Book Review: Human Dignity in Bioethics and Law

The four principles of Beauchamp and Childress, namely autonomy, beneficence, non-maleficence and justice, are deemed by many to be the framework upon which biomedical decisions are based. This was certainly what I was taught at both an undergraduate and postgraduate level. These principles have been around for over forty years and, although there have been debates on their hierarchy; they still remain the medical ethic paradigm.

With that in mind, I was slightly sceptical when I read the back cover description of Charles Foster's book, 'Human Dignity in Bioethics and Law'. It seemed to be promising so much, namely that Foster was set to challenge the very basis of my bioethical understanding by arguing an alternative to the four principles. It was with trepidation that I opened the front cover....

On reading the foreword by Lord Justice Munby, who describes the book as a 'profoundly important', I began to feel that my initial scepticism was unfounded. In this latest text, an almost continuation from his 2009 book, 'Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law', Foster seeks to eradicate the four principles and instead replace them with what he sees as the 'bioethical theory of everything': dignity.

Foster's opening chapter lays the groundwork for his thesis. He states that 'dignity is the key that, properly wielded, unlocks all problems in medical ethics and bioethics'. Being a self-confessed autonomist myself, this is a profound claim.

Foster understands dignity as being human. And by this he means objective human flourishing; that every transaction must be managed so as to maximise the amount of dignity in it. In his words, 'dignity-enhancement is the process of humanisation. That is what we should be aiming at in our lives, loves and laws'. Moreover, he takes a community-wide approach to applying dignity: that the dignity interests of allthe parties involved in the transaction must be taken into account. Using this approach, Foster seeks to discard what he sees as the current and limited focus of medical law on the individual, and instead promotes the view that humans do not live in a vacuum; that we instead exist in a social, political and physical environment.

To support his argument, Foster provides a very useful history of dignity and a succinct evaluation of the theorists and philosophers who have written on dignity. In doing so, he highlights the role that dignity has played in shaping the ethics and values we employ today. Thereby proclaiming that as all legal rights have, as their basis, a grounding in dignity, it is only dignity that will suffice as an over-arching principle. Because of this, Foster believes that to use any other principle, such as autonomy or beneficence, risks diluting the value of dignity. He states, 'beneath rights, there is something much deeper, which gives rise, no doubt to rights, but has many other intellectual and experimental offspring. This is dignity'.

Throughout the book, Foster looks at how a dignity analysis has been the underlying basis and justification for various ethical conundrums and legal cases. He uses a number of national and international conventions and declarations (such as the Human Rights Act 1998, the European Convention on Human Rights 1950 and the UNESCO Universal Declaration on the Human Genome and Human Rights 1997), as well as legal judgments (R v Brownand Airedale NHS Trust v Bland), to illustrate his point. Further, he applies his definition of dignity to several medical law scenarios from human enhancement to cloning via end-of-life decisions and abortion. In doing so, Foster hopes to prove that dignity, as a universal principle that every human being is entitled to, is the only principle that can provide the right answer to a problem. Whereas he contends that autonomy alone is inadequate to deal satisfactorily with even the most trivial of problems in medical ethics because it is focuses too much on the best interests of the individual.

Foster has produced a very readable and engaging text with some interesting and relatable issues and anecdotes as illustrations to his thesis. Moreover, I agree with Lord Justice Munby when he declares this book to be of profound importance. However, the scepticism that I felt at the beginning of my reading is still present in my mind. I agree with Foster that dignity is the basis by which all other principles are founded. But I believe one of the main reasons human dignity hasn't been the over-arching principle in bioethics and law, is because of the difficulty in defining it. I'm not sure Foster provides a workable definition. I can understand and accept how he has gone about defining dignity, but, for me, this definition still lacks something. For example, what does 'human flourishing' really mean? How do we know when we are making a decision that promotes human thriving? Or is it just a case of 'we know it when we see it'?

Given this though, I still think it is an important book for people with an interest in this area to read, as it serves as a reminder of how significant the principle of dignity is in bioethics and law. But I don't think that Foster has persuaded me that it should be the ­only principle. Maybe this is because I have been indoctrinated to see autonomy as the sovereign principle? Or maybe it is because I haven't read his previous book? I am more inclined to suggest that dignity should be added to Beauchamp and Childress' four principles as the fifth. Given the overwhelming praise for this book from some prominent names in the medical law and bioethics field, I strongly advise you to read this book and make up your own mind.

Buy Human Dignity in Bioethics and Law from Amazon UK.