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
The 5th Sapporo Conference for Palliative and Supportive Care in Cancer (SCPSC) will be held this July. This conference takes as its theme “Cancer Palliative Care Entering a New Era” and seeks to examine new scientific developments in palliative care and the framework of values that underpins them. I would like to express my gratitude to the speakers and chairs, as well as to all participants who support the aims of this meeting.
At this conference, the relationship between assisted dying (euthanasia and physician-assisted suicide [PAS/MAiD]) and palliative care will once again be addressed. This issue is not confined to institutional or legal debate, but serves as an opportunity to reexamine the normative foundations underlying palliative care.
In the previous article, I considered the issue of assisted dying as a turning point and examined the possibility of a medical episteme (the structure of knowledge and institutional framework in medicine) that could replace QOL-centered approaches, arguing that the Kantian concept of “human dignity,” particularly the ethical perspective of autonomy, could serve as a new normative framework.
Here, I take this a step further by examining how this concept of “human dignity” can be implemented in clinical practice. Rather than leaving dignity as an abstract ideal, I attempt to clarify how it may be positioned within the structure of clinical practice, elucidating its theoretical conditions and practical scope.
Can the concept of ‘human dignity’ become a future episteme in cancer palliative care?
The Concept of ‘Human Dignity’ from an Ethical Perspective
In the previous article, “1. The Historical Genealogy and Kantian Foundation of the Concept of ‘Human Dignity,’” ¹ we systematized the concept of ‘human dignity,’ which has been used in multiple senses through its historical development, and reexamined autonomy as presented by Kant as its ethical foundation. According to Kant, human beings, as rational beings, possess the capacity for thought and judgment (autonomy), and are beings who act on the basis of an intrinsic moral law, whose value is not dependent on external conditions. ², ³
However, in contemporary medicine, this concept of autonomy is often reduced to the procedural criterion of ‘the presence or absence of decision-making capacity.’ As a result, our understanding of human beings as entities who form and express their dignity within relationships with others is not sufficiently reflected.4-6
Building on this notion, here we examine how the Kantian concept of dignity can be implemented in clinical practice. In particular, from the perspectives of Dignity Therapy and Epistemic Justice (with consideration given to epistemic injustice), we clarify the possibilities and challenges of medical efforts toward the restoration and preservation of dignity.
Dignity Therapy in Palliative Care
Dignity Therapy, proposed by the Canadian psychiatrist Harvey Chochinov, is a psychosocial intervention aimed at the preservation of dignity for terminally ill patients. ⁷ This therapy is characterized by facilitating the “reconstruction of the self-narrative” through a process in which patients speak about their values, the meaning of their lives, and the messages they wish to convey, which are then documented. At the core of this intervention is the affirmation of the patient’s worth through the creation of a “Generativity Document,” which is shared with family members. This method has been positively evaluated in multiple studies.8-10 Chochinov’s recent book, Dignity in Care: The Human Side of Medicine,11 presents an intellectual maturation that is aligned with the direction of the present article. That is, it may be understood as a philosophical-clinical translation of the Kantian concept of dignity.
(1) Theoretical Background
a. Restoration of dignity through self-narrativization: By rearticulating one’s life as a meaningful story, a sense of dignity is restored.
b. Social recognition: By sharing that narrative with family members and others, the patient’s personal worth is recognized by others.
c. Affirmation of human existence including death: Even under the extreme conditions at the end of life, affirmative experiences of humanity can be formed.
(2) Limitations and Challenges.
a. The Problem of the Psychologization of Dignity: Dignity Therapy tends to construe dignity as a subjective psychological experience; however, from a Kantian perspective, dignity is a universal moral value that does not depend on an individual’s subjective feelings. Therefore, even if a patient experiences a loss of a sense of dignity, dignity itself is not actually lost.
b. The Power of Professional Interpretation: When healthcare professionals take a leading role in interpreting and reconstructing patient narratives, there is a risk that patient autonomy and alterity may be undermined. This issue is fundamentally connected to the problem of the power structure inherent in the clinical editing of narratives.
c. Limitations to Cultural Universality: Dignity Therapy generally presupposes an individualistic and narrative-based understanding of the self, and this may limit its applicability in relational or community-oriented cultures. However, when considered in light of the Kantian concept of dignity, this criticism is not necessarily valid.
In his recent book,11 Chochinov himself notes that “a clinical approach to dignity is constituted through dialogical reciprocity,” and attempts a shift from the conventional psychiatric intervention model toward Dignity Therapy grounded in a more ethical relationality (moral relationality). This may be understood as a maturation beyond a mere psychological technique, toward the regeneration of dignity within relationships.
Epistemic Justice in the Field of Mental Health
In recent years, the concept of Epistemic Justice, which has attracted attention in the fields of mental health care and social medicine, was proposed by the British philosopher Miranda Fricker.12 Epistemic Justice is an attempt to rectify injustices in the formation of knowledge. Its importance lies in the fact that it identifies structures in which patients’ voices are marginalized by professional knowledge and makes visible the imbalance of power in healthcare. Epistemic Justice is grounded in the protection of “the dignity of human beings as epistemic subjects.” 13-15
In mental health service settings, patient self-reports and experiential knowledge are rarely placed on an equal footing with biomedical knowledge. The approach of Epistemic Justice seeks to recognize patients not merely as objects of treatment, but as subjects who possess knowledge about their own conditions. This shares common ground with the respect for rational judgment as autonomy in the Kantian concept of dignity and more fundamentally aspires to the restoration of dignity. Patient participation in medical decision-making is not simply a matter of “listening to patient choices,” but of acknowledging patient epistemic authority. However, Epistemic Justice can at times function as an “ethics of the knower.” That is, it may contain a top-down recognition structure in which those who possess knowledge attempt to restore justice by respecting the voices of the parties concerned. Thus, it can be said that Fricker’s theory presupposes the asymmetry of epistemic power.
(1) Theoretical Background
a. Testimonial Justice: Accepting patients’ experiences and values as having equal epistemic value to medical professional knowledge.
b. Hermeneutical Justice: Ensuring patients have access to the conceptual and linguistic resources necessary to understand and articulate their own experiences.
(2) Limitations and Challenges16,17
a. Risk of support becoming overly interventionist: The stronger the healthcare provider’s intention to supplement the patient’s narrative, the more likely it is that interpretive authority may unintentionally shift toward the provider, resulting in the patient’s agency being replaced once again.
b. Relational imbalance: The role-based and structural asymmetry between healthcare providers and patients always carries the risk that support may transform into guidance or manipulation.
c. Educational challenges: The clinical application of epistemic justice requires both healthcare providers and patients to develop maturity as speaking subjects (thinking capacity).
According to Kant, a person is an “end in itself” and must never regarded be merely as a means under any circumstances. The value of personality in this sense presupposes respect for the human capacity to think and judge autonomously. From this perspective, epistemic injustice (the unjust dismissal or undervaluation of a patient’s narrative and experience) is not merely a problem of knowledge formation, but an ethical issue involving a violation of dignity, insofar as the patient is not treated as an end in themselves. Therefore, epistemic justice presents the epistemological conditions under which a patient’s narrative can be rightfully established in clinical practice concerning dignity. Conversely, the absence of these conditions simultaneously signifies an ethical violation. In this sense, epistemic justice is not an auxiliary concept external to dignity ethics, but is deeply involved in the very process by which dignity is concretized within clinical practice.
(3) Dignity as the Intersection of Ethics and Epistemology
The concept of dignity cannot be reduced to the presence or absence of decision-making capacity; it encompasses both ethical and epistemological value. While Dignity Therapy is an ethical practice that generates narrative, Epistemic Justice is an epistemological form of justice that treats narrative as legitimate knowledge. Dignity emerges as a value concept at the point where these two approaches intersect within clinical practice. Although ethics and epistemology have generally been regarded as distinct domains, in clinical settings ethical issues are often simultaneously issues of recognition and knowledge. Many situations in which a patient’s dignity is undermined are those in which their narrative is not treated as legitimate “knowledge.” Therefore, the preservation of dignity requires both the ability to speak (expression) and the reception of that speech (recognition). The integrated application of Dignity Therapy and Epistemic Justice is thus envisioned as a practical framework for achieving this aim. 18,19
Other Practices Oriented Toward the Concept of Dignity and Theoretical Challenges
Recent clinical practices such as Narrative medicine20, Relationship-centered care21, and Compassionate communities22 all present practical significance as models of “good care” that support patients’ dignity. However, these approaches are sometimes disseminated without their philosophical foundations being sufficiently articulated. Empathic attitudes, attentive listening to patients’ narratives, support for decision-making, and collaboration with families are highly valued in contemporary clinical settings; yet the fundamental questions underlying them; namely, why they are ethically good, what kinds of values they promote, and how they are consistent with the concept of dignity, have not always been adequately theorized.23–25 If these questions remain insufficiently examined, “good care” risks being reduced to activity reports or demonstrations of empirical effectiveness, treated merely as a practical concept lacking ethical and philosophical justification. Put simply, there is a danger that it may fail to attain the universality necessary to respond to continually changing social and cultural values.26 Therefore, it is necessary to reconstruct these practices as a theoretical framework grounded in the concept of human dignity and endowed with ethical coherence.
Summary: Relationships themselves are the locus of dignity.
Human dignity is not something restored by a particular technique of care; rather, it is a value that ought always to be presupposed within relationships in which a person speaks, is understood, and is treated as a knowing subject. The intellectual-historical positioning of the theoretical framework termed the “medical episteme” used in this paper will be briefly outlined in the appendix.
References
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