To explore the application of patient dignity in clinical settings in Iran, Torabizadeh and her colleagues interviewed 20 hospitalised patients during an 11-month period in three public educational hospitals.1

Human dignity has been referenced and emphasised in many international documents—for instance, article 3 of the UNESCO Universal Declaration on Bioethics and Human Rights states that ‘human dignity, human rights and fundamental freedoms are to be fully respected’.2 However, none of the international documents have clearly defined the concept of human dignity, and there is no consensus on its definition and no clarity in its application.

There is an integral relationship between respect for the dignity and the vulnerability of persons.3 In healthcare settings, patients are uniquely vulnerable, and they depend on the skills, judgement and good will of the healthcare providers. There are no guidelines for healthcare providers to safeguard individual patients’ dignity. In practice, attending to patients’ notions of human dignity in healthcare settings and their experience in hospital can help healthcare providers to understand this controversial concept through patients’ eyes.

The qualitative study carried out by Torabizadeh et al, in Iran, elaborates some elements of respect for patients’ dignity based on patients’ perspective. The findings of their study show that patients’ dignity would be valued by respecting their privacy, effective communications, access to facilities and a full understanding of the need for a companion.

The results of their study confirm that in determining the elements of human dignity, socio-cultural context in different healthcare settings is an influential factor and has to be taken into account. As explained by Anderberg et al,4 dignity consists of inherent and external factors that are common to all human beings, but at the same time are unique to each person, depending on social and cultural aspects. For example, some patients in their study complained that they were called by their first name. In many countries in the West, calling patients by their first name is more friendly and desirable, but in some other countries, people would like to be called by their family name as they see it as more respectful.

As shown in their study, in Islamic society, it is important for Muslims to avoid unnecessary exposure of their body, and obviously, it is disrespectful to their dignity if while in a vulnerable situation as a patient, they cannot observe this religious necessity. The same can be said about gender-related issues because, in Islamic society, a visit by a healthcare provider of the opposite sex should be avoided unless necessary.

One might disagree that ‘respecting a patient's companion’ is important in respecting patient dignity. However, patients in the study said they feel unvalued and disrespected if healthcare providers do not respect their companions.

However, there are several points in this article that need careful attention. First, is that the paper lacks a brief explanation about the healthcare system in Iran that could illuminate some of the findings of their study, and bring more clarity to patients’ perception of dignity in clinical settings. For instance, in Iran, there are public and private healthcare services. Medical care in public hospitals is cheaper but the care environment and the behaviour of the healthcare providers is less satisfactory. Therefore, knowing that, one would not be surprised to see different results if patients in a private hospital were interviewed. For instance, patients complained about healthcare providers disregarding unofficial caregivers (usually a family member), and we can expect that a similar study in a private hospital would produce different results.

Second, in analysing the data from the interviews, the authors have merged patients’ dissatisfaction with their dignity. There are many factors contributing to patient dissatisfaction—for example, a patient might not be satisfied with the course of treatment and the alleviation of suffering, but this does not necessarily imply disrespect of patient dignity. In this study, statements such as ‘many patients were unsatisfied with ineffective communication of healthcare providers’ clearly show patients’ dissatisfaction but not necessarily feelings of disrespect to their dignity. The same can be said about their opinion on the scarcity of resources, medical equipment, quality of facilities, excessive noise and the lack of DVD players and televisions in patient's room. As expressed by the patients, these are the reasons that caused dissatisfaction, but not a violation of their dignity. Therefore, it is important to distinguish the factors that cause patient dissatisfaction from those which may cause a patient may feel unvalued and disrespected. In order to get a better sense of patients’ opinions about the concept of human dignity and to understand exactly what it means for an individual patient, the authors could have asked participants a direct question about what they consider as human dignity in clinical settings.

Third, the authors have referenced the patient charter of rights in Iran, but the referenced charter is the old one and a new charter has been developed. The current Iranian patient's rights charter has been formulated in five chapters and 37 articles, and was endorsed by the Ministry of Health and Medical Education in 2009. Although, like other related documents it does not provide any definition of human dignity, in chapter 1, article 1.1, it emphasises that in providing healthcare, human dignity, cultural values and religious beliefs must be respected. In addition, in the vision and values, the charter asserts; ‘all citizens are committed to maintain and respect human dignity. This fact is more important when individuals are suffering from illness’.5

In Iran, a great improvement to healthcare services could be made if policymakers took the elements of human dignity found in their study into account and translated it into practice. No doubt, for a better understanding of the nature of human dignity, especially at times of illness and other vulnerabilities, more empirical studies should be conducted.