Abstract
This article offers a conceptual analysis of self-respect and self-esteem that informs the ethics of psychotherapy in palliative care. It is focused on Chochinov’s Dignity Therapy, an internationally recognized treatment offered to dying patients who express a need to bolster their sense of self-worth. Although Dignity Therapy aims to help such patients affirm their value through summarized life stories that are shared with their survivors, it is not grounded in a robust theory of self-respect. There is reason to be skeptical about deathbed narratives, and Dignity Therapy can unintentionally encourage distorted representations at odds with the self-respect it aims to affirm. Dignity therapy can also encourage distortions of self-esteem that are in conflict with self-respect. Although Chochinov does not address it, the distinction between self-respect and self-esteem is relevant to deathbed accounts. Dillon’s feminist revisioning of self-respect can inform the practice of Dignity Therapy by encouraging honest life stories through a reckoning with one’s moral complexity, especially in moral generativity cases where patients seek forgiveness, relate atonement, or present their lives as examples to be followed. Her concept of self-esteem allows for therapeutic benefits that are less demanding, but no less significant, than those derived from a moral reckoning. Appropriate affirmations of self-esteem can provide much-needed solace when self-respect is damaged beyond adequate repair. Dillon’s account of self-respect and self-esteem enables a richer understanding of the kinds of personal evaluation and disclosure that Dignity Therapy accommodates. As such, their place in Dignity Therapy needs more critical evaluation than it has received.
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Notes
Existential suffering comprises a range of experiences that can be especially acute in palliative care. These feelings include retrospective disappointment and remorse, hopelessness, futility, death anxiety, and loss of agency, identity, and interpersonal connectedness. By 2011, acknowledgement of existential suffering was ascendant among palliative care physicians and nurses, although subject to multiple (i.e., at least fifty-six) definitions [3]. The maintenance or reestablishment of meaning, purpose, and self-worth are central goals in treating the existential suffering of palliative care patients [4, p. 313; 5, p. 71].
Dillon rejects the “false claim” that damaged self-respect is limited to women. But insofar as her feminist revisioning understands self-respect as reflecting “prevailing forms of social and political life,” many of which are oppressive to women, damaged self-respect cannot be fully understood “without taking its gender dimensions seriously” [20, pp. 236, 244].
Dillon extended her initial revisioning to include basal self-respect, or the most primordial valuing of ourselves as having worth [20]. I focus here on how the initial account modifies traditional notions of an abstract agent in favor of a more particularist version of a self-respecting person. An examination of the issues raised by basal self-respect is beyond the scope of this paper.
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I am grateful to Dr. R. S. Turner, Ted Killen, Katelyn MacDougald, and two anonymous referees for comments on previous drafts.
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Waring, D.R. Telling it like it was: dignity therapy and moral reckoning in palliative care. Theor Med Bioeth 42, 25–40 (2021). https://doi.org/10.1007/s11017-021-09542-3
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DOI: https://doi.org/10.1007/s11017-021-09542-3