【作者】 王云岭；

【导师】 陈晓阳；

【作者基本信息】 山东大学 ， 人文医学， 2011， 博士

【摘要】 人的尊严是哲学和伦理学中已经探讨较多的问题,但是人在生命最后阶段的尊严,即死亡的尊严,到目前为止,国内学术界还少有人问津。人拥有尊严是世界文明的一个核心要素,人拥有死亡的尊严也同样是人类文明的重要标志。本文试图通过对现代科技文化背景下尊严理论的建构和对现代医学情境下人的死亡状况的研究,来探讨现代医学情境下死亡的尊严的基本理论,并借以考察终末期病人死亡的尊严之现状。本项研究的理论意义在于将对人的尊严的研究定位于人的生命最后阶段,是人的尊严研究领域的更加具体的理论探讨,填补了国内尊严研究领域的一项空白。实践意义则在于通过对终末期病人生存状况的研究,提醒医学界和社会关注终末期病人的临终状态,还他们以死亡的尊严,并为医疗机构对终末期病人的医疗干预提供人文医学指南和参考。在研究方法上,本文主要使用了文献分析法、会议研讨法、个案访谈法等人文医学研究方法。毫无疑问,尊严是人类追求的重要价值,“尊严”概念也是人们在日常生活中经常使用的熟语,但其实对于什么是尊严,不但在日常生活中,而且在严格的学术研究中,都仍然存在诸多争议,尤其涉及到诸如“死亡的尊严”这样的用语,其内涵到底是什么,就更加需要严谨的分析和严肃的澄清。为此,本文第一章首先简要回顾了历史上人的尊严思想的发展过程。中西方文化传统中都有着丰富的尊严思想,但是其表现形式和思维方式有所不同。其中,西方文化中的尊严思想多与宗教神学思想纠缠在一起,并且将人的特性诉诸于理性,而中国文化中的尊严思想则是世俗的,并且多诉诸于人本主义。在人的尊严思想发展历程中,影响最大的无疑是康德的目的论尊严思想。康德使用了三个理论支柱,即普遍立法、意志自律和人是目的,证成了“只有道德以及与道德相适应的人性,才是具有尊严的东西”这样一个著名观点。自此以后,人类的尊严无需再依靠上帝的恩赐,而完全可在自身的内在性中寻找根据。康德的尊严思想成为德国人性尊严思想的三个重要来源之一,也成为当代宪政尊严思想的重要来源之一。随着现代科学技术的发展,科技文明对人的尊严也产生了巨大影响。一方面,在现代医学科技文化中,“尊严”概念经常被用于技术的可接受性论证,各种涉及现代医学新技术应用的伦理学讨论几乎都与尊严有关,而另一方面,为了分享现代科技文明,人们也可能面对技术对人性尊严的威胁做出妥协。为了对这种影响做出严肃的分析和探究,本文对现代医学科技文化背景下的“尊严”概念做出了新的理论建构。这一任务的重要性不仅在于研究当下问题的需要,还在于回应某些伦理学者关于放弃“尊严”概念的主张。某些伦理学者以“尊严”概念并不比尊重人或人的自主性包含更多含义为由主张放弃使用这一概念,从而引发学界的讨论。本文认为,“尊严”概念具有三个重要价值：1、“尊严”概念反映了人类某些用其他语言不能加以言说的重要价值；2、“尊严”概念是生命伦理学的核心价值观念；3、现代科技文化背景下,“尊严”概念反映了人类对抗工具理性泛滥,防止人性异化的价值目标。然而这种分析仍是逻辑意义上的,最有力的反驳乃是对“尊严”概念内涵的澄清。本文认为,“尊严”概念在现代科技文化背景下内涵明确,外延清晰：“所谓‘尊严’,就是自尊与他尊的结合,就是受到自己和他人的尊敬与重视。其本质是标志主体身份属性的社会关系样式。”所谓社会关系样式,是指主体在某种社会关系中因为其所具有的身份而受到他人对待的状况,也包括自己对自身的态度与行为。社会关系样式既反映了主体与他人的社会关系性质,也反映了他人对主体的态度与行为。把尊严的本质理解为“标志主体身份属性的社会关系样式”,在哲学和伦理学领域都具有原创性。使用这一定义,我们可以很好地对“应该享有的尊严”与“尊严的意义”做出区分,从而解决人们在使用“尊严”概念中的思维混乱,并可以初步对“死人是否享有尊严”之类问题做出阐释。现代科技文化背景下的“尊严”理论建构为讨论“现代医学情境下的死亡的尊严”思想奠定了坚实的理论基础。但即使如此,对于死亡的尊严问题,学者们也仍然存有三个方面的争议。其一,死亡与尊严的关系是什么；其二,死亡的尊严是否可以加以客观的讨论；其三,如果确实存在死亡的尊严问题,那么这对医务人员会有何影响?对这三个问题,西方学者们曾进行过较为深入的讨论。这些讨论表明了死亡的尊严问题在西方学界已经成为严肃的学术问题。为了更清楚地说明这一问题的重要性,本文总结了死亡的尊严的三个意义：首先,死亡的尊严实际上是生命的尊严之一部分；其次,从病人角度来看,死亡的尊严其实意味着没有痛苦、没有侮辱的一种生命的善终；再次,从病人家属的角度来说,死亡的尊严意味着一种轻松舒缓的心理安慰。但“死亡的尊严”的内涵是什么?本文认为,严格说来,死亡的尊严是一种普遍的哲学,而不仅仅与现代医学背景下的终末期病人的死亡相关。死亡的尊严作为一种人生哲学,其实是生命尊严的一部分。作为普遍的日用哲学,死亡的尊严“就是主体因自身的死亡而受到的自己和他人的尊敬与重视。其本质是标志主体身份属性的社会关系样式。”这种理解要求严格区分“死亡方式的尊严”与“牺牲的尊严”这两种很接近但并不相同的尊严。同时,这种理解揭示,死亡的尊严是主体通过个人意志选择所赢得的一种价值,一般来说,他人与社会并不能赐予主体死亡的尊严,但是在主体的死亡过程中,他人与社会既可以通过施加侮辱以贬损其死亡的尊严,也可以通过避免施加侮辱以保护其死亡的尊严。据此,“现代医学情境下的死亡的尊严”可以理解为“主体因自己死亡过程而受到自己和他人的尊敬与重视,包括靠自己的意志努力赢得的尊严和靠他人避免施加侮辱所获得的尊严。其本质是标志主体身份属性的社会关系样式。”根据这种定义,我们可以辨析生命维持疗法的价值,可以理解延迟死亡和自然死亡的区别与意义,可以辨识长期依赖生命维持疗法者的尊严,还可以对终末期病人接受侵入性治疗的尊严问题做出分析,并进而提出现代医学情境下死亡的尊严的基本命题。在死亡的尊严的现实层面,病人的自杀和安乐死问题往往构成病人追求尊严的主要表现。但是由于现代医学的异化和家庭主义的原因,中国终末期病人的主体地位却面临被消解的境况。这种主体地位的被消解意味着病人无法自己掌控命运,由此会带来尊严被贬损的危险。在这种前提下考察终末期病人的自杀现象、临终关怀以及安乐死与死亡的尊严之关系,就更加具有针对性。文章认为,自杀,接受临终关怀,以及安乐死可以视为终末期病人维护自己尊严的三种选择,但是值得注意的是,并不是所有的自杀病人都会赢得死亡的尊严,其中,出于逃避无法控制的躯体或精神痛苦的自杀是对死亡的尊严的争取,而因社会家庭因素和经济因素自杀是否能够赢得死亡的尊严应视情况而论。与自杀相比较而言,从理论上来说,临终关怀与安乐死其实是病人更好的选择。这两者在理念上有诸多相通之处。虽然因为观念和立法的障碍,安乐死在中国存在诸多困难,但是对于终末期病人维护死亡的尊严来说,两者其实殊途同归。现代医学情境下人们对死亡的尊严的追求实际上体现了人类面对死亡时在某些观念或理念影响下的一种价值选择。这些影响人们选择的观念或理念将决定未来时代死亡的尊严的发展前景。死亡的尊严在未来的发展将取决于两个重要观念,一个是“全人”,一个是“优死”。所谓“全人”,即视人为一种多向度的存在。而所谓优死,即善终,包括死亡时刻没有痛苦和死亡之前未曾经受病痛折磨,特别是长期的病痛折磨。引进全人观念和优死理念对现代医学的意义在于对人的存在状态的关注和对死亡的接纳。未来医学不会只争取人的存在,而要问这是一种什么样的存在。这使未来的医生和医学更加具有人情味和人文性。未来医学也不会再把死亡仅仅视为一种恶,如果一个人的存在不再能够创造或者具有意义,如果一个人的存在给他本人带来的只是痛苦和侮辱,那么死亡对这个人来说就是一种善。更多还原

【Abstract】 While human dignity is an issue much discussed in philosophy and ethics, the dignity at the final stage of a human life, that is, the death with dignity is scarcely mentioned in the academic community in China. Human dignity is a core element of the world civilization, and the death with dignity is also an important symbol of human civilization. Through the construction of the dignity theory in the context of modern scientific and technological culture and the study of death against the backdrop of modern medicine, this paper attempts to discuss the basic theories of death with dignity against the background of modern medicine and, depending on this, investigates the current situation of the death with dignity of terminal patients.The theoretical significance of this study lies in the fact that by focusing the study of human dignity at the final stage of a human life, it specifies the theoretical discussions in the research of human dignity and fills the gap in the research of dignity in China. The practical significance is to urge the medical community and the society at large to pay attention to the terminal stage of dying patients and give them the death with dignity and also to provide humanistic guidelines and reference for the medical institutions that treat terminal patients with medical interference. In terms of research methodology, the paper uses humanistic medicine approaches including literature analysis, conference seminar and case interview and etc.There is no doubt that dignity is one of the important values pursued by human beings. The word "dignity" is frequently used in people’s daily lives. However, there are many arguments about what dignity really is, not only in our day-to-day life but also in strict academic researches, particularly when it comes to phrases like "the death with dignity", the meaning of which needs to be carefully analyzed and clarified. To this end, the first chapter takes a brief review over the developments of the thoughts about human dignity in history. In the eastern and western cultural traditions, there is no lack of mediations on dignity, only in different expressions and ways of thinking. In the western culture, the idea of dignity is often entangled with religious theology, where human characteristics are associated with rationality, while the idea of dignity in the Chinese culture is secular and, more often than not, appeals to humanism. In the course of the development of the thinking on human dignity, the most influential is the teleological dignity proposed by Immanuel Kant, who uses three theoretical pillars, i.e. universal legislation, autonomy of will and "humanity as an end in itself", to prove one of his most famous points, "only morality and the humanity that is compatible with such morality are the things with dignity." From then on, human dignity no longer depends on the benediction of God; instead, it can find a place inside the human beings themselves. Kant’s thought on dignity has become one the three most important sources of German ideas about human dignity and one of the origins of the contemporary constitutional dignity.With the development of modern science and technology, modern civilization has had a tremendous impact on human dignity. On the one hand, in modern medical science and technology, the concept of "dignity" is often used to demonstrate the acceptability of technologies and almost all kinds of discussions on ethics of applying modern medical technologies are related with dignity. On the other hand, in order to share the technological advancement, people may compromise in the face of the technologies that threaten human dignity. In its effort to analyze and explore this impact with seriousness, this article constructs new theories for the concept of "dignity" in the context of modern culture of medical science and technology. This task is important not only because it is necessary for addressing the issue in question, but also because it responds to the abandonment of "dignity" advocated by some moralists, who claim that the concept of "dignity" contains no more meanings than the respect for humans or human autonomy and therefore should be discarded. This has triggered debates in the academic community. The paper maintains that the concept of "dignity" has three important values in that it 1) reflects some important values indescribable with human languages,2) remains the core value of bioethics, and 3) represents the endeavor that human beings make in fighting the abuse of instrumental rationality and preventing the alienation of human nature. However, this analysis is made in the sense of logics. A better response to counter the point presented by those moralists would be the clarification of the concept of "dignity". The paper holds that in the context of modern science and technology, the connotation and denotation of "dignity" are crystal clear:Dignity refers to the combination of self-esteem and other-esteem, the respect and care by oneself and others, whose essence is the social relationship that marks the subject’s identity attributes. Social relationship refers to the treatment that the subject receives in certain social relations as a result of his or her status and also includes his or her own attitude or behavior towards him- or herself. Social relationship reflects the nature of the subject’s social relations with others, as well as other people’s attitude and behavior towards the subject. The interpretation of dignity as essentially the "social relationship that signifies the subject’s identity attributes" is an original idea both in philosophy and ethics. This definition differentiates "the dignity that one should have" from "the meaning of dignity", which prevents confusion in using the concept of "dignity" and also tentatively answers the question as to "whether a dying person has dignity".The construction of theories of "dignity" against the backdrop of modern science and technology provides a solid theoretical foundation for the "death with dignity in the context of modern medicine". Nevertheless, the dispute about the death with dignity centers on three aspects,1) the relationship between death and dignity,2) the possibility of objective discussion about the death with dignity, and 3) the impact on the medical staff if the issue of the death with dignity exists at all. Western scholars have carried out some in-depth debates on the three questions, which shows that the problem concerning the death with dignity has already become a serious academic matter in the west. To make a clearer assertion of the importance of this issue, the paper summarizes three significances of the death with dignity:first, the death with dignity is an integral part of the dignity of life; second, from the patient’s perspective, death with dignity means good death, the death without pain or insult; finally, from the patient’s family’s perspective, death with dignity is a soothing and psychological comfort. As for the connotation of the "death with dignity", the paper maintains that, in a strict sense, the death with dignity is a universal philosophy, more than the idea associated with the death of terminal patients in the context of modern medicine. As a philosophy of life, the death with dignity is also a part of the dignity of life. As a daily philosophy in general, the death with dignity is "the respect and care by oneself and others as a result of the death of the subject. Its essence is the social relationship that marks the subject’s identity attributes." For better understanding, it is necessary to differentiate "the dignity of the manner of death" from "the dignity of sacrifice", the two very close but different kinds of dignity. Meanwhile, such interpretation reveals that the death with dignity is a value chosen by the subject of his or her own will. In general, other people and the society cannot grant the subject with the death with dignity, but can diminish or protect his or her death with dignity by means of humiliation or the avoidance of it in the course of the subject’s death. Therefore, "the death with dignity in the context of modern medicine" can be understood as "the respect and care by oneself or others in the course of one’s death, including the dignity that one acquires through one’s willpower or others avoiding exerting humiliation. Essentially, it is the social relationship that marks the subject’s identity attributes." Based on this definition, we can identify the value of the life-sustaining treatment, understand the difference between delayed death and natural death and their respective significance, recognize the dignity of the patient that depends on life-sustaining treatment, analyze the issue of dignity concerning invasive therapy for terminal patients and take a further step to make the basic proposition of the death with dignity in the context of modern medicine.In the reality of the death with dignity, the patient’s pursuit of dignity often takes the form of suicide and euthanasia. However, because of the alienation of modern medicine and familism, the subject position of terminal patients in China is reduced, which means patients have no control over their own destiny, giving rise to a diminished dignity. In this context, the discussion of the relations between the suicide of terminal patients, hospice and euthanasia and the death with dignity is more pertinent. The paper maintains that suicide, hospice and euthanasia can be seen as the three options for terminal patients to assert their dignity. It should be noted that not all patients that kill themselves can acquire the death with dignity. While the suicide that ends the uncontrollable physical and mental pain is the effort to honor the death with dignity, the suicide because of social, familial or financial reasons is yet to be determined as to whether it can result in the death with dignity. Compared with suicide, hospice and euthanasia, in theory, are better options for patients. The two concepts have a lot in common. Although euthanasia is not widely accepted in China due to the traditional mindset and the legislation, both approaches lead to the same goal of maintaining the terminal patient’s death with dignity.In the context of modern medicine, the pursuit of the death with dignity is a value that the human beings choose in the face of death under the influence of certain concepts or ideas which will determine the prospect of the death with dignity in the future times. The developments of the death with dignity in the future depend on two important concepts, the "whole person" and the "good death". "Whole person" considers a person an existence of multiple dimensions. "Good death" means peaceful death without pain at the time of dying or any distress that has not been suffered prior to the moment of death, particularly chronicle distress. The significance of the concepts of whole person and good death lies in the care for human existence and the acceptance of death. The future medicine will not only focus on its endeavor for human existence but also the effort in answering the question as to what kind of existence it is. This will make the doctors and the medicine more humane and humanistic. The future medicine will consider death not only an evil, but also a good for a person, if the person’s life ceases being productive or meaningful and such existence brings nothing but pain and indignity to the person.更多还原