Human dignity and the physician's conscience.

Abstract

This is recognizable if medical behavior is considered in view of current ethical problems at the beginning and at the end of life, but also regarding the terrible tribulations during the totalitarian deformations of society by the dictatorships of the past century. One need only remember the mandatory report of patients for compulsory sterilization required from physicians by National Socialist law, or the misuse of psychiatry by compulsory referral and treatment of dissidents in the former Soviet Union, or the presently disputed question of physician-assisted suicide. Such influences from society will become even clearer if moral judgments are compared between different epochs. However, it also happens that one and the same moral problem will be judged by individual physicians—by invoking their conscience—rather differently and will lead to different consequences. This difference may be due to different developmental imprinting from their familial micro-social context. Moreover, conscience as the normative framework of individuals differs not only between individuals but can change also during an individual life time. This may indicate the influence of particular life events and special situations [1]. The question is about the role of understanding human dignity in the physician’s conscience, the weight of which aspect of dignity: Self-determination or care? Self-determination prior to care? Self-determination and care well balanced with regard to the actual situation? Can the at times as an antagonistically experienced relationship of respect for self-determination to care as an obligation of the physician be understood as complementary? There are manifold examples of physical and of psychic threats that have an impact on the individual conscience, particularly in totalitarian deformed societies [1]. However, in a more subtle mode even in liberal societies some societal trends and prevailing views may also affect the physician’s conscience. Human dignity is a term with multiple interpretations. Often it is used in connection with self-determination by viewing autonomy as an expression of dignity [4]. However, human dignity is not only seen as a human capability but also as the essence of man, i.e., this “dowry”-dignity [2] is inherent in all human beings just because they are human beings. Whereas the first mentioned “contingent” dignity can be lost by disease, the latter inherent dignity exists at least as long as the human being lives. Contingent dignity stands at the side of the inherent dignity. Inherent dignity—besides the respect for the self-determination of the patient—as dignity of the ill in need of help guides the actions of the physician, i.e., his care for the patient as an expression of his respect for the ill human being in front of him. Although the recognition of the right of self-determination began to gain significance in medicine only during the time of enlightenment and really only during the past century, the ethical principles of physicians committed to inherent dignity have been expressed for millennia as being bound to the well-being of the patient (salus aegroti) and not to harm him (nil nocere). These principles have shaped the physician’s conscience, but have not been sufficient to immunize it against the tribulations of the times. Specific features of the social and cultural atmosphere, the prevailing opinion of the societal context, the macro-social environment, the so-called Zeitgeist, may modulate the effectiveness of the principles.