Balancing Safety and Freedom: Understanding "Dignity of Risk"

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My mom went for a wedding to Daman. When she was at the Dadar Station platform, waiting to catch a train to Vapi, she stumbled, fell flat and sustained multiple bruises with nasal bleeding, but luckily without major injuries. She continued her trip to Vapi and came back, a little shaken, with her ego more wounded than her body. 

Given the importance of “Do Not Fall”, our first reaction was to tell her not to undertake such journeys anymore. But how can you restrict an active, social person and prevent them from traveling to weddings, funerals and other social occasions…events that keep them active and busy? We would like to keep her safe, but that does not mean keeping her cloistered in the house or making sure that she doesn’t go anywhere, or if she does, be always accompanied by able-bodied people.

That is the tension, isn’t it…not trampling on her freedom to decide what she wants to do, when and how, while at the same time trying to ensure she does not fall and fracture…a spine or hip fracture would significantly reduce her quality of life and reduce her lifespan. It is not easy. Since we live in the same building and have meals together, it is easy for us to keep a watch over my parents. If you were a distance or continents away, it gets harder for everyone. The elderly resent restrictions on their ability to move around and the children and grandchildren worry that if they move around too much, especially in Indian cities, they may fall or get hit by a vehicle and get seriously injured or worse, die. 

We all want to keep our parents and grandparents safe. But we need to make sure that we do not infringe on their “dignity of risk” (DoR). DoR is a concept that “involves respect for persons, self-determination and attempts to minimize paternalism or parentalism” [1]. It means “respecting people’s right to live their lives, even with risk.” [2]

I am now 60. Thirty years ago, a 60-year-old would be considered old, decrepit and put out to pasture (the official retirement age still reflects that mentality, such that at 60, you start being called a “senior citizen”). Imagine if my kids were to turn to me and say, “please stop running on the roads now Dad, it is too dangerous. Just stay at home, we will call the trainer and you can walk on the treadmill and do some weight training”. I would never listen to them. So why is it any different for those who are currently over 80 or 90 years of age? 

My Dad does not like to travel the way my Mom does. He is comfortable in his environment, going to the clinic at age 88 and reading X-rays and performing procedures. It keeps him active and alive and I cannot picture him being told to stop working (unless he starts making mistakes). Not being able to go to the clinic physically during Covid-19 was hard on him.

Perske wrote in 1972, “there can be such a thing as human dignity in risk and there can be a dehumanizing indignity in safety!” [3].

Not wearing seatbelts increases the risk of death during a car accident. Smoking increases the risk of lung cancer, COPD and many other cancers and diseases. Excessive alcohol consumption has many downsides and can reduce lifespan. Not controlling high blood pressure and high blood sugar almost certainly will reduce healthspan and lifespan. Therefore, does an individual have the right to live life without following any of these guidelines, given the risk of a reduced healthspan and lifespan? Or is it necessary for family and society to impose some safety rules even if they transgress that person’s dignity?

The tension is between the burden that falling sick or getting a head injury during a car crash imposes on those around you, on society and the healthcare system versus ensuring that people as a rule should follow healthy practices not just for their individual benefit, but for society as a whole. Hence there are penalties for not wearing helmets and seatbelts or for smoking in public places. Insurance companies now penalize you with higher premiums if you have sustained high blood pressure and high blood sugar. Following some rules and laws, whether willingly or unwillingly, in an attempt to live long, healthy is part of living in society, as part of a community.

The question of DoR comes into play when the imposition of these rules becomes detrimental to a person’s health and well-being. If you drink 3-4 pegs a day every day, it may be fair for those around you to try to stop you or to try and reduce the amount you drink. However, if you prevent a person in their 80s or 90s from imbibing a peg or two once in a while, that would just be excessive use of unnecessary power.

“The act of honoring the dignity of risk or engaging in risk/safety or benefit/burden calculations involves an interpretation of information” [4]. But that decision making should be done in a shared manner. When we asked my Dad not to go to the clinic during the height of Covid-19, it was because the information at the time suggested that not only was he high-risk, contact with patients coming for chest X-rays would increase that risk substantially. Once the pandemic itself subsided, the risk subsided and then it was relatively safe, though he still caught Covid twice, once from well-wishers and once probably from a patient.

When a parent refuses to leave the country and live with their children abroad, they are exercising their “dignity of risk.” They want to live by themselves with their loose social support system. You can’t force them to uproot themselves and live the rest of their lives in a strange environment, even though you believe it is for the best because you can apparently take better care of them when they are in front of you.

When a person with end-stage cancer finally decides they don’t want to continue treatment, their wishes should be acknowledged. Just the way we should honor the wishes of those who have signed a “living will” regarding hospitalization and resuscitative measures when terminally ill. Doctors should learn not to “treat patients as separate from the risks they have taken and the risks they are willing to take” [5].

So what does this mean for you and I? If you are old, surrounded by well-wishers who try to restrict your activities for your own safety, then it is fine to rebel to maintain your “dignity of risk.” If you are a well-wisher child or grandchild, who wants to keep their parents and grandparents safe at all costs, do so without trampling on their rights and diminishing their “dignity of risk.”

Footnotes:

1. Mukherjee D. Editor's Introduction: Disability, Social Justice, and Dignity of Risk at 50 Years. Perspect Biol Med. 2022;65(2):157-161. doi: 10.1353/pbm.2022.0010. 
2. Ken Rockwood. Keynote Lecture. British Geriatric Society - Autumn Meeting. Nov 2024.
3. Perske, R. 1972. “Dignity of Risk and the Mentally Retarded.” Ment Retard 10 (1): 24–27.
4. Mukherjee D. Dignity of Risk and Attributions About the Other. Perspect Biol Med. 2022;65(2):213-220. doi: 10.1353/pbm.2022.0017. 
5. Hulkower A. A Place of His Own: Applying Dignity of Risk to Bioethics Consultation. Perspect Biol Med. 2022;65(2):232-241. doi: 10.1353/pbm.2022.0019.