Human Dignity and Bioethics: Essays Commissioned by the President's Council on Bioethics

Chapter 18: Dignity and Bioethics: History, Theory, and Selected Applications

Daniel P. Sulmasy, O.F.M.

The word "dignity" has become something of a slogan in bioethics, often invoked by both sides of debates about a variety of scientific and clinical issues, supporting contradictory conclusions. For instance, in arguments about assisted suicide, those who favor the legalization of the practice base their conclusion on a moral imperative to provide "death with dignity," while those who oppose legalization do so because they see intentionally rendering a human being dead, even out of mercy, as a direct assault on human dignity.¹ Certainly this suggests that dignity is a concept in need of clarification.

Ruth Macklin has noted this lack of conceptual clarity surrounding the use of the word "dignity" in the bioethics literature and has concluded that dignity is a "useless concept," reducible to respect for autonomy, and adds nothing to the conversation.² This hasty conclusion, casting aside thousands of years of philosophical writing, ignoring the contemporary bioethical discourse of continental Europeans, and sweeping away a whole body of international law, can be justified only by begging the question. If one defines a word completely in terms of another concept more to one's liking, it will always follow that the word in question adds nothing to the concept one already endorses. While shrouded in rhetoric, this is precisely the structure of Macklin's argument. Premise: dignity means nothing more than respect for autonomy. Conclusion: therefore dignity means nothing more than respect for autonomy and (Corollary) therefore dignity adds nothing to bioethical discourse.

A more careful treatment of the topic is in order. In this essay I will, first, describe three ways the word "dignity" has been used in moral discourse, both in the history of Western thought and in contemporary bioethics. I call these the attributed, the intrinsic, and the inflorescent uses of the word.

Second, I will argue that, while all three senses have moral relevance, the intrinsic sense of dignity is the most fundamental from a moral perspective. I will advance this argument in two ways. I will call the first the Axiological Argument and the second the Argument from Consistency.

Third, I will outline some of the general norms that follow from accepting the moral primacy of the intrinsic sense of human dignity.

Finally, I will show how this vigorous understanding of dignity helps to give shape to arguments in bioethics. As examples, I will show (briefly) how it applies to questions about justice and access to health care resources, the care of the disabled, embryonic stem cell research, cloning, euthanasia, and the care of patients in the so-called permanent vegetative state.

I will conclude that a notion robust enough to supply answers to all of these questions is not useless.

Three Senses of Dignity

Throughout Western history and in contemporary debates, the word dignity has played a prominent role in ethical discussions. It may be surprising to both religious and non-religious persons to know, however, that dignity is not a word that entered the Western moral vocabulary through the Judeo-Christian heritage. Dignity is not an important word in either the Hebrew or Christian scriptures. For almost two millennia, it was not an important theological term. Until very recently, dignity was almost never invoked by moral theologians in making arguments about abortion, euthanasia, or economic justice.³

Neither was dignity an important concept for all Western moral philosophers. For instance, dignity was not an important word for Plato or Aristotle. The first Western philosophers for whom dignity was an important philosophical term were the Roman Stoics. Cicero and Seneca, especially, used the word to designate important concepts in their moral philosophies.

Cicero defined dignity as "the honorable authority of a person, which merits attention and honor and worthy respect" ( dignitas est alicuius honesta et cultu et honore et verecundia digna auctoritas ).⁴ He used the word dignitas frequently in his writings. As one translator put it, the meaning of dignitas in Cicero's use is literally "worthiness," but he often used it (as did others in his day) to refer to a person's standing, reputation, or even office in the civitas.⁵ Importantly, in Cicero's account, this dignitas is not so much dependent on the subjective evaluation of others as it is on the ability of everyone to recognize an instance of true human excellence. For example, in De Officiis, Cicero writes,

If we wish to reflect on the excellence and dignity of our nature, we shall realize how dishonorable it is to sink into luxury and to live a dainty and soft lifestyle, but how honorable to live thriftily, strictly, with self-restraint, and soberly.

Atque etiam, si considerare volumus, quae sit in natura excel lentia et dignitas, intellegemus, quam sit turpe diffluere luxuria et delicate ac molliter vivere, quamque honestum parce, continenter, severe, sobrie.⁶

In other words, for Cicero, one's standing in the community ought to be based on one's true excellence. For him, to have dignity was to have a merited degree of respect from others because of one's excellence as a human being.

The Stoic use of the term, however, is not the only historical conception of dignity. Hobbes, for instance, defined dignity in a very different way. He eliminated any necessary connection to true human excellence and took the meaning of dignity to depend solely upon the inter-subjective judgments of the market. In the Leviathan he writes:

The Value or worth of a man, is, as of other things, his price; that is to say, so much as would be given for the use of his Power; and therefore it is not absolute; but a thing dependent on the need and judgment of another.. The publique worth of a man, which is the Value set on him by the Commonwealth, is that which men commonly call dignity.⁷

Hobbes writes clearly and bluntly. Dignity is the value one has to the Commonwealth regardless of whether one actually merits this based on one's true excellence as a human being or on one's nature as a human being.

Kant never explicitly cites Hobbes, but in presenting yet a third view of dignity, he seems to be writing in direct reaction to Hobbes. The Kantian view of dignity ( Würde ) continues to exert a powerful influence to the present day. Kant wrote,

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.⁸

Kant connected dignity with his idea that human beings should never be treated as pure instruments of another's will. In the Grundlagen, he writes, ".[T]hat 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."⁹ More simply, he states elsewhere, "Humanity itself is a dignity."¹⁰

Thus, the Kantian view of dignity is neither based on one's value to others, nor on the esteem they ought to show based on one's degree of human excellence, but rather on one's humanity itself.¹¹ The Kantian view of dignity is powerful, influential, and substantially different from the notions that preceded it. The Kantian notion of Würde may be one of his greatest contributions to moral philosophy.

These three historical uses of the word "dignity" are illustrative of three senses of the word that are still active in philosophical discourse and in ordinary language today. These three general senses of dignity can be understood according to the following names and descriptions.

By attributed dignity, I mean that worth or value that human beings confer 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, in a sense, created. It constitutes 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, ability to evoke admiration, or any particular set of talents, skills, or powers. Intrinsic dignity is the value that human beings have simply by virtue of the fact that they are human beings. Thus we say that racism is an offense against human dignity. Used this way, dignity designates a value not conferred or created by human choices, individual or collective, 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.¹² Thus, dignity is sometimes used to refer to a state of virtue-a state of affairs in which a human being habitually acts in ways that expresses the intrinsic value of the human. We say, for instance, that so-and-so faced a particularly trying situation with dignity. This use of the word is not purely attributed, since it depends upon some objective conception of human excellence. Nonetheless, the value to which this use of the word refers is not intrinsic, since it depends upon a prior understanding of the intrinsic value of the human. The Stoic use of the word, while it sometimes borders on an attributed sense, is generally an inflorescent sense of dignity.

These conceptions of human dignity are by no means mutually exclusive. Attributed, intrinsic, and inflorescent conceptions of dignity are often at play in the same situation. Yet each has been taken as the central basis for particular moral claims in bioethics.

Does it matter which of these senses of dignity one invokes in ethical discourse? The short answer would seem to be "yes." At the very least it seems important to keep these senses straight. For example, those who claim that death with dignity requires that euthanasia be permissible seem to be using the word "dignity" in an attributed sense,¹³ while those who claim that euthanasia is a direct offense against human dignity appear to be using the word in an intrinsic sense.¹⁴ Still others who oppose euthanasia appear to argue from an inflorescent sense of dignity, suggesting that the practice represents less than the most noble and excellent response a human being can make in the face of death.¹⁵ Merely noticing these distinctions can help us clarify arguments and understand points of disagreement.

But more than this, is there anything that can be said about the relationship between these senses of dignity? Is there an order or moral priority? If there is a conflict between moral claims based on differing senses of dignity, does one count more than the other?

I will argue that the intrinsic notion of dignity is foundational from a moral point of view. I will advance two arguments to support this claim. I call these the Axiological Argument and the Argument from Consistency.

The Axiological Argument

The axiological argument depends on the theory of value or axiology.¹⁶ By understanding what values are, how values get into the world, what sorts of values there are, and how they are related, it will be argued that one can arrive at the conclusion that the intrinsic sense of dignity is the fundamental sense.

Classically, axiology distinguishes between intrinsic and instrumental values. Instrumental values, however, are best characterized as a subclass of attributed values. I have argued that the primary distinction in axiology is between intrinsic values and attributed values.¹⁷

Intrinsic value is the value something has of itself-the value it has by virtue of its being the kind of thing that it is. It 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."¹⁸

Attributed values are those conveyed by a valuer. Attributed values depend completely on the purposes, beliefs, desires, interests, or expectations of a valuer or group of valuers. That is why I argue that instrumental values are a class of attributed values. An instrumental value is one that is attributed to some entity because it serves a purpose for a valuer. The instrumental value of the entity consists in its serving as a means by which the valuer achieves some purpose. But there can be non-instrumental attributed values as well. For example, the value of humor may serve no clear instrumental purpose.

Attributed values play important roles in human life. The authority of government, for instance, is attributed. The value of money is attributed. The value of technology is attributed. Importantly, some attributed values are morally flawed, such as attributing value to human skin color or attributing too much value to the opinions of other persons.

Intrinsic values and attributed values are asymmetrically related. Intrinsic values, as intrinsic and objective, must be recognized by an intelligent valuer. Recognition, of course, requires attribution, and thus an intelligent valuer must attribute intrinsic value to whatever does have intrinsic value in order to be correct in his or her evaluation. It would be incorrect for the valuer to attribute no value to what has value intrinsically. This is not to suggest that the act of evaluation confers the value, but that the value must be attributed to whatever has intrinsic value in order for the act of evaluation to be correct. By contrast, the mere fact that value has been attributed to an entity has no logical implications with respect to intrinsic value. One may freely attribute value to things on the basis of individual preferences, social customs, or instrumental needs. One may also recognize (i.e., correctly attribute value to) an entity that has intrinsic value. The bare fact that value has been attributed does not allow us to conclude whether the value at stake is attributed or intrinsic.

I have suggested that there is yet a third category of values, inflorescent values. Certain processes or states of affairs in an intrinsically valuable entity are considered especially valuable. This is the case because these processes or states of affairs either are conducive to or instantiate the flourishing of an intrinsically valuable thing as the kind of thing that it is. The flourishing of a member of a natural kind is a good state of affairs, but that goodness depends upon something about the kind of thing that is flourishing. Thus, the value of that state of affairs is, in a sense, derivative. One might be tempted to say that flourishing is intrinsically good, but the goodness of flourishing is always dependent upon the kind of thing that is said to be flourishing, and thus that state of affairs is not, strictly speaking, intrinsically valuable. Rather, it is the thing that is flourishing that is intrinsically valuable, and its flourishing can only be understood in terms of the intrinsic value of that thing.

On this view, human virtues, such as courage, are not, in a technical sense, intrinsically valuable. We seek virtue not for its own sake, but for the sake of our humanity. For instance, since the virtue of courage is a state of affairs of an individual member of the human natural kind, the value of courage is dependent upon knowledge of what kind of thing a human being is and upon the value of being human. Human virtues are good because they instantiate aspects of the flourishing of the human natural kind in virtuous individuals.

What relationship does this discussion have to dignity? "Intrinsic dignity" is just the name we give to the special type of intrinsic value that belongs to members of natural kinds that have kind-specific capacities for language, rationality, love, free will, moral agency, creativity, aesthetic sensibility, and an ability to grasp the finite and the infinite. The phase "attributed dignities" refers to several non-instrumental values that are attributed to members of any natural kind that has intrinsic dignity. The phrase "inflorescent dignity" refers to a variety of states of affairs in which a member of a natural kind that has intrinsic dignity is flourishing as the kind of thing that it is. By definition, then, intrinsic dignity is the fundamental notion of dignity. One defines attributed and inflorescent dignity in terms of intrinsic dignity.

The next step in the argument is to note that, 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 brings me to the notion of natural kinds, a relatively new concept in analytic philosophy.¹⁹ 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, in turn, leads to what its proponents call a "modest essentialism"-that 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. The alternative seems inconceivable-that reality is actually completely undifferentiated and that human beings merely carve up an amorphous, homogeneous universe for their own purposes. Reality is not homogenous but "lumpy." It comes differentiated into kinds of things. It seems bizarre to suggest that there really are no actual kinds of things in the world independent of human classification-no such things, de re, as stars, slugs, or human beings.

Intrinsic value, to repeat, is the value something has by virtue of its being the kind of thing that it is. 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. Intrinsic dignity, then, is 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, aesthetic sensibility, and an ability to grasp the finite and the infinite.

One should note that 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, they would also have intrinsic dignity-whether angels, extra-terrestrials, or (arguably) other known animal kinds.

Importantly, the logic of natural kinds suggests that one picks individuals out as members of the kind not because they express all the necessary and sufficient predicates to be classified as a member of a species, but, rather, by virtue of their inclusion under the extension of a natural kind that, as a kind, has those capacities. The logic of natural kinds is extensional, not intensional. As Wiggins puts it,

[The] determination of a natural kind stands or falls with the existence of law-like principles that will collect together the actual extension of the kind around an arbitrary good specimen of it; and these law-like principles will also determine the characteristic development and typical history of members of this extension. ²⁰

For example, very few bananas in the bin in the supermarket express all the necessary and sufficient conditions for being classified as fruits of the species Musa sapientum. We define a banana as a yellow fruit. Yet some specimens in the bin are yellow, some are green, some are spotted, some are brown, and some are even a bit black. Nonetheless, they are all bananas. They fall under the extension that gathers them around an arbitrary good specimen (or two) of a banana.

Health care depends profoundly upon this logic. 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 make the diagnosis of a disease.

So, if there is such a thing as intrinsic value in the world, then intrinsic dignity is the name we give to the value of all the individual members of any and all kinds that, as kinds, share the properties we think essential to the special value we recognize in the human. Thus, because a sick individual is a member of the human natural kind, we recognize that this individual has the intrinsic value we call dignity. It is in recognition of that worth that we have established the healing professions as our moral response to those of our kind who are suffering from disease and injury. The plight of the sick has little instrumental value, rarely serving 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 health care professionals serve them. Thus I would argue that intrinsic human dignity is the foundation of health care.

The Argument from Consistency

The argument from consistency is an alternative means of reaching the conclusion that intrinsic dignity is the primary moral sense of dignity. The argument is simple in its form. Consistency is at least a necessary condition of a valid moral argument, even if one would quickly add that consistency is not sufficient.²¹ In discussions about its fundamental moral meaning, the word "dignity" can be defined as the value or worth that a human being has either: (a) in terms of some property that some entities have and some do not, or (b) in terms of simply being human.ⁱ But I will show that defining the fundamental moral meaning of dignity as the value certain entities have by virtue of their possession of any particular candidate property leads to gross inconsistencies in our universally shared, settled moral positions if applied to all human beings. Therefore, one is led to the alternative: that dignity, in its fundamental moral sense, is defined in terms of simply being human-i.e., as an intrinsic value. This kind of argument depends on the exhaustiveness of the list of candidate properties and is not decisive. But at least it puts the burden of proof on those who oppose assigning moral priority to the intrinsic sense of dignity to come up with an alternative property (such as age, size, strength, brainwaves, or skin color) to define what gives an entity the fundamental worth or value we call dignity.

What Sorts of Candidate Human Properties Might Be Proposed?

First, some have argued that human dignity, in its most fundamental moral sense, depends upon the amount of pleasure and pain in a human life. Hedonism certainly has its adherents, whether egoistic or utilitarian. But even hedonists might not want to promote the pleasure/pain calculus as a theory of human dignity. Certainly, most of us are able to tell stories about the extraordinary lessons in human dignity we have learned from persons whose lives have been racked by pain, and most of us also know undignified human beings who have spent their whole lives in the pursuit of pleasure. Basing morality squarely on a balance between pleasure and pain has seemed, since the time of Aristotle, to be an anemic account of morality and human dignity, and one that most people would reject.²²

Second, some might think that Hobbes was right-that human dignity depends upon one's market price. But there are problems with such a conception of human dignity. The unemployed, the severely handicapped, the mentally ill, and all others who cannot contribute to the economic well-being of society would then have no dignity. Yet our society has gone to great lengths to recognize the dignity of such persons. If we did not believe that human dignity remains even if people are disabled and lose their economic value to society, then we would not be making access ramps for them. This Hobbesian conception of dignity seems inconsistent with some of our most basic moral and social views.

Third, some might think that human dignity depends upon the active exercise of freedom. Dignity, on this view, is the value we give to entities that actively express a capacity for rational choice. But this view is also hard to sustain consistently. One would have to hold that those who have lost control of certain human functions, or have lost or never had the freedom to make choices, have lost or have never had dignity. This would mean that infants, the retarded, the severely mentally ill, prisoners, the comatose, and perhaps even the sleeping would have no human dignity. This seems obviously wrong.

Now some might suggest that these are "straw man" arguments. What counts, they would aver, is the possibility of exercising control and freedom, not the actual exercise of control and freedom. One might suggest that some individuals without full control and freedom nevertheless deserve to be treated with dignity either because they have a potential for exercising such a capacity (so that children, for instance, come to be regarded as placeholders for actual persons with dignity), or they have a history of having exercised such a capacity (so that the demented, for instance, come to be regarded as remnants of persons with dignity).²³ But these arguments are quite tenuous. Who would feel dignified and secure as a placeholder or a remnant? Further, these arguments still cannot answer why those who never could and never will make free, rational choices (such as the severely mentally retarded) are worthy of being treated in accord with human dignity.

Certain advocates of the position that dignity means the capacity to exercise rational choice (at least above a certain threshold level) do not believe their argument is thus refuted. They fail to see how arguments that would lead to the moral legitimization of practices such as infanticide²⁴ and experimentation upon permanently unresponsive patients without their consent²⁵ need to be regarded as reductio ad absurdum refutations of their position. Rather, these philosophers fancy themselves heroes, bravely embracing these stark conclusions as the moral consequences of a new and enlightened form of thinking, finally free from the prejudices that weigh the rest of us down.

To argue against this position, one must move the argument one step logically prior to the argument about dignity. One must investigate the underlying theory of the good that drives some philosophers to cling so tenaciously to the idea that dignity means the active exercise of free choice, that they are willing to become champions of infanticide rather than give up the idea of dignity as freedom. One must ask, are things good merely because we choose them? Although space limitations preclude a fuller discussion, simply put, is it not the case, rather, that we choose what we think is good, aware that we can be mistaken in our choices? The meaning of the human good is not exhausted by the exercise of free choice. It is metaphysically impossible to choose one's biological parents. It is metaphysically impossible to choose to come into existence. It is impossible to choose to be loved by someone. In the instant that the choice is one's own rather the free choice of one's lover, what one receives ceases to be love. And it is impossible to choose not to die. Thus, defining the most fundamental human good as the exercise of free choice results in a moral system that simply cannot account for the great human questions, among them: existence, biological relationship, love, and death. The human good must be far deeper than the freedom to choose. The most fundamental meaning of human dignity is not human freedom and control.

Fourth, and finally, some might think that human dignity is something individuals are free to define as they choose, according to their own inner lights. But this view also leads to major moral inconsistencies. First, the concept of a moral term implies that it has universal meaning, a position acknowledged both by Kant²⁶ and by utilitarians such as R. M. Hare.²⁷ Second, to say that human dignity is subjective is to claim that one person can never reliably recognize the dignity of another person, because one can never know exactly what the other thinks dignity means at any given moment. This explains why empirical projects designed to understand dignity by asking each in a collection of individuals to describe "what dignity means to me," while well-intended, are profoundly misguided.²⁸ Morality seems to depend upon our mutual commitment to knowing that each of us has dignity before we open our mouths and explain our notions of dignity to each other. Human dignity cannot be a purely subjective concept.

Thus, the argument from consistency claims that fundamental human dignity must be something each of us has simply because we are human. It is the notion of dignity that drove the U.S. civil rights movement. It is the notion the Rev. Dr. Martin Luther King, Jr., says he learned from his grandmother, who told him, "Martin, don't let anyone ever tell you that you're not a somebody."²⁹ No matter what value others may attribute to persons because of properties such as skin color, or how free they are to do as they would like, they have dignity because they are somebodies-human beings. Being somebody, being a human being, is the foundation of the notion of human dignity. The argument from consistency says that, if this is what dignity means in civil rights, this is what dignity must mean in bioethics.

Norms Derivable from Intrinsic Dignity

The conclusion that intrinsic dignity is the fundamental sense of dignity has significant moral implications. The notion of intrinsic dignity entails both self-regarding and other-regarding moral duties for beings that have intrinsic dignity. One of the primary features distinguishing the intrinsic value of a natural kind that has intrinsic dignity from other natural kinds is a kind-typical capacity for moral agency. All members of a natural kind that has intrinsic dignity (and are individually capable of exercising the moral agency that is distinctive of their natural kind) have moral obligations to themselves, to any other entities that have intrinsic dignity, and to the rest of what exists. The following list describes some of these duties. Space limitations preclude a full discussion of how these principles follow from this theory of dignity, but many will appear quite plausible on their face. This list is also not meant to exhaust the fundamental principles of ethics. It is limited to those fundamental principles that are most directly connected to the theme of dignity. But these duties should be taken as sufficiently fundamental and general to be considered true principles. All members of a natural kind that has intrinsic dignity and are, as individual members of that natural kind, capable of exercising the moral agency that in part constitutes their intrinsic dignity, have the following duties:

P-I. A duty of perfect obligation to respect all members of natural kinds that have intrinsic dignity.

P-II. A duty of perfect obligation to respect the capacities that confer intrinsic dignity upon a natural kind, in themselves and in others.

P-III. A duty to comport themselves in a manner that is consistent with their own intrinsic dignity.

P-IV. A duty to build up, to the extent possible, the inflorescent dignity of members of natural kinds that have intrinsic dignity.

P-V. A duty to be respectful of the intrinsic value of all other natural kinds.

P-VI. A duty of perfect obligation, in carrying out PP-I-V, never to act in such a way as directly to undermine the intrinsic dignity that gives the other duties their binding force.

While the language of these principles might seem unfamiliar to bioethicists, the concepts are quite familiar. The second formulation of Kant's categorical imperative might be considered a corollary of P-I. Together, P-I, P-II, P-III, and P-VI elaborate the meaning of Respect for Persons; P-III sounds as if it comes directly from a Stoic discourse on dignity; P-IV and P-VI are related to Beneficence and Non-Maleficence; P-V is the clarion call of environmental ethics. Justice arises from the need to balance the requirements of PP-I-V.

It is also important to note that the duty to build up the inflorescent dignity of any human being depends logically on the intrinsic dignity of human beings. The primary duty is to recognize and respect that intrinsic dignity. The duty of building up the inflorescent dignity of human beings is a way of concretizing the fundamental duty of respect for intrinsic dignity. If one is to show respect for a dynamic, developing, living natural kind as an intrinsically valuable thing, then it follows that one ought to show that respect by concrete actions that help to establish the conditions by which that thing can flourish as the kind of thing that it is. Thus, one waters a rosemary bush and assures that it has proper sunlight. One feeds a human child and teaches him or her to read.

It is the intrinsic value of the human that grounds our moral duties towards our fellow human beings and gives these duties their special moral valence. It is a minor indiscretion to go on vacation and forget to arrange for someone to water one's rosemary bush. It is an unspeakably immoral evil to neglect to feed or educate one's child. Human beings have a special intrinsic value, and it is this value that commands that we act towards our fellow human beings in a special way. The ground of our duties towards our fellow human beings is not merely that they have interests. Rodents also have interests. As David Velleman has argued, from an ethical point of view, 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 that this person has lost a degree of independence that I have the capacity to restore through the medical arts? 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.³⁰ This fundamental respect is for intrinsic dignity-the "interest-independent" value of a human being. Without this primary respect, there is no basis for interpersonal morality.

Consequences of This View for Bioethics

This conception of dignity has important implications for addressing a variety of issues in bioethics.

Justice and Access to Health Care

Access to health care and the just distribution of health care resources are pressing questions both within individual nations and between the nations that constitute our globalized world community. Human dignity is often invoked in such discussions, but without much clarity or rigor.

Intrinsic dignity, as elaborated in this essay, can be understood as the foundation of all human rights. We respect the rights of an individual because we first recognize his or her intrinsic dignity. We do not bestow dignity because we first bestow rights. Human beings have rights that must be respected because of the value they have by virtue of being the kinds of things that they are.

Intrinsic dignity is at the core of all our beliefs about moral obligation. Of particular relevance to discussions of access to health care resources are principles P-I and P-IV.

Absolute rights (also called negative rights or natural rights) are based on P-I, the duty to respect all members of natural kinds that bear dignity. These include, for example, the rights not to be killed, not to be treated disrespectfully, and not to be experimented upon without one's consent. These rights can and should be respected by all persons and all societies regardless of their ecological, historical, physical, social, or economic circumstances. In Kantian terminology, these rights entail duties of perfect obligation.

I have argued that health care is not an absolute right or a natural right in this sense of the word.³¹ To assert a right to health care is to assert a positive right-a right to goods and services that must, of necessity, vary according to the ecological, historical, physical, social, and economic circumstances of individual persons and societies. In Kantian terminology, these rights entail duties of imperfect obligation. They apply to the degree that they can be instituted in various circumstances. Such so-called positive rights are based on P-IV, the duty to build up the inflorescent dignity of individuals belonging to a natural kind that has, as a kind, intrinsic dignity.

Health is critical for the flourishing of any member of any living natural kind. This is no less true for members of the human natural kind. Diseases diminish health. Accordingly, the concept of disease necessarily includes reference to the adverse effects of the condition on the flourishing of the affected individual. As I have defined it elsewhere, "A disease is a class of states of affairs of individual members of a living natural kind X, that: (1) disturbs the internal biological relations (law-like principles) that determine the characteristic development and typical history of members of the kind, X,.(4) and at least some individuals of whom (or which) this class of states of affairs can be predicated are, by virtue of that state, inhibited from flourishing as Xs."³² Thus, an anatomical variation such as an anomalous branch in the brachial artery going around the median nerve may violate the law-like generalizations and characteristic development of human beings, but such a variation has no adverse effect on the flourishing of any human being and is not a disease. By contrast, a condition such as rheumatoid arthritis inhibits one's ability to walk, to care for oneself, to open a jar, or to hold a spoon. It causes such pain that one may lose the ability to concentrate on other aspects of life. It is a real disease. Rheumatoid arthritis inhibits one who bears the stamp of intrinsic dignity from flourishing as a human being, either directly or by virtue of the fact that health is required for so many other forms of human flourishing-family life, friendship, work, art, politics, scholarship, and more. Respect for an afflicted individual requires, in recognition of this dignity, a concrete response. Medicine is one of the major forms of human response to such affliction, capable at times of restoring the flourishing of the individual, and at other times limiting the degree to which the disease or injury detracts from human flourishing. In terms of concrete medical practice this can mean either cure, or assistance with the activities of daily living, or amelioration of pain or other symptoms if this is possible. The duty to provide such care follows from P-IV. A society that fails to provide for health care has violated P-IV.

Health is also a fundamental condition for attributions of value, either reflexively by an individual, or by the attribution of others. To see this, one need only reflect on the ways in which illness and injury assault the attributed dignity of human beings. Those who are ill are robbed of their stations in life. They lose valued independence. They often become disfigured. They lose their social productivity. They lose esteem in the eyes of others and may even begin to question their own value. If there are any duties to build up the attributed dignities of human beings, surely health care is one of the primary means of doing so.

As argued above, however, the fundamental reason one provides health care is out of respect for intrinsic dignity. And intrinsic dignity inheres in the human with a radical equality. In its intrinsic sense, dignity is inalienable and does not admit of degrees. Thus, a duty to build up the inflorescent dignity of human beings through health care, founded upon respect for intrinsic human dignity, applies equally to all. So, while there might not be a natural right to health care, a just society has a moral obligation, founded upon human dignity, to provide equal access to health care, to the extent possible in its particular ecological, historical, physical, social, and economic circumstances.

Thus the conception of dignity presented here provides a normative basis for determining what it means for a society to distribute health care resources justly. This would seem to make dignity a useful concept.

Euthanasia

As I discussed earlier, understanding the three senses of dignity presented in this essay helps to explain three very different ways the word has been invoked in debates about euthanasia and physician-assisted suicide. This, in itself, seems a significant contribution to bioethics. Proponents of euthanasia and assisted suicide argue that the practice ought to be permitted because the assaults that illness and injury mount upon the attributed dignities of human beings can be so overwhelming that some patients might be led to attribute no more worth or value to themselves, thus making euthanasia a reasonable option. Opponents of euthanasia make two dignity-based arguments: one based on an inflorescent sense of dignity and the other based on an intrinsic sense of dignity. Neither argument denies the assault that illness and injury can mount against the attributed dignity of a human being. The argument from inflorescent dignity suggests, however, that the value of the human is expressed most fully (i.e., flourishes) in the ability to stand up to such assaults with courage, humble acceptance of the finitude of the human, nobility, and even love. To kill oneself in the face of death or to ask to be killed, on this view, is precisely the opposite of what it means to face death with dignity.

The argument from intrinsic dignity suggests that the fundamental basis for the duty to build up the inflorescent dignity of sick human beings-the root of any motivation to attribute dignity to them-is the intrinsic value of the human, the value human beings have by virtue of being the kinds of things that they are. As argued above, no circumstances can eliminate that intrinsic dignity. As Duty P-VI states, there is a duty of perfect obligation, in carrying out PP-I-V, never to act in such a way as directly to undermine the intrinsic dignity that gives the other duties their binding force. Thus, while one might, out of human sympathy, suggest that a duty to build up attributed dignity legitimizes euthanasia, the conception of dignity presented in this essay would argue that this cannot be permitted because it undermines the fundamental basis of morality itself-respect for intrinsic dignity.

A conception of dignity with the explanatory power to understand the basis for arguments on both sides of the debate about euthanasia as well as the normative power to settle that argument in favor of prohibiting the practice seems much more than a "useless" concept.

The Care of the Disabled

The proper treatment of persons with disabilities has become a matter of great controversy in bioethics, with significant implications for our society. A famous philosopher has even argued with a disability rights activist about these issues in the pages of the New York Times Sunday Magazine.³³ Could the conception of dignity presented here illuminate these debates?

First, it is clear that disability does not transform a human being into another natural kind. One classifies a person as disabled because one has first picked that individual out as a member of the human natural kind, noting the kind-typical features that the individual does not express. The disabled therefore have intrinsic dignity. Respect for intrinsic dignity would dictate, as argued above, that one recognize the radically equal intrinsic dignity of a severely mentally retarded adult and of a philosophy professor at an Ivy League university. No matter how severe the disability, there are no gradations in intrinsic dignity. It is the value one has by virtue of being the kind of thing that one is-a member of the human natural kind.

Second, respect for intrinsic dignity would prohibit, as described above, euthanizing disabled human beings of any age on the basis of their disability. As discussed, in violation of P-VI, this practice would undermine the most fundamental basis of any human morality.

Third, as discussed above, the duty to build up the inflorescent dignity of human beings-a duty based on respect for intrinsic dignity-carries with it a notion of the radical equality of the intrinsic dignity of all human beings. Just as skin color, income, education, and social worth ought not be the basis for differential access to health care, likewise disability ought not be invoked as a basis for justifying unequal access to health care.

Yet, as a duty of imperfect obligation based on P-IV, the duty to provide health care to the disabled will have limits even in the wealthiest society. A disabled person cannot be euthanized, but there will be limits to how far one goes in sustaining the life of a disabled person, just as there will be limits to how far one must go in sustaining the life of any person. These limits include the physical, psychological, social, spiritual, and economic resources of the individual in his or her particular circumstances as well as the limits of a society's resources. It is critically important to add, however, that any criterion for deciding upon limits must not be based on the disability in itself, since this would constitute a judgment regarding the worth of the person and violate the principle of equal respect for intrinsic dignity. Rather, such judgments must be based on the same criteria one would use for deciding on the limits of care for any individual, whether disabled or not. That is, based on the inefficacy of the intervention, on absolute scarcity, or on the individual's own judgments about burdens and benefits. Limits based on judgments of social worth, whether made by physicians or third parties, are inconsistent with the meaning of respect for intrinsic dignity.

Thus, the conception of dignity presented here is in full harmony with the traditional distinction between killing and allowing to die, converging on that distinction by noting differences in the types of dignity and the moral duties associated with each. The conception of dignity presented here provides a strong basis for preventing discrimination against the disabled and for supporting claims of equality of access to health care for the disabled. Such a conception of dignity would appear quite useful to bioethics.

Embryonic Stem Cell Research

A currently vexatious issue facing biomedical science is the morality of using human embryonic stem cells for research. Arguments opposing this practice on the basis of respect for human dignity have been vigorously attacked in the bioethics literature as vacuous. Does the conception of human dignity presented in this essay shed any light on these arguments?

If there is such a thing as intrinsic value, then, as I have argued, it is the value something has by virtue of its being the kind of thing that it is. Intrinsic value inheres in natural kinds, since artifacts have only attributed, and not intrinsic, value. I defined intrinsic dignity as the intrinsic value of natural kinds that have, as natural kinds, the capacity for language, rationality, love, free will, moral agency, creativity, aesthetic sensibility, and an ability to grasp the finite and the infinite. These are characteristic features of the human natural kind. Thus, the human natural kind (at least) has intrinsic dignity.

As I have argued, this value is not based on the active expression by an individual of any one (or even several) of the particular characteristics that confer intrinsic dignity on the natural kind as a whole. I made this argument in two ways. First, I explained that the extensional logic of natural kinds dictates that one first pick out an individual as a member of a kind by including it under the extension provided by one or two representative samples of the kind, backed by a full understanding of the typical history, the development, and the law-like generalizations that characterize members of that kind. The very notion of natural kinds entails acceptance of this "modest" essentialism. The presence or absence of no single specifiable characteristic or set of characteristics is sufficient to determine this "essence," in all of its modesty. Second, I showed that each of the candidate characteristics one might suggest, by intensional logic, as the dignity-conferring characteristic, leads to gross inconsistencies when applied universally, clashing with our most deeply held moral views. One is therefore led, by a process of elimination, to accept that dignity is the worth all human beings have simply by being human.

On the basis of all that I have explained about dignity thus far, it follows that if a human embryo is a member of the human natural kind, then it has all the intrinsic dignity of the human natural kind. And if that is true, then it cannot be killed, even to do good for others, without violating the fundamental moral duties that flow from recognizing intrinsic dignity. Thus, the fundamental question with respect to whether a human embryo has intrinsic dignity is whether that embryo is an individual member of the human natural kind.

What else is a human embryo, however, but an individual member of the human natural kind at the earliest stages of its development? This is what a human embryo is, biologically and ontologically. It is not a different kind of thing (say a slug or a porpoise). It is what every human being is (or was) at 0-28 days of development.

Judith Thompson has argued that "a fetus is no more a human being than an acorn is an oak tree."³⁴ Thompson is precisely correct in her analogy, but precisely wrong in the biological, ontological, and moral conclusions she draws from it. Despite her rhetorical fervor, Thompson has it backwards. A fetus (or an embryo) is a member of the human natural kind at the earliest stages of development, just as an acorn is a member of the oak tree natural kind at the earliest stages of its development. Every human being's history can be traced back, as a continuous existent, to its own embryonic stage. Every oak tree's history can be traced back, as a continuous existent, to its own acorn stage.³⁵ In fact, the continuity is clearer in the case of human development. The concept of natural kinds has been introduced into philosophy to do just this: to account for the continuity and change of individuals over time. "Embryo" and "acorn" are not terms used to sort different natural kinds. Rather, these words are used to distinguish phases within the development of two distinct biological natural kinds. "Embryo" is a phase-sortal term for animals and "acorn" is a phase-sortal term for oaks.³⁶ If intrinsic value inheres in individuals as members of kinds, then it inheres in them throughout their natural histories as members of that kind undergoing the development that typifies the kind. Thus the intrinsic dignity of the human inheres in embryonic members of the human natural kind every bit as much as it does in adult members of the human natural kind.

Space limitations preclude a full discussion of long-standing arguments about the distinction between persons and members of the human natural kind. Suffice it to say that "person" is not a phasesortal, like "fetus" or "adolescent." Even if "person" were a phasesortal, one could not make personhood the basis for intrinsic dignity without completely subverting the notion of intrinsic value, which must, by definition, inhere in each individual by virtue of its being the kind of thing it is, and not by virtue of the phase it is in during its development as a member of that kind.

Some have argued that the fact that an early human embryo can split into two, forming twins, means that there is no individual until after 14 days of development, so that any developing entity younger than 14 days is not an individual human being and therefore has no dignity. As Germain Grisez³⁷ and Robert P. George³⁸ have pointed out, however, this argument is totally specious. The fact that one amoeba can split into two amoebas is not an argument that what was there before the split was not an amoeba. It is among the law-like generalizations and is typical of the natural history and features of individual members of the human natural kind that they can split before 14 days of development and form identical twins. This is hardly an argument that human embryos younger than 14 days are not individual members of the human natural kind in whom intrinsic dignity inheres.

Finally, some have argued that the fact that some human zygotes will develop into tumors known as hydatidiform moles means that one need not regard the developing entity as human, since it could be a mole.³⁹ For simplicity's sake I will consider only the case of a complete hydatidiform mole. It is uncertain whether this "mole" objection is intended as an ontological argument or an epistemological argument. Interpreted as an ontological argument, it is tainted with genetic reductionism, presuming (falsely) that whatever has a 46 XX or XY set of chromosomes is a human being. But a hydatidiform mole is neither a human being nor a human embryo. A mole is not even an organism. Its chromosomes are only of paternal origin, and these are abnormally imprinted, even if the DNA sequence is totally human. No actual embryo ever develops, only abnormal trophoblastic tissue. From its origin, a mole is a different kind of thing, even though it has human genes. As a different kind of thing, a mole does not have intrinsic dignity. Therefore, the possibility of mole formation is not an argument that a human embryo in the Petri dish does not have intrinsic dignity. If what is in the dish is a human embryo, then it has intrinsic dignity. If what is in the dish is a mole, then it does not.

Interpreted as an epistemological argument, however, this line of reasoning suggests that, because one might not be able to determine until later in development whether what is growing in the uterus or the Petri dish is a mole, one therefore cannot speak meaningfully of the intrinsic dignity of a five-day old blastocyst. It is true that, in vivo, given current technology, there is no good way to tell an embryo from a mole at 5 days of developmental age. In vitro, by contrast, it has been demonstrated that even at the 2-cell stage one can detect characteristic abnormalities in hydatidiform moles.⁴⁰ However, prescinding from the question of whether one has epistemic access to the true (if modest) essence of the thing undergoing development, as a practical matter this possibility does not seem morally decisive. Moles are rare. If there is a 99.9% chance that what I see stirring in the woods is a fellow hunter, and a 0.1% chance that it might be a deer, prudence suggests not shooting. And any epistemic doubts I might have about what stirs-in the woods, the womb, or the Petri dish-do not suffice to change the ontological status of the thing that stirs. There is a correct answer to the question, is this a mole or an embryo? If what is in the dish is an individual member of the human natural kind in the embryonic stage of development, then it has intrinsic dignity. My uncertainty does not change the kind of thing that it is, nor does my uncertainty change its intrinsic value.

A theory of dignity that can provide such explanations and guidance in moral decision-making about the treatment of human embryos would not seem useless.

Cloning to Bring Babies to Birth

All of the arguments I raised above about why it is a violation of intrinsic human dignity to destroy already existing human embryos for research purposes apply a fortiori to creating human embryos expressly in order to destroy them for research purposes. However, a different set of considerations arises in examining the morality of cloning to bring babies to birth.

Curiously, cloning to bring babies to birth has met with widespread opposition by persons of many different philosophical and theological orientations. Most subscribe to the notion that this practice would deeply offend human dignity. There has yet to be, however, an entirely compelling explanation of exactly why this might be so. Does the conception of dignity offered in this essay shed any light on this bioethical issue?

The intuitions of many observers may be captured by attempting to understand how the difference between an artifact and a natural kind is related to the conception of dignity that I have presented. Artifacts have no intrinsic value. The value of an artifact is purely attributed-conferred on the artifact by its artificer. Typically, this attributed value is instrumental. I make a knife in order to cut things because cutting them is useful to me. I manufacture a mobile telephone because telephones have an instrumental value to me that is enhanced by making that instrumental value portable. The very notion of the intrinsic value of biological entities, as I have discussed, entails the notion of natural kinds-the value things have by virtue of being the kinds of things that they are. Intrinsic dignity is the name we give to the intrinsic value of members of the human natural kind. This value is discovered, not made. It is decidedly non-instrumental.

The introduction of various reproductive technologies into clinical medicine has worried many observers for many years, but few have articulated these worries carefully. The possibility of cloning for reproductive purposes seems to have led many observers to agree that these long-standing worries have had genuine moral substance. The President's Council on Bioethics has expressed this unease as the difference between begetting and manufacture.⁴¹ A child born of the normal course of affairs is begotten. A child brought to birth after having been cloned seems manufactured. The conception of dignity expressed in this essay perhaps gives a more fundamental basis for explaining the worry captured by the pithy distinction between begetting and manufacture. Cloning blurs the line between the value one discovers in the human as a natural kind (i.e., intrinsic dignity) and the value that is merely conferred upon artifacts by human attribution.

In one very serious sense, a human clone would be an artifact. As such, it would have value only to the extent that value would be conferred upon it by its artificers. If the clone were created and then destroyed for research purposes, perhaps one could convince oneself that what one had destroyed was not a member of the human natural kind and therefore had no dignity. But if that clone were brought to birth, one could not avoid confronting the artifact vs. natural kind question. The scientist would stare the clone in the eye and say, "I have created you." The value of the clone would be artifactual, not already given, commanding recognition and respect. An artifact's value is purely instrumental and attributed. Thus, the very notion of intrinsic human dignity would be radically threatened. And with it, our whole system of morality, founded upon respect for intrinsic dignity, would be threatened.

In another sense, of course, a cloned human being brought to birth would have intrinsic dignity. While born out of the natural course, perhaps suffering from genetic disorders associated with that manner of coming into being, the clone would still be a member of the human natural kind. Clones are not created from scratch-from a soup of nucleotides and DNA polymerase. Somatic cell nuclear transfer depends on the pre-existence of members of the human natural kind from which the clones would be derived. A human clone brought to birth would be picked out as falling under the extension of the human natural kind. While quite likely to be genetically defective, such an individual would still have a developmental history traceable back to a human embryo. Such an individual would still obey most of the law-like generalizations that characterize the human natural kind. Thus, such an individual would be a member of the human natural kind and would still have intrinsic dignity.

Given the way in which the individual came into being, however, the real and acute worry would be that this individual's intrinsic dignity would be open to question, because the individual might be considered an artifact and not a member of a natural kind, and might therefore be considered to have only attributed and not intrinsic value. And when the intrinsic value (the intrinsic dignity) of any member of the human natural kind is threatened, the moral system that characterizes us as a kind is threatened.

A theory of dignity that explains the common intuition that the bringing to birth of a cloned human being would be a transgression against dignity is a robust theory of dignity. This suggests that the concept of dignity is not irrelevant to bioethics but, rather, extremely important.

The Care of Persons Suffering from Post-coma Unresponsiveness

The proper care of persons suffering from the Permanent Vegetative State and related neurological conditions has become a highly contentious bioethical topic in the Western world. Even the name of the condition has become a matter of controversy. Although a good biologist or philosopher who has studied Aristotle knows that the term "vegetative" is purely descriptive and not pejorative, many persons, sadly, have abused the term and have called patients who suffer from the condition "vegetables." Because of this, the Australian term, "post-coma unresponsiveness" may be the most descriptive name one can use for this condition and may also be the least liable to misinterpretation.⁴² Accordingly, "post-coma unresponsiveness" is the term I will use to describe the condition of persons who initially become comatose after anoxic or traumatic brain injury, but gradually develop into a state in which they are able to open their eyes, have intact brain stem functions and are able to breathe and exhibit sleep-wake cycles, but never recover signs of cognitive awareness or conscious interaction with their environments.

One line of argument in bioethics suggests that such individuals have lost all dignity and therefore should either be euthanized, experimented on, or denied access to life-prolonging therapies. The conception of dignity presented in this essay provides a basis for understanding that this line of argument cannot be sustained. That is because such arguments are based solely on an attributed sense of dignity.

Human beings suffering from post-coma unresponsiveness (PCU) have not undergone an ontological change. Such patients have not become some other kind of thing. We pick them out as members of the human natural kind as a precondition for our judgment that they are severely ill. Even an argument, for example, for euthanizing such patients, based on their profound loss of attributed dignity, presumes, as I have argued, that they are members of the human natural kind and still have intrinsic dignity. All duties to build up or to create conditions conducive to a patient's possibilities for inflorescent dignity depend upon respect for intrinsic dignity. Likewise, any perceived duty to build up diminished attributed dignity also depends upon respect for intrinsic dignity. Respect begins with recognition, and recognition does require an act of attribution, yet this attribution does not create the value. Rather, recognition is best described as an act of attributing correctly, an acknowledgement of the intrinsic dignity of the patient that cannot be eliminated even should it go unrecognized. The dignity here acknowledged is an objective value that presents itself as worthy of respect. Before we can attribute any additional values to human beings, whether sick or well, and call those values "dignities," we must first recognize and respect them as bearers of intrinsic dignity. Those suffering from PCU may represent a limiting case. They have severely diminished attributed dignity, and extremely limited possibilities for inflorescent dignity. Yet it is only by virtue of having first picked them out as members of the human natural kind and having recognized their intrinsic value that we concerned about either their attributed or their inflorescent value. Those who strive to build up the attributed dignity of patients suffering from PCU have already conceded that there is such a thing as intrinsic dignity by the very fact that they show concern for these patients. While extraordinarily impaired, these individuals still have intrinsic dignity by virtue of being the kinds of things that they are- members of the human natural kind. Therefore, according to the moral duties that follow from a fundamental duty to respect intrinsic dignity, someone suffering from PCU cannot be euthanized or experimented upon without consent (P-VI).

Such individuals have an intrinsic dignity that also demands equality of treatment. Accordingly, such individuals cannot be denied access to care that other ill human beings would be afforded merely on the basis of their medical conditions. Treatment might be refused, but treatment must be offered. Comfort, care, and respect must never be abandoned. As discussed above, this duty to provide care is limited by the individual's physical, psychological, social, spiritual, and economic resources in his or her particular circumstances as well as the availability of a given society's resources. The diagnosis of PCU itself, however, must never be the basis for unilaterally withholding or withdrawing care that would be rendered to others.

It is undeniably true that such individuals are extremely restricted in their ability to flourish as the kinds of things that they are. They are incapable of expressing courage, or honor, or even understanding their predicaments. Thus, their capacities for inflorescent dignity are profoundly restricted. No one wishes to be in such a state. Therefore, respect for equal intrinsic dignity also ought to assure such persons the same rights as others to withhold or withdraw life-sustaining treatments that are futile, or more burdensome than beneficial.

The conception of dignity presented in this essay thus also has concrete implications for understanding how to care for individuals suffering from post-coma unresponsiveness. This gives further evidence of the critical importance of a serious consideration of dignity in debates about pressing issues in bioethics.

Conclusion

In this essay, I outlined three ways the word "dignity" has been understood in the history of Western thought and explained how these three senses of dignity-the attributed, the intrinsic, and the inflorescent-are still at play in contemporary bioethical debates. I offered two arguments about why the intrinsic sense of dignity is the most foundational-the Axiological Argument and the Argument from Consistency. In so doing, I stressed the importance of the conception of natural kinds to all three senses of dignity. I then outlined several general moral norms that specify what it means to respect dignity. Finally, I applied this theory of dignity and its associated moral norms to a variety of pressing ethical questions in contemporary bioethics, showing how this conception of dignity is extraordinarily powerful in helping us to understand how we ought to proceed in answering these questions. Space has precluded a fuller explication of this theory or a full consideration of counter-arguments. However, it seems clear that if this is what dignity means, then dignity is anything but a useless concept.

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FootNOTES

i. There is a third logical possibility that I will not discuss, although some nihilists accept it-namely, that human beings have no dignity.

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EndNOTES

1. Daniel P. Sulmasy, "Death, Dignity, and the Theory of Value," Ethical Perspec tives 9 (2002): 103-118, reprinted in Euthanasia and Palliative Care in the Low Countries , ed. Paul Schotsmans and Tom Meulenbergs (Leuven, Belgium: Peeters,
2005), pp. 95-119.

2. Ruth Macklin, "Dignity is a Useless Concept," BMJ 327 (2003): 1419-1420.

3. Charles Trinkaus, "The Renaissance Idea of the Dignity of Man," in Dictionary of the History of Ideas , vol. 4, ed. Philip P. Weiner (New York: Charles Scribner's Sons, 1973), pp. 136-147; Daniel P. Sulmasy, "Death with Dignity: What Does it Mean?" Josephinum Journal of Theology 4 (1997): 13-24.

4. Cicero, De Inventione I.166.

5. Miriam T. Griffin and E. Margaret Atkins, "Notes on Translation," in Cicero: On Duties (New York: Cambridge University Press, 1991), pp. xlvi-xlvii.

6. Cicero, De Officiis I.106, trans. Walter Miller (New York: Macmillan, 1913), pp. 106-109.

7. Thomas Hobbes, Leviathan , chapter 10, ed. Richard Tuck (Cambridge: Cambridge University Press, 1991), pp. 63-64.

8. Immanuel Kant, "The Metaphysics of Morals, Part II: The Metaphysical Principles of Virtue," Ak419-420, in Kant, Ethical Philosophy , trans. James W. Ellington (Indianapolis, Indiana: Hackett, 1983), pp. 80-81.

9. Immanuel Kant, Grounding for the Metaphysics of Morals , Ak 434, trans. James W. Ellington (Indianapolis, Indiana: Hackett, 1981), p. 40.

10. Ibid.

11. Thomas E. Hill, Jr., Dignity and Practical Reason in Kant's Moral Theory (Ithaca, New York: Cornell University Press, 1992), p. 43.

12. In my essay, "Dignity and the Human as a Natural Kind," included in Health and Human Flourishing , ed. Carol R. Taylor and Roberto Dell'Oro (Washington, D.C.: Georgetown University Press, 2006), pp. 71-87, I called this the "derivative" sense of dignity. However, some commentators, especially those who would be counted as using the word this way, have worried that "derivative" sounds less"dignified" than is appropriate.

13. Timothy E. Quill, "Death and Dignity: A Case of Individualized Decision Making," New England Journal of Medicine 324 (1991): 691-694.

14. Dónal P. O'Mathúna, "Human Dignity in the Nazi era: Implications for Contemporary Bioethics," BMC Medical Ethics 7 (2006): E2.

15. Leon R. Kass, Life, Liberty and the Defense of Dignity: The Challenge for Bioethics (San Francisco, California: Encounter Books, 2002), pp. 231-256.

16. See Noah M. Lemos, "Value Theory," in Cambridge Dictionary of Philosophy, ed. Robert Audi (New York: Cambridge University Press, 1995), pp. 830-831; also Michael J. Zimmerman, "Intrinsic vs. Extrinsic Value," Stanford Encyclopedia of Philosophy (2004 edition), ed. Edward N. Zalta, available online at http:// plato.stanford.edu/entries/value-intrinsic-extrinsic/. The standard views either distinguish intrinsic from instrumental values, or intrinsic from extrinsic values. The theory of intrinsic value outlined in this essay, however, following Holmes Rolston III, Environmental Ethics (Philadelphia: Temple University Press, 1988), aligns with the views of Kant, Brentano, Broad, Ross, and others, that whatever is intrinsically good is worthy of being valued in itself.

17. See Sulmasy, "Death, Dignity, and the Theory of Value."

18. Rolston, Environmental Ethics , p. 116.

19. Credit for initiation of the discussion of natural kinds is usually given to Saul Kripke, in his two essays, "Identity and Necessity," in Identity and Individuation ed. Milton K. Munitz (New York: New York University Press, 1971), pp. 135-164,
and "Naming and Necessity," in Semantics of Natural Language , ed. Gilbert Harman and Donald Davidson (Dordrecht, Netherlands: Reidel, 1972), pp. 253-355. For a good contemporary approach to the concept of natural kinds, see David Wiggins, Sameness and Substance (Cambridge, Massachusetts: Harvard University Press, 1980), pp. 77-101, and his Sameness and Substance Renewed (Cambridge: Cambridge University Press, 2001).

20. Wiggins, Sameness and Substance , p. 169.

21. Tom L. Beauchamp, Philosophical Ethics (New York: McGraw-Hill, 1982), pp. 5-21.

22. Aristotle, Nicomachean Ethics 1095b, trans. Terence Irwin (Indianapolis, Indiana: Hackett, 1985), p. 7.

23. H. Tristram Englehardt, Jr., The Foundations of Bioethics (New York: Oxford University Press, 1986), p. 213.

24. Michael Tooley, Abortion and Infanticide (Oxford: Oxford University Press, 1983).

25. Raymond G. Frey, "Pain, Vivisection, and the Value of Life," Journal of Medical Ethics 31 (2005): 202-204.

26. Kant, Grounding for the Metaphysics of Morals , Ak 421, p. 30.

27. Richard M. Hare, Moral Thinking: Its Levels, Methods, and Point (New York: Oxford University Press, 1981), pp. 107-116.

28. Thomas F. Hack, et al., "Defining Dignity in Terminally Ill Cancer Patients: A Factor-analytic Approach," Psychooncology 13 (2004): 700-708.

29. Garth Baker-Fletcher, Somebodyness: Martin Luther King, Jr. and the Theory of Dignity , Harvard Dissertations in Divinity, No. 31 (Minneapolis, Minnesota: For tress Press, 1993), p. 23.

30. J. David Velleman, "A Right to Self-Termination?" Ethics 109 (1999): 605-628.

31. Daniel P. Sulmasy, "Dignity, Rights, Health Care, and Human Flourishing," in Human Rights and Health Care , ed. G. Diaz Pintos and David N. Weisstub (Dordrecht, Netherlands: Springer, in press 2007).

32. Daniel P. Sulmasy, "Diseases and Natural Kinds," Theoretical Medicine and Bioethics 26 (2005): 487-513.

33. Harriet McBryde Johnson, "Unspeakable Conversations," New York Times Sunday Magazine , February 16, 2003, p. 50. The philosopher was Peter Singer.

34. Judith Jarvis Thompson, "A Defense of Abortion," Philosophy and Public Affairs 1 (1971): 47-66.

35. Robert P. George and Patrick Lee, "Acorns and Embryos," The New Atlantis 7 (Fall 2004/Winter 2005): 90-100.

36. Alfonso Gómez-Lobo, "Does Respect for Embryos Entail Respect for Gametes?" Theoretical Medicine and Bioethics 25 (2004): 199-208.

37. Germain G. Grisez, "When Do People Begin?" Proceedings of the American Catholic Philosophical Association 63 (1990): 27-47.

38. Robert P. George, "Human Cloning and Embryo Research," Theoretical Medicine and Bioethics 25 (2004): 3-20.

39. Carlos A. Bedate and Robert C. Cefalo, "The Zygote: To Be or Not Be a Peron," Journal of Medicine and Philosophy 14 (1989): 641-645; Thomas J. Bole, III,"Metaphysical Accounts of the Zygote as a Person and the Veto Power of Facts," Journal of Medicine and Philosophy 14 (1989): 647-653.

40. Nicanor Austriaco, O.P., "Are Teratomas Embryos or Non-embryos?" National Catholic Bioethics Quarterly 5 (2005): 697-706.

41. The President's Council on Bioethics, Human Cloning and Human Dignity: An Ethical Inquiry (Washington, D.C.: Government Printing Office, 2002), pp. 104-107.

42. National Health and Medical Research Council of Australia, "Post-Coma Unresponsiveness (Vegetative State): A Clinical Framework for Diagnosis," December 18, 2003, available online at http://www.nhmrc.gov.au/publications/synopses/_files/hpr23.pdf.

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