In his paper, ‘What moral work can Nussbaum’s account of human dignity do in the context of dementia care?’, Soofi seeks to modify Nussbaum’s conception of dignity to deal with four key objections that arise when appeals to dignity are made in the context of dementia care. We will not discuss the first of these, the redundancy of dignity talk, since this issue has already been much discussed in the literature. Instead, we will focus on the remaining three issues raised, (...) that of the exclusion of persons with advanced dementia from having dignity, unjustified speciesism as a ground of human dignity, and the unclear practical implications that follow from having dignity. (shrink)

Hojjat Soofi successfully developed a novel dementia-specific model of human flourishing.1 Based on a modified version of Nussbaum’s account of dignity (ie, the theoretical framework of the capabilities approach), and integrated with Kitwood and Bredin’s empirically informed list of indicators of well-being for people with dementia (ie, the field of empirically informed ethics), this model provides guidance on how to actually care for people with dementia in real-life practices, according to the moral requirements of respect for dignity. More specifically, we (...) deem the contributive value of the model to be threefold. (1) It is a successful specification and contextualisation of Nussbaum’s original list of capabilities in the context of dementia care. (2) The table clearly distinguishes between dementia-specific capabilities and their possibly dementia-related progressive deprivation (ie, the internal conditions), and the possible external setbacks or facilitators for human flourishing. (3) The model is proposed as being open to include new and additional insights from further empirical research on what forms of caregiving do (or do not) align with respect for the dignity of people with dementia. In our commentary, we want to focus on the source of dignity, that is, the locus and starting point of our moral requirements on which the author takes an explicit stance. First of all, by being founded on the list of dementia-specific capabilities, Soofi’s model places the source of our moral requirements of respect for the dignity of people with dementia within the persons themselves, ‘having some of the basis capabilities listed’ (p.6). This, in turn, brings classic discussions concerning a …. (shrink)

Flourishing is an increasingly common construct employed in the study of human wellbeing. But its appropriateness as a framework of wellbeing at certain stages of life is contested. In this paper, we consider to what extent it is possible for someone to flourish at the end of life. People with terminal illness often experience significant and protracted pain and suffering especially when they opt for treatments that prolong life. Certain aspects of human goods, however, that are plausibly constitutive of flourishing—such (...) as meaning and purpose, deep personal relationships, and character and virtue—can be uniquely realised when life is ending. We argue that there is a qualified sense in which one can flourish at the end of life but that one must make important modifications to the criteria implicit in conventional conceptions of flourishing. We close with a discussion of the empirical assessment of wellbeing at the end of life and explore the possibility of introducing a flourishing measure in palliative care practice. (shrink)

I thank the commentators for engaging with my work and for their thoughtful and constructive contributions. I also extend my gratitude to the editors of the _Journal of Medical Ethics_ for facilitating such a lively scholarly dialogue on the topic. In this response paper, I will briefly address some of the key issues raised by the commentators and attempt to bring into conversation different viewpoints put forward by the commentators. Questioning whether my proposed account evades the objection of redundancy of (...) the dignity talk, Barclay 1 invites me to clarify why my position cannot be framed as: because of their inherent, basic, capabilities all human beings have moral worth, which grounds obligations on others to ensure they live a flourishing life [Barclay, XX]. 1 In response, I raise two points. First, the above formulation would be under-specified about both the forms of capabilities and moral worth... (shrink)

Soofi1 aims to develop an account of dignity in dementia care based on Nussbaum’s capabilities approach. He does this by drawing on the Kitwood and Bredin2 list of well-being indicators, in order to fill out her account of human flourishing to cover aspects such as practical reasoning that appear beyond the reach of those with relatively severe dementia. As Soofi points out, Nussbaum’s claim that such lost abilities can be compensated through guardianship measures is implausible. He asserts in response that (...) his account of dignity is sufficient to address the desiderata he sets out at the start, including especially the problem of exclusionary implications any putative account should address. So far, so good, but an objection Soofi raises for his own account is that it seems unable to cover cases of severe late-stage dementia. His response is, > …that there is insufficient factual evidence to suggest that people at the very advanced stages of dementia lose all capabilities. But for the sake of argument, let’s suppose that this is true. This, however, still does not undermine the conceptual rigour of the modified version of Nussbaum’s account. This is because the list of the dementia-specific capabilities that I …. (shrink)

Hojjat Soofi develops a modified version of Martha Nussbaum’s capability approach, which he offers as a conception of dignity for people living with dementia.1 He argues that this modified version can address what he identifies as four main criticisms of the concept of dignity. The first and most substantial criticism was developed by Macklin: that appeals to ‘dignity’ add little to moral debates or to the rich field of existing moral values.1 Soofi’s account of dignity does not evade this criticism: (...) to the contrary, it represents another clear example of what Macklin complained about, namely, a moral proposal in which the concept of ‘dignity’ plays no substantive role. We have much to learn from Soofi’s rich account of how to ensure the flourishing or well-being of people living with dementia, but it has little to do with dignity as such. According to Soofi, Macklin’s argument is that ‘dignity’ is just another word for respect for persons or their autonomy. This is a rather truncated representation of Macklin’s argument, which is in fact broader. Her argument is that the concept of ‘dignity’ adds nothing to the vast array of rich moral values that already populate the field of ethics, mainly because it is a less precise restatement of these existing values.2 She explicitly …. (shrink)

In Ending Midlife Bias: New Values for Old Age, I argued that dignity can give practical guidance for patient care, especially dementia care.1 Using a capability-informed analysis, I detailed threats to central human capabilities that undermine dignity for people with dementia and provide practical suggestions for managing these threats in paradigm cases. In an article in this issue, Hojjat Soofi argues that a capability-informed account of dignity is exclusionary of people with dementia and does not translate into practical ethics guidance.2 (...) Soofi maintains that people with intellectual impairment ‘might not be able to exercise (or even have access to)’ the capabilities in question (Soofi, p4).2 Focusing on Nussbaum’s capability view, Soofi cautions, it gives a narrow, blinkered assessment of what it means to live a full and flourishing human life. In this commentary, I argue that Soofi’s critique of the capability view hastily generalises from a narrow set of premises to expansive, unwarranted conclusions. Soofi’s first objection, that a capability view of dignity excludes people with dementia, is a sweeping and strong claim. In its support, Soofi cites dignity of the Kantian sort, which requires ‘cognitive competence to exercise rational agency,’ to argue that ‘if we want to include people with dementia in the circle of human beings …. (shrink)