Author: Dr. Kunihiko Ishitani
President of The International Research Society of the Sapporo Conference for Palliative and Supportive Care in Cancer (SCPSC) President, Higashi Sapporo Hospital, Japan
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Introduction
Can the concept of “human dignity” become a future episteme in cancer palliative care?
Michel Foucault (1926–1984) defined the concept of episteme in The Archeology of Knowledge as the underlying structure of knowledge in a given historical period; i.e., the deep framework that determines “what counts as knowledge and truth.” Foucault further presented the episteme as fundamentally different across historical epochs. For example, he contemplated that the fundamental structures of knowledge are transformed historically, moving from the Renaissance “episteme of resemblance” to the Classical “episteme of order and representation,” and finally to the modern “invention of ‘man’ as an object.”1) In this paper, the term “medical episteme” does not strictly follow Foucault’s original usage; Rather, it refers – somewhat metaphorically – to the dominant framework of understanding that guides medical practice.
Background
The Concept of ‘Human Dignity’ from an Ethical Perspective Abstract
The concept of “human dignity” has undergone diverse interpretations throughout its historical development. This paper aims to reposition the ethical foundations of cancer palliative care through three main approaches: (i) a historical examination of the genealogy of the dignity concept and a reappraisal of autonomy as the basis for human dignity in Kantian philosophy; (ii) an analysis of representative embodiments of the concept in medical practice, such as Dignity Therapy and Epistemic Justice; and (iii) a reconstruction of the concept of dignity as a new medical episteme.
Reflections
The Sapporo Conference for Palliative and Supportive Care in Cancer (SCPSC) has consistently addressed the issue of euthanasia as a central theme, probing the very essence of medicine and medical practice.２）Since the 1990s, the concept of “Quality of Life (QOL)” has exerted significant influence as a major episteme in the fields of medicine and healthcare. However, in discussions surrounding the ethical issue of euthanasia, it has become apparent that the concept of QOL alone is insufficient as a basis for decision-making. 3)4) In this context, Canadian psychiatrist Harvey Chochinov and colleagues introduced Kant’s concept of “human dignity” as a central principle in palliative care, bringing a new perspective to the field of medical ethics.５）Since then, the concept of “human dignity” has been anticipated to achieve theoretical maturity as an emerging medical episteme that may supersede the QOL paradigm. In this paper, we provide an overview of the historical and philosophical background of the dignity concept to lay the groundwork for these discussions, while examining the potential roles and limitations of its clinical applications, such as Dignity Therapy 6) and Epistemic Justice. 7)8) Building on this, I would like to reflect on the potential and future directions of the concept of “human dignity” in cancer palliative care. In consideration of space constraints, this discussion is organized into three parts. In this first section, I will attempt a basic examination of the concept of dignity as a prospective medical episteme.
1. The Historical Genealogy and Kantian Foundations of the Concept of Dignity
1.1 Diversity and Historical Development of the Concept of Dignity
The term “dignity” has carried different meanings depending on the era, region, and intellectual context in which it was used. In ancient Rome, dignitas was a hierarchical notion tied to social status and public honor, markedly different from the ethical conception of dignity recognized today. In the Middle Ages, under the influence of Christian thought, the basis of human dignity lay in a theological understanding that humans were created “in the image of God (imago Dei). In the modern era, the influence of Cartesian rationalism and Enlightenment thought gave rise to the dominant view that human reason itself constitutes the foundation of dignity. In contemporary bioethics, however, the concept of dignity has become even more diversified and pluralistic
・Dignity as intrinsic value (German conception): The view that every human being possesses unconditional worth simply by virtue of their existence. This approach emphasizes the inviolability of personhood, as symbolized in documents such as the Grundgesetz (Basic Law).
・Dignity as a relative or culturally situated value (American conception): The view that the essence of dignity lies in an individual’s freedom to make autonomous choices and to realize them. This understanding places strong emphasis on personal autonomy.
・Dignity as relational or socially constituted value (Continental European conception): The view that dignity is constituted through interpersonal relations and social recognition. This approach resonates with phenomenology and political philosophy.
The above categories do not constitute a strict classification, but rather outline tendencies in our understanding of the concept of dignity. This diversity reflects the lack of a single, universally accepted foundation for contemporary dignity discourse. At the same time, however, many of these diverse interpretations are underpinned by a unifying Kantian insight.
1.2 The core of Kant’s concept of “human dignity”
Immanuel Kant’s discussion of human dignity in his Groundwork of the Metaphysics of Morals (1785) represents the origin of the modern concept of dignity and remains, to this day, its most philosophically sound theoretical foundation.9)10)
For Kant, autonomy is regarded as the basis of human dignity. Autonomy refers to the capacity to implement moral law for oneself, signifying a free will that is not determined by others or by personal desires. To paraphrase Kant’s well-known formulation, “Humans alone possess an unconditional, incomparable value, because only humans are subjects of autonomy and capable of giving moral law to themselves.The crucial point here is that autonomy does not signify mere personal freedom, but rather entails obedience to the moral law.
Kant’s second formulation of the categorical imperative states: “Act only according to that maxim whereby you can at the same time will that it should become a universal law.” While his third formulation states: “Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end, and never merely as a means.
“In other words, moral obligations to oneself and those to others are inseparable. An autonomous person is obligated not only to align their own actions with universal moral law but also to respect others as equally autonomous beings.11）
What follows from this is the fundamental insight that dignity is an intrinsic value inherent in human nature and also concretely manifests within relationships in which this value is mutually recognized.
1.3 The contemporary relevance of the Kantian concept of dignity
The concept of dignity grounded in Kantian principles remains relevant in the contemporary context for the following reasons.
First, it reconciles universality with plurality. Kantian dignity belongs unconditionally to all human beings (universality), while its concrete realization depends on cultural and relational contexts (plurality). Thus, it provides a theoretical foundation for the coexistence of people with diverse values in a globalized world.
Second, it provides a justification for moral responsibility. If dignity were understood solely as a right, humans could claim unlimited entitlements. From a Kantian perspective, however, dignity is at the same time an obligation that entails a responsibility to respect the dignity of others. It is precisely this asymmetry that makes ethical practice possible.
Third, it encompasses the dignity of the entire human life, including death. While the strict interpretation of the text is open to debate, this article will extend the Kantian framework to consider fetuses, people with severe dementia, and the deceased as bearers of dignity, regardless of their productivity or whether they are conscious, from the perspectives of “human beings as a species” and “potentially rational beings.” This offers a robust philosophical position that stands in opposition to utilitarian approaches to bioethics.12)13）In the second instalment of this article, we will examine how the Kantian concept of dignity can be implemented in clinical practice from the perspectives of Dignity Therapy and Epistemic Justice, and clarify both its potential and challenges.
(Continued in the next issue)
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References
1. Foucault, M. L’Archeologie du savoir. 1969. (The Archaeology of Knowledge, trans. Yujiro Nakamura, Kawade Shobo Shinsha, 1974)
2. Sapporo Conference for Palliative and Supportive Care in Cancer. http://www.sapporoconference.com/en/index.html
3. Karnik, S., Kanekar, A. Ethical Issues Surrounding End-of-Life Care: A Narrative Review. Healthcare 2016, 4(2), 24. https://doi.org/10.3390/healthcare4020024
4. Symons, X., Rhee, J., Tanous, A., et al. Flourishing at the end of life. Theor Med Bioeth 45, 401–425 (2024). https://doi.org/10.1007/s11017-024-09679-x
5. Chochinov, H. M., et al. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol. 2005; 23(24): 5520-5525.https://doi.org/10.1200/JCO.2005.08.391
6. Chochinov, H. M. Dignity in Care: The Human Side of Medicine. Oxford University Press, 2024. https://doi.org/10.1093/med/9780199380428.001.0001
7. Fricker M. Epistemic Injustice: Power and the Ethics of Knowing. Oxford University Press,2007
DOI: 10.1093/acprof:oso/9780198237907.001.0001
8. Grim, K., Pamon, S. Working towards successfully centering dignity and epistemic justice in mental health practice. Academia Mental Health and Well-Being 2025; 2(4). doi.org/10.20935/MHealthWellB7930
9. Kant, I. Grundlegung zur Metaphysik der Sitten. 1785. In: M. Gregor (trans.), Practical Philosophy, Cambridge University Press, 1996. (Groundwork of the Metaphysics of Morals, trans. Yoshiyuki Mikoshiba, Jinbun Shoin, 2022)
10. Kant, I. Kritik der praktischen Vernunft. 1788. (Critique of Practical Reason, trans. Hideo Shinoda, Iwanami Bunko, 1961)
11. Hill, T. E. Dignity and Practical Reason in Kant’s Moral Theory. Cornell University Press, 1992. DOI 10.7591/9781501735035
12. O’Nell, O. Constructing Authorities: Reason, Politics and Interpretation in Kant’s Philosophy. Cambridge University Press, 2015.
DOI:10.1017/CBO9781316337141
13. Ishitani, K. Chapter 4: The Circular Structure Surrounding “Human Dignity.” IRS-SCPSC Newsletter: Winter Issue 2025. https://irs-scpsc.com/newsletter-winter2025/