Introduction
The existential philosopher Søren Kierkegaard emphasizes the importance of accepting the anxiety of personal responsibility. He suggests that as life is deeply contradictory and full of tensions our only option is to learn how to face it and live with it. For Kierkegaard, when we turn our backs on our deepest inner values, we condemn ourselves to despair (van Deurzen et al. Reference van Deurzen, Craig and Längle2019). As such, for Kierkegaard that guilt has existential roots; it is built into life and is inevitable. Kierkegaard introduces three life-view attitudes, the Esthetic, the Ethical, and the Religious (Dion Reference Dion2019). A person preoccupied with the Esthetic is concerned with the physical, the material, and the pleasurable. There is little self-questioning. Guilt is little present. A person will usually encounter the Ethical when they realize the benefits of the Esthetic are short lived and superficial. The person turns toward the inner world and starts to consider the social world and their effects on others. As such, a person’s guilt revolves around everyday, ontic, considerations. The Religious person is someone who knows that social conventions are relative and socialization is not the solution to a contented life. Therefore, life cannot be approached through simple pleasure or with reason, but through faith. The paradox is that the only truths that really matter are those cannot be known. This is ontological guilt, existential guilt. Kierkegaard’s ontological perspective on life and his description of the nature and forms of anxiety and despair influenced philosophers, such as Heidegger and Sartre, and also existential psychologists, such as Binswanger, May and van Deurzen (van Deurzen et al. Reference van Deurzen, Craig and Längle2019).
Heidegger considers guilt in its basic and existential sense as being a prerequisite for living a life that can truly be called “one’s own” or authentic (Binder Reference Binder2022). Thus, like existential anxiety, existential guilt is not considered a negative experience, but a mentor on the path to greater freedom (Cooper Reference Cooper2016). The concepts intended by Heidegger and Kierkegaard are somewhat different from the English concept of “guilt,” and are closer to sense of responsibility in a broader sense. Their concept of existential guilt is an inevitable and ever-present issue. That is, we are always guilty because we are always responsible for ourselves (Binder Reference Binder2022). Heidegger describes existential guilt in the form of “Being-the-ground of a nullity” (Heidegger Reference Heidegger2010). That is, existential guilt tells us that there is no external foundation for our decisions, and that there is no certainty in the future. According to Worrell, existential guilt is revealing and it is a response to the principle of existential uncertainty (Menzies et al. Reference Menzies, Menzies and Dingle2022). This guilt invites a person to be the basis of his action. Thus, when we choose, we must accept the groundlessness that existential guilt provides for us. It also means that we can never achieve all our potential because by choosing one course of action we sacrifice another that could have become ours, had we chosen it. Therefore, choosing always limits the things that are possible for a person. So, we cannot be all our possible selves and we must always exclude some of them (Panza and Gale Reference Panza and Gale2008). Moreover, existential guilt becomes exacerbated when we refuse to take risks or try to deny our agency (Iacovou and Weixel-Dixon Reference Iacovou and Weixel-Dixon2015). So, through the call of conscience, in addition to facing existential anxiety and groundlessness, we also discover resolution and can take responsibility for our lives authentically and recognize its possibilities and limitations in the world we live in (van Deurzen et al. Reference van Deurzen, Craig and Längle2019).
Sartre also uses the term “bad faith.” Bad faith refers to the way we ignore or deny our freedom for example by attributing our decisions or actions to the influence of culture or deterministic power of the past, we are showing bad faith. But on the other hand, if we take the attitude that we can keep all possibilities open without making a choice then we are in a state of “falling” and therefore “guilty” (Iacovou and Weixel-Dixon Reference Iacovou and Weixel-Dixon2015) through denial of ownership of choice.
In the psychological translation of existential guilt, it seems that the tradition of European existential counseling remains closer to Heidegger’s intended concept. That is, these psychotherapists, for example van Deurzen, believe that a person becomes aware of his inauthenticity or bad faith through existential guilt (Van Deurzen and Adams Reference Van Deurzen and Adams2016). According to them, the ultimate goal of counseling and existential psychotherapy is authenticity. An authentic life means the ability to follow the path that one’s conscience shows as the right direction and thus become the author of one’s own destiny (Van Deurzen Reference Van Deurzen2012). As van Deurzen states, instead of following the lead of the people or the “public” (from Kierkegaard) or being immersed in “they” (from Heidegger), the authentic person follows his/her own guide by not going along unthinkingly with what is conventionally “done” or “not done.” Finally, these theorists talk about the cycle or dialectic between authenticity and inauthenticity and say that people constantly fluctuate in a cycle of authenticity and inauthenticity (Van Deurzen and Adams Reference Van Deurzen and Adams2016). We are never simply authentic or simply inauthentic.
Another reading of existential guilt is by psychologists like Rollo May and Irvin Yalom. Following Kierkegaard and Heidegger, Rollo May considers anxiety and guilt to be ontological and says that a person is in a state of anxiety when they face the realization of his/her potentiality. Now, if a person denies these potentials, and fails to realize them, he will be in a state of guilt (May Reference May2015). Binder argues that May’s theory of existential guilt is clearly inspired by Heidegger’s philosophy, but is mainly formulated within the framework of humanist-existential psychology. That is, the existential guilt considered by May is more of a psychological and therefore an everyday “ontic” phenomenon, not an ontological condition and it is always indicative of the unaccomplished construction of the self (Binder Reference Binder2022).
Nevertheless, many common points can be seen between the views of existential guilt from philosophy and existential psychotherapy. A major point is that they all consider existential guilt as a thoroughfare to authentic living and responsible acceptance of realities (facticity), annihilations and limitations. In a word, it can be said that existential guilt is consistent with mental health and is even a part of it (May and Yalom Reference May, Yalom, Corsini and Wedding2005).
Clinically, existential issues are very important in cancer patients (Blinderman and Cherny Reference Blinderman and Cherny2005), and in particular, one of these issues is existential guilt. Also, many existentialist therapists believe that existential guilt is the root of death anxiety and anger during our approach to death. In this regard, Viktor Frankl points out that the latent duty of the process of dying is the relief of existential guilt (Breitbart Reference Breitbart2017). For this reason, the present research is designed to qualitatively investigate existential guilt in cancer patients in order to have a unified, empirical and more concrete understanding of this concept and investigate its presence in the context of contemporary Iranian culture. Following this, it is hoped that suggestions can be made for ways it can be addressed therapeutically.
Methods
Population, sampling method, and inclusion criteria
The statistical population of the current research is composed of all cancer patients in Tehran’s Firouzgar Hospital who were diagnosed with cancer by a specialist in 2022. In this way, this hospital was selected by convenience sampling, and the purposeful sampling method was used to select the participants, and interviews continued until all the obtained categories reached saturation (Speziale et al. Reference Speziale, Streubert and Carpenter2011). The inclusion criteria of the research included the following:
1. That there must be at least 6 months between since the diagnosis of cancer and the participants have full knowledge of their disease (based on the patient’s case file and the initial interview);
2. The patient must have sufficient ability to communicate properly. Therefore, interviews that contained insufficient information, or in which individuals were unable to describe their experiences, were excluded from the study.
Data collection and analysis method
Prospective participants were assured of confidentiality by a numerical code be used instead of their name and that the recorded interview files would be completely deleted after being transcribed. In order to respect the rights of the participants, a written informed consent was signed by them. The participants were subjected to face-to-face semi-structured in-depth interviews by the first author. A safe and quiet place where people feel comfortable was allocated for conducting the interviews. Since a concrete, accurate, and uniform definition of the concept of existential guilt was not available, the conventional content analysis method was used. Thus, the interview started with this general question: “What is your experience of your illness and current condition?” Then more open-ended questions were asked, such as: “How do you feel about yourself, the life you’ve lived and the life you have ahead of you?” The participants’ answers to these main questions guided and determined the follow-up questions. In order to analyze the data obtained from the interviews, the method of Graneheim and Lundman (Reference Graneheim and Lundman2004) was used. In this way, the interviews were recorded and then transcribed on paper, and then the final text was typed on a computer. After several reviews, the transcription of the interviews was broken down into constituent semantic units, and then into smallest meaningful units, and a number was assigned to them, as the initial concept. Afterwards, the codes were reviewed for several times in order that they could be replaced into main categories and sub-categories based on their semantic similarity. The initial texts and final categories were reviewed for several times until the researcher and participants reached a semantic agreement on the categories.
Scientific accuracy and validity of the findings
To determine the accuracy of the data, the four criteria of credibility, transferability, dependability, and conformability were used (Lincoln and Guba Reference Lincoln and Guba1986). In order to determine the credibility of the data, there was a continuous engagement with the subject and data of the research. The text of the interviews and the extracted codes and subcategories were discussed with the participant, supervisors, and advisors, and their opinions were used. In order to determine the dependability of the data, an external observer familiar with qualitative research was asked to review the data, the work processes, and findings. To determine the conformability of the findings, all the activities carried out including the process of doing the work and how the findings were obtained were documented. Finally, to determine the transferability of the data, the findings were discussed with two cancer patients who were outside the research and had the same condition as the participants in the research, in order to ask them for their opinion on the data.
Findings
The demographic characteristics of the 18 participants of the present research – who reported significant levels of existential guilt – are listed in Table 1. The result of the interview with these patients was 94 codes or initial concepts related to existential guilt, which were obtained after the final analysis of three main categories, which are as follows: (1) incompleteness, (2) passivity, and (3) feelings of harm to self and others. Each of these categories includes sub-categories that we have described below along with patient quotes.
Incompleteness
These patients complain about the destruction of their usual life process due to the disease and its progress, and they also have a vague feeling about the future, and they are especially worried about the future of their loved ones after their possible death. The incompleteness category that arises from facing the threatening cancer disease consists of two subcategories:
1. Worrying about the future of their loved ones: The patients participating in the present research are worried about the future of their family members, especially the younger and more vulnerable members. They are worried that what kind of fate their loved ones will face after their decease. As patient number 1 says: “Cancer makes this future path unclear for me, you don’t know if you can continue or not, the dream I have for my daughter can come true or not. I have to provide for my daughter’s future.” Such statements suggest that the patients are worried about their family members due to their sense of responsibility; to the extent that they may hide the illness from them in order to take care of them: “I’m just worried about my mother. I don’t want her to know that I got sick. If she finds out, she’ll suffer. I’m worried about her” (participant number 13).
2. Disturbance in the current and future life course: Cancer disease disrupts a person’s routine and plans and blurs the person’s image of the future. In this regard patient number 14, who is 20 years old, says: “You know, my life has not progressed to the point where I wish to live a challenging life. That’s what bothers me.” The statements of patient number 12 show the intensity of this impact better: “All my plans and all my ideas of a marital life and the future have been ruined. Lung cancer is not a joke. With this disease, all my threads for the future became cotton.” In general, the concept of incompleteness in these patients shows that the current life, joint plans for the future, and the future of their loved ones are in an aura of great uncertainty due to the disease, and it seems that there is the least certainty and predictability possible.
Table 1. Sociodemographic characteristics of participants
Passivity
This concept shows that after facing cancer as a borderline situation, and thinking about their lived life, patients regret, and are unhappy with their way of being or acting, which is characterized by a kind of passivity. This category consists of five subcategories:
1. Lack of self-expression and following others: patients who feel that they have imitated others too much, have put other’s problems on their own shoulders, and sacrificed themselves excessively, have lived under the control of others and in a way dependent on them, and have often lived to please others, feel regret. For example, patient number 9 says: “I never took care of myself. I got burned by the problems of the people around me.” And patient number 7 says: “If I get back, I will do what I wish. I’m going to work for myself, I won’t be so dependent on my husband.”
2. Lack of agency and action: Realizing necessary but undone actions and the ability to do more actions in the past, feeling like continuing to make obvious mistakes, entrusting important life decisions to others, and not dealing with problems effectively, indicate that one is sorry for this passivity. For instance, patient number 17 says: “I could do many things. It makes me feel bad to think how much better I could be than this. I can even say that I became nothing, I have nothing to be proud of. I don’t know how these 37 years of my life passed, I ask myself, what did I do?”
3. Failure to pursue important talents and interests: Patients who feel that they have failed to realize their talents, or pursue their interests, somehow feel guilt and regret in relation to these unfulfilled potentials. For example, patient number 6 states: “I think I spoiled myself a lot… I loved studying, I liked art a lot, I wanted to be someone…” Or patient number 9 says with the regret of not being a mother: “I liked being a mother very much. 15 years have passed of our marriage and we did not have children. One of my mistakes was not pursuing motherhood… Now that I am sick, I can never be a mother.”
4. Lack of career dynamism: Patients stated that pursuing an undesired job and work schedule, or in other words, not having a job in which they feel dynamism and harmony, especially when they blame themselves for this lack, gives them an unpleasant feeling. For example, patient number 17, who does not consider himself following a specific program, says: “I did not follow any specific [work] program. That’s why I was always so depressed that I didn’t have the guts to live, as if there was never anything that I was very serious about.”
5. Postponing life: After facing a life-threatening illness, patients realize how much they have neglected life, neglected important things, and devoted themselves to work. As patient number 3 says: “I feel I owe it to myself and my wife. The life of an employee was such that I did not leave time for myself and my wife. We did not have a good trip. It didn’t fit, all work, work.” And patient number 17 says about neglecting the value of life: “Life is a great and strange opportunity. On the other hand, we ignore it and leave it alone, and when we are very seriously ill, we realize its value and importance and cling to it with both hands. I did ridiculous things and ignored life.”
Feeling of harm to self and others
It is the third and last concept or category of the present research. The feeling that I have harmed myself or others, that I have been careless, that I have not fulfilled my duties, makes people feel guilty. This concept includes two subcategories:
1. The feeling of harming self: Harming oneself includes harming one’s body and health. For example, patient number 18 says: “I humiliated myself a lot with addiction and became a prisoner of something that had no end.” Or patient number 6 states: “Three years ago I felt a small tumor in my chest. The gynecologist said it was a cyst, but you have to follow up. I was very relaxed. These things did not matter to me. I mean, I said that everything will be solved by itself… I left it for a year and it was growing.”
2. Non-constructive relationship with others: patients who did not have satisfactory relationships with others, especially family members, experienced feelings of regret and guilt and the need for compensation. In this regard, patient number 10 states: “A female colleague entered into a relationship with me… It’s been eight years now that I’ve been leading two lives at the same time. …Well, I spent a large part of the time I should have left for my wife and our child in another relationship. For example, I spent all my vacations with that lady… Now that I’m dealing with my illness and I find myself facing death in an unusual way, it’s time to reach my wife and child and make up for these years.”
Undoubtedly, these categories and sub-categories overlap with each other in some places. For example, not realizing important interests and talents overlaps with not having a desirable job consistent with one’s values and capabilities, and not having agency in life. But what is important is that these patients experience existential guilt in different ways.
Discussion
Typically, most people in Iranian culture are not familiar with the concept of existential guilt, and would probably confuse it with moral or religious guilt. But when we listen to their words about how they live their life, they express regrets, remorse, and dissatisfactions that they usually blame themselves for.
Being free and being finite provides the ground for imperfection, and as a result, we cannot overcome this ontological-existential finitude and the consequent existential guilt (Dion Reference Dion2019). As we have seen in the present research, cancer patients face more and more incompleteness and the serious possibility of not realizing their desired possibilities. That is, patients find out that many of their desires, responsibilities, and plans for their loved ones are left incomplete or there is a serious possibility that they will remain incomplete themselves. Therefore, it can be said that one of the sources of existential guilt is the incompleteness that patients experience especially in the form of ambiguity, worry, and uncertainty. According to Breitbart (Reference Breitbart2017), practitioners should consider sources of existential guilt in cancer patients. The incompleteness that cancer causes, in turn, feelings such as anger, fear, and worry in patients. Breitbart suggests strategies for mitigating this aspect of existential guilt in patients with advanced cancer: completing tasks that can be completed; planning in order to feel confident about the safety of the family; paying attention to the fact that the patient’s wife/husband is able to successfully raise and take care of the children; allowing the spouse in advance to be free to remarry or regain happiness; and writing advice for children so they can accept the bereavement (Breitbart Reference Breitbart2017). Practitioners can also help patients to plan a flexible and dynamic daily schedule, taking into account existing conditions, and, if needed, revise their goals, daily schedules, and life priorities. Additionally, it is useful to consider inherent human imperfection, and here the therapist can help the patient forgive himself simply for being human – that defect is an inherent part of him (Breitbart Reference Breitbart2018).
The more we hide from our freedom and potentiality, the more we will experience this guilt (Cooper Reference Cooper2016). In fact, incompleteness is something that the disease and the construction of existence gives to the patient, but passivity – which causes existential guilt – depends to a large extent on the patient’s performance. As we can see it in the passivity category in the present research, patients reported passivity and lack of agency in different ways in their lived life. This passivity is composed of a feeling of a wasted life and paths not taken, unfulfilled talents and potentials, which aggravates the existential guilt in people. This category is consistent with the literature of existential psychology. For example, from the point of view of Van Deurzen and Adams (Reference Van Deurzen and Adams2016) and Adams (Reference Adams2013), existential guilt indicates such things as: not facing the basic anxiety of life and getting used to temporary and wrong reliefs; following they or the public; ignoring important and necessary tasks and pretending to be unable to do something; lack of seriousness in life and being reactive instead of active; inability to realize one’s potential and feeling indebted to oneself. So, what should be done with this regret and guilt, especially in the setting of cancer? As Cole (Reference Cole2016) says, the experience of existential guilt and anxiety can represent an experience of authenticity. In fact, through facing these regrets, authentic existence reveals everyday versions of the finitude due to the inability to change the past (Cole Reference Cole2016). Here it can be said that the main component and challenge of authenticity, as defined by Spinelli (Reference Spinelli2014) is: “Remaining open to and embracing that which is there in the way that it is there.” This could means accepting the life as lived and, of course, looking at the present and the future. In fact, being receptive to this guilt can pave the way for accepting the past, and moving on to what is necessary in the here and now. Although the call of conscience confronts us with inauthenticity and existential guilt (van Deurzen et al. Reference van Deurzen, Craig and Längle2019), existential guilt is considered a constructive emotional state that calls us to examine our assumptions about ourselves and our relationship with the world and examine potential ways of being (Binder Reference Binder2022). According to Rollo May, existential guilt is the perception of the difference between what is and what should be (May Reference May2015). So, the participants of the current research were aware of this gap that they consider themselves to be the cause of, and it is up to the therapists to encourage them to step toward authenticity, and change what is needed. By listening to the voice of their own conscience, patients can find out what is appropriate, necessary and right in this situation, probably in spite of the little time which is left for them.
An important point that should not be neglected is the dialogical aspect of existential guilt. Some of the participants of the present research felt guilty about harming others and not having constructive relationships with others. According to Friedman (Reference Friedman2002), who is influenced by Martin Buber, our existence becomes real only in the inter-human dimension, in our relationships, and therefore, existential guilt cannot be limited to the area of the person’s non-fulfillment of potentials (Friedman Reference Friedman1991). According to Buber, relationships make us who we are. He describes the I-thou relationship as a cooperative and mutual relationship. Man becomes I through the sense of the other; it is the “thou” that makes us present (Buber Reference Buber1970). In fact, our potential as a person is fundamentally tied to our ability to form relationships with others (Binder Reference Binder2022). Nevertheless, wherever there are relationships, there can be a ruptures. Rollo May (Reference May2015), thinking relationally, considers existential guilt toward our fellow human beings to be caused by the fact that we all, as individuals, see others from our own limited and biased point of view. This means that we always show some degree of violence toward others and we always fail to understand and meet the needs of others to some extent. In fact, this guilt that is rooted in our existential structure is one of the most powerful sources of healthy humility and an unsentimental attitude of forgiving others (May Reference May2015). As the participants of the present research reported, not having distinct and meaningful relationships (either blindly following others or neglecting and harming them) was actually a kind of harm to self. However, what is important here is the ability to forgive oneself, seek forgiveness from others, and make amends for some mistakes (Breitbart Reference Breitbart2017) and try to improve relationships with others. It is important that therapists do not pass by the patient’s statements about dialogical guilt easily. In this regard, Buber (Reference Buber1957) describes three steps to compensate for the damaged order: (1) self-illumination: it means listening to the conscience that does not shy away from looking into the depths. And then, (2) the patient shows endurance and tolerance in this path of illumination so that he can reach the main stage of reconciliation; and (3) so that he can actively, and through an active devotion to the world, restore the order damaged by him in a way. Because of the uniqueness of each person’s relationship to the human order, no one but the person who caused the damage can heal the damage. According to Buber, the person or persons whom we have harmed may not even be alive, but we can heal the harm in an infinite number of situations other than where we have harmed them (Friedman Reference Friedman1991). The important point is that each patient can find his own way and path to repair the damage and the therapist should be by his side to discover and finally follow this personal path.
Conclusion
As far as we know, the present research has qualitatively investigated existential guilt in cancer patients for the first time and suggests that the concept of existential guilt is not just an abstract and philosophical concept. Rather, all of the patients in our sample experienced this feeling of guilt to different degrees, and familiarizing therapists with this feeling of guilt seems necessary. Existential guilt is the revealer of groundlessness and imperfection that must be accepted and accompanied, and it is also a call from ourselves to ourselves, a reminder of our debt and failure to ourselves, our lives, and of course, to those around us. Hiding this feeling of guilt from the therapist’s eyes is like hiding the feeling of physical pain from the doctor’s eyes, as a result of which its source remains unknown and untreated. This hiddenness denies the patient the opportunity to open up to this feeling and, as a result, make the most of it and mitigate it, because mitigating existential guilt in efficient ways means living an authentic life. In fact, heeding the call of conscience is a way to live a life clearly threatened by cancer.
Acknowledgments
We sincerely thank the dear patients who agreed to cooperate in this research, and considered the researcher as a worthy person to talk about their feelings and experiences with.
Author contributions
The original idea belongs to Arian. He has played an active role in interviews and writing the article. Khanjani was the supervisor of this research and helped greatly in its designing and writing. Adams provided effective help in the philosophical part of the article, reviewing it, and editing the scientific language. Ebadi played an effective role in qualitative method and content analysis. Younesi and Azkhosh were involved in data analysis. Hosseinzadeh played a prominent role in searching for sources. All authors read the manuscript effectively and made some changes.
Funding
This study is a part of the first author’s doctoral thesis titled “Explaining the concept of existential guilt, developing the instrument and psychometric properties in patients with cancer” which approved at the University of Social Welfare and Rehabilitation Sciences (code of ethics IR.USWR.REC.1401.003.).
Competing interests
None.
