# introduction<fnref n="1" />

“Dying with Dignity Canada” (DWDC) has been a vocal and aggressive activist for Canada’s expanding medical assistance in dying (MAiD) regime. On the one hand this is not particularly noteworthy in that there are many advocacy and activist groups active in Canada supporting a broad range of social and/or political causes. What is unique about DWDC, however, is that this group is closely aligned with the Canadian Association of MAiD Assessors and Providers (CAMAP), the organization that has been recognized and endorsed by the federal government to provide education and support to those providing MAiD services across the country (1). Despite the rapid expansion of MAiD services in Canada over the past decade, there are still many unsettled questions about the ethical probity of many MAiD practices. Nevertheless, DWDC and by extension, CAMAP, continue to push for further expansion and more liberal access. It is both disturbing and concerning that in promoting CAMAP the federal government is effectively endorsing the views of DWDC, a particularly aggressive advocate for liberal policies and practices regarding MAiD.

DWDC’s mission, ostensibly, is the promotion of “death with dignity”; yet the notion of ‘dignity’ that underwrites this organization’s activism is largely unexamined. Indeed, a similar unexamined notion of dignity tends to (mis)inform much of the ongoing policy debate motivating the expanding MAiD regime in Canada. In this paper, I examine the notion of human dignity as it is employed by MAiD activists in Canada. Drawing upon previous work I’ve done on this notion over the past three decades (2-7), I demonstrate that the narrow and somewhat skewed notion of ‘dignity’ employed in these public debates is ill equipped to provide a foundation for a comprehensive public policy that supports medicalized homicide.

Central to this critique is the distinction between two related but fundamentally different conceptions of human dignity, which for present purposes I will designate ‘moral Dignity’ (upper case) and ‘aesthetic dignity’ (lower case) respectively. Moral Dignity is that notion recognized in such documents as the Universal Declaration of Human Rights (8), which opens with a “recognition of the inherent [D]ignity and of the equal and inalienable rights of all members of the human family....” Such Dignity is enjoyed by every human being; nothing need be done to earn it, and nothing can ever erase it. It is an objective presupposition of international human rights legislation. But this is not the notion of dignity that underwrites the current MAiD debate and the increasingly liberalized policy in Canada. This latter conception of dignity is much more akin to an aesthetic notion. It is subjective in nature and trades on contingent variables. It is a socially constructed concept. As such, some individuals’ lives may be assessed as ‘dignified’ while others are thought to be ‘undignified’. Indeed, one of the concerns of the disability community in Canada is that the subjective aesthetic evaluations of some (the abled) are judging the lives of others (those with disabilities) to be undignified and hence not worthy of protection. Put otherwise, those consigned to such an undignified existence would be better off dead. Indeed, this last is essentially the chilling conclusion of a recent paper by two Canadian bioethicists (9).

In this paper, I discuss the dynamic relationship that exists between the moral notion of ‘Dignity’ and its aesthetic counterpart, ‘dignity’. It will be argued that a pluralistic society requires both notions, but only the objective moral notion (Dignity) is adequate to serve as the foundation of a fundamental legal regime. While any pluralistic society must provide opportunities for the expression of subjective aesthetic notions of dignity, the latter can neither serve as the foundation of a comprehensive public ethic in general, nor can it set the parameters of a public policy on medicalized homicide. Indeed, the unmitigated expansion of a particular notion of dignity such as that promoted aggressively by DWDC/CAMAP threatens to expunge the more fundamental conception of Dignity that serves as the foundation of any liberal democratic society.

<footnote n="1">A slightly expanded version of this paper will appear as a chapter in a forthcoming volume published by Springer titled: Medical Assistance in Dying (MAID) in Canada: Current Trends and Consequences, edited by Jaro Kotalik and David Shannon. The title of that chapter is: “MAiD as a Harbinger of the Death of Dignity.” The version is printed here with permission.</footnote>
# Two Conceptions of Dignity

In various publications over the past three decades, I’ve endeavored to articulate the distinction between the two conceptions of dignity outlined above while stressing the symbiotic relationship between the two. My argument has been that a comprehensive understanding of human dignity requires a recognition of both the moral and the aesthetic dimensions of the concept. In this respect, ‘dignity’ bears some resemblance to the Greek ‘ta kalon’ which can be translated as both ‘morally good’ and ‘aesthetically beautiful’.

While both conceptions are necessary to a comprehensive understanding of dignity, it is useful to distinguish between the two to gain a better appreciation for the fecundity of the unified concept. Table 1 summarizes some of the basic distinctions between these two conceptions; Table 2 illustrates how various longstanding fundamental tensions in moral and social political philosophy map onto these conceptions of ‘Dignity’ and ‘dignity’ respectively.

<table><caption>Table 1 — Dignity Value Distinctions</caption><tr><td>Moral DignityAesthetic dignity“Basic Dignity”“Personal
            dignity”OntologicalExistential/RelationalIntrinsic WorthSocially constructed
            notionFundamental/Objective moral notionSubjective aesthetic notionNon-contingent:
            applies to all humanity categoricallyContingent: can be gained or lostInalienable: one
            does nothing to earn it, and nothing can take it awayOften closely tied to notions of
            individual autonomy and personal choice. As such its status is tenuous</td></tr></table>

As noted previously, Dignity emphasizes the moral dimension of the concept. As such it captures the intrinsic moral value of every human being as an ontological necessity. Elsewhere, I’ve argued that this notion functions as a meaning constraint on moral discourse in general (7). One does nothing to earn this Dignity, and nothing can take it away. Simply by virtue of being a member of the human species one enjoys this fundamental, inalienable moral worth.

By way of contrast, aesthetic dignity is a socially constructed notion. At times I refer to it as ‘personal dignity’ but this sense of dignity need not necessarily be individualistic. Inasmuch as aesthetic ‘dignity’ is socially constructed it could, depending on context, be tied to broader community or cultural values that extend beyond the individual. Nevertheless, in an increasingly individualistic society such as contemporary Canada, such dignity is often viewed as synonymous with individual autonomy and personal choice.

<table><caption>Table 2 — Mapping Dignity to Common Moral and Social Political Tensions</caption><tr><td>Moral DignityPersonal dignityUniversalParticular‘The Right’‘The
            Good’ObjectiveSubjectiveEqualityLiberty/’autonomy’Species referencedIndividually
            referencedRespectHonorWe have rights because we have DignityAn individual right to be
            treated with dignity</td></tr></table>

Table 2 captures how some of the fundamental tensions in moral and social-political philosophy map onto these two conceptions of dignity, respectively. Moral Dignity is a universal, objective notion while the aesthetic notion is subjective and particularist. Moral Dignity emphasizes the equal moral worth of all human beings while the aesthetic conception prioritizes liberty. While the moral conception focuses on respect for each and every human being, the aesthetic conception emphasizes honouring particular kinds of lives that display some socially constructed perception of what it means to live a dignified life. Think here of ‘dignitaries’ and the honor afforded them as in some sense superior to those who lack this special status.

While the foregoing tensions have garnered much attention by moral and political philosophers in the ongoing debates between universalism versus particularism, liberalism versus communitarianism, liberty versus equality and so forth, I argue that a proper understanding of human dignity requires both the moral and aesthetic aspects. Moral Dignity is the fundamental moral concept that sets the moral foundation for a liberal society. Aesthetic dignity is the expressive dimension that allows individual citizens to choose for themselves their conception of the beautiful life. Any liberal society aims to allow for the widest expression of individual liberty/dignity. However, the latter expressive notion must always be anchored, and to some extent constrained, by the more fundamental moral conception. To paraphrase Kant, moral Dignity without aesthetic dignity is empty; aesthetic dignity without moral Dignity is blind.
# The Dynamics of Dignity

The dynamic tension between these two complementary conceptions of dignity can be further illustrated with reference to another oft discussed tension in social/political philosophy, that between the ‘Right’ and the ‘Good’. The question here is which notion should be prioritized when thinking about the just society. Do we settled on some shared notion of the Good that society in general aims to promote, and then use that notion to determine what is right in terms of various laws and social sanctions that promote this shared vision? Or do we determine instead some basic understanding of the Right that will set some general and common standard of appropriate social behaviour (i.e., right conduct), and then leave it to each individual citizen to determine what ‘the Good’ is for themselves individually?

Fundamentalist religious groups often serve as examples of communities that prioritize the Good over the Right. The religiously informed vision of what the good life should be is ostensibly shared by all members of the group; right and wrong conduct are then assessed against whether particular actions either promote or undermine this shared notion of the Good. Liberal democratic societies, by way of contrast, ostensibly prioritize the Right by setting legal standards and parameters aimed at permitting citizens the greatest liberty to pursue their individual conceptions of the Good. On this latter reading the Good in question is not a moral Good per se; it is rather an aesthetic understanding of what constitutes “the Beautiful life”.

A concerning feature of the DWDC/CAMAP conception of dignity is that it tends to equate dignity with autonomy. The dignified/beautiful life on this view is one in which the individual has the greatest latitude to express their dignity as they see fit. Hence, any restrictions on the individual’s liberty to choose the time and reason for dying is a matter of restricting individual choice. So far this seems to track the standard liberal democratic understanding that prioritizes the Right over the Good. At the same time, however, this notion of dignity suggests that anyone who lacks the capacity to live the beautiful life as viewed through the lens of individual autonomy thus lacks dignity and would be better off dead. In so doing, it effectively conflates its own notion of the Good with a somewhat narrow conception of what is Right. To date the Canadian political and legal systems have effectively endorsed and enforced this DWDC/CAMAP perception. Lower courts have consistently challenged restrictions on individual liberty concerning the rationale for or timing of MAiD. The federal government has in turn refused to challenge such liberal interpretations, choosing instead to amend the law to make MAiD more accessible. In so doing, however, the federal government is effectively endorsing the DWDC/CAMAP vision of the Good. That is, the good life according to DWDC/CAMAP is one that entails a particular aesthetic vision of what it means to have a dignified life and death. Canada, as a liberal democracy, should in principle endorse no particular vision of the Good. However, by succumbing continually to the DWDC/CAMAP ideology of maximum liberty tied to a narrow notion of autonomy and a particular view of what it means to live a dignified life and/or to experience a dignified death, the Canadian government has effectively prioritized this notion of the Good, using it as a guide for determining Right action. In so doing it is prioritizing a particular aesthetic notion of dignity that risks undermining the more fundamental moral notion of Dignity that underwrites the Charter of Rights and Freedoms for all Canadian citizens.
# Dignity and the limits of Liberty

I turn now to a brief review of three hypothetical cases of “assisted dying” to illustrate why particular conceptions of liberty/autonomy that inform certain aesthetic perceptions of dignity and what it means to live or die with dignity, must always be constrained by the more fundamental notion of Dignity outlined above. Failing to do so risks undermining the moral foundations of society. Put otherwise, unbridled “dying with dignity” threatens the death of Dignity.

## Three Cases of Assisted Dying

Case 1: Mrs. B is a 47-year-old mother of two young adult children. She suffers from an incurable neurodegenerative condition that will eventually result in her death. Although she does not yet want to die, she can foresee a time when her condition will deteriorate to the point that she would prefer death to life. However, she fears that by that point she might be physically unable to end her own life. Hence, she is considering MAiD.

Case 2: Mr. C is a 76-year-old gentleman who suffers from cognitive impairment. He was found wandering on the street and was taken to a medical facility. Since he lacked the ability to care for himself, he was admitted to long-term care where he has been followed by a psychiatric geriatrician for the past 6 months. From time-to-time Mr. C complains that he hates being in this facility and says that he wants to die. His geriatrician has assessed him as globally incompetent thus lacking capacity to consent to MAiD.

Case 3: Mr. D and Mr. E are both in their mid 40’s. They met in an online forum that caters to persons who like to experiment with unusual sexual fetishes. Both Mr. D and Mr. E would be considered mentally competent, and aside from what might be viewed as their somewhat extreme desires and preferences in this particular area, they would be deemed otherwise normal. Mr. D has long fantasized about killing someone and then consuming their flesh. But he would only do this if he found someone willing to consent to the act. Mr. E is so inclined and has signed an ‘informed consent’ to permit Mr. D to complete his fantasy.

While the three cases outlined here are all hypothetical, each is modeled on an actual situation. Case 1 closely approximates the case of Sue Rodriguez, the woman who first petitioned the Supreme Court of Canada (SCC) in 1993 to amend the law to permit her to receive medical assistance in dying. Case 2 mirrors an actual case in which I was involved as an ethics consultant. The consultation arose because the patient had been assessed by a MAiD provider as competent to receive MAiD. Case 3, while not a case of MAiD per se, nevertheless involves an instance of an assisted death. It is modeled on an actual case that took place in Germany over two decades ago involving Armand Meiwes who killed and then consumed the flesh of Bernd Brandes. Brandes had previously consented to the act (10). I do not intend to discuss these three cases in detail here, although each raises interesting discussion points regarding the notions of liberty, dignity and assisted dying. Rather, I use the three cases to illustrate the limits of liberty and why aesthetic notions of dignity must always be constrained by a moral conception of Dignity in any liberal democracy that hopes to remain healthy and functional.

Case 1, in my view, is the easiest to accommodate in a traditional liberal-democratic understanding of how to balance individual liberty against some general conception of the common good, or put otherwise, how and to what extent a notion of our shared Dignity can accommodate individual expressions of dignity in the “dying with dignity” space. Although Sue Rodriguez was unsuccessful in her petition to the SCC, essentially the same case came before the SCC again in 2015 in the person of Gloria Taylor. Although that case is widely referred to as the Carter decision after the first plaintiff named in the decision, the SCC deliberations focused on Ms. Taylor who had joined several others in petitioning the court to strike down the Canadian Criminal Code prohibition against assisted suicide. Like Sue Rodriguez before her, Gloria Taylor suffered from amyotrophic lateral sclerosis (ALS), an incurable degenerative neurological disease. When the SCC first addressed the prohibition on assisted suicide in the 1993 Rodriguez decision, both conceptions of Dignity/dignity figured in its deliberations (11). Justice Sopinka, and the majority of the SCC justices who adjudicated the Rodriguez case, worried that opening the door to assisted suicide might erode respect for the fundamental Dignity that serves as the foundation of individual rights and freedoms for all Canadians, and especially for the most vulnerable amongst us. Justice McLachlin, one of the dissenting justices, disagreed, arguing that Ms. Rodriguez’s interest in promoting her own dignity over-road such concerns. By the time the SCC revisited the issue again in 2015 in what is now known as the Carter decision (12), Justice McLachlin was the Chief justice. This time her perspective dominated, and the nine justices of the SCC voted unanimously to amend the criminal code to permit MAiD. While the notion of dignity figures again in the latter SCC discussion, it is only the aesthetic conception that receives the court’s attention.
# Concern for moral Dignity does not figure in the SCC
        deliberations on Carter

The SCC in Carter was careful to note that their deliberations focused only on the case of Gloria Taylor, a woman with a terminal illness who faced a potentially terrible death. Unlike in the Rodriguez decision in which considerations of Dignity were very much part of the deliberations, such concerns are not mentioned in the Taylor case. The implication is that Ms. Taylor’s interest in protecting her aesthetic dignity did not, in the SCC’s view, threaten to undermine the fundamental Dignity which serves as the guarantor of the rights of all Canadians. In my view, had the subsequent law (Bill C-14) been crafted to accommodate this somewhat narrow class of cases (i.e., those involving an imminent and potentially terrible death where resources and means to mitigate suffering are limited), “dying with dignity” in that sense would not undermine the more fundamental Dignity on which the Canadian Charter is predicated. However, once death with dignity was defined in terms of individual autonomy and the right to choose (the DWDC position), neither parliament nor the courts have been willing or able to restrain this kind of aesthetic vision. Indeed, given the reasoning of the lower courts in various decisions following Bill C-14, and parliament’s subsequent acquiescence by amending the law (Bill C-7) to permit wider and easier access to MAiD, one wonders whether similar rationale might be used to justify Case 3 type scenarios as well. If not, why not?

In fact, the Case 3 cannibalism scenario is introduced as a kind of reductio ad absurdum. That is, regardless of one’s general sense that society should promote and protect individual liberty and how that belief translates into one’s position on whether and under what circumstances to permit assisted dying, generally only the most extreme type of libertarian would argue that Case 3 type scenarios should be permitted. In other words, the notion of moral Dignity that undergirds our liberal democratic society cannot sustain just any particular aesthetic vision tied to notions of individual liberty and choice. Some such aesthetic visions are simply beyond the pale. The key point here is that any liberal society requires a notion like moral Dignity to function as a background constraint on the expression of individual liberty of its citizens.

This brings us back to Case 2, the individual declared globally incompetent by one physician but deemed capable of understanding and making a formal request for MAiD by others. This case involved an extensive consultation with two physicians who are members of CAMAP, one of whom served on the board of DWDC. Both CAMAP physicians were of the opinion that even though this patient suffered from dementia, he nevertheless experienced periods of lucidity in which he was capable of understanding what a request for MAiD entailed and was capable, in that moment, of providing consent. Even though the patient might not remember having had this conversation subsequently, these physicians were confident that the request and consent, in that moment, should be considered valid. Indeed, one of the physicians declared that he had provided MAiD to a number of similar patients in the past. The geriatrician who had been following this patient closely over an extended period of time, disagreed, arguing that the patient was simply incapable of appreciating the full extent of what a MAiD request entailed. I, as the ethics consultant, expressed my own strong reservations that a patient with dementia lacked capacity for making an autonomous choice, especially one as momentous and irrevocable as what was being contemplated. Nevertheless, the case was referred on to legal counsel for an opinion. Much to my chagrin, the legal opinion based only on a summary of the case, and which did not include direct discussion with any of the physicians involved, including the most responsible physician for this patient’s care, concluded that there was no legal reason to prevent moving forward with the MAiD request.

Regardless of whether one in principle supports the availability of MAiD for Case 1 type scenarios, Case 2 should raise concerns on a number of levels. My focus here, however, is only on the DWDC position that links dignity with autonomy and personal choice. Inasmuch as this patient’s capacity to make an informed and autonomous choice was dubious at best, as argued repeatedly by the geriatrician most familiar with the patient’s history, the CAMAP physicians were adamant that the patient was eligible to receive MAiD. Although they did not use this terminology exactly, their position was that the patient’s current life situation lacked dignity as they perceived it. Thus, even though the patient’s capacity to make an autonomous decision was questionable, they concluded the patient would be better off dead. Of course, they couldn’t express that position in so many words. Instead, they performed moral and legal gymnastics to shoehorn this patient’s supposed expression of a desire to die into the category of a bona fide request for MAiD supported by a supposedly valid consent. It boggles the mind as to how that conversation between physician and patient might have unfolded.
# Erosion of the Moral Conception of
        Dignity

When the SCC first deliberated the matter of assisted suicide in the Rodriguez case, Justice Sopinka and the majority of the SCC justices agreed that the prohibition on assisted suicide, as contained in the Criminal Code, did in fact contravene Ms. Rodriguez’s equality rights as outlined in the Charter. In effect, they acknowledged that her capacity as a disabled person to express her own aesthetic dignity was compromised by the Criminal Code prohibition. Nevertheless, the majority worried that opening the door to assisted suicide might erode respect for the fundamental Dignity that serves as the foundation of individual rights and freedoms for all Canadians, and especially for the most vulnerable amongst us. This latter Dignity is the guarantor of all our rights, especially for those who may lack the physical, mental or emotional capacity or have access to the resources necessary to achieve what this now privileged perception deems to be a dignified existence. Joshua Briscoe captures succinctly what is at stake in this regard“. He writes:

> What is our culture like? What repertoire for dying does it offer us? It is a culture that glamorizes youth and the untethered autonomy of the individual. Aging is the story of losing vitality, control, and dignity—of increasingly burdening our loved ones and our medical system to care for us until we die... Human dignity, by this reasoning, is not unconditional. Only the autonomous have it. Those who are dependent on others no longer do, and are therefore no longer deserving of our care.
> — 13

Inasmuch as the DWDC’s conception of dignity is aesthetic in nature, it should come as no surprise that other aesthetic perceptions are also available, especially as these pertain to end-of-life care. Perhaps the most significant alternative perspective in this regard is that developed and popularized by Canadian psychiatrist Harvey Max Chochinov. Chochinov’s focus is palliative care and over the past three decades he has become internationally renowned for his work on what he describes as “dignity therapy.” (14) The intent of Chochinov’s therapeutic approach is to work with dying patients to discover what provides dignity and meaning for them as they face their final life’s journey, and to support them to the end in experiencing both a dignified life and death. Of particular significance to the present discussion is Chochinov’s adamant rejection of MAiD as a means of preserving dignity in the end-of-life space (15). Instead, his approach entails coming along side the dying individual to journey with them through this valley of shadows. Both our terms ‘compassion’ and ‘sympathy’ connote “suffering with.” The beautiful life and death from the perspective of dignity therapy entails compassionate and sympathetic care that includes an understanding of shared suffering as part and parcel of the human condition. In this respect, the aesthetic perception supported by dignity therapy remains firmly anchored to the moral Dignity that defines the kind of people we want to be.

DWDC and CAMAP have effectively conflated the moral notion of Dignity with their own narrow and somewhat impoverished aesthetic conception of dignity. But aesthetic expressions of dignity must always remain tethered to and constrained by the fundamental moral notion of basic Dignity. This latter Dignity is the guarantor of all our rights, especially for those who may lack the physical, mental or emotional capacity or have access to the resources necessary to achieve what this now privileged perception deems to be a dignified existence.

There is plenty to suggest that the concerns expressed by Justice Sopinka in the 1993 decision were warranted. The somewhat narrow perspective of what constitutes a dignified life and death championed by DWDC and CAMAP continues to shape legal precedent, legislative amendments, and public perceptions. Although disturbing cases of vulnerable individuals not near the end of their natural lives who opt for MAiD out of desperation continue to be reported, those who champion this now dominant aesthetic perception of what constitutes a dignified life and death remain unphased. Indeed, some have openly stated that such aesthetically undignified persons would be better off dead (9).
# Conclusion

Human Dignity is a fundamental moral notion that serves as the foundation of any liberal, democratic society. Aesthetic dignity is a complementary conception that captures the need to allow for liberty of expression in determining what constitutes a good/beautiful life and/or death for each citizen. But this latter aesthetic dignity must always be tethered to and to some extent constrained by the formal, moral conception of Dignity. Failure to do could lead eventually to Case 3 type scenarios.

Aesthetic dignity is open to wide interpretations, and as noted previously, in the context of end-of-life care a range of such perspectives are available. In the case of MAiD in Canada, however, a rather narrow conception of what constitutes a dignified life and death has been championed by DWDC, and by extension, CAMAP. That skewed perception has been effectively endorsed by the federal government. Both the courts and legislature have continually acquiesced to this narrow conception thus encouraging continuing appeals for further expansion of the law to permit even greater access to MAiD. Case 2 type scenarios are already common in Canada as we have effectively abandoned the means to constrain such narrow visions of what constitutes a dignified life and death. As such, dying with dignity in Canada as defined by DWDC/CAMAP is eroding our understanding of and appreciation for the fundamental Dignity we all share. Indeed, dying with dignity (as championed by DWDC and CAMAP) may be a harbinger of the death of Dignity.

## Références

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D. Human non-persons, feticide, and the erosion of dignity. Journal of Bioethical Inquiry. 2010;7(4):345-51.

D. Yes, there are universal ethical principles that should govern the conduct of medicine and research worldwide. In: Kaplan A, Arp R, editors. Current Debates in Bioethics. Hoboken: Wiley-Blackwell; 2014. p. 17-26.

8United Nations. Universal Declaration of Human Rights.

K, Mullin A. Choosing death in unjust conditions: hope, autonomy and harm reduction. Journal of Medical Ethics. 2024;50(6):407-412.

10Dalrymple T. The case for cannibalism: If everything is permissible between consenting adutls, why not? City Journal. 5 Jan 2004.

11Rodriguez v. British Columbia (Attorney General), [1993], 107 DLR (4<sup>th</sup>) 342 (S.C.C.).

12Carter v. Canada (Attorney General), 2015 SCC 5 (CanLII), [2015] 1 SCR 331.

13Briscoe JC. Dying, but not alone. The New Atlantis. Summer 2021.

HM. Dignity Therapy. New York: Oxford; 2012.

15Sonu Gaind K, Bertrand M, Chisvin M, et al. More Canadian psychiatrists respond: no MAiD for mental illness. Impact Ethics. 28 Nov 2023.