From ontological to relational: A scoping review of conceptions of dignity invoked in deliberations on medically assisted death

Abstract

Background

Dignity is omnipresent in Western ethics, but it also provokes dissension and controversy. One of the most striking examples is the debate on medically assisted death, where dignity is invoked to support antagonistic positions. While some authors conclude that the concept is useless as an ethical reference, many others invite us to deepen our analysis from a multidimensional perspective, to enrich it and make it useful. This scoping study is intended to provide an overview of the different conceptions of dignity used in the assisted dying debate, to better grasp the multiple facets of the concept.

Methods

The Joanna Briggs Institute's JBI Manual for Evidence Synthesis guided the scoping review. Key words were based on the researchers' expertise and were used to identify relevant literature in French and English. Eleven databases covering the last six decades were consulted. Initially, 2,071 references were found in the databases. After excluding duplicates, screening titles, abstracts, and full texts, and after a specific literature search on the concept of relational dignity, 156 papers were found to match the identified inclusion criteria.

Results

The literature highlights the stark confrontation between two dominant conceptions of dignity: ontological and autonomist. However, a lesser-known conceptualization of dignity integrates these two perspectives, underlining the relational and social dimensions of dignity. As a result, dignity emerges as a dynamic, experiential, and dialogical concept, that modulates itself according to circumstances. This raises the possibility of breaking through the binary debate and questioning the current frameworks that define dignity.

Conclusions

This multidimensional conceptualization of dignity could lead to a more complete and nuanced understanding of the concept, as well as open richer normative horizons regarding the issue of medically assisted death.

Background

There is no question that Western liberal societies place tremendous value on the concept of human dignity. Indeed, it is striking to note just how often dignity is brought up in everyday language, political and legal discourse [1], normative ethical arguments [2, 3] and the principles underlying professional practices such as nursing [4]. Thus Rigaux [5] described a “contemporary explosion” or “overheating” of deliberations on dignity, as witnessed by the reams of related literature. This does not mean, however, that there is any consensus on the interpretation or meaning of dignity. In fact, the definition of dignity and its use are the subject of considerable controversy.

Of all the contemporary issues in the Western world involving the concept of dignity, surely, one of the most patent examples is the controversial issue of legalization and decriminalization of medically assisted death.¹ In the fierce debate on dignity [6,7,8,9,10], many authors point to the paradoxical use of the concept to support contradictory positions on the practices of euthanasia and assisted suicide [7, 9, 11,12,13,14,15,16,17,18,19,20,21,22,23,24,25]. This antilogy is certainly not without bearing on the position of the many authors who bemoan the multivocity, ambiguity, lack of clarity and “plasticity” of dignity and the lack of consensus regarding its content [3, 4, 7, 8, 26,27,28,29,30,31,32], or who go so far as to deem it outright meaningless [33]. Therefore, some even suggest eliminating references to dignity in all ethical and clinical reflections and adhering to concepts such as respect for autonomy or respect for the individual, which they find to be more effective guides [34,35,36,37], especially in regard to end-of-life issues, including medically assisted death [32].

However, these exhortations to ignore the concept of dignity have led to several arguments reasserting its relevance. While some authors point out or deplore the polysemy of the term ‘‘dignity’’ [5, 38], for others, the many ways in which dignity has been conceptualized can be a source of fecundity, and an incentive to pursue discussion on the topic [1, 39]. Although it is wishful thinking and inappropriate to seek an unequivocal definition of dignity [40,41,42], due to its complexity and even its ambiguity, we argue it is essential to explore and better understand its multiple facets and interpretations, and to study them more in depth so that dignity may ultimately prove a useful concept in normative ethics and bioethics [1, 3, 9, 16, 43, 44].

This analysis of the term of dignity and its various uses is even more worthwhile in the specific context of euthanasia and medically assisted suicide, since it seems, according to some, to provide a language within which conflicting values and rights appear to cohabitate [1]. Moreover, since the concern for dying with dignity is unanimously espoused both by proponents and opponents of medically assisted death [11, 13, 15, 39, 42, 45], if it is better conceptualized, dignity could become a “nodal point” [39], thus furthering ethical reflection on the issue. At least, this is what Muders [33, 42] proposed when he urged us to enrich the concept of human dignity so that it could play a useful role in applied ethics, including in the specific case of medically assisted death. He writes:

although assisted death is still a prominent topic in bioethics, the relevance of human dignity for this debate has not yet found the adequate, multifaceted treatment it deserves, namely a treatment that assembles all important perspectives and positions, examines the arguments that may be enhanced by it, and enriches the yet undertheorized role it currently holds in this debate ([42], p.3).

This is the framework for this scoping review, which aims to explore the various conceptions and uses of the term of dignity in the debate surrounding medically assisted death. This method of analysis is particularly helpful in examining the scope of a complex subject based on vast quantities of heterogeneous literature [46,47,48]. It will also make it possible to map the key elements related to the concept [46, 48, 49], highlight potential avenues in future research to enrich ethical reflection, and perhaps even contribute to the treatment of the issues of dignity, medically assisted death, euthanasia, and medically assisted suicide.

Methods

Primary question

In the debate on medically assisted death in the past sixty years in North America, Europe, and Australia, what are the main conceptions of dignity, and which ones seem to open up new possibilities?

Subquestions

• What are the conceptions on which the practice of medically assisted death is based?

• What are the conceptions on which criticism of the practice is based?

• Should some of these conceptions be revisited in an effort to enrich the debate?

Review method

A scoping review was conducted based on Joanna Briggs Institute’s 2020 version of the JBI Manual for Evidence Synthesis [47]. The manual is available at https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews.

Research strategy

First, one of the members of the research team, who assisted a committee of Quebec experts exploring the eligibility of incompetent patients for medically assisted death, identified the references relevant to the question of dignity. These documents served as a springboard for reflection. Then, keywords adapted to the specific characteristics of each database were identified with the help of a research librarian (see Table 1).

Table 1 Keywords for search strategy

The team subsequently conducted systematic research in eleven databases, two specializing in philosophy, four in biomedical science and five in social sciences and the humanities (Philosopher’s Index, Religion & Philosophy Collection [RPC], CINAHL with Full Text [EBSCOhost], MEDLINE, Cochrane, PubMed, Sociological abstract, SocINDEX, Cairn, JSTOR and Érudit); two multidisciplinary databases [Repère and Scopus]; and two others including grey literature [Google Scholar and Santécom]. The literature review took place between September 2021 and April 2022 and was updated in March 2023.

The Boolean operators “OR” and “AND” were used for text searches in Abstract/Title/Keyword, crossing the following two concepts:

• Concept 1:(dignit* OR dignified OR dignif* OR “perceived dignit*” OR “dignity loss” OR “loss of dignity” OR indignit*) AND (conception OR perception OR definition

AND

• Concept 2: (Euthanas* OR “right to die” OR “assisted suicide” OR “medical* assisted suicide” OR “medically assisted death” OR “hasten death” OR death OR dying OR “droit à la mort” OR “aide médicale à mourir” OR “suicide assisté”)

Research criteria

Since the goal was to determine the scope and construct a map of the conceptions of dignity related to medically assisted death, the inclusion criteria were intentionally broad. The literature had to (1) have been published since 1960, (2) be published in English or French, and (3) take one of the following forms: experimental, quasi-experimental, evaluation, observational or qualitative protocols; joint studies; philosophical analyses and reflections; trials; or grey literature. The target population was (1) adults and (2) those capable of consenting to assisted in dying. The exclusion criteria were as follows: (1) references published before 1960, (2) were published in a language other than English or French, and (3) were social media or mass media publications.

Selection of references

Initially, 2,071 references were in the databases (for an example, see Fig. 1). The reference management software EndNote was used and deleted 187 entries. Thus, 1,884 references were imported into Covidence for the purpose of screening the titles and abstracts. The software program deleted an additional 223 duplicate entries. The remaining 1,661 references were subsequently analyzed in parallel by two members of the research team. A third member made the final decision in the case of disagreement. Thus, with an interrater agreement of 81%, 1,327 references were rejected. Another 122 articles were deleted after discussion within the team. Of these, 110 made only marginal reference to assisted death. The other 12 references were either published in a language other than English or French, were unavailable or were proven to be duplicates. In the end, 212 references were exported to NVivo (R 1.6) for full screening (Fig. 2). A few book chapters (37) were also extracted and treated individually. Eighteen references (including 13 from a single collection) were imported on the recommendation of two external experts in the field of assisted death: an ethicist and a jurist. In a March 2023 update, 6 references were added. Finally, during the process, the research team noted what appeared to be the emergence of a literature on “relational dignity”. Although writings embracing a relational conception of dignity were still marginal, the team deemed it pertinent to perform a specific search on this concept, using the same databases. This additional search provided 3 more references. After a full analysis of the literature, 119 references were rejected because they did not meet the selection criteria. In the end, 156 references were codified using NVivo (R 1.6), which made it possible to answer the study’s primary question involving the identification of the different conceptions of dignity used in the debate on medically assisted death.

Fig. 1

Example of search strategies

Fig. 2

Flow diagram

To codify the references, the principal investigator iteratively developed a grid of typologies of dignity based on the initial readings and the selection of references by title/abstract. After approval by the other two members of the research team, the final version of the grid was adopted.

Charting the data

The majority (51%) of the references included (Additional file 1) were from North America: 51/156 from the United States, 26/156 from Canada, including from Quebec, and 2/156 from both countries. Approximately 41% (64/156) of the included documents were written by Europeans. Of these, 16/156 were from France, 13/156 from the United Kingdom, 7/156 from Germany, 6/156 from Belgium, 5/156 from the Netherlands, and 5/156 from Switzerland. In addition to the five references by Australian authors, two literature reviews were included although they were from Iran and Singapore since almost all of the included documents were written in the West. Additionally, although only 25 of the references were published before 2000, more than 60% (95/156) were published after 2010, testifying to the growing interest in the subject.

Results

Apart from a few framework documents, such as reports of commissions or expert committees, almost all the literature analyzed (134/156, or 86%) comprised reflective or analytical works. Many of them were in the field of philosophy, ethics, or bioethics. Only 7/156 of the documents were scientific literature reviews, three of which were systematic reviews. In addition, six studies were identified, of which only two were specifically aimed at exploring conceptions of dignity from the point of view of people at the end of life [14] or the elderly [50]. This vast, heterogeneous collection of literature raises a variety of questions about the nature and function of dignity. For example, what is it that justifies the concept of human dignity? Should it be understood in absolute or in relative and subjective terms [27]? Can it be considered the basis for human rights [51, 52]? More generally speaking, as McCrudden suggested [1], there are basically two levels in the debates surrounding dignity: the foundational level, or the grounding of the concept, and its ability to provide a guide for human action. By circumscribing the literature to what is relevant to assisted death, we can provide a general overview of the conceptions of dignity employed in discussions on the subject, starting with those whose use, whether to oppose or support euthanasia or assisted suicide, is easiest to define.

Conceptions of dignity that argue against assisted death

Dignity from an ontological perspective

Different terms

Without question, according to the terminology used by several authors, ontological dignity [25, 27, 30, 38, 41, 51, 53,54,55,56,57], that is, a dignity inherent to the human being qua human being, is the most common conception of dignity evoked in the literature on medically assisted death, essentially among those who oppose it.² Other terms are used in a similar fashion, including human dignity [4, 11, 16, 19, 22, 28, 38, 44, 58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75]; intrinsic dignity (sometimes referred to as “intrinsic human dignity”) [12, 13, 15, 22, 23, 25, 28, 30, 38, 39, 74, 76,77,78,79,80,81,82,83,84,85,86]; inherent dignity [9, 27, 28, 53, 64, 65, 75, 76, 81, 83, 87, 88]; basic or fundamental dignity [9, 17, 25, 30, 51, 52, 60, 75, 78, 81]; absolute dignity [13, 22, 27, 28, 38, 53, 68, 89, 90]; universal dignity [13, 27, 28, 52, 60]; and, finally, objective dignity [13, 15, 22, 25, 51, 89, 91]. Although some of these terms are at times used differently (for example, human dignity, which is not always understood in the ontological sense³), overall, the different formulations affirm the idea of unique value [92] and are recognized as applying to every human being, not because of what they “have” but because of what they “are” [20] “by virtue of their very existence” [53, 54], in other words, unconditional human dignity [27].

Groundings

This idea of the inherent dignity of every human being, “indissolubly attached” to the “human family” [27], has a long tradition [66]. It can be found as far back as in the writings of Cicero [80, 93,94,95], who alluded to dignity in relation to human beings’ unique ability to learn and contemplate [3] as well as reason [94]. Seneca and, more broadly, the Stoic philosophers of ancient Greece, often associated human dignity with the possession of reason [74, 80]. However, other groundings for ontological dignity have also been postulated. Specifically, from a religious, and especially Judeo-Christian viewpoint, the unique value of humans is predicated on the fact that they were created in God’s image (Imago Dei) [3, 5, 9, 12, 17, 25, 28, 32, 39, 56, 63, 69, 73, 74, 95, 96]. Although dignity is not an exclusively religious concept [65, 85, 88, 95], Christian thought, by combining the Stoic notion of rationality and the idea that human beings were created in God’s image, has made ontological dignity a key element of its theology and ethics [80, 85] and led to its wide dissemination. It is therefore unsurprising to hear that critics say that dignity has too much of a religious connotation to guide ethical reflection [3, 5]. Nevertheless, some authors point out that there are also secular foundations for intrinsic dignity in legal, political, and human rights related arguments [85]. Many authors mention the determining role of the Universal Declaration of Human Rights published in 1948, which contributed to the rather recent promotion of the concept of dignity, particularly in ethics, bioethics, and law [3, 5, 12, 18, 22, 25, 27, 28, 34, 38, 51, 53, 54, 63, 65, 80, 83, 97, 98]. At any rate, regardless of its foundation or justification, in ontological terms, dignity admits of neither degree nor relativity; for it is given at the same time as humanity, and refers to the latter's absolute value, its intangibility [97]. As it does not depend on the gaze of others, (ontological) dignity cannot be conferred or taken away by human decision because it is inalienable and unavailable [23, 25, 52, 64, 69, 85, 97]. No one can waive their dignity since no one has the power to exile themselves from humanity [97]. Similarly, no condition or situation can alter it or cause a person to lose it, whether through illness, old age, suffering or even imminent death [23, 39, 53, 54, 62, 78, 85, 99, 100]. Therein lies its connection to respect for human life.

Dignity and sanctity of human life

Ontological dignity applies not only to certain human attributes, such as reason but also, to the entire being, including the physical body. As such, human life has value, independent of any judgment [9, 77, 78, 91, 101, 102], and that justifies its inviolability and respect [28]. This explains the often-postulated connection between dignity and the sanctity of human life [23, 39, 69, 71, 74, 101]. Obviously, the sanctity of human life can be understood from a religious perspective, where life is considered a gift from God [35, 63, 99], which humans cannot simply manipulate as they please without it being an insult to the sanctity of life or a usurpation of divine authority [8, 99, 103]. This approach clearly leads to an argument against medically assisted death. However, like the concept of ontological dignity, to which it is related, the sanctity of human life is not strictly a religious or Christian idea [61, 89]. Some interpretations go so far as to suggest that respect for it may include putting an end to life when it loses its meaning [89], but these are few and far between.

Conceptions of dignity that argue in favor of assisted death

Dignity from an autonomous perspective

Different terms

The second perspective on dignity, copiously used in the debate on medically assisted death, could be referred to as “dignity/autonomy,” as described by Landheer-Cieslak [79]. In our view, this term can be used as an umbrella notion covering several concepts, such as relative dignity [12, 25, 39, 63, 68], contingent dignity [39, 63, 74], subjective dignity [3, 11, 12, 15, 22, 39, 60, 75, 79, 80, 82, 89, 91, 104], experienced dignity [25, 80], phenomenological dignity [25], personal dignity [4, 9, 11, 17, 20, 22, 52, 57, 58, 60, 68, 73, 76, 88, 105,106,107,108,109], individual dignity [76, 87, 110] and dignity as freedom [38, 53, 87, 97]. Despite the nuances in the definitions of these various terms and in the way they are used, they share the same general meaning. More specifically, in arguments in favor of assisted death, these variants support the idea that it is exclusively up to the person concerned to define the conditions under which they can live and die with dignity [15, 89, 105, 111].⁴These are subjective forms of dignity based on an assessment by the person, who feels that they have dignity or that they are losing it [27, 80]. In concrete terms, from this perspective, in the case of physical or mental deterioration as a result of a severe illness, for example, a person who deems that they are no longer living with dignity should be able to choose to die [24, 67, 89, 93, 112,113,114,115,116]. This choice is seen as ensuring dignity, both because it allows the person to escape from a life they deem void of dignity [117] and that impedes “authentic human freedom” [112], and because it embodies the exercise of free existential choice [115, 117, 118]. Here, dignity is clearly associated with freedom [89, 117] in the sense of self-determination [119].

Groundings

While it is possible to trace the concept of dignity as freedom all the way back to Pico della Mirandola (1463‒1494) [3, 80], the concept of subjective dignity or dignity as autonomy is more modern [9, 53, 70]. Some authors associate it with Descartes [27, 39], who advocated for autonomy and mastery [12] and who is thought to have inspired the postmodern idea of moral and political emancipation [27]. Others refer to Kant [3, 70, 101, 116], although as we shall see below, the reading of Kant is open to disagreement. In any case, several authors embrace this perspective, according to which individual autonomy is the foundation of dignity or, at the very least, is closely related to it [90, 104, 111, 112, 120,121,122,123,124]. In fact, in Western society and from a more global perspective, the terms “autonomy” and “dignity” are so often used together [20, 29, 35, 57, 67], or even combined, that they are sometimes considered synonyms [11, 34]. According to some authors, the Anglo-Saxon philosophical, political, legal, and bioethical traditions are undoubtedly responsible for the importance of individual autonomy in this conceptualization of dignity [10, 57, 119, 125].

Dignity, integrity, and identity

From the perspective of dignity as autonomy, a particularly influential conception is that grounded in respecting a person’s integrity and identity. This vision is part of a narrative or biographical approach to dignity [65, 116, 126], and its most well-known version was described by the American liberal philosopher and jurist Ronald Dworkin in the early 1990s [96]. According to this approach, human life, from beginning to end, revolves around critical interests. These interests give life coherence and shape, and ensure the person’s integrity, thereby preserving their identity [127]. Respect for human dignity is based on respect for these critical interests. From the narrative perspective, death is seen as the final chapter in a person’s life [128] or as the final act of existence, and, since everything is intensified at that point in time, the manner of death can affect the overall character of the person’s life [116, 126, 127]. In other words, when the circumstances of a person’s death go against their convictions regarding their critical interests, it is like a story, says Dworkin, “whose bad ending mars what went before” ([127], p. 27). As a result, to maintain the integrity and coherence of their life, to show consideration of the values that provide coherence and are at the very core of their self-identity, a person may choose to die and avoid ending their life in a manner that, in their opinion, would betray or be inconsistent with the pursuit of their critical interests [127]. This person is making sure they die with dignity, since their death will be in line [70] with the values they have always lived by [128] and will preserve the integrity of their life until the day they die [96].

The abovementioned approach contributes to the argument in favor of legalizing medically assisted death for those who ask for it [109, 116, 128] and, as such, it supports the argument made by certain advocacy organizations [11, 45, 129]. Moreover, various official documents granting access to medically assisted death in Quebec, Canada and elsewhere, including reports from advisory boards and other experts, judgments, and legal analyses, are directly or indirectly partly based on Dworkinian theory. In brief, they take up the idea that, to preserve dignity, it is up to the person approaching death to determine what aligns with the aspirations and values (religious or secular, philosophical, etc.) that have guided them up to now and to be able to make their choices accordingly.⁵ Some of the documents go so far as to talk about the right to die [12, 13, 20, 32, 35, 51, 67, 76, 107, 130,131,132,133,134].

The Kantian conception of dignity: Conflicting interpretations and impasse

The Kantian conception is another conception of dignity that cannot be overlooked in the debate on medically assisted death, although it is not without its detractors. It is most often invoked by those who oppose medically assisted death and who ground their opposition in a ontological conception of dignity. For these authors, the fact that Kant’s view is that human beings have absolute value, above all price [12, 18, 88, 97], which requires that they be treated as an “end in themself,” conforms to this vision of dignity [5, 12, 22, 27, 39, 54, 66, 72, 74, 78, 80, 84, 96, 100]. Moreover, although the Kantian view of dignity was not initially religious, theologians, especially Catholics, but also other Christians, integrated it into their doctrine [85] and into their argument against euthanasia and assisted suicide. Several authors cite Kant’s categorical opposition to suicide [5, 12, 31, 41, 66, 78, 95, 96, 135,136,137]. By extension, several of them conclude that the Kantian perspective opposes assisted death [32, 41, 78].

However, this widespread interpretation is on the other hand criticized by others [70, 121, 135,136,137,138,139,140], especially by those who emphasize the importance, in the Kantian view, of rationality, moral autonomy or agency, and personal autonomy⁶), as the foundations of dignity [3, 70, 101, 116, 119, 121, 125, 135, 141]. Some of these authors point out that the opportunity to autonomously choose to hasten one’s death to “die in dignity” is consistent with respecting a person’s moral agency and status as a rational being [116, 121, 140]. According to these authors, this is especially true since the end-of-life process, prior to natural death, can alter the rationality (practice) and moral agency upon which, in this view, dignity is based [58, 116, 119]. Some authors go even further, postulating that prohibiting medically assisted death could even run counter to Kantian thought.⁷ For example, according to Lossignol and Dumitrescu [68], refusing someone the right to die as they wish under the pretext of respecting their dignity (in the ontological sense) is manipulative. In their view, this amounts to using the person as a means to an end decided by others who oppose assisted death (e.g. caregivers), which also conflicts with the Kantian principle of non-instrumentalization.

Given these divergent and deeply conflicting interpretations of the Kantian perspective, when it comes to debating the issue of medically assisted death and the role dignity plays in it, some analysts conclude that the concept is ambiguous [74] and of no use in furthering reflection. In its report End-of-Life Decision Making, the Royal Society of Canada Expert Panel states that “the influential Kantian approach to ethics does not provide an unequivocal ethical guidance and justification on the issue of assisted dying” [32], suggesting that the divide between the different Kantian interpretations can only lead to an impasse on the subject.

Minority views on dignity and their ambiguous role in medically assisted death

In addition to the conceptions previously discussed, the literature addresses a few other, lesser-known views of dignity. One of them can be termed dignity as a virtue or flourishing dignity, based on the Aristotelian tradition, and essentially refers to dignified conduct or a dignified nature, admirable for its virtue [20, 38, 52, 70, 74, 77, 78, 84,85,86, 88, 96, 126, 136]. There is also dignity as status or attributed dignity, which is based on the value conferred on a person by others according to a certain scale [52, 78, 85, 86, 99, 135]. Many authors also cite the etymological meaning of the Latin word dignus and the Roman concept of dignitas, which essentially refers to a recognized value, deserving of honor, respect, or esteem [3, 5, 10, 12, 51, 58, 70, 72, 86, 101, 113, 135].

These conceptions, like some of those found sparingly in the literature (e.g., dignity as decency [38, 53, 54, 97] and esthetic decency [9], etc.), do not play a clearly defined role in the debate on medically assisted death. In a way similar to Kantian’s interpretations of dignity, because of divergent readings of his philosophy, these conceptions (of dignity as virtue, as status or decency) can be used to argue against or in favor of the practice. In addition, many of these definitions of dignity overlap, which makes it difficult, if not impossible, to provide a clear and exhaustive overview of the different terms. For example, Van Brussel [74] used external dignity to cover everything to do with a person’s conduct (dignity as a virtue), social status (attributed dignity) and self-identify (narrative dignity), although the latter appears to be somehow better described as internal than external. Given all of this, it is easy to understand why some authors believe that the concept of dignity is too “vague” [16] and not of much use in regard to ethical reflection.

Relational dignity: a relatively unexplored conception

Although it remains relatively marginal, another conception of dignity articulated in discussions on medically assisted death is that of “relational dignity”. In fact, many authors, including those who endorse the dominant conceptions of dignity, already mention the influence of relational or social elements in the experience of dignity, even if they do not make these elements central to their definition of the concept [3, 19, 24, 25, 39, 53, 54, 57, 61, 65, 77, 78, 90, 92, 93, 104, 109, 114, 121, 122, 124, 126, 128, 142,143,144,145]. For example, some address the impact of other people's perceptions (particularly those of family and friends) on a person’s sense of dignity, especially when the person is ill and dependent [10, 19, 21, 25, 73, 82, 83, 95]. Others evoke the inexorable interdependence of human beings, sometimes criticizing the contemporary social tendency to value personal autonomy (in the sense of independence) and individualism [20, 44, 57, 62, 75, 88, 92, 108, 146, 147] or self-sufficiency [71, 73]. Regarding this social or collective point of view, several authors mention how the prevailing culture, societal values or the state and its laws tend (or have the power) to shape the way dignity is conceived in the context of end-of-life choices, and medically assisted death [8,9,10, 13, 16, 25, 26, 28, 50, 69, 71, 73, 76, 82, 92, 95, 106, 124,125,126, 141, 148,149,150,151,152,153,154]. Authors of religious persuasion, such as Daly [16], Schirrmacher [71] and Engelhardt [106], are particularly critical in this respect. Others note the influence of messages conveyed by the media about end-of-life choices [74, 142].

In terms of research on the desire to hasten death, a few studies have been conducted among sick patients and seniors [14, 50, 75, 155], as well as some conceptual and discursive analyses [4, 10] and various literature reviews [30, 57, 108, 156]. They empirically confirm the importance of the relational dimension in the way people come to experience a sense of dignity or, conversely, the loss of a sense of their own dignity. For example, the fear of dependence and having to be reliant on others [155] or of being seen as a burden, both by loved ones and by society at large, tends to undermine the sense of dignity of sick patients, the elderly and people approaching the end of life, and to affect their perception of their identity [50, 57, 75]. Apprehension of losing one’s dignity could be experienced through encounters with others and, therefore, the experience of dignity is no longer merely a personal issue, but an intersubjective issue [83] as well as a social and structural one. However, few authors explicitly discuss the conception of relational dignity [3, 10, 28, 50, 56, 80, 110]. Moreover, among those who do, there seems a lack of conceptual and theoretical normative underpinnings. Care ethicist Carlo Leget [80] appears to be an exception to the rule, advancing a relational conception of dignity (he uses the term “social/relational dignity"), his perspective being based on the research of psychiatrist and expert in palliative care Harvey Chochinov [14], philosopher Paul Ricoeur’s “little ethics,” and the ethics of care. This conception of dignity is notable in that it places the relational dimension at its heart, while at the same time connecting it to the conceptions of dignity usually encountered in the debate on assisted dying.

Groundings and possible connections with subjective and ontological dignity

Like some care ethicists, including Berenice Fisher and Joan Tronto, Leget [80] emphasizes how a person’s moral conceptions are defined based on the social practices in their surroundings. Thus, the understanding of dignity a person acquires and, by extension, the view they have of their own dignity will be vastly different if they are raised in a culture that values intrinsic dignity or in one that considers it a metaphysical aberration [80]. Based on Ricoeur’s work, Leget argues that self-respect and one’s perception of one’s own dignity, which go hand in hand with a “good life,” depend heavily on the recognition of others. They are therefore closely linked to attitudes of respect and care, which ensure the cohesion of communities and make personal fulfillment possible. Thus, for Leget [80], social/relational dignity “genealogically” and “systematically” generates subjective dignity, since the former, through manifestations of recognition, is the basis for the latter. This dynamic can be seen not only in communities but also at the heart of interpersonal relationships. This was clearly demonstrated by the research that led to Chochinov’s dignity therapy, a palliative intervention that helps heighten the sense of dignity of patients near the end of life. According to Leget [80], ontological or intrinsic dignity serves as a “counterfactual” moral landmark in the cultural landscape, thereby helping create or consolidate institutions that ensure a certain amount of stability and continuity in communities. Leget’s perspective [80], in which relational dignity is part of a tripartite model along with the subjective and intrinsic conceptions of dignity, does not appear, however, to have made its way into the literature on medically assisted death. In contrast, as this review has shown so far, the literature reveals a persistent gap between the two main conceptions of dignity involved in the discussion.

Dignity and assisted death: a persistent debate between two conceptions

Counterarguments

Different conceptions of dignity have evolved outside the two main perspectives (ontological dignity and dignity as autonomy) solicited in the dialog on medically assisted death. However, the literature review shows not only how dominant these two perspectives are, but also how much they tend to be used on opposite sides of the debate. In this sense, the concept of dignity appears to stall more than advance the dialog between proponents and opponents of medically assisted death. Burnier [157] laments the “duologue,” the dichotomous thinking that dismisses the other party’s perspective, tending to evacuate the polysemy of the concept. It is true that the counterarguments on both sides of the debate are often rather mordant.

On the one hand, opponents and critics of euthanasia and assisted suicide condemn several aspects of the conception of dignity as autonomy. In general, they criticize the promotion of individualism [145, 146], akin to subjectivism [27, 77, 102], which rejects the interdependence inherent to the human condition [6, 28, 39, 62, 65, 92, 136, 147, 158]; undermines the general sense of the social and community life [19, 38, 97, 143]; and, in the case of people in a position of dependence, can contribute to intensifying the feeling of being a burden [11, 13, 19, 50, 71, 73, 105, 124, 148, 158, 159]. More specifically, and perhaps as a criticism of the narrative conception of dignity, they condemn the idea of a dualistic anthropology that seems to give priority to the life of the mind, notably by prioritizing self-determination, the exercise of personal autonomy and freedom, and by depreciating mere biological human life, limited to an instrumental role [53, 54, 77, 78, 88]. In their view, the Dworkinian notions of identity and integrity are based on an illusion, that of human independence and absolute, limitless control over one’s own life [44, 65, 69, 73, 92, 158]. They find it even more incongruous in the socioeconomic context in which, for years, the range of options has constantly been reduced due to resources scarcity and utilitarian-guided governmental cuts in health care [57, 160], which have a more significant impact on those on the margins of society, whose needs are the greatest [11, 149, 150].

Additionally, many critics point to what they consider to be a fundamental contradiction. While respect for autonomy and dignity is the main argument used to support the right to medically assisted death in the case of a person who is suffering, these critics believe that some of the mechanisms for regulating the practice not only contradict this principle, but also promote discrimination. For example, in countries that sanction medically assisted death, access to the practice requires that a third person (often a physician) certifies that the person meets the MAID eligibility criteria. As a result, the evaluation of the life and dignity of the person who is requesting to die becomes a shared responsibility. Some authors interpret this as a sort of “heteroevaluation” or “heterodetermination” that goes against respect for a person’s autonomy and calls into question the purported neutrality of the third-party evaluator. In their view, the latter's involvement contributes to categorizing, or at least confirming, certain lives as unworthy [6, 28, 38, 77, 78, 82, 91, 92, 124, 151]. Moreover, in the case of adults capable of exercising autonomy, these authors question the implementation of criteria (e.g., suffering or terminal illness) restricting access to assisted death [39] because, in addition to seeming discriminatory [78], these criteria appear to encourage a substantial evaluation (by a third party) of the person’s reasons for wanting to die [134]. Some critics also point out that, ironically, the procedures for obtaining approval for medically assisted death and the intervention itself (especially in the case of euthanasia) give physicians undue power and contribute to the medicalization of death [57, 131]. Whereas the initial objective, as many proponents of medically assisted death point out, was to support the autonomy (or the dignity as autonomy) of persons approaching the end of life by promoting freedom from medical power and futile medical care [13, 39, 69, 77, 112, 122, 132, 133, 150].

On the other hand, many supporters of medically assisted death strongly criticize the conception of ontological dignity and the role it plays in the debate. To them, the idea of “everlasting” dignity appears to contradict, or reject, the experience of people nearing the end of life, while the sense or fear of losing their dignity is one of the main reasons why people request medically assisted death [4, 14, 24, 59, 94, 136, 144, 155, 161,162,163,164]. The seriously ill, for whom dignity is an invaluable possession, experience that sense or fear very keenly [10, 11, 14, 24, 27, 83]. The conditions frequently identified by authors as potential threats to a sense of dignity include physical and mental decline and, more broadly, suffering [13, 20, 39, 94, 112, 115, 117, 132, 136, 164]. In particular, situations in which a human being is so dependent that they are incapable of expressing and carrying out their wishes or making key choices, according to their conceptions and personal values, and are therefore subject to heteronomy [79], are often described as unbearable, undignified, subhuman and “worse than death” [13, 21, 67, 111, 112, 116, 118, 122, 123, 132, 147, 159, 161, 164]. On the other hand, elements such as decision-making ability, self-determination [12, 30, 113] and physical control [30, 35], especially when it comes to basic human needs (e.g., elimination), are crucial for materially preserving a person’s view of themself and their sense of dignity [10, 30, 73]. Considering these concrete and physical realities, which demand compassion, ontological dignity may be too abstract a concept, real only in an intellectual sense, and somewhat disconnected from these experiences [11, 27, 80, 94].

Another criticism of ontological dignity is that it is too strongly affiliated with religious metaphysics [3, 20, 32, 35], especially because of its relationship with the principle of the sanctity of human life [90]. Consequently, some authors associate it with perfectionist and paternalistic aims [39, 51, 103, 104, 112, 120], or with the imposition of moral norms removed from what they see as actual human experience [68]. For the critics of ontological dignity, this perspective is irreconcilable with the political liberalism of pluralistic and democratic occidental societies [35, 76, 82] where the emphasis is placed on personal autonomy and morality [19, 112, 119, 120, 134]. It is up to the individual alone, not society or the state⁸to determine their own vision of a good life [132]. From this perspective, the ontological conception of dignity should give way to a subjective conception of dignity, a conception based on what patients themselves have to say about the matter [68, 104].

The gap between the main conceptions of dignity

In recent years, in more and more places, the century-old ban on assisted death based on the sanctity of human life and intrinsic dignity has been giving way to a more liberal approach to medically assisted death Under this view, as we saw previously, where dignity is reconceptualised in such a way as to support freedom of choice and respect for moral and personal autonomy [13, 27, 74, 87, 119, 120, 130, 132]. This trend is apparent in Anglo-Saxon countries, including the United States, England, Australia, and Canada [32, 76, 87, 123, 165], as well as in countries such as Germany [134], France [38], Spain [120] and Belgium [112]. This evolving situation brings the public debate on euthanasia and assisted suicide back to the fore. In this context, some authors note that proponents and opponents are still confronting each other, as the “combat” or “controversy” continues [12, 21, 38, 157, 166], and each side is trying to delegitimize the other’s arguments, including its different interpretation of the concept of dignity. These seemingly irreconcilable views prompt some authors to conclude that the concept has been instrumentalized to support the ideological goals of both sides [18, 80, 137]. Some authors bemoan the impasse in a debate where both sides are rigid and immovable [17], and some believe that dignity is being employed like an empty slogan [12, 21, 25, 28, 34, 39, 84, 91, 143, 146] or a rhetorical element used as a conversation stopper [55, 65, 95, 138, 140].

In this context, following his analysis of the Consultative Commission discussions that preceded the legalization of medical aid in dying in Quebec, Burnier [12] urges us to move beyond such binary and polarized discourse. Many others agree [17, 33]. This is even more important since the two main perspectives in the debate could each have moral legitimacy [109] and be incorporated into a single theory of dignity [33].

Discussion

Dominant views on dignity and the desire to overcome the impasse

This scoping review is limited to the literature on dignity in the context of medically assisted death. Most of the texts reviewed are philosophical, reflective and argumentative. Many of them refer to the underlying conceptions of dignity that support the two principal stances on medically assisted death (for and against), and often provide justification for one or the other. As previously discussed, the two predominant conceptions of dignity (dignity as autonomy and ontological dignity) are different but important angles from which to shed light on the issue of medically assisted death [108]. But, as we have just seen, they tend to be placed in opposition to each other, which ultimately leads the debate into an impasse. The question is: what strategies can be employed to move beyond this binary discourse?

Claiming the relational dimension of dignity

To begin with, in order to distance ourselves from the fragmented perspectives on dignity, as some authors suggest, it might be useful to identify the elements that unify the various approaches to the concept of dignity [80]. On closer examination, our review of the different conceptions of dignity almost systematically highlights the principle of respect as a fundamental element. In the literature reviewed, this principle takes two forms: self-respect and respect from others [73, 93, 95]. Self-respect refers to the positive perception we have of ourselves, which also sustains self-esteem or even fuels pride [14, 101, 113]. It is therefore associated with subjective dignity or dignity as autonomy [39, 75, 80, 93, 113]. Respect from others concerns the way in which others, society as a whole or institutions perceive and treat people [93].

Respect from others is all the more important because, according to some, it is an essential condition for maintaining self-respect [116]. To illustrate, in the early stages of human development, self-respect or a sense of subjective dignity is initially reflected by the image mirrored by one’s parents. Subsequently this self-respect must be continually nurtured through interpersonal relationships throughout one’s life [10]. In fact, reciprocal recognition (i.e., seeing oneself in others) is fundamental to establishing any relationship, and underpins personal and social self-determination [61, 95]. Indeed, some argue that this mutual recognition is essential not only for defining oneself, but also for shaping one's social world [61]. In ethical terms, this mutual recognition can contribute to self-respect by opening up an intersubjective space of shared validation, where individuals can assess their conduct and perceive themselves in an honorable light through the eyes of others [95]. We believe that this process, where self-respect is developed and the individual defined through a dialogical dynamic between “self and other,” holds very great promise for understanding and appreciating the inherently relational dimension of dignity.

Respect (both self-respect and respect from others), and its relationality, plays a fundamental role in various conceptions of dignity. Recognizing this commonality can serve as an initial step for building bridges between approaches to dignity seen as fundamentally opposed. Nevertheless, the relational conception of dignity is still insufficiently explored and would warrant greater attention in future discussions.

A multidimensional view of dignity worth exploring

The multidimensional perspective on dignity articulated by Leget stands out in our review as particularly interesting. This approach aims to integrate the concerns of both traditional conceptions of dignity (both subjective/autonomist and ontological) and, drawing on Ricoeur’s work [167], emphasizes the “social and relational” dimension of dignity, a focus recently highlighted by care ethicists and feminist philosophers. In fact, Leget, building on Ricoeurian and relational care ethics, proposes a multidimensional conception of dignity not to challenge traditional views or resolve debates but rather aims to provide a possible way out of the ongoing conflict between them and to circumvent the impasse. While this scoping review does not claim that this approach is the key to the debate (which would require further philosophical and argumentative study to verify), it appears worthy of further exploration for three reasons.

The first idea worth considering about this multidimensional conception of dignity is its overlap with the concerns of ethical and feminist philosophers. Indeed, since the late 1990s, ethical and feminist philosophers have highlighted the deeply relational dimension of human life. And they have emphasized the (potentially oppressive) socio-cultural contexts within which individual preferences and choices are formed, shaped, directed, exercised, or constrained. In recent decades, several feminist philosophers have also emphasized the central role that “others” play in identity formation and self-perception. Namely, we can think of philosopher Margaret Urban Walker [168], who is rethinking the notion of dignity by advocating for a conception she describes as “humanized,” which is to be understood in a “fully relational” sense. She argues that an adequate understanding of dignity should not be limited to recognizing attributes of agency and rationality in human subjects (i.e., confined to seeing human dignity solely as the full and free exercise of rational attributes). In fact, for her, dignity should also consider “The relations and responses […] that join us in what human beings recognize as particularly modes of connection […] in and through which we learn responses, responsibilities, and feelings that embody appropriate acknowledgments” ([168], p. 177). That is why she suggests that dignity is an “interpersonally effective standing” ([168], p. 179). Just as Leget talks about dignity as an “intersubjective category,” it seems inconceivable to Walker to conceptualize it independently of its deeply relational dimension.

The second idea worth considering concerning Leget’s multidimensional conception of dignity is its “synergistic” quality. Indeed, for Leget, dignity should be conceived as the product of a synergy between three fundamental dimensions: (1) the subjective dimension, (2) the intrinsic dimension, and (3) the social/relational dimension of dignity. Although each of these dimensions has its own gaps and limitations when considered in isolation, conceiving them as interconnected and synergistic would, in his view, mitigate their specific weaknesses and provide a more precise and complete understanding of dignity.

The third significant aspect of Leget’s multidimensional conception of dignity is its recognition of the dynamic and fluid nature of dignity. This intuition, often overlooked by traditional conceptions of dignity, is supported by empirical studies. Indeed, some authors working on medically assisted death show that the sense of one’s own dignity is dynamic, unstable, and vulnerable. It evolves over time and varies according to individual and collective contexts. For example, in their analysis of qualitative studies, Rodríguez-Prat and Leeuwen [57] observed that the feeling of dignity among people who wish to hasten their death is influenced by several factors, including social (or relational), as well as physical, psychological, and spiritual factors, which in turn are further shaped by the experience of severe illness. At the societal level, the ontological or intrinsic notion of dignity, typically regarded as stable and a moral benchmark [9], is also described by Leget [80] as dynamic and unstable. He argues that dignity is vulnerable, and subject to being undermined or contested (he precises that conceptions of intrinsic dignity "are as vulnerable as their authority or plausibility is" ([80], p. 949).

Arguing that “[c]oncepts like dignity are powerful tools to organize the world we live in” ([80], p. 950), Leget analyzes what he calls “dying with dignity” through the lens of care ethics, applying his multidimensional conception of dignity in practice. He concludes 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” ([80], p. 952), our emphasis). Dignity, which is not conceived outside the intersubjective space, is “constituted and upheld by people who are interrelated in caring relationships” ([80], p. 952). Again, Leget aligns with Walker [168], for whom dignity, as an ideal of human interaction, recognition, and concern, has “a normative power.” We find these ideas particularly compelling when considering medically assisted death, as they suggest that the phenomenon extends well beyond individual choices [149] and also engages ethical considerations that clearly impact society as a whole.

Social issues to be clarified in relation to the ordinary concept of dignity

From a societal perspective, enhancing our comprehension of dignity in the context of medically assisted death is crucial, given its omnipresence in the public space and discussions, debates, and media coverage [74, 142]. Among other things, the ordinary concept of dignity and common discourses on dignity—specifically the ones surrounding dying with dignity—makes dignity a tool for constructing ways of thinking and acting [10]. However, similar to other practical language tools, the term "dignity" can be misleading, or even be harmful if it is used in a way that has a negative effect on specific categories of already oppressed or marginalized people [80].

In this context, some studies highlight several issues affecting severely ill or elderly people: the stigma and exclusion they experience their apprehension of becoming a burden or losing control over their lives, the belief that such a life is not worth living, and the link between these factors and the desire to hasten death [30, 57, 75, 155]. Such studies point to unresolved questions and underscore the need for further research at the theoretical, argumentative, and empirical level. How significantly do prevailing views on the nature of dignity at the end of life shape the self-perceptions of gravely ill individuals and influence their consideration of assisted dying? Is it possible that these people have internalized negative stereotypes that portray dependency, vulnerability, and old age as undignified states of being [75]? Does the prevalent conception of dignity, when closely associated with control, inevitably result in choosing to hasten death [10, 169]? Does this preclude the possibility of considering other perspectives and making different choices? Could it be that the high value Western societies place on autonomy, independence and self-sufficiency actually undermines those who are no longer autonomous, stripping them of their identity [14] and, consequently, of their dignity? Such questions deserve further research and debate.

Recommendations

Like some authors, we postulate the importance of identifying and examining the ideas, frameworks and influences that, in our societies, define the contours of dignity and associated concepts such as dependence and vulnerability [75, 92, 170]. We could achieve this by exploring the understanding of dignity held by those who are considering medically assisted death, while also highlighting the prevalent ideas and discourses in the collective space. In this respect, Leget’s [80] multifaceted conception seems to us an interesting tool to explore. Especially since this approach doesn't seem to have been really taken up yet. First and foremost, this exercise would help us better understand the subtleties of the construction, experience and understanding of dignity, allowing us to break away from what some authors condemn as the dominance of narrow and uniform discourse on what constitutes a “good death” [169]. Second, the analysis would fuel and elevate the discussion on medically assisted death above the current binary discourse and disembodied theoretical debate. This approach is even more relevant since medically assisted death is still one of the most socially and politically controversial issues in North America and Europe [39]. Additionally, considering the small number of empirical studies identified in this Scoping Review, there seems to be a need for more empirical data about conceptions of dignity as embraced by individuals themselves, irrespective of the different theoretical approaches review here. For example, in Quah et al.’s [156] systematic review of “Stakeholder Perspectives of Dignity and Assisted Dying” between 2001 and 2021 of the 663 references initially reviewed, 88 were selected, and only 13 specifically addressed the patients’ point of view on medically assisted death. Of these, only 4 were studies conducted among patients.

Limitations

This review was limited to references in English and French, which inevitably limit its scope. In addition, our focus was put on a Western perspective of dignity and was therefore necessarily colored by dominant Western values. This choice, since the debate surrounding medically assisted death is most prevalent in North America, Europe or Australia, have necessarily resulted in the neglect of other perspectives nourished in other cultures. For example, discussions based on Confucian [171, 172] or Buddhist [173] ethics were not considered, although they would probably have provided complementary points of view. Future comparative analyses by culture could be beneficial.

Conclusion

Although, as Muders [42] asserts, dignity has not yet found its rightful place, and the multifaceted analysis it deserves in the debate on medically assisted death, the avenues for reflection proposed by Leget [80] could help remedy these shortcomings. By taking a more in-depth look at the relational aspect of dignity without ignoring its other, more “traditional” dimensions, we could come to a more comprehensive and nuanced conception of the concept that might, as Dige [17] hopes, make room for normatively richer positions on an issue as sensitive for our societies as medically assisted death.