Human Dignity in Inpatient Care: Fragments of Religious and Social Grounds

Round 1

Reviewer 1 Report

-In general, I found this paper quite hard to follow. The authors want to make a claim about the religious foundations of the concept of human dignity, but cite so many various sources on the concept it is hard to know what unique contribution the author is making.

-The author is also clearly coming from a particular Christian tradition that needs to be stated up front. The author makes many claims about what comprises human dignity that many Christians would not agree with or even recognize.

-The author also seems to be coming from a particular geographical region that practices medicine in a particular way, and that context should be explicitly stated

-It is unclear to me how the paper coheres or section 2 follows from section 1, or how section 2 relates to section 3. The author begins by summarizing a great deal of different ideas about human dignity from healthcare providers without commenting on who has a good definition or how the different definitions relate. Then I am unsure why do we a religious framing of human dignity to believe that we should treat patients with respect? How does this religious framing relate to universal declarations on human rights?

-I am unsure who would disagree with the authors about treating patients with respect, which leads me to believe the thesis statement is underdeveloped

-In general, it seems to me that there are far too many ideas happening in the paper. Human dignity has a long and contested history and it is unclear how the author is moving from biblical and theological understandings to direct application with patients (and various different kinds of patients being treated by different specialists)

Specific comments

Pg. 1, ln, 33: is there a word missing after “at the end of…”

Pg. 1: The definition of human dignity is quite vague and I’m unclear why this particular article would be taken as an authority on such a definition

Pg. 2: The author seems to be offering several different views of human dignity with very little comparative work being done. A typology or taxonomy of the differences would be helpful. It is also not clear to me why any of the authors cited should be taken as authorities on the definition of human dignity, which of course is a very broad category with a long history (even if we restrict the notion to healthcare)

Pg. 2: The author ought to evaluate the different definitions of dignity offered, rather than merely stating them as if they were all equally correct and authoritative.

Pg. 3: I’m finding the structure of the paper (methods, objectives, results, conclusion) to be odd given that this is not an empirical study but one that uses traditional humanities methods. The use of the word ‘study’ to describe the paper is similarly odd.

Pg. 3: The thesis of the paper seems underdeveloped. The authors want to incorporate religion into an understanding of human dignity for hospitalized patients. I am unclear what is novel about this approach, or what “religion” means in this context. I cannot imagine many clinicians or ethicists disagreeing that respect for the patient’s religion is important.

Pg. 3, ln 83-84: I am not sure which religion would restrict human dignity to he ability to control one’s own life. I am also worried that the author is using religion (or respect for religion) as a tool to maintain a patient’s autonomy, whereas many religious people would understand their faith as an ultimate good, not a tool for some other good (autonomy)

Pg. 3: The author should define ‘socio-theological’ as well as ‘bio-psycho-social-spiritual’

Pg.3: The paragraphs on this page seem repetitive.

Pg. 3, ln 102: We have now moved onto an entirely different definition of human dignity rooted in vaguely Christian terms. This needs a transition and explanation

Pg. 4, 105-7: This is a highly contested interpretation of the image and likeness of God.

Pg. 4: this narration of Christianity and other religions is not universally held and should not be presented as such. The author seems to be using all Orthodox sources and should be clear about the tradition they are drawing from.

Pg. 4: The author is again defining image of God, which seems repetitive and contestable

Pg. 4-8 need to be framed as specific eastern Orthodox account of human dignity

Pg. 4-8: There are far too many citations in this section to keep up with, coming from a vast variety of sources that do not seem to be comparable in their authority

Pg. 8 (Preservation of human dignity) begins with another litany of definitions of human dignity from a variety of sources, including theologians from different traditions

Pg 9: The transition to quality of life from human dignity is hard to follow

Pg. 9: I’m not sure who would disagree that we should provide dignified treatment to hospitalized patients or why we needed the preceding 8 pages to give us that insight.

Pg. 9: I’m confused about how human dignity, suffering, dignified care, quality of life and self-esteem are all being defined and relating to one another

Pg. 10: I’m not sure how the practices of patient care being described relate to dignity or the theological notions provided previously

Pg. 10, 11, elsewhere : the phrase “the ill” to describe hospitalized patients is odd

Pg. 12: The list of human rights abuses in palliative care comes out of nowhere and the context in which these critiques are being leveled is unclear; the remainder of the paper continues to list best practices without clear reference to why we need a religious understanding of human dignity undergird them

Author Response

In response to the constructive comments from the reviewers, we have undertaken an extensive revision of our manuscript to address each of the raised issues. Herein, we outline the revisions and adjustments made for each point:

1. The unique contribution and argument of the paper have been clarified in the introduction. The focus on Eastern Orthodox tradition, as well as the incorporation of other Christian theological sources, and the specific geographical context of Central Europe, particularly Slovakia, is now explicitly stated. This refined focus articulates the distinctive perspective of our work.
2. To improve the coherence of the paper, we have explicitly indicated how each section contributes to the overall argument, creating a more clear, logical flow throughout. Where necessary, the structure has been altered for better coherence and readability.
3. In addressing definitions, the concept of human dignity has been given an in-depth and contextual discussion early in the manuscript. The discourse is concentrated on key definitions that directly contribute to our argument, rather than presenting an array of varying views.
4. We have strengthened the link between our religious framing of human dignity and the principles of human rights and respect for patients. The necessity and usefulness of this religious framing in the context of human dignity in healthcare is now more comprehensively articulated.
5. A clear account of our perspective on the image of God and human dignity is provided, expressly stating that this interpretation is from a specific Eastern Orthodox tradition and that other interpretations indeed exist within the broader Christian theology.
6. Key terms and concepts have been defined with greater clarity, including 'socio-theological' and 'bio-psycho-social-spiritual.' Furthermore, the terminologies referring to "the ill" or "hospitalized patients" have been standardized using universally recognized terms.
7. To address the concern of presenting too many ideas or citations, we have streamlined the discussion to focus on key ideas and sources that directly inform our argument. Superfluous citations have been eliminated, and the focus is now on directly relevant and influential works.
8. The discussion on patient care, dignity, and quality of life has been refined to ensure clarity and coherence, with a direct link to our argument or analysis. Any critique or discussion of best practices is now clearly contextualized.
9. To address the reviewer's concerns about the use of the term 'the ill', we have revised the manuscript to refer to 'hospitalized patients' instead. We have also sought to ensure a smooth and logical flow of ideas throughout the manuscript, carefully transitioning between different concepts and sections, and providing clear definitions and explanations for key terms.

These revisions were aimed at making our manuscript clearer, more focused, and better articulated, thereby enhancing its overall quality and relevance. We are grateful to the reviewers for their insightful comments and believe that the revised manuscript substantially addresses their concerns. We believe that the revised manuscript provides a clearer, more nuanced, and more compelling exploration of the concept of human dignity in healthcare. We look forward to the reviewer's further comments and suggestions.

Reviewer 2 Report

I consider the article to be of good quality. It can be concluded that the authors have done a fairly good job. The article is acceptable both from the point of view of theory and topicality of the topic. Methodologically, the work is well managed. In the context of current trends, this article brings insights into the constant need to discover problems that are connected to value searches and orientation in today's world. This is especially true in life's borderline situations. The work is well structured, the abstract is concise and long enough. The conclusions correspond to the corpus of the text. The reference literature is adequate and its number as well as the time horizon are in order.

Despite this assessment, I have several reservations about the text.

Formal page.

References are missing in the bibliography:

1; 7 (not in accordance with the requirements is indicated in the list); 16,28,31,32,33; 49; 66 (Szabo ...); 73;

Lines 647-651: The same literary source is used twice.

Link 47 Susy AmeliaMarentek (no space - technical error)

Dойчик, Максим.; Устян, Виктория Геннадьевна - Latin transcription is missing in the Bibliography.

I recommend a comprehensive check of the bibliographic references.

Material page

Lines 24-27:

„The study underscores the significance of maintaining human dignity in inpatient care from a religious perspective. It recommends a collaborative approach between healthcare providers, patients, and their families to foster an environment that supports the dignity of the ill person.“

The study declares the above approach. However, it does not mention any approach from the relatives, the family, their contact with the patient, with the medical staff, what kind of cooperation, in what, etc.. I recommend adding it briefly in the text of the article.

Line 39:

„There is a lack of dignity when an individual feels incompetent ...“

It cannot be a lack of dignity as a fact. I recommend using the wording - feeling of lack, etc.. I recommend adding it briefly in the text of the article.

Lines 62-63:

„The dignity of the identity may be impaired or taken away, for example, by the actions of others or by illness.“

Can it be taken away completely? I would suggest rewording it.

Lines 208-209:

„Without it, man is weak and does not differ from an animal.“

I recommend leaving out the second part of this sentence. If it were to remain in the text, it would need a deeper analysis and clarification.

Lines 269-271:

„... Universal Declaration of Hu-269 man Rights, the Convention for the Protection of Human Rights and Fundamental Free-270 doms or the Charter of Fundamental Rights and Freedoms.“

I recommend adding: .. and the Charter of Rights of the European Union.

Lines 318-320:

„It is widely acknowledged that the ability of people to make autonomous decisions is considered a good thing.“

I recommend avoiding such general formulations. Instead, it is necessary to state the definition of human autonomy, the point of view of some authors, etc. Alternatively, such a sentence should be removed from the text.

Lines 338-339:

„... ontological concepts, such as transcendental nursing care, which promotes dignified care.“

This is an interesting concept and the authors use this term further on in the text. However, there is no corresponding clarification. This concept needs to be brought closer, clarified, explained.

 Lines  391-392:

„Illness, disability, various needs, lack of privacy, treatment and hospitalization can affect human dignity. Limits in the dignity of patients affect their body, mind, mood and expose patients to stress.

I recommend completing the sentence: ... can affect perception of human dignity.

I recommend rewording the sentence: Limits in patients' perception of their own dignity ...

Line  400: „... offering privacy, providing nutrition ...“

I recommend completing the sentence: ... offering and ensuring privacy ...

Line 483: „The implementation of an intervention plan tailored to the specific ...“

What is the plan? Do the authors have in mind the intervention plan for the provision of social services that we find in the laws and regulations of several countries?

I recommend adding a clarification.

Some ideas are unnecessarily repeated in the article. I recommend checking the entire article in this context.

Author Response

Due to some serious critical remarks from one of the reviewers, we have decided to completely rework our manuscript, including the bibliography. Some entries in the bibliography were either incomplete or duplicated - we have taken care of this. When it comes to writing in the Cyrillic alphabet, we will offer a transcription into Latin if the editors of the journal request it. 
We would like to hereby thank the reviewer for his valuable comments.

Reviewer 3 Report

The following reference does'nt make sense to me:

The super-178 natural aspect of human dignity is also expressed in the mission of Christ's Church, for 179 which man is ‘the only way’.35

35 Artur Stolarczyk et al., “Influence of diabetes on tissue healing in orthopaedic injuries“, Clinical and Experimental pharmacology and Physiology 45, no. 7 (July 2018): 619–627.

Author Response

We thank the reviewer for his positive evaluation of our paper. We have reworked the manuscript, including the footnotes and bibliography. We hope that the revised version contains no mistakes or inconsistencies in the references.

Reviewer 4 Report

In my opinion the article could be improved by giving concrete examples how theological doctrine of the dignity of human being can influence a secular health care provider. (Case study?)

Also it would enhance practical usefulness of the article if theological doctrines applied to the dignity of humans is compared with e.g. European Charter of Patient's Rights

Author Response

We thank the reviewer for his positive evaluation and suggestions. 
We have added case studies and a section on the European Charter of Patient's Rights. Also, we have made substantial revisions to the whole manuscript to make it more coherent and to address the comments from other reviewers.

Round 2

Reviewer 1 Report

This paper is much improved from the last version that I saw. I have only minor suggestions moving forward.

Perhaps my most substantive critique, is that I am not convinced that religion/theology is offering an absolutely 'unique' lens on healthcare practice as the authors claim. For example on pg. 9, the authors claim that religion offers a unique lens in healthcare right after describing practices (e.g., holistic care, biopsychosocialspiritual care) that are common practices or at least common phrases in secular healthcare ethics. The same could be said for the later section on "dignity conserving care in palliative contexts") when outlines various practices I would have taught in a secular medical context (e.g., person centered care, respect for autonomy, communication skills). It might be better to say religion complements and at best extends (which the authors also say) rather than offers something 'unique' unless there is truly something theology would teach that is not already a concept in ethical healthcare. Of course the paper would be stronger if the argument could be made for religion's unique insights.

I think the authors could be more careful in the beginning (before the section on different ways to understand dignity) to use terms that do not suggest dignity can lost (e.g., dignity-conserving/maintaining) as this will strike some readers as moving against the idea that all people have inherent dignity from God.

Authors should define palliative care when it is first used on pg. 4, since readers might be confused that it deals only in end of life care (as is the topic of the paper)

Authors should avoid using 'man' to describe all human beings, except when quoting others.

Authors should say Roman Catholic Church rather than Catholic Church if this is what they mean.

It might be helpful to briefly explain what current palliative care in Slovakia looks like as a comparison. Again, all the suggestions for ethical healthcare looked to me like best practices in America without any religious framing.

Author Response

We appreciate the reviewer's further comments and suggestions. We have made appropriate revisions to our manuscript.

“For example on pg. 9, the authors claim that religion offers a unique lens in healthcare right after describing practices…”

Our changed text: In sum, a theologically informed framing of human dignity complements (and, theologians would argue, extends) our ability to view and address ethical issues in healthcare.

“I think the authors could be more careful in the beginning (before the section on different ways to understand dignity) to use terms that do not suggest dignity can be lost (e.g., dignity-conserving/maintaining) as this will strike some readers as moving against the idea that all people have inherent dignity from God.”

We understand and appreciate the reviewer’s concern on this matter. The way we address this issue is by proposing a typology of human dignity (p. 4). “It comprises three main categories: intrinsic, attributed, and inflorescent dignity. 'Intrinsic dignity' relates to the inherent worth of a person due to their human nature, in line with the theological perspective. 'Attributed dignity' refers to the value ascribed to a person based on their attributes or accomplishments, resonating with societal and cultural factors. 'Inflorescent dignity' encapsulates the concept of dignity as a quality that can flourish or diminish depending on the conditions of one's life, reflecting the quality of life and healthcare perspectives.” Hence, when we use terms such as “dignity-conserving” (etc.) that might evoke the idea that one can lose one’s dignity, we are referring to the ‘ascribed’ and ‘inflorescent’ types of dignity, not the inherent dignity, which can never be lost.

“Authors should define palliative care when it is first used on pg. 4, since readers might be confused that it deals only in end of life care (as is the topic of the paper)”

Thank you for this comment. We have included a short definition of palliative care in the Introduction section of our paper. On page 4, we mention the term ‘palliative care’ in the context of summarizing Chochinov’s views on the subject, so it might be more suitable to offer a definition beforehand.

“Authors should avoid using 'man' to describe all human beings, except when quoting others.”

We have made appropriate changes. Thank you for the reminder!

“Authors should say Roman Catholic Church rather than Catholic Church if this is what they mean.”

We have made appropriate changes. Thank you for the reminder!

Reviewer 2 Report

I consider the article to be of good quality. It can be concluded that the author (s) have done a fairly good job. The article is acceptable both from the point of view of theory and topicality of the topic. Methodologically, the work is well managed. In the context of current trends, this article brings insights into the constant need to discover problems that are connected to value searches and orientation in today's world. This is especially true in life's borderline situations. The paper is well structured, the abstract is concise and long enough. The conclusions correspond to the corpus of the text. The reference literature is adequate and its number as well as the time horizon are in order.

The author(s) incorporated de facto all my comments regarding the material side. The author(s) promised to remove technical details.

I recommend text of the paper for publication.

Author Response

We thank the reviewer for his second assessment and words of encouragement.