“Financial Toxicity” from the Perspective of "Human Dignity": An Ethical Reconsideration in Cancer Care
Introduction
I recently attended the Annual Meeting of the Multinational Association of Supportive Care in Cancer (MASCC), held in Seattle over three days from June 26 to 28, 2025. This year’s program was particularly noteworthy for the depth of its scientific discourse and the coherence of its structure, setting it apart from previous conferences. Among the various sessions, I was particularly drawn to the discussions on “Financial Toxicity,” which has emerged as a critical global issue in cancer care. My primary objective in attending was to engage directly with the “live discussions” among leading international researchers who are actively addressing this complex challenge.
 
The Current Landscape Regarding Research on “Financial Toxicity”
“Financial toxicity” refers to the multifaceted negative impact of the economic burden associated with cancer treatment on patients and their families, particularly in light of the increasing use of high-cost therapies such as molecular targeted drugs, immunotherapies, and gene therapies. This issue has rapidly gained attention in the context of health policy and clinical ethics. To date, much of the research has focused on identifying and understanding the extent of financial toxicity, with repeated findings highlighting its serious effects on treatment continuity and patients’ quality of life (QOL). More recently, there has been growing interest in addressing the problem through shared decision making (SDM), an approach in which healthcare providers and patients work together to determine the most appropriate course of treatment.
In particular, there has been progress in the implementation of decision aids and cost communication, both of which aim to support patients in making informed choices that align with their personal values and financial circumstances. These research efforts have largely converged on how to effectively integrate SDM into individual decision-making processes in clinical settings.
However, within the current context of cancer care (particularly in palliative care, where interdisciplinary collaboration is already well established), SDM has become an implicit and routine part of clinical practice. In this sense, the discussions at this year’s annual meeting did not necessarily transcend what is already accepted in the field. That said, the depth of inquiry and the strong clinical interest demonstrated by researchers clearly reflected the urgency and gravity of the issue.
 
The Concept of “Human Dignity”
From the latter half of the 20th century into the early 21st century, the episteme of medicine; that is, the underlying system of knowledge shaping a given era's worldview, as theorized by Michel Foucault, has been largely supported by the concept of Quality of Life (QOL). In cancer care as well, the advancement of medical practice has been significantly driven by efforts to enhance QOL based on patient-centered values. However, as I have repeatedly emphasized in platforms such as the Sapporo Conference for Palliative and Supportive Care in Cancer newsletter, I believe that the concept of "human dignity" as a more fundamental ethical foundation that cannot be fully captured through the visible and measurable framework of QOL alone is now emerging as a central guiding principle in clinical practice.
 
The term “human dignity” as used here does not refer to the common vague or ambiguous notions of “dignity” or “honor.” Rather, it is grounded in the principle articulated by Immanuel Kant in his Groundwork of the Metaphysics of Morals, which states that “a person is an end in themselves and must never be merely treated as a means to an end.” This reflects a philosophical stance by which human existence possesses inherently non-exchangeable and inviolable value. From this standpoint, “human dignity” serves as a normative criterion for evaluating whether our medical actions (including decisions about treatment plans and the design of healthcare systems) truly regard individuals as ends in themselves.
From this perspective, it provides an extremely important clarification by viewing patients not as "subjects of treatment" but as "beings who live meaningful lives."
 
“Financial Toxicity” from the Perspective of “Cultural Ethics”
The issue of financial toxicity goes beyond the mere visualization of economic burden. Rather, it poses an ethical question: does this burden impede a patient’s process of self-formation and meaning-making; that is, the fundamental human endeavor to narrate, choose, and live one’s life as one’s own? In situations where patients are unable to choose the most appropriate treatment due to financial constraints, or even when they can, the social pressure is so great that their decision can hardly be considered an act of free will, and the institutional justification of "respecting the patient's wishes" alone cannot be said to have fulfilled ethical responsibility.
If we understand this framework as one of “cultural ethics”, it points to an ethical perspective that acknowledges medicine as deeply embedded within social, historical, and cultural contexts, and intimately tied to prevailing values around how people live and die.This perspective calls for medical care to be provided in a manner that respects the worldviews, beliefs about life and death, and social backgrounds of patients and their families, rooted firmly within their cultural context.
I have often said that “medicine is a science, but medical care is culture.” Culture itself has a layered structure, evolving from material and institutional aspects (material culture), through behavior and relationships (behavioral culture), to values and views on life and death (spiritual culture). The problem of financial toxicity carries the risk of cutting off this cultural progression, through economic constraints, at its earliest, most material stage before it has a chance to unfold and deepen.
When financial hardship silently robs patients of their ability to speak, to hope, and to find meaning, it is not only a matter of treatment choices; rather, it is fundamentally an issue of cultural ethics.
 
Conclusion
In light of these circumstances, future discussions in cancer care, including those surrounding financial toxicity, must be grounded in human dignity as a point of departure. It is essential to reconstruct ethical medical practice on the basis of this fundamental ethical value. Only from this starting point can we reexamine and recontextualize practical concepts such as QOL and SDM, revealing their deeper significance beyond procedural legitimacy.
Supporting patients who face financial toxicity ultimately means asking how we can protect and sustain the conditions that allow them to live a meaningful life as human beings, which is our most fundamental ethical responsibility.
 

References
1.Kant I. Groundwork of the Metaphysics of Morals. Translated by Mary Gregor. Cambridge University Press; 1997.　
This is the classical work that laid the foundation of Kantian ethics. His notion that "a person is an end in themselves" defines human dignity, and continues to serve as a central principle in modern medical ethics.
2.Virchow R. Mittheilungen über die in Oberschlesien herrschende Typhus Epidemie. Berlin: G. Reimer, 1848. 
In 1848, Rudolf Virchow was commissioned by the Prussian government to investigate a typhus outbreak in Upper Silesia. In his report, he pointed out that the cause of the epidemic was not purely an infectious disease outbreak, but was rooted in social factors such as poverty, poor living conditions, lack of education, and political neglect. He argued that fundamental solutions to illness required reform of the social structure. His famous statement, "Medicine is a social science, and politics is nothing else but medicine on a large scale," remains widely known. This report laid the foundation for social medicine and public health.
3.Link BG, Phelan JC. Social Conditions as Fundamental Causes of Disease.Journal of Health and Social Behavior, 1995, Vol. 35, Extra Issue: Forty Years of Medical Sociology:The State of the Art and Directions for the Future, pp. 80–94. DOI： 10.2307/2626958
The authors pointed out that social and economic factors are risk factors for disease, and that inequalities in access to healthcare in particular lead to health disparities, which are perpetuated without intervention through social policy. This study continues to serve as a basis for research and policymaking in social epidemiology and the social determinants of health.
4.Zafar SY, Abernethy AP. Financial toxicity, Part I: a new name for a growing problem. Oncology (Williston Park). 2013;27(2):80-1, 149 PMID: 23530397This pioneering paper was the first to introduce the concept of “financial toxicity” on a broad scale. It highlights the impact of the economic burden associated with cancer treatment on patient quality of life and treatment decisions.
5.Delgado-Guay MO, Ferrer J, Rieber AG, et al. Financial distress and its associations with physical and emotional symptoms and quality of life among advanced cancer patients. Oncologist. 2015;20(9):1092-1098. doi:10.1634/theoncologist.2015-0026
This empirical study demonstrated the association between financial distress and physical symptoms, psychological burden, and quality of life in patients with advanced cancer, providing clinical evidence for the impact of financial toxicity.
6.Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6　
This seminal paper presented a clinical model of shared decision-making (SDM), proposing a practical framework to support collaborative treatment decisions between patients and healthcare providers.
7.Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. Basic Books; 1988.　
A classic work in medical anthropology, this book illustrates how illness narratives reveal how medical care should be understood within cultural and personal contexts, laying the foundation for “cultural ethics.”
8.Mack JW, Smith TJ. Reasons why physicians do not have discussions about poor prognosis, why it matters, and what can be improved. J Clin Oncol. 2012;30(22):2715-2717. doi:10.1200/JCO.2012.42.4564　
A brief report examining why physicians often withhold poor prognoses from patients, discussing its significance and areas for improvement. It includes a perspective that questions the “structure of silence” in decision-making support.
9.Unger JM. Financial toxicity: A ubiquitous condition in patients with cancer. Cancer, Volume131, Issue4,15 February 2025.e35748DOI:10.1002/cncr.35748
This study clearly demonstrated that financial toxicity is widespread among cancer patients, with 34% of participants in early-phase clinical trials (phase 1/1-2) experiencing thus problem. Financial toxicity was associated with reduced quality of life and psychosocial distress, but no significant difference in survival rates was observed. 10.Ishitani K. SCPSC Newsletter New Year Special Issue has been published on BMJSPCare Blog.https://blogs.bmj.com/spcare/2024/02/15/irs-scpsc-newsletter-new-year-special-issue/
The 2024 New Year issue of the SCPSC Newsletter, published on the BMJ Supportive & Palliative Care Blog, presents a perspective that centers on human dignity and moves beyond traditional notions of quality of life.