Ezra Griffith, M.D.: Human Dignity at Heart of Medical Ethics and Psychiatric Care

Psychiatrists have a “responsibility to commit to serious reflection on the place of dignity in our work and lives,” said Ezra Griffith, M.D., this year’s recipient of APA’s Chester M. Pierce Human Rights Award.

“If we maintain a focus on human dignity in much of what we do, we may improve our interactions with each other, clarify our self-definitions, and reaffirm our moral commitment to patients and our communities.”

In a wide-ranging lecture tracing the history of the concept of human dignity in philosophy and medical ethics and in the practice of psychiatry and forensic psychiatry, Griffith said that the dignity of individuals was at the heart of the vision of Chester Pierce, M.D., especially his vision for people involved in the criminal justice system. Pierce was a pioneering Black researcher known for his innovative research on humans in extreme environments and a lifelong advocate against disparities, stigma, and discrimination, coining the term “microaggression” in 1970. He was the founding national chair of the Black Psychiatrists of America.

For Pierce, Griffith said, “prisons served as exemplars in his conceptual schemes of an extreme environment, places where one’s space, time, and energy are controlled and exploited by others. Professor Pierce fought against the processes of such systematic dehumanizing in broad swaths of social structures. He felt that the systematic deprivation or lowering of one’s human dignity could lead to degradation of the human spirit.”

Drawing on a history of dignity in bioethics written by F. Daniel Davis, Ph.D., of the Kennedy Institute on Ethics, Griffith noted that the concept of dignity was first formally recognized in the context of American biomedical research and clinical care when Richard Nixon signed the National Research Act on July 12, 1974. That law created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, whose charge was “to identify the ethical principles that should govern the conduct of biomedical and behavioral research with human subjects.”

A major catalyst for creation of the Research Act and the National Commission was public awareness of the Tuskegee Syphilis Study in 1972. The study (originating in 1932 as the Tuskegee Study of Untreated Syphilis in the Negro Male) initially enrolled 600 Black males, of whom 399 had syphilis. For four decades, until the study was shuttered in 1972, informed consent was never obtained from any of the subjects, and none of the men with syphilis were treated with penicillin, though it had become widely available and the treatment of choice in the 1940s.

The National Commission on Protection of Human Subjects of Biomedical and Behavioral Research produced seven reports, the last of which is known as the Belmont Report. In that report, the commission identified three principles relevant to the ethics of research involving human subjects: respect for persons, beneficence (the obligation to secure another’s well-being and to do no harm), and justice (fairness in distribution of burdens and benefits).

Griffith then outlined the contributions of seminal medical ethicists to the understanding of dignity in medical and psychiatric practice.

Daniel Sulmasy, M.D., Ph.D., director of the Kennedy Institute of Ethics at Georgetown University, described three broad categories of dignity:

• Intrinsic dignity is the value that human beings have simply by virtue of the fact that they are human.

• Attributed dignity refers to “worth, stature, or value that human beings confer upon others by acts of attribution.”

• Inflorescent dignity is captured in the expression “someone died with dignity,” which expresses admiration for the courageous manner in which one confronted the process of dying.

“One might say that all the patients in a hospital ward should be treated equally because of their intrinsic dignity, which cannot be lost or diminished,” Griffith said. Patients disfigured by their illness may sometimes be regarded as having lost their attributed dignity, he continued. “Or one could also draw attention to how some patients have coped well with the intense suffering caused by their illnesses and demonstrated inflorescent dignity.”

The late Edmund Pellegrino, M.D., appreciated that medical patients, under stress, often lose confidence in their own worth or inherent dignity, Griffith said. “In that situation, it should be an important therapeutic objective to reassure patients that intrinsic dignity is enduring and inviolable.”

Harvey Chochinov, M.D., a professor of psychiatry at the University of Manitoba and a leader in compassionate end-of-life care, advanced four elements as the basis of what he called dignity-conserving care.

• Attitude: Clinicians’ attitudes toward patients should enable clinicians to establish open and empathic relationships with patients.

• Behavior: Clinicians’ behavior toward patients should be based on kindness and respect.

• Compassion: A deep awareness of the patient’s suffering should be linked to the desire to relieve it.

• Dialogue: An interpersonal exchange of information and conversation between clinician and patient should verify the patient’s personhood beyond the illness.

Lena Karin Gustafsson, Ph.D., a forensic psychologist at Malardarens University in Sweden, addressed the importance of maintaining dignity in the forensic setting, where patients may have committed grave crimes. “Gustafsson argued that the important first step is to provide experiences to these forensic patients that maintain and strengthen their self-image, which is to say their extrinsic dignity,” Griffith said. “It is ultimately the staff who must work to protect the forensic patients from situations that are embarrassing, humiliating, or shameful.”

Now retired, Griffith is professor emeritus of psychiatry and African American studies at Yale. He has served in the APA Assembly, the APA Council on Psychiatry and Law, the APA Ethics Committee, and the APA Committee on Judicial Action. He is also a columnist for Psychiatric News (see “On Radishes and Other Culinary Memories”) and serves on its Editorial Advisory Board. Among the books he has written is Race and Excellence: My Dialogue With Chester Pierce, published recently by APA Publishing.

The Chester M. Pierce Human Rights Award recognizes the efforts of individuals to promote the human rights of populations with mental health needs. Originally established in 1990, the award was renamed in 2017 to honor Chester M. Pierce, M.D. (1927-2016). ■