TopPersons And Playfulness
Philosophers use the term dignity to refer to the special moral value of persons. According to Immanuel Kant’s (1997) well-known articulation of this value,
everything has either a price or a dignity. What has a price can be replaced by something else as its equivalent; what, on the other hand, is raised above all price and therefore admits of no equivalent has a dignity. (p. 42)
This implies that things with dignity have both infinite and irreplaceable value. Persons have infinite value in not being equivalent to any number of things that have a price. Persons have irreplaceable value in that their value is not comparable to that of anything else, including other things with dignity (Zagzebski, 2001). In clinical practice in the United States, the obligation to respect persons’ dignity has primarily been interpreted as the obligation of institutions and individuals to respect patients’ autonomous decision-making. To fulfill this obligation, clinical institutions primarily focus on promoting and protecting what individuals need to make informed decisions about their own lives and bodies, including providing access to and ensuring understanding of relevant information, obtaining consent for interventions and treatments, and enforcing prohibitions on overriding the autonomously made decisions of individuals.
Some bioethicists have taken issue with this interpretation of respect for persons as coextensive with respect for autonomy, on the grounds that it is overly narrow or reductive with respect to what recognition of human dignity requires (Killmister, 2010; Morrissey, 2016). There are at least two ways we can interpret the obligation to treat people “as” persons (Spelman, 1978). In the first sense, treating someone as a person is a matter of recognizing her as a being with a certain status. In this case, recognizing her as an autonomous decision-maker, a rights-bearer, or, most generally, a rational agent. In the second sense, treating someone as a person is a matter of recognizing her as “the person she is.” Instead of recognizing someone as an instance of a particular kind, we recognize her by acknowledging, attending to, taking up, or considering her individual interests, perspective, history, and traits. When we demand this kind of treatment or respect from others, we are not asking them to recognize that we instantiate a quality that grants us a particular moral status. We are calling on them, instead, to “respect me, for who I am.” That is, to recognize us as the unique, individual selves that we are, and, in this way, non-fungible, even with respect to other things with dignity.
Both interpretations of respect for persons are relevant to clinical practice. With respect to treating patients as “a person,” as discussed above, there are well known ethical concerns about protecting and promoting patients’ autonomous decision-making. Though less frequently discussed, treating patients as “the person they are” is also relevant to contemporary healthcare. Our clinical institutions are often large and anonymous. They serve, govern, and employ a number of different people with different levels of responsibility for care of patients. To function, these systems require rules and policies to make clear which healthcare providers (including physicians, nurses, administrators, etc.) are responsible for what kinds of decisions, and to make decision-making consistent across different levels and domains of the institution. This, in turn, often requires specific, clear procedures and metrics for measuring outcomes suited to relatively quick, consistent, and transparent decision-making, for example, the use of QALYs (Quality-adjusted life year) in allocation of scarce resources. The requirements of operating this kind of bureaucratic institution, thus, require abstracting away from the specific individuals at issue, to view patients either in aggregate or as substantially indistinguishable from one another. These bureaucratic necessities risk failing to respect patients as “the persons they are.”
Recognition of someone as “the person they are” rather than “a person” requires demonstrating our attentiveness to them as an individual. Playfulness is one way of doing so. Lugones (1987) describes playfulness as an attitude that we exercise in being with other people creatively. We are playful when we spend time with or approach others in a manner not wedded to any particular way of doing things. In this way, playfulness exercises an ability to operate without relying on heuristics for social interaction or rote rule-governed responses and behaviors, while, at the same time, engaging in cooperative intentional activity. It requires flexibility, openness, and being “game.”