Note: The following essay was published by the Park Ridge Center for Health, Faith, And Ethics ( in 2003.

Abiding Loneliness: An Existential Perspective On Loneliness

By Michele A. Carter

Loneliness is a condition of human life, an experience of being human which enables the individual to sustain, extend, and deepen his humanity. Loneliness is within life itself. [1]

Throughout history, accounts of loneliness appear in the writings of poets, novelists, theologians, and philosophers. Loneliness, whether a state of being alone, feeling lonely, or experiencing solitude, is portrayed as an essential aspect of human existence, an inescapable fact of life. Loneliness is depicted as one of the most profound and disturbing of human experiences, often resonating with the more contemplative or spiritual aspects of our being.

Like suffering, existential loneliness is a spiritual phenomenon that may be conceived of in either positive or negative terms. It may be inherently valuable, a source of creativity and a means of reconciliation and revelation, particularly for patients with terminal illness. The purposeful and therapeutic engagement of the patient's experience of existential loneliness can deepen our understanding of human need and of the moral responses appropriate to it, paving the way for a more meaningful experience of life and death.

Here I describe existential loneliness from three distinct frames of reference: philosophy, literature, and clinical care, and suggest that the more common approaches to the "treatment" of loneliness are insufficient. I briefly summarize some of the social science literature that depicts loneliness as abnormal and destructive, a condition requiring remedial measures.

Writing about the existential dimensions of illness is fraught with difficulties. First, the term existentialism is usually associated with abstract, philosophical notions that are believed to have little use in the concrete, science-based, and decision-oriented culture of health care. The latter half of the twentieth century was marked by an unprecedented proliferation of advances in scientific and medical achievements. In the effort to eradicate human disease we have amassed considerable scientific knowledge and medical technology. And yet, as the discourse of progress infiltrates our social practices, personal relationships, and healing institutions, something important to our humanity seems unutterably lost. Many contemporary writers decry the spiritual emptiness, violence, and impoverishment of meaning so evident in these postmodern times. Indeed, in a generation so estranged from the inner domain of the soul that many argue it simply does not exist, the implausible effort by some to "quantify the heart's agony and ecstasy" [2] leaves us lonely, disengaged from our deeper selves. The quest for authentic existence and the search for meaning intrinsic to the existential mode of being certainly seem at odds with an American view of the pursuit of happiness, wealth, and leisure as the highest good.

There is a second reason why it is difficult to talk about existential concepts in the health care arena. If and when existential ideas of doctoring or nursing are discussed in teaching programs or with patients and families, they inevitably provoke questions about vulnerability, angst, anxiety, emptiness, and the search for meaning. For health care professionals trained to be objective, to solve concrete problems, to follow a plan of care toward a particular end, and above all to do no harm, existentialism can be an unwelcome and alien concept. And yet, how many of the corridors of hospitals and clinics are filled with people, patients and practitioners alike, whose genuine sickness is despair, loss of meaning, and loneliness-one treatment for which lies buried deep in our shared humanity? For some patients, even those committed to the spiritual discipline of solitude, illness can disrupt one's faith and provoke new forms of isolation and aloneness not previously experienced. For others, patients and caregivers alike, the very idea that loneliness could be a path to our shared humanity and thus a moral good is simply too vague, threatening, and unacceptable.

Loneliness has been variously interpreted. Most health care providers have sociological and psychodynamic views. Psychologist R.S. Weiss defines loneliness as a response to the absence of a particular type of relationship or attachment. [3] There are two types: emotional loneliness and social loneliness. Emotional loneliness occurs in the loss or absence of a close attachment figure, such as a spouse or partner. Social loneliness refers to isolation one feels when there is an absence of an engaging social network. Similarly, K.S. Rook defines loneliness as "an enduring condition of an emotional state that arises when a person feels estranged from, is misunderstood or rejected by, and/or lacks appropriate social partners for a desired activity, particularly activities that provide a sense of social integration and opportunities for emotional intimacy." [4]

Scholars in psychology, sociology, nursing, and social science have tracked the prevalence of loneliness in American life, with estimates ranging from 8.4% to 10% in childhood [5] to 25% among adults in 1969. [6] Loneliness is particularly troublesome for such disparate groups as single adolescent mothers with low incomes, alcoholics, freshman college students, divorced and widowed adults, and the elderly. It is inversely related to measures of self-esteem and strongly associated with anxiety, depression, interpersonal hostility, substance abuse, suicide, health problems [7], and eating disorders. [8] Clearly, social loneliness is a subjective and multidimensional state involving emotional distress, social inadequacy, interpersonal isolation, and self-alienation. [9]

Psychodynamic perspectives view loneliness as pathological, resulting usually from problems in interpersonal relationships, or in infant and childhood attachments. Social loneliness has been associated with symptoms seen in neuroses [10] and schizophrenia. [11] Intolerance for being alone was included in the Diagnostic and Statistical Manual of Mental Disorders third edition as one of the diagnostic criteria for borderline personality disorder. [12] In a recent publication on the relationship of loneliness, narcissism, and intimacy, psychoanalyst Shmuel Erlich notes that although descriptive accounts of loneliness are a common phenomenon in clinical psychoanalytic theory and practice, the meaning of loneliness remains "an enigma." [13]

Thus, sociological perspectives are concerned with social and environmental forces that increase or intensify the prevalence of painful feelings associated with being isolated or feeling alienated from others. Psychodynamic perspectives see loneliness as unpleasant and distressing and look to deficits or inadequacies in the character or development of the individual as root causes.

These frameworks reflect a deeply disturbing and paltry account of what the experience of being human calls forth. To regard loneliness as abnormal is to misunderstand its vital purpose in our lives: to discover and accept who we are, and to reconcile ontological claims of human finitude with our needs for personal connection and spiritual transcendence. The existential perspective, on the other hand, regards loneliness as intrinsic to what it means to be human.

Existentialism is a philosophical movement that takes the central question of philosophy to be that of the meaning of human existence. It is regarded by some as a revolt against traditional philosophy and its concern with objectivity, reason, and what Immanuel Kant called the "thing-in-itself." Existentialism cannot be reduced to axioms or principles; it is concerned with people as they consciously experience the phenomena of everyday life-the anxieties, moods, concerns, and choices made possible by human freedom. Existentialism concerns itself with the engagement of the self in the activities and projects of life, including the subjective projects of ascribing meaning or purpose to our actions and pursuits. It deals with questions about how to live authentically, how to confront one's inner life, and how to approach the problem of death. Most forms of existentialism explore the conditions under which human life is ordered and experienced. Existentialism asks what it means "to be" or "to become," and proposes the ontological questions, "Who am I? Why do I exist?" Put another way, why are we? What is the purpose for which we live? What gives life its meaning, value, dynamic force, and rational aim? In its final chapters, or even at this present moment, can I genuinely say of my life that it really matters at all? And finally, what is it that death cannot destroy, to which I contribute something of value that abides and serves every moment of my life? Existentialists do not provide systematic answers to these questions, because the task for each of us is to accept responsibility for who we become-a challenge that provokes a quest for individual meaning and, paradoxically, a desire to connect one's separate existence to the existence of others. This paradox, that each person is, on the one hand, an independent and unique self striving for meaning and purpose in a particular human life, and yet also a relational, social self that depends on others to become more fully human, reflects the universal tension of human co-existence.

Even intensely religious persons ask these questions of themselves. For Søren Kierkegaard, the Christian existentialist, it is not possible to escape being what one is-a finite, temporal, interior self "thoroughly absorbed in the root by which he is connected with the whole." [14] His writings bear witness to the necessity of affirming the integrity of the individual self in the concrete activities and choices of daily existence. For Kierkegaard, human existence manifests in three basic modes or spheres: the aesthetic, the ethical, and the religious. In describing these stages of life, Kierkegaard's concern is to demonstrate the utter subjectivity of human existence, especially in relation to the question of what it means to be a Christian.

The aesthetic sphere of life is marked on the surface by the pursuit of pleasure and materiality but masks a passive alienation and loneliness. In the ethical sphere the individual engages a sense of duty, moral reflection, and choice. For Kierkegaard, the stages of life culminate in the religious sphere, marked by a deliberate leap of faith whereby the gap between the finite and infinite, the immanent and the transcendent is bridged. For Kierkegaard, faith always involves a choice, a daring risk, and a commitment, and the sole antidote to the common experience of despair or loneliness is the courage of faith. Without this leap of faith, the individual remains forever alienated from the ground of his very being. The purposeful confrontation of the despair which constitutes the loneliness of being, becomes a means of revelation and recovery.

Many writers in the Western tradition portray this existential form of loneliness as an unavoidable condition of our humanity. It resides in the innermost being of the self, expanding as each individual becomes aware of and confronts the ultimate experiences of life: change, upheaval, tragedy, joy, the passage of time, and death. Loneliness in this sense is not the same as suffering the loss of a loved one, or a perceived lack of a sense of wholeness or integrity. Further, it is not the unhealthy psychological defense against the threat of being alone, especially if being alone means we must confront the critical questions of life and death. Rather, existential loneliness is a way of being in the world, a way of grasping for and confronting one's own subjective truth. It is the experience of discovering one's own questions regarding human existence, and of confronting the sheer contingencies of the human condition. From an existential perspective, the lonely individual seeks to grasp some meaning in the face of life's impermanence, the angoisse of human freedom, and the inevitability of death. In his beautiful and tragic essay "God's Lonely Man," novelist Thomas Wolfe connects the intense loneliness of his own life to this universal aspect of humanity. He writes:

The whole conviction of my life now rests upon the belief that loneliness, far from being a rare and curious phenomenon, peculiar to myself and to a few other solitary men, is the central and inevitable fact of human existence. When we examine the moments, acts, and statements of all kinds of people-not only the grief and ecstasy of the greatest poets, but also the huge unhappiness of the average soul…we find, I think, that they are all suffering from the same thing. The final cause of their complaint is loneliness. [15]

For Wolfe, the experience of loneliness is neither strange nor curious, but "inevitable and right" because it is part of the human heart. Just as the experience of joy is heightened by sorrow, loneliness, "haunted always with the certainty of death," [16] makes like precious. Loneliness and death are thus inescapable facets of human existence, each ontologically necessary for a coherent human life.

Loneliness is not the experience of what one lacks, but rather the experience of what one is. In a culture deeply entrenched in the rhetoric of autonomy and rights, the song of God's lonely man so often goes unvoiced and unheeded. It is ironic how much of our freedom we expend on power-on conquering death, disease, and decay, all the while concealing from each other our carefully buried loneliness, which if shared, would deepen our understanding of each other.

The notion that loneliness is a positive good and an ontological necessity can be traced to the philosophical works of the German existentialist, Martin Heidegger. In Being and Time, he develops the idea that human existence is understood through a particular individual's personal and practical concerns. [17] By fully engaging in these concerns and the projects that matter to us we become open to what we are: subjective, vulnerable, responsible, and self-interpreting beings. It is up to each person to decide how to face the loneliness of imminent death or the threat of meaninglessness, which strikes at the root of existence. According to Heidegger, we are in an authentic mode of existence when we choose and act with full awareness of our ultimate freedom, responsibility, finitude, and aloneness. In contrast, the person who flees from these human conditions and permits others to define and shape his values surrenders himself to an anguished and inauthentic life.

In his moving treatise Loneliness, Clark Moustakas probes the depths of loneliness from a phenomenological perspective. In his view, existential loneliness is that fundamental human attitude or experience provoked by the quest for being. A person enters the state of loneliness when some compelling, essential aspect of life is suddenly challenged, realized, threatened, altered, or denied; the individual is confronted with the awareness of choice and the possibility of meaning or its lack. Loneliness is not merely a normal part of human life, it is essential for human growth and authentic existence. By truly experiencing loneliness, the individual affirms his being and authenticity. When positively embraced and confronted, loneliness has a salutary role: the integration and deepening of self. Through loneliness, the individual "discovers life, who he is, what he really wants, the meaning of his existence, [and] the true nature of his relation with others." [18] To face up to our loneliness, to recognize it in the faces of others, is to participate in morality itself.

Moustakas distinguishes between two types of loneliness. There is the loneliness of solitude in which one experiences a peaceful state of being alone with the ultimate mysteries of life-the harmony of people, nature, faith, and the universe. Secondly, there is the loneliness of a life suddenly shattered by tragedy, illness, betrayal, deceit, and death. The crisis penetrates the person's immediate world. [19] When this experience occurs, the loneliness is unique to each individual and is expressed in many ways. In confronting loneliness, the individual directly faces the crisis with a willingness to experience fully the emotions the crisis has generated: fear, grief, bewilderment, pain, or loss. Confronting these emotions gives rise to suffering, but this suffering in turn deepens one's sensitivity to self and to others, paving the way to healing, to true compassion, and to a sense of renewed vitality and hope.

This idea that loneliness is a fundamental aspect of our spiritual selves is central to the work of theologian Paul Tillich, whose existential writings were informed by Kierkegaard. In The Eternal Now, Tillich regards loneliness as an inevitable facet of human existence, but one that is ultimately manifested in personal and spiritual growth. The experience of being alone becomes a source of creativity and a heightened sense of self, which often results in more profound connections with other individuals or God. To be aware of one's loneliness or of the existential quest for meaning in life requires courage. This is both an ethical reality and an ontological concept. Ultimately, it is through faith that one has the courage "to be as oneself:" an authentic being. [20]

In a similar vein, Thomas Merton invokes this idea of human transcendence. In Thoughts in Solitude he writes:

The man who fears to be alone will never be anything but lonely, no matter how much he may surround himself with people. But the man who learns, in solitude and recollection, to be at peace with his own loneliness, and to prefer its reality to the illusion of merely natural companionship, comes to know the invisible companionship of God. [21]

For each of these religious existentialists, only in the crisis of loneliness and despair can an individual have access to the truth about him or her self. In the end, this subjective truth is the path of reconciliation, but getting there requires initial confrontation and subsequent faith. In confrontation with the self, the individual is summoned to a deeper existence, which produces a deeper suffering, or an even deeper faith. As Kierkegaard notes, recovery or reconciliation presupposes that love is present, "like the sprout in the grain," [22] and opens the way to forgiveness and self-transcendence.

The literature on human loneliness is immense and provocative. Many thinkers have declared existential loneliness an inevitable and inescapable facet of human life, and that its conscious presence in our lives can lead to a more profound sense of meaning and spiritual purpose. How does the phenomenon of existential loneliness manifest itself in the illness experience? To what degree can awareness of existential loneliness be a positive response to it? Questions that inform this exploration include: What human good does the experience of existential loneliness permit, inhibit, fulfill, or constrain? What moral concerns, if any, does understanding the experience of existential loneliness in critically ill patients raise for health care providers or other caregivers? And finally, does the experience of existential loneliness in dying patients awaken us to some aspect of our humanity that is otherwise hidden from us? In short, does existential loneliness have anything worthwhile to teach us?

Illness, like loneliness, love, and death, is an ontological feature of human life. Illness represents a distinct way of being in the world, typically characterized as a loss or interruption of the familiar patterns of life. It is well known that the experience of being ill can elicit strong and uncomfortable emotions, raising anxious questions about self, dignity, and bodily integrity, as well as concerns about the ineffable or redemptive mysteries of human life. Often illness provokes a sense of frustration and helplessness as familiar roles and life projects are disrupted. The stress and burden of illness can weaken an individual, generating feelings of anxiety, dread, and worry. According to Eric Cassell, the experience of illness is often characterized as a state of suffering, a loss of wholeness or integrity, provoked by the awareness that one's familiar way of being in the world has been suddenly threatened or shattered. The person becomes aware that his body can no longer be taken for granted or ignored; it asserts its claim on our attention through pain, dysfunction, or impairment. [23] This paradox, that in illness we "are brought home to a heightened awareness of the body, but it is a body in which we are no longer home," [24] is a common experience for many patients, and illustrates the sense of deep contradiction that serious illness often imposes on the self.

In The Meaning of Illness, S. Kay Toombs argues that "existential aloneness is necessarily a part of serious illness." [25] In the life-world of illness, the meaning and significance of our humanity is created from that which defines us-finite, embodied, mortal selves engaged in the daily projects of life and living. The experience of illness is characterized by losses-loss of identity, bodily integrity, freedom, control, and certainty-that penetrate over sense of invulnerability. Ultimately, illness is a private experience with the self, often causing unavoidable preoccupation with pain, malaise, incapacity, and change. Moreover, a life-threatening illness elicits profound emotional reactions, which may ultimately challenge one's faith or reason for existence. In some patients, the experience of being ill invalidates one's sense of self, time, and agency, often culminating in fear and isolation. In others, the disequilibrium of illness is experienced as an altered state of reality, often provoking existential questions about the ultimate value, meaning, and purpose of human life.

David Barnard has argued that physicians and other practitioners should integrate these existential concepts into patient care. He identifies three of the most important existential realities that caregivers and their patients must confront: mortality, finitude, and spirituality. Mortality is more than the certainty of our own death. It is the passage and loss from our life of the things we value and care about. To be conscious of our mortality is to be conscious of the irreversibility of time and the inevitability of change. In Barnard's view, our lives involve a "letting go" of valued sources of meaning so that new ones can be born. Finitude encompasses more than mortality. It is the awareness of the many forms of limitations we must endure. For patients there may be limits on mental capacity, physical strength, moral courage, or physical endurance. For caregivers, the limits may be inadequate knowledge, powerlessness in the face of certain illnesses, moral weakness, a melancholy sense of fate, futility, or uncertainty. Spirituality is not limited to organized religious belief systems, but incorporates the search for meaning, connection, and transcendence. The human need to pursue meaning is "the dimension of depth in all of life's endeavors and institutions." Following Tillich, Barnard regards the spiritual dimension of our lives as an immediate and inseparable aspect of our humanity-that sphere of meaning which engulfs who we are, why we suffer, and what morality obliges us to do or to be. [26]

Barnard defines existential in a very specific way: the existential level of subjective experience and discourse emphasizes the interior or inner dimension of a person. His primary concern is that human beings are creatures who seek love and meaning in the face of death. He focuses on the tension between the physician's persona-the effectively neutral or detached concern of the physician as a professional; and the physician as a person-affected by the full range of emotions, needs, vulnerabilities, and fears that constitute a human being's inner life. While some distinction between the professional and personal is both appropriate and necessary in clinical practice, a strict cleavage between them results in the loss of something crucial to the therapeutic relationship. He advocates for an existential perspective on doctoring, one that reconnects doctors to the inner life of the human beings who are their patients, to their psychological and spiritual selves. He concludes that the caregiver's ability to form reliable, empathic relationships with patients as they embrace illness and relinquish parts of the self provides a safe "holding place" for patients, a place where the self becomes coherent, reconnected, centered, and whole. In addition, by redirecting our attention away from the physician as a technician solving problems of disease and treatment, we come to appreciate the physician as a person who also strives for authenticity, personal significance, and a richer understanding of the human experience.

The following case story, I explores themes of existential loneliness embedded in the relationship between a hospitalized patient being treated for a terminal illness and myself, her primary caregiver. To regard existential loneliness as manifesting only in the person who is ill, and not in the caregiver as well, is to deny a fundamental aspect of the caregiver's humanity-the quest for being. Therefore, I acknowledge that this account of the patient's experience is as much my own personal story as it is hers. Because I hope to convey an accurate description of the patient's own experience, the patient's words are given verbatim where possible.

Kelly Ann, a twenty-nine-year-old mother from a large Irish family had a cancer of the lymphatic system. Ten years of conventional chemotherapy and radiation treatments kept her illness in intermittent states of remission. We met her when she was hospitalized for management of systemic herpes, pancytopenia, fever, anemia, and the administration of chemotherapy. The chemotherapy has caused total alopecia, severe nausea and vomiting, weakness, weight loss, and premature menopause.

Married and divorced twice, Kelly Ann had a nine-year-old daughter and received Medicaid as well as occasional child support. She was not able to work and resided with her daughter in government-supported housing. Her older sister lived in the same complex and was the patient's principal emotional support. For most of her hospitalizations she was under the care of doctors and nurses with whom she had established relationships of considerable trust and confidence. During these hospital visits, Kelly Ann consistently experienced a great deal of emotional stress and physical symptoms, but she was able to make her own decisions about her care and about the welfare of her daughter.

I encountered Kelly Ann in the solarium next to her hospital room. She looked weak and tired, but seemed to relish the chance to talk. She conversed in a halting voice, frequently sipping water to relieve her dry throat. When asked how she was feeling, she confessed that she wanted to give up her therapy. She knew that she would "be dead" if she did not continue with the chemotherapy protocol and was afraid her doctor would be disappointed in her if she did not continue the recommended therapy. On the other hand, she did not think she could continue a therapy that left her acutely ill for three out of every four weeks. This vacillation regarding treatment produced a diffuse anxiety, manifesting as nervous chatter, frequent gesticulations, restlessness, and uncertainty. She described the "uncomfortable and lonely" feeling of being all alone in making these "life and death" decisions, stating that she definitely wanted to live and get well so that she could take care of her daughter. "She is my reason for living. She has never known me when I wasn't sick. She is my blessing."

Several days later a conversation took place in which Kelly Ann acknowledged that for the first time she had "started thinking a lot more about what I really want in life. I want my pastimes back, I want my body the way it used to be." When asked what or who would be most helpful to her she replied: "I have to live with myself the way I am every day of my life, so I just ask God to help me make the right decisions so I can get through this terrible time in my life." She admitted to feeling depressed about the recent breakup of her relationship with her boyfriend and the lack of any true friendships other than with her sister. She admitted to periodic "crying spells, angry tantrums, and feeling sorry for myself." She said her illness made her feel "all alone," "apart from others," "deserted by her friends," like being "cut off in a room full of people."

In most of these conversations Kelly Ann's affect was flat and her manner withdrawn, although paradoxically she also seemed to welcome the opportunity to talk and relate to others. She spoke of the changes her illness was causing in her family and church friends and expressed some unrealistic hopes for "going back to school." She continued to express ambivalence about continuing her treatments and diet and longed for the day when she could return to "a normal existence." In my assessment of her at this phase of her illness it was clear that Kelly Ann was suffering from a social form of loneliness, manifested as a social isolation, situational depression, a fear of being alone, and a dark, brooding mood.

As her body's ability to ward off the disease and the potent drugs that attempted to control it steadily diminished, Kelly Ann became increasingly distressed and agitated. Slowly, she confronted the painful reality that her disease was terminal and that most likely she would die before her child's tenth birthday, now only a month away. The slow, bewildering recognition that she was beginning to separate "from her own life" evoked a variety of intimate feelings in us both. She began to be more introspective, often reflecting upon her life before she became ill, and she began to relinquish certain tasks and goals she had set for herself. Anguished over her young daughter and the guilt she felt in "deserting her,"she took comfort in the thought that maybe others could learn from her illness: "You know, being bald and yellow at the prime of my life."

Frequently, I sat in silence next to her as she lay in bed, her wounded body drawn up in a fetal position. Gazing at her face-a curious mixture of confusion, rage, hope, and denial-I was struck with a feeling that can only be described as a recognition. It felt as if I was recovering some long forgotten dialogue within myself, recollecting like some Platonic soul a deep knowledge I already possessed. I watched her grow and decay in quiet, nearly imperceptible ways, knowing that her being and mine lay coiled in our separate selves, each secreting its own loneliness. We endured the span of time between her immediate existence and its inevitable end, navigating that universe between being and nothingness. Our relationship deepened further as her need for inclusion, affection, and validation finally gave way to her need to "let go." We spoke quietly of the ways in which her bloated and scarred body would soon cease functioning and of her ultimate fear that she would suffocate in her own vomit. These conversations reduced some of her dread about "how dying happens." Each day she would place my stethoscope over her heart, hoping to assert some control over her final destiny. In the midst of constant reassurance, family love, and genuine dialogue, Kelly Ann released her hold on life and died two days before her thirtieth birthday.

In the end, Kelly Ann's existential quest for being was never fulfilled, as she could only ask, "Why is this happening to me?" It is a familiar question for patients who face serious illness, but for Kelly Ann its meaning was never fully grasped. I understood the loneliness that engulfed her spirit-the loneliness of a broken and abbreviated life, yet I am convinced that confronting this loneliness with her opened up new vistas of compassion and genuine understanding in us both. Her loneliness revealed her true being. It made her who she was and without it she could not have been the person she was trying to become. I know now that her loneliness, and, for that matter, my own, is not something that should be eradicated or cured; it is a loneliness that connects us to each other, and reconnects us to a larger aspect of our shared humanity. I know, too, that to die before one's own children must be an unfathomable burden, but to die without a sense of human tenderness, connectedness, or a core of being that matters to another is a moral waste. In the end, it is not death's dignity that will give our patients and us the peace we seek. It is the affirmation of who we are-moral, finite, vulnerable beings striving to fashion a life of our own. Kelly Ann's life, made even more precious by its brevity, closed before its full meaning could be revealed. The forces of love and death that pulled her in opposite directions for so many months were finally reconciled in her young daughter's last embrace.

Clearly, physicians, nurses, and other caregivers possess a special moral privilege as they witness the efforts of patients who struggle to give their lives a sense of meaning and purpose in the face of disease or death. To provide merciful care to patients experiencing serious disruptions in their health, spiritual well-being, and personal identity, practitioners must be able to identify and appropriately respond to the existential dimensions of illness. Many patients facing critical or terminal illness experience existential loneliness, the understanding of which is vital to a morally adequate patient-provider relationship. Additionally, I have argued against those who pathologize the experience of loneliness, believing instead that it should be confronted and embraced, rather than disguised or treated through the use of drugs or distraction techniques. By helping patients talk frankly and openly about the impact the illness is having on their lives and future goals, practitioners can help patients discover new insights about themselves and others. By definition, existential loneliness is an aspect of our basic humanity, an ineliminable feature of our species. For some patients, loneliness may manifest in an outward cry for meaning or affirmation of oneself before God, while for others it may be a quiet song of faith. Either way, it awakens us to the real existence of others and to the moral features of the helping relationship.

The most important tool for assessing and responding to the existential needs of a patient is the clinical or therapeutic dialogue, understood as a form of relating in which the patient is regarded as an existential subject rather than as an object of care. Dialogue is the therapeutic tool through which the meaning of the patient's illness experience is realized, shared, and owned. In many situations involving terminal illness, the dialogue may be unspoken, captured more in expressions of tenderness, listening, and being with the other. As the Russian literary critic and theorist Mikhail Bakhtin has noted, the human "being" is in the dialogue that is shared, and through this language our mutual humanity springs forth. According to Bakhtin: "Life is dialogical by its very nature. To live means to engage in dialogue, to question, to listen, to answer, to disagree. [27] The goal of the dialogue between a patient and a caregiver is not so much to interpret the patient's ordeal, but to "responsively understand." [28] This understanding serves to nurture the patient's sense of well being, to nourish the ideal of self-authenticity, and to restore or the broken pieces of self.

In the context of existential loneliness, the goal of the therapeutic dialogue is to help the patient recover his or her own inner dialogue, to discover a deeper sense of self worth, and to open the self to the possibility of new understanding and meaning in life or illness. Genuine dialogical engagement by the caregiver is not only a therapeutic activity geared toward the patient's good. It is also a moral act that enhances the humanity of both the patient and practitioner as they confront the loneliness of life and the mysteries of human existence. In approaching patient care from the perspective of existential loneliness, an inescapable tension between faith and experience, tragedy and serenity, and alienation and affirmation becomes palpable. To encounter patients from this perspective may bring both celebration and despair to patients as well as providers, but inevitably and unmistakably it binds us together, restoring wholeness and integrity to the human community.

The assertion that loneliness is an irreducible part of the very fabric of human life can be traced throughout the existential writings of philosophers, poets, theologians, and literary scholars. Many have written that the very essence of humanity is our separateness and aloneness. Many have asserted that the human response to loneliness is the reaching out to another, either directly, such as relating to another person or group, or indirectly, through creative expression, solitude, or important life projects. The existential dimension of illness and the loneliness it can produce are rarely talked about in clinical practice and even more rarely taught; yet they are essential aspects of human existence and moral understanding. Not only should we avoid fleeing from the expression of loneliness in our patients and in ourselves, we should avoid the urge to treat it with pills or placebos. Rather, the existential loneliness of illness should be confronted, embraced, and engaged, for it is within the loneliness of our shared existence that our deepest human responses may be realized and reciprocated.

1. Clark E. Moustakas, Loneliness (Englewood Cliffs, NJ: Prentice-Hall, Inc., 1961), ix.

2. Rollo May, Existential Psychology, 2nd edition (New York: Random House, 1960), 40.

3. R.S. Weiss, Loneliness: The Experience of Emotional and Social Isolation (Cambridge, MA: MIT Press, 1973), 17.

4. K.S. Rook, "Research on Social Support, Loneliness and Social Isolation: Towards an Integrated Review of Personality," Social Psychology 5 (1984): 209.

5. Karen L. Kristensen, "The Lived Experience of Childhood Loneliness: A Phenomenological Study," Issues in Comprehensive Pediatric Nursing 18 (1995): 125-137.

6. N. Bradburn, The Structure of Psychological Well-being (Chicago: Aldine, 1969).

7. Ami Rokach, "Relations of Perceived Causes and the Experiences of Loneliness," Psychological Reports 80 (1997): 1067-74.

8. Jari-Erik Nurmi, "Social Strategies and Loneliness," The Journal of Social Psychology 137, no. 6 (1997): 764-77.

9. Ami Rokach and Heather Brock, "Loneliness and the Effects of Life Changes," The Journal of Psychology 131, no.3 (1997): 284-98.

10. Karen Horney, The Neurotic Personality of Our Time (New York: W.W. Norton & Company, Inc., 1937).

11. F. Fromm-Reichmann, "Loneliness," Psychiatry 22 (1959): 1-15.

12. John G. Gunderson, "The Borderline Patient's Intolerance of Aloneness: Insecure Attachments and Therapist Availability," American Journal of Psychiatry 153, no. 6 (June 1996): 752-8.

13. Erlich H. Shmuel, "On Loneliness, Narcissism, and Intimacy," American Journal of Psychoanalysis 58, no.2 (1998): 135-162.

14. Søren Kierkegaard, Either/Or: A Fragment of Life, vol. II, trans. W. Lowrie (Princeton, NJ: Princeton University Press, 1944), 220. Originally published in Danish 1943.

15. Thomas Wolfe, "God's Lonely Man," in Masterworks of English Prose: A Critical Reader, ed. John L. Bradley and Martin Stevens (New York: Rinehart and Winston, Inc., 1968), 454-462.

16. Ibid., 26.

17. Martin Heidegger, Being and Time, trans. J. Macquarrie and E. Robinson (New York: Harper and Row, 1968). Originally published in German 1927.

18. Moustakas, Loneliness, 102.

19. Clark E. Moustakas, Loneliness and Love (Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1972).

20. Paul Tillich, The Eternal Now (New York: Charles Scribner & Sons, 1963).

21. Thomas Merton, Thoughts in Solitude (New York: Doubleday, 1968), 40.

22. Kierkegard, Either/Or, 220.

23. Eric J. Cassell, "The Nature of Suffering and the Goals of Medicine," The New England Journal of Medicine 306 (1982): 639-45.

24. Drew Leder, "Illness and Exile: Sophocles' Philoctetes," Literature and Medicine 9 (1990): 1-11.

25. S. Kay Toombs, The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient (Boston: Kluwer Academic Publishers, 1992), 36.

26. David Barnard, "Love and Death: Existential Dimensions of Physicians' Difficulties With Moral Problems," The Journal of Medicine and Philosophy 13 (1998): 409.

27. Tzvetan Todorov, "Mikhail Bakhtin: The Dialogical Principle," trans. Wlad Godzich in Theory and History of Literature. Vol. 13 (Minneapolis: The University of Minnesota Press, 1984), 97.

28. Ibid., 112