119. The other aspect of the matter which, in my judgment, is of considerable importance relates to what is meant by dignity in this context. Much of the debate with East Sussex County Council (ESCC) and much of the argument which has been addressed to me has proceeded on the scarcely articulated but nonetheless pervasive assumption that manual handling is dignified whereas mechanical handling is undignified, in other words that A and B’s dignity interests are served by manual handling but are not served if equipment is used. This, as it seems to me, is a highly questionable, in truth a dangerous and misleading, assumption. I say so for two reasons.

120. I recognise of course that the compassion of the carer is itself a vital aspect of our humanity and dignity and that at a very deep level of our instinctive feelings e value and need the caring touch of the human hand. That no doubt is one of the reasons why the nobility of compassionate carers as different in their ways as Florence Nightingale, Leonard Cheshire and Mother Teresa resonates so strongly with us. It underlies the most savage of AWN Pugin’s Contrasts, his comparison of the compassionate care of the medieval monastery and the cruel heartlessness of the early modern workhouse. Even those who do not believe in any God know that a human being is more than a machine consisting of a few rather basic chemicals operated by electric currents controlled by some animalistic equivalent of a computer located in the skull – and that, no doubt, is why we have an instinctive and intuitive preference for the touch of the human hand rather than the assistance of a machine. As disabled persons or invalids our instinctive preference is to be fed by a nurse with a spoon rather than through a naso-gastric or gastrostomy tube.

121. But, and this is the first point, insistence on the use of dignified means cannot be allowed to obstruct more important ends. On occasions our very humanity and dignity may itself demand that we be subjected to a certain amount – sometimes a very great deal – of indignity. Dignified ends may sometimes demand the use of undignified means. The immediate dignity of a person trapped in a blazing building is probably the very last thing on his mind or in the mind of the fireman who bundles him undignified out of the window to save his life. And one thinks of the gross violence and indignity of the methods necessarily used by the crash team in its desperate efforts to save life in the Accident and Emergency Department. But this does not mean that means must be allowed to triumph over ends. There is a balance to be held – and it is often a very difficult balance to strike. It is difficult enough to balance the utility or possible futility of means against the utility or possible futility of ends: it is all the more difficult when one has to assess in addition the dignity or possible indignity of the means against the end in view. Modem medical law and ethics illustrate the excruciating difficulty we often have in achieving the right balance between using undignified means in striving to achieve dignified ends.

122. The other point is this. One must guard against jumping too readily to the conclusion that manual handling is necessarily more dignified than the use of equipment. A disabled person or invalid may prefer manual handling by a relative or friend to the use of a hoist but at the same time prefer a hoist to manual handling by a stranger or a paid carer. The independently minded but physically disabled person might prefer to hoist himself up from his bath or chair rather than to be assisted even by his devoted wife. Dignity in the narrow context in which it has been used during much of the argument in this case is in truth part of a much wider concept of dignity, part of a complicated equation including such elusive concepts as, for example, (feelings of) independence and access to the world and to others. Hoisting is not inherently undignified, let alone inherently inhuman or degrading. I agree with Ms Lang that certain forms of manual lift, for example the drag lift, may in certain circumstances be less dignified than hoisting. Hoisting can facilitate dignity, comfort, safety and independence. It all depends on the context.