensibility, and a capacity to grasp the finite and the infinite. This definition is decidedly anti-speciesist. If there are other kinds of entities in the universe besides human beings that have, as a kind, these capacities—whether angels or extra-terrestrials—they would also have intrinsic dignity.

Importantly, the logic of natural kinds suggests that one picks out individuals as members of the kind not because they express all the necessary and sufficient predicates to be classified as a member of the species, but by virtue of their inclusion under the extension of the natural kind that, as a kind, has those capacities. In technical language, this is extensional, not intensional, logic. For example, very few lemons in the bin in the supermarket express all the necessary and sufficient conditions for being classified as lemons. Suppose we define a lemon as a yellow fruit. We find, however, that some specimens in the bin are yellow, some are green, some are spotted, and some are even brown. Nonetheless, they are all lemons.

Health care depends profoundly upon this extensional logic. For instance, it is not the expression of rationality that makes us human, but our belonging to a kind that is capable of rationality that makes us human. When a human being is comatose or mentally ill, we first pick the individual out as a human being, then we note the disparity between the characteristics of the afflicted individual and the paradigmatic features and typical development and history of members of the human natural kind. This is how we come to the judgment that the individual is sick. And because that individual is a member of the human natural kind, we recognize an intrinsic value that we call dignity.

It is in recognition of that worth we have established the healing professions as our moral response to our fellow humans suffering from disease and injury. The plight of the sick rarely serves the purposes, beliefs, desires, interests, or expectations of any of us as individuals. Rather, it is because of the intrinsic value of the sick that we serve them. Thus I would argue that intrinsic human dignity is the foundation of health care.

Moral norms and respect for intrinsic dignity

Intrinsic dignity is a value that commands respect. To respect something requires both that one recognize its value and that one make choices consistent with the proper appreciation of that value.

Respect begins with recognition and acknowledgment. If a value is attributed, one is free not to make such an acknowledgment. People can differ in their attributions. If the value at stake is truly intrinsic, however, then it is an objective value—one that must be recognized by everyone. To fail to recognize and acknowledge an intrinsic value is to make a mistake.

So, if there is such a thing as intrinsic dignity, then it must first be acknowledged and recognized for its worth. Recognition and acknowledgment of such a great value further imply a duty of respect. Respect means to make choices that are compatible with the value one is obliged to recognize. So, if there is such a thing as intrinsic dignity, then one is morally obligated to recognize and acknowledge the intrinsic value of a member of a dignified natural kind, and one is morally obligated to make choices that are consistent with a proper appreciation of the value of the entity.Footnote 3

As Velleman (1999) has argued, there must be something more fundamental to ethics than interests—i.e.—a reason to respect a fellow human being’s interests in the first place. The question can be asked, for example, why should I care about this dying person who has lost a measure of independence that I have the capacity to restore partially through medical treatment? Velleman’s answer is that we seek to protect and promote a fellow human being’s interests because we first respect the human being whose interests they are. This fundamental respect is for intrinsic dignity – the “interest-independent” value of a human being. Without this primary respect, there is no basis for any form of interpersonal morality.

Intrinsic dignity is inalienable. It can neither be sold nor seized nor abdicated nor erased. Intrinsic dignity is the foundation of all human rights (Sulmasy 2007). We respect rights because we recognize intrinsic dignity. We do not bestow dignity to the extent that we bestow rights.

Respect for intrinsic dignity implies, importantly, duties to build up the attributed dignity of others and to maintain and foster conditions for their flourishing. Dignity is thus the originating point for all interpersonal ethics.

Intrinsic dignity as a Christian notion

The foregoing analysis has been largely philosophical, with arguments intended to address persons of all faiths and of no faith. The sources cited in support of the notion of intrinsic dignity have been Christian, pre-Christian, and post-Christian. This suggests both that that the notion of intrinsic dignity is an idea that can be defended independent of Christian thought and that it has had wide application as an important concept in philosophical ethics across the centuries.

Thus, while Christians might consider dignity to be an important concept, Christians must recognize that they did not invent the idea. I will argue that Christians give different reasons to justify and explain the notion of intrinsic dignity while not rejecting the possibility that one could come to justify and understand the notion of dignity independent of religious belief. Non-Christians might consider the reasons Christians give in support of the notion of intrinsic dignity to be, at most, adjunctive, and, at worst, nonsensical. Christians would consider their reasons to be deeper, richer, and fuller.

Space precludes a fuller discussion, but it is precisely this nexus between philosophical and theological ethics that has driven Roman Catholic Christian thinking about ethics for centuries. Catholic Christians hold that God gave all persons the power to reason about ethics and the possibility of orienting their wills towards the good. This means that Catholic Christians hold that all persons are capable of moral thinking and judgment, even if they have not been baptized or explicitly informed by Christian revelation. Thus, Catholics believe one can address all persons of reason and good will about ethical issues, and that a diverse group of persons can come to a common consensus on the morally right course of action independent of faith. Catholic Christians would also hold, however, that reasoning independent of faith is flawed, and that Christian revelation provides a fuller justification for ethics and that the grace of God extends to all human beings the assistance they need to pursue and choose the good.

This essay thus provides a bridge between the philosophical and the theological justification for the notion of intrinsic dignity. As I argued above, as a matter of the history of ideas, Catholic Christianity borrowed the concept of dignity from philosophy to name a concept that Christians had always held but had not formally named until the late nineteenth century. What follows is a theological understanding and justification of dignity that converges on the secular notion as a matter of practical ethics, but springs from different premises.

Christianity holds that human beings are beings-in-relationship. Christians hold that the fundamental relationship human beings have is with God. Christians hold that human beings are creatures of God, created in the image and likeness of God, and are of inestimable value. Human beings are the apple of God’s eye (Deu. 32:10), the pinnacle of the created order.

Yet human beings are also finite—physically, morally, and intellectually. Human beings thus occupy a very specific place in the manifold goodness of the web of God’s creation. Human beings are “worth more than sparrows” (Mt. 6:26), “more than the birds of the air” (Mt. 10:30–31), and “more than sheep” (Mt. 12;12), yet “lower than the angels” (Heb. 2:7). This is the value of each human being—intrinsic dignity—the value human beings have by virtue of being what they are.

Since this dignity is based upon nothing more than the bare fact of membership in the human natural kind, it is radically equal among human beings. It does not admit of degrees. Christians note that this is the value that Jesus sees in prostitutes, tax collectors, the poor, widows, orphans, the sick, and the dying. Each one equally created in God’s own image.

Christians hold that this intrinsic value is unmerited. Human beings do not create themselves, and so must recognize that the value they have by virtue of being the kinds of things that they are is a gift. The fact that we are is not of our own doing. Simply being human is the foundation of human intrinsic value—more than sparrows, less than angels. Thus understood, intrinsic dignity is the foundational notion of dignity for Christianity.

Christianity holds that God’s creative urge is dignity’s only source. Moreover, since God loves human beings, created in God’s own image, members of the human natural kind also have a value that is bestowed upon them by virtue of their ongoing relationship to God, the relationship by which they are held in being. Christians believe that God thought human beings worthy of being sent his Son as savior. This unmerited worthiness is thus both the source of human dignity and its supreme verification.

This theological justification for the concept of intrinsic dignity arises from premises that not all persons will share, yet the concept can be put to common use by persons of all faiths and of no faith if they can arrive at roughly the same concept for different reasons. The non-theological reasons one can give for accepting the idea of human dignity include philosophical arguments based on the intrinsic value of the human natural kind (as I have made, see Sulmasy 2008), Velleman’s notion of “interest-independent value” (Velleman 1999), legal arguments (Foster 2011), rights theory (Waldron 2012), or neo-Kantian conceptions (Hill 2013). It is not a problem for Christian ethics per se that human beings, created, as they believe, in the image and likeness of God, should to come to understand the notion that all human beings have an intrinsic worth or value simply because they are human, even if they fail to recognize that the ultimate reason for this value depends on the one who created them.

Dignity and the care of the dying

For all human beings, Christian or non-Christian, the fact of mortality raises questions about one’s worth. Dying raises questions about one’s value as one is dying; about the value of the life one may have led up to the moment of death; and about whether anything that is valuable about oneself perdures beyond the moment of death. One major spiritual task for the dying is to reject, or to discover, or to re-cover, or to affirm their own grasp of their own intrinsic human dignity. Sickness and the dying process mount a relentless assault against attributed human dignity. In the wake of physical failure, inflorescent dignity appears to fail as well. Accordingly, dying persons naturally begin to ask, is that all there is? Is there nothing more about me that is of value now except how I feel, how I appear to others, how much I can do without anyone else’s help, and how productive I can be?

The only value that can perdure in the face of death is intrinsic value. Consideration of the idea that one has intrinsic value may lead to further questions, such as, what is the source of that value? Can such a belief be validated? Does my value continue after death? These are all spiritual questions, whether raised in a religious context or not.

Christianity teaches that one can actually flourish in death, through an open acceptance of one’s intrinsic value. This value is one’s intrinsic dignity—a worth that is more than that of the sparrows, but less than that of the angels. Human hearts and minds reach to the heavens, but human beings are mortal creatures nonetheless. A truly Christian death requires final and full acceptance of oneself for who and what one is—in humility and in hope.

Christianity teaches that people need to know the value they have by virtue of being the kinds of things that they are—beings in relationship with God and with God’s people. They need to know that while finite—morally, intellectually, and physically—they are loved radically and exuberantly by the God who created them and offers them redemption in Christ. No human being deserves such love. But Christians hold that God sees in us what we cannot see in ourselves, and became incarnate and died to show us what we could only see, at best, imperfectly by ourselves.

Death offers us the possibility of seeing this value clearly. An acceptance of our intrinsic value is an integral part of the beatific vision offered to the Christian in death.

Respect for the dying requires that those who will survive them attend to their spiritual struggles. Christians are called to point out, in word and in deed, the dignity that is already there to be grasped by their dying brothers and sisters. The dying need to be reminded of their dignity at a time of fierce doubt. They need to understand that they are not grotesque because of the way disease has altered their appearance; not merely bothersome because they are dependent; not unvalued because they are unproductive. They dying need to know that they are worth the time, attention, and resources of others. In short, they need a demonstration that the community affirms their intrinsic dignity.

Roman Catholics count visiting the sick among the “corporal works of mercy” (Catechism of the Catholic Church § 2447). Jews consider the practice a mitzvah. The choice to visit the dying is a choice that itself communicates a recognition of the intrinsic dignity of the terminally ill, and can assist them in coming to accept their own intrinsic dignity.

Families sometimes have so internalized the medicalization of dying that they avoid their dying loved ones. In our contemporary culture, death is considered something that happens rarely, is to be avoided at all costs, and when it is about to happen should be hidden from view in nursing homes and intensive care units. Christians concerned about the dignity of the dying must overcome their own reluctance to visit them. Human beings, while exalted among the creatures of the earth, are not angels. The dying remind us of this.

The dying can also teach those who will survive them about their own dignity. If they have met Christ in their dying, they give witness to the promise of life with God that only comes through dying. This is the transcendent meaning of hope.

Christians will also show respect for intrinsic human dignity by action to build up, to the extent possible, the inflorescent dignity of their fellow human beings, provided this does not undermine or contradict the intrinsic human dignity that is the ground of moral action. In other words, to respect someone’s intrinsic human dignity demands that one show that respect concretely.

Physicians, nurses, and others can help dying patients to grasp their own intrinsic dignity by concrete actions that thwart or mitigate the assault that the dying process mounts against their patients’ inflorescent dignity. To say that one respects the intrinsic dignity of the dying requires that one assist them in their concrete needs. Respect for the dying is shown by bathing them, feeding them, treating their pain, relieving their nausea, and helping them to get out of bed. Respect for the dying is shown by being with them, and listening to them attentively, paying careful attention to the lessons they can teach those who survive them.

Respect for the dignity of the dying certainly means that one ought never act with the specific intention in acting of making patients dead by way of one’s action.Footnote 4 This is hardly consistent with respect for intrinsic dignity. One ought never act in such as way as to undermine the intrinsic dignity that gives all other moral duties their binding force. How can one claim to respect what one intentionally destroys? Those who claim that “death with dignity” implies the permissibility of euthanasia or assisted suicide can only do so by narrowing the scope of dignity to its attributed meaning. One can justify these actions only if one is convinced that all dignity is lost, or that it has fallen below some threshold. What is truly intrinsic, however, can never be lost and does not admit of degrees—even if one has lost sight of one’s own intrinsic worth or others have become blinded to it.

Intrinsic dignity is not destroyed by pain or nausea or feelings of dependence or depression. One’s intrinsic worth or value is not dependent on any degree of rationality or consciousness. In fact, psychiatrists point out that the person who asks for assisted suicide is often merely testing the waters, looking to see whether others will confirm one of their own deepest fears—that they truly have become worthless (Hendin 1996). Christianity proclaims that by virtue of having been created by God and redeemed in Christ no one is ever worthless. The dying have this value by virtue of being human, and nothing more.

Nonetheless, respect for intrinsic human dignity encompasses an acknowledgment that while we human beings are of inestimable value, we are not of infinite value. We are worth more than sparrows but less than the angels; made in the image of God, but not gods.

As the Psalmist says, “a little lower than God” (Ps 8:6). Thus, while there might be an absolute prohibition on killing, the duty to maintain life is finite. The Roman Catholic tradition has called life-sustaining treatments that go beyond what a finite human being can be obliged to bear, “extraordinary” means of care.Footnote 5 Christians respect human life, but do not worship human life. While one cannot make death one’s aim, one can forgo measures that forestall death, realizing that death will likely follow as a consequence. In fact, in some cases, striving to stay alive at all costs can be inconsistent with respect for one’s own dignity—if it is rooted in a refusal to accept the finitude that is characteristic of the kinds of things we are as human beings.

Thus, withholding or withdrawing life-sustaining treatments that are futile, burdensome, costly, or complicated, or when their use would interfere with our ability to carry out other moral obligations, is perfectly consistent with respect for the intrinsic dignity of the human. Respect for intrinsic dignity implies that one should act in a manner consistent with one’s true intrinsic value, neither clinging vainly to this life nor denying the intrinsic value of this life.

Respect for intrinsic dignity also requires attention to the spiritual needs of patients and giving patients the space to grow spiritually—to attend to their needs for growth in inflorescent dignity. Christian faith proclaims that human beings can truly flourish as the mortal kinds of things that they are, even as they are dying. Death has a powerful way of making clear what is really important, what really matters.

Death raises questions about meaning, value, and relationship that ultimately have only a transcendent answer (Sulmasy 2006). Christians hold that this transcendent answer has been given in Christ and in his Spirit. The dying person brings his or her entire life to the moment of death. If that life has the love of God as the foundation of its value, the source of its hope, and its model of right relationship, Christian theology teaches that this is exactly what will be irrevocably, absolutely, and eternally determined in the dying of that person.

One of the most remarkable opportunities I have as a clinician is the privilege of caring for such patients. When I enter their rooms, I sometimes feel the urge to remove my shoes, because I know that the ground on which I am about to tread is holy. I find that I myself am the one transformed, the one to whom enormous grace has been revealed.

Seeing God reflected so purely by the dying can inspire and transform a caregiver who affirms that “neither death, nor life, nor angels, nor rulers, nor things present, nor things to come, nor powers, nor height, nor depth, nor anything else in all creation will be able to separate us from the love of God in Christ Jesus our Lord.” (Rom 8:38). Christians hold that this Love is the cause of human dignity, the lens through which they see dignity in themselves and in their dying brothers and sisters, the inspiration for loving service to them, and the destiny to which all persons are called. The Gospel’s vision of Death with Dignity is one that Christians must never tire of proclaiming.