LAUSR

Soofi makes a persuasive case that a modified version of Nussbaum’s capabilities approach can be used to develop effective care guidelines for persons with dementia. I agree with Soofi that, so elaborated, the capabilities approach can avoid the four problems that are typically taken to beset dignitarian theories—redundancy, exclusion, speciesism and vagueness. Moreover, I do not seek to challenge the utility of the care guidelines Soofi derives from the capabilities approach—they are clear, practicable and appropriately wideranging. I do, however, challenge the idea that this framework would be sufficient to protect the dignity of those with dementia. To see the gap that remains to be filled, we need to unpack what Soofi’s approach can say about the wrong of degrading treatment. In the context of explaining the need to differentiate respect for dignity from respect for autonomy, Soofi notes that ‘abusive, degrading or insulting forms of caregiving compromise the dignity of people with very advanced dementia (p.2)’, even though they are no longer capable of being autonomous, and hence can’t have their autonomy disrespected. I question, though, whether a capabilities approach can fully account for this judgment. The difficulty is that a capabilities approach construes all dignity violations in terms of failure to adequately support an individual’s basic capabilities. Given this foundation, it is unsurprising that when degrading treatment appears in Soofi’s framework, it does so in relation to the capability for selfrespect: as he sets out in table 2, belittling remarks constitute an external setback to the basic capability for selfrespect, and hence violate the dignity of people with dementia. However, in order for a belittling remark to constitute a setback to selfrespect, the individual in question must experience it as belittling. This makes the connection between degrading treatment and dignity violations problematically contingent on a level of selfawareness and social awareness that may be absent, especially in latestage dementia. In order to capture the scope and import of dignity violations, especially in the context of caring for people with dementia, it is important to expand our focus beyond just the instrumental effects of certain forms of treatment on an individual’s capacities (as important as these are). Even if degrading treatment only occurs when a resident is unconscious, or heavily sedated, and hence unaware of what is happening to her, it is nonetheless a dignity violation, and this ought to be reflected in care guidelines. In order to capture such cases, though, we need a way of thinking about dignity that takes the nature of our interactions with others to matter for their own sake, rather than for the damage they may or may not do to our capacities. I have elsewhere attempted to develop such a conception, and I briefly sketch it here as a friendly supplement to Soofi’s framework. In Killmister 2020, I suggested that we can fruitfully think of dignity as having three strands: personal, social, and status. It is social and status dignity that matter for present purposes. To have social dignity, I claim, is to be subject to social standards, such that upholding those standards raises you in the eyes of your community, and violating those standards lowers you. Accordingly, to have your social dignity violated is to be compelled to violate the relevant social standards, whether through force or by failure to provide necessary support. In the context of dementia care, this would include actions such as toileting a patient in view of others, or failing to promptly clean her after an incident of incontinence. Status dignity is subtly different: it refers to the standing we have, in virtue of occupying a particular role, to be treated in accordance with the community’s norms for that role. To be treated contrary to the norms for the role we occupy is to have our status dignity violated. In the context of dementia care, a highly salient role is simply that of an adult human being. To be spoken to like a child, or spoken about as if you aren’t there, would thus constitute a status dignity violation. Crucially, the primary harm involved in such dignity violations does not depend on the action having any subjective effect on the individual: she is harmed even if she is unaware of what has happened. This is because it is a harm to the individual’s standing within her community—when an individual’s social or status dignity is violated, the action communicates to the broader community that this individual is not an equal member, and need not be treated as such. Recognising the significance of such harms is especially crucial in contexts such as dementia care, where it may be questionable whether an individual’s capacity for selfrespect is affected by degrading treatment, because it is questionable whether she is experiencing the treatment as degrading. It thus offers an important supplement to a capabilities approach to dignity. This raises the question, though, of whether Soofi’s capabilities approach could incorporate these insights—especially given that social sensitivity is already one of the dementiaspecific capabilities included in the schema. One reason to be doubtful is that even relational capabilities such as social sensitivity are predicated on properties inherent to the individual— that is, the basic capabilities on which the combined capabilities are to be built (p.3). If an individual loses the basic capability, it would seem, there is nothing for a capabilities approach to demand protection of. This requirement could potentially be loosened, if basic capabilities were taken to include something like the capacity to be brought into community with others: such a capability would not be lost when the individual changed, because it hinges on the attitudes of those around her. Given Soofi’s scepticism about Kitwood’s conferralist approach to personhood, though, I suspect he would be reluctant to expand the basic capabilities in such a direction. If that’s right, the capabilities approach would need to be supplemented by a different framework, one that takes social interactions to be intrinsic to dignity, rather than instrumental to it.