A question of dignity and respect

The intrinsic nature of a healthcare setting creates challenges to maintaining the human right to dignity and respect

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No one would disagree that patients deserve to be treated with respect and dignity. Indeed, a patient’s right to be shown respect and dignity is spelled out in the Australian Charter of Healthcare Rights, which applies to all Australian health settings. But what do those terms mean, exactly?

And how do we apply what we understand about respect and dignity in a practical way, focusing in this article, on a hospital setting where most of the literature is based?

Big ideas

Describing dignity and respect feels a little like describing a fine wine. Instinctively you know it’s good, but unless you’re an oenologist, it’s difficult to explain precisely why.

For such a task, you need a philosopher or ethicist, and in this sphere, dignity and respect are defined reasonably clearly. According to Dr Patrick Stokes, senior lecturer in Philosophy at Deakin University, the present-day notion of dignity began to emerge around the 18th century.

“Immanuel Kant was the major figure here,” explains Dr Stokes, “arguing that humans have an intrinsic dignity just by virtue of being rational and autonomous. The ability to determine for ourselves what we want to do and how we want to live gives us a value that other animals lack.”

Similarly, ethicist Dr Matthew Beard of The Ethics Centre describes dignity as an intrinsic part of being human.

“Dignity is often used as a substitute for a term like human rights, because it’s not seen to be tied to capabilities in any way. You don’t earn dignity by virtue of the things that you can do. You possess dignity merely in being who you are, that is a human being. And respect, in that context, simply means acknowledging that someone has dignity, and treating them in the way that dignity requires us to treat them. So the two concepts are connected to one another.”

Clearly, dignity and respect help us define what it is to be human. But what happens when we take a human, with all the inherent dignity and respect that commands, and transfer them to a healthcare setting, where they may face lack of privacy, insertion of tubes and wires, pain, nudity, loss of control over bodily functions and even unconsciousness?

Dr Beard says the preservation of dignity is particularly pertinent, “in any setting where a person is vulnerable, where a person is not necessarily in a position to assert their own autonomy or their own rights. And that is often what happens in a healthcare context, especially in a hospital.

“So there are a range of reasons why, when patients come into a hospital, they are vulnerable, and that they rely on healthcare providers in order to flourish in that context. The reason that dignity’s important is because they don’t lose any of their moral value – nothing changes about their moral status – simply because they’re vulnerable.”

Health departments and hospitals clearly reflect this understanding in their stated core values, codes of conduct and their patient care policies. Look through any Australian health organisation’s governance documents and you won’t have to search far to find a mention of respect and dignity. For example, the Australian Charter of Healthcare Rights states patients have “a right to be shown respect, dignity and consideration”.

We know dignity and respect are important enough to ratify, but that doesn’t necessarily give those terms a practical, workable definition.

Perhaps dignity and respect are best defined by what they’re not. Like many grand, but essentially fuzzy, values, dignity seems more noticeable when it’s absent than when it’s present.

Dr Stokes frames dignity in terms of qualities which, when they are removed, make us less distinct from non-humans.

“The things we take to be violations of dignity, particularly in medical contexts, are the things that expose or overwhelm us with our animal nature: nudity, loss of control of bodily functions, inability to do basic things for ourselves,” he says.

Intensive Care Specialist Dr Rachel Heap at Lismore Base Hospital in NSW says dignity and respect are intangible.

“It’s a little bit like trust. It’s there or it isn’t. If it’s not there, you very much miss it. But can you define what it is? I don’t actually know.”

The law certainly isn’t much help here either. From a legal perspective, the concept of dignity is not explicitly defined or relied upon, making it effectively non-existent. Lawyer and ethicist Dr Sascha Callaghan of Sydney Law School explains: “It’s not a very useful concept, legally. And it’s not used legally. It’s just more like the sort of touchstone idea that people might use to frame laws and guidelines.”

Wicked problems

Of course, many necessary medical interventions and procedures are, by anyone’s measure, undignified.

And in an emergency, respect must frequently play second fiddle to expediency. Furthermore, the value we place on patient autonomy means we must respect a person’s right to refuse care if they have the capacity to make that decision, even if it puts them in danger.

As Dr Beard explains, “In ethics we sometimes talk about Wicked Problems, which are problems where there’s no easy resolution. And I think when you’re talking about the tension between positive health outcomes and patient autonomy – especially in the case of someone who wants to go home, that is a Wicked Problem. It’s one where there’s not necessarily going to be a happy outcome.”

In her ICU, Dr Heap is often required to harmonise respectful behaviour and medical reality.

She explains, “To be a good healthcare provider; to do the best thing for your patient and that patient’s health; doesn’t always mean agreeing with them.”

Dr Heap stresses the importance of open communication and appropriate language as tools for showing respect and maintaining dignity.

For example, while some people feel it’s disrespectful to be direct and give a patient a tough diagnosis, such as cancer, or tell them they’re dying, Dr Heap believes it can be avoiding the ‘C’ word or the ‘D’ word that’s actually disrespectful.

“You’ve got to find the right language to be able to say that so the person who’s listening to it doesn’t think you’re belittling or demeaning or distancing their fears.”

Putting into practice

Aside from the sweeping, sanguine and subjective interpretations of dignity, what words, actions and behaviours are we asking healthcare professionals to use to respect a patient’s dignity?

The Clinical Excellence Commission (CEC) in NSW, which promotes and supports improved clinical care, safety and quality across the NSW public health system, has proposed a patient-based care model to help achieve their aims.

“Initiatives included starting each board meeting with a story of patient care; involving patient advisors in strategic planning processes and including accountability for patient care experience in all job descriptions. These are some of the practical steps that help hospitals show respect for patients and give them dignity through the care process,” a CEC spokesperson said.

Danny*, a theatre nurse in Sydney, sees little ambiguity in patient respect and dignity: “I work within NSW Health and there are eight steps outlined to ensure our patients are cared for with respect and dignity being at the forefront of care: They include communicating frequently with patients and carers, protecting patient privacy during consultations and treatment, managing noise for patient comfort and avoiding mixed-gender accommodation.”

Jo Benhamu is a Clinical Nurse Consultant with specialist experience in endoscopy units across several hospitals in Australia and the UK. She sees privacy and its relationship with hospital design as a key factor in respecting patient dignity.

“In one of these hospitals, patients would be admitted to an open pre-procedure waiting area, where a thin set of curtains would be pulled around the bed while [an] enema was administered. They would then have to make a mad dash to the bathroom once the enema had taken effect, where the sounds of their bowels explosively emptying could be heard by the other patients,” she explains. “I believe that these indignities could be avoided if we planned hospitals better so as to provide patients with more privacy.”

Dr Rhianna Miles, a nephrologist in Queensland, sees communication between hospital staff and patients as the primary tool for respecting dignity.

“I am not a lawyer, nor am I involved much in hospital litigation, but it’s very clearly told to us all that your chances of being sued are far greater if you don’t communicate well with your patients and their families, regardless of the standard of medical care you provide,” she says.

Even when dignity and respect are translated into specific behaviours, maintaining those behaviours isn’t always easy. When patients, for whatever reason, fail to respect the dignity of their hospital carers, the strictest guidelines and best intentions can be tested, as Dr Heap explains: “It’s really hard for the staff to remain empathetic when somebody’s calling you a c*** and spitting in your face.

“Yes, of course there are patient rights but there are also patient responsibilities. And together with rights come responsibilities and therefore there should be consequences to your actions.

“So I’m really happy that there actually should be patient rights, and healthcare providers need to treat their patients as human beings, but patients need to treat their healthcare providers as human beings as well.”

How long is a piece of string?

Can respect and dignity be quantified? If, as these professionals have illustrated, patient dignity and respect are demonstrated through certain behaviours, it stands to reason that assessing those behaviours could help measure how well a hospital and its departments live up to their stated values.

Most hospitals in Australia monitor how they are perceived by patients – regarding respect, dignity and many other factors – using patient surveys. For example, recent survey results published by the Bureau of Health Information in NSW showed that over 83% of patients said they were ‘always’ treated with respect and dignity while in hospital.

However, as many health carers have described, feedback from patients can be heavily influenced by what the patient and their family perceive as dignity and respect. A health care provider may demonstrate all the appropriate behaviours associated with patient dignity and respect, but still score badly on a survey if their patient’s expectations were not met. Or vice versa.

In 2015, researchers in the US developed a checklist to objectively assess how ICU patients were treated by staff in terms of respect and dignity.

The checklist was used by observers in seven ICUs within the John Hopkins Health System, who scored nurses, doctors, therapists and other clinicians on how well they displayed specific behaviours such as greeting patients, speaking at eye level, protecting patients’ modesty and having a pleasant demeanour. By employing direct observation rather than patient feedback, the checklist aimed to reduce the bias and subjectivity of consumer surveys.

A checklist like this one could feasibly be used in all Australian health facilities, to see how well hospital staff deliver on their commitment to patient respect and dignity, and to target areas for further training.

Getting it right

Like defining the concepts themselves, trying to identify tangible effects of respecting patients’ dignity can be like pinning jelly to a wall. If we can’t definitively point to respect and dignity, we can only indirectly link them to physical and mental health outcomes.

And because respect and dignity are not defined legally, it’s near impossible to draw a clear link between them and the rates of patient complaints or litigation. In the words of Dr Callaghan: “It certainly wouldn’t be part of any legal action because there is no such legal action. The reasons that people sue hospitals – part of it is going to be because they’ve suffered damage. But, generally speaking, people have a sort of psychic assault of some kind. They feel wronged.

“And feeling wronged can be associated with feeling as though they were treated with a lack of respect. So I guess in that very general sense you might, sort of, emotionally encourage litigation. But it is not something which can be the subject of litigation in and of itself.”

What is clear though, according to Dr Miles, is that happy patients have better outcomes. “I think that’s clear in the literature, and I’m sure people are happier if they’re respected and afforded dignity.”

*Danny is a pseudonym for a theatre nurse working in a public hospital who asked not to be identified