Suffering, justice, and scarcity: philosophical reflections on the burden of cancer in LMICS using Nigeria as a case study

Abstract

Cancer represents a significant and growing public health emergency in Nigeria, where high mortality rates, late-stage presentation, inadequate infrastructure, prohibitive costs and pervasive stigma combine to produce a multidimensional crisis. While epidemiological data and health system analysis illuminate the scale of the problem, they fail to capture the deeper ethical, structural and existential realities that shape the lived experience of cancer. This paper employs key philosophical concepts, including distributive justice, social justice, structural violence, biopolitics, epistemic injustice, care ethics, existentialism, Ubuntu philosophy, vulnerability theory and the capabilities approach to analyze the complex realities of cancer in Nigeria. It is a critical reflection on the rationale for practices and policies that are often taken for granted, using the tools of formal philosophical inquiry, with a view to either grounding the practices in proper ethical understanding, or rethinking them along proper ethical lines. We argue that applying these philosophical frameworks reveal deep-seated inequities, challenges to patient agency, the corrosive effects of stigma rooted in epistemic failures, relational deficits in care, and the profound existential struggles patients and families face. By examining the interplay among scarce resources, cultural beliefs, systemic weaknesses, and fundamental questions of value and meaning, this paper argues that a philosophical perspective offers a roadmap for more humane, just, and culturally grounded reforms in cancer prevention, diagnosis, treatment, palliative care, and compassionate responses within the Nigerian context.

Introduction

Nigeria, Africa’s most populous nation, faces a daunting cancer burden. Estimates suggest over 100,000 new cancer cases annually, with mortality rates disproportionately high compared to global averages, primarily due to late diagnosis and inadequate treatment facilities [1, 2]. Common cancers include breast, cervical, prostate, colorectal, and liver cancers, often presenting at advanced stages where curative options are limited and palliative care is scarce [3].

The healthcare system struggles with insufficient funding, a severe shortage of oncologists and specialized equipment (such as radiotherapy machines), and fragmented service delivery [4]. For many Nigerians, a cancer diagnosis precipitates a catastrophic health expenditure, pushing families into poverty [5]. While these statistics paint a grim picture, they only partially convey the reality of cancer in Nigeria. The experience of cancer is deeply interwoven with cultural beliefs, social structures, economic realities, and fundamental questions about life, suffering, fairness, and death. It is here that philosophy offers critical tools for deeper understanding.

Historically, the global and national discourse on cancer has prioritized statistics, incidence, mortality, and treatment outcomes, while the emotional, psychological, and existential suffering of patients has remained at the margins of attention. However, the burden of cancer transcends the physical body. It infiltrates the individual’s emotional fabric, stirring profound feelings of fear, isolation, uncertainty, and loss. Within the Nigerian context, where social and cultural frameworks shape perceptions of illness and mortality, these emotional dimensions are often intensified [6–8], and patients also battle with the stigma, economic hardship, and moral questioning that accompany it. Thus, to understand the actual burden of cancer, one must look beyond the clinical and into the affective and philosophical — the realm where suffering, meaning, and hope coexist in fragile tension. Hence, documenting incidence rates or treatment gaps overlooks the ethical dilemmas inherent in resource allocation, the challenges to patient autonomy in diverse cultural settings, the impact of societal beliefs and stigma on help-seeking behaviour, and the profound existential questions that arise when facing a life-limiting illness in a context of scarcity and uncertainty.

This paper aims to bridge this gap by applying core philosophical concepts to analyze the multifaceted burden of cancer in Nigeria. It argues that understanding this burden requires moving beyond a purely biomedical or economic framework to engage with fundamental questions of justice, agency, knowledge, meaning, and responsibility. By exploring these philosophical dimensions, we can gain a richer appreciation of the challenges faced by patients, families, healthcare providers, and policymakers and potentially identify pathways toward more ethically sound and human-centred approaches to cancer control and care in Nigeria. The paper examines the Nigerian cancer context through the lenses of distributive and social justice, autonomy and informed consent, epistemology, belief, stigma, existential concerns of suffering and meaning, and social responsibility and community solidarity. These theories provide the conceptual scaffolding for narratively examining the lived experiences and moral implications of cancer burden in Nigeria (Table 1).

Table 1.

Philosophical perspectives on justice and equity, and suggestions for implementation in Nigeria

Theory	Principle	Highlights	Strength	Limitation/Implementation Challenge	Policy Suggestions
Utilitarianism	Maximize total welfare	Prioritize interventions that yield the most health per resource (e.g., treatments with the best efficacy)	Efficient allocation; outcome-oriented	Can marginalize the worst-off (advanced disease, poorest patients); ignores equal moral worth	Use cost-effectiveness data but protect minorities via equity safeguards; combine with equity cushions
Egalitarianism	Fair equality of opportunity	Health services are prerequisites for equal life opportunities; it is unfair if access is unequal	Strong emphasis on fairness and social justice	Hard to implement under relative scarcity and weak redistribution mechanisms	Policies to ensure universal basic access (screening, basic treatment); prioritize capacity building and equitable distribution
Libertarianism	Individual liberty, minimal state; sees healthcare as a commodity	Access determined by ability to pay; aligns with the current out-of-pocket reality in Nigeria	Respects personal freedom and market incentives	Deepens inequities where poverty is systemic; ethically problematic for life-saving care	If market-driven, pair with safety nets (subsidies, targeted public provision) to avoid catastrophic outcomes
Capabilities Approach	Justice is assessed by real opportunities/abilities to function	Focus on what people can actually do or be; see health as a central capability	Human-centered, holistic; captures dignity, functioning, agency	Hard to implement and costly; needs cross-sector action	Invest in services that restore capabilities: affordable care, social protection, education, livelihood support
Social Determinants / Social Justice	Social, economic, and environmental conditions shape health	Cancer risk and outcomes are driven by poverty, education, and environment	Addresses root causes of poverty; labor markets, industrial structure, corruption and supports population-level prevention.	Requires long-term multisectoral policies; political will	Creation of accessible employment opportunities and empowerment programs. Effective approaches to curtail corruption may include establishment of policies that strengthen transparency (using open contracting and e-procurement systems to reduce opportunities for manipulation), reformation of public procurement, and digitalization of public services. Also, policies that encourage vaccination, environmental protection regulation, educational campaigns are essential in improving population health outcomes.
Social Contract / Human Rights (state responsibility)	State duty to protect citizens’ rights, including health	Views health as a public duty: failure to fund services is an injustice	Anchors claims collective/state responsibility	Implementation depends on governance/fiscal capacity	Advocate for national cancer control, budgetary commitments, and universal coverage
Communitarianism / Social Solidarity	Community values, social capital, mutual support	Family/community as primary support networks for patients	Leverages local networks for care/support	Vulnerable to stigma; variable capacity across communities	Strengthening community groups, involving religious/traditional leaders in outreach
Epistemic Injustice	Social structures can influence people’s knowledge	Patients’ testimony may be dismissed; there is a lack of conceptual tools to articulate experience	Highlights recognition, voice, and credibility	Requires cultural and clinical change in attitudes	Training clinicians on testimonial justice, patient advocacy, and inclusive communication
Existentialism (Frankl, Heidegger, Sartre)	Meaning, freedom, being-toward-death — human response to suffering	Emphasizes meaning-making, dignity, and confronting mortality in care	Addresses emotional/psychological needs; supports palliative goals	Not a distributional theory; it requires psychosocial services	Integrate psychosocial and spiritual care; palliative services; advance care planning
Global Justice (Pogge)	Moral obligations across borders for fairer global arrangements	International inequities in access to medicines, technology, and research funding	Frames the obligations of richer persons	Requires international cooperation and political will	Advocacy for fair pricing, tech transfer, funding & capacity building

Methodology

This paper adopts a narrative conceptual review approach, synthesizing insights from philosophy, bioethics, oncology, psychology, and public health. Rather than conducting a quantitative systematic review, the goal is interpretive and analytical: to illuminate the moral, epistemic, existential, and structural dimensions of cancer care in Nigeria. Relevant literature was identified through concept-driven searches of PubMed, Google Scholar, Scopus, philosophical books, and key bioethics journals from 2000 to 2024. Search terms included combinations of “cancer AND justice AND Nigeria”, “structural violence AND health, “epistemic injustice AND illness, “Ubuntu AND ethics”, “care ethics AND healthcare”, “existentialism AND suffering”, “LMIC resource allocation AND oncology”, “Nigeria oncology infrastructure scarcity”, and “burden of disease”. Sources were selected based on their theoretical contribution, ethical relevance, and interpretive value, rather than a methodological hierarchy. Analytical synthesis was conducted narratively rather than quantitatively. Rather than systematically aggregating data, it organizes discourse around key themes, debates, and ethical frameworks relevant to healthcare inequality and patient experience. Each section is organized around philosophical frameworks that deepen understanding of the Nigerian cancer landscape. The paper is structured thematically into ten conceptual domains: (1) Distributive Justice and Resource Allocation (2) Social Justice and Social Determinants (3) Autonomy, Paternalism, and Consent (4) Epistemology, Stigma, and Trust, (5) Existential Dimensions on Suffering and Mortality (6) Collective Responsibility and Solidarity (7) Structural Violence and Biopolitics (8) Care Ethics and Relationality (9) Ubuntu Philosophy (10) Vulnerability and Capability Deprivation.

Results

Different philosophical theories of justice and ethics were critically examined in relation to one another, highlighting their convergences and divergences, as well as the unique insights each offers into questions of fairness and moral responsibility in cancer care in Nigeria.

Distributive justice and resource allocation

The theories of distributive justice concerning the fair allocation of resources, benefits, and burdens within a society are explored below. Firstly, the Utilitarian perspective, which seeks to maximize overall good or happiness and suggests prioritizing treatments with the highest chance of success or those that benefit the most members of society. In the context of Nigerian healthcare, marked by limited cancer diagnostic tools, treatments (chemotherapy, radiotherapy, surgery), and palliative care services, this perspective is overwhelmed by the stark reality of scarcity. The resources are insufficient to maximize benefits and optimize outcomes for most cancer patients. (Table 1). Secondly, Egalitarian theories, particularly those emphasizing equality of opportunity or access, challenge the disparities in Nigeria. Norman Daniels’ (1985) extension of Rawlsian justice to healthcare argues that society has an obligation to ensure access to services that maintain normal species functioning, which is necessary for fair equality of opportunity [9]. In Nigeria, the limited accessibility to affordable cancer care for the majority, despite initiatives by the government [10], drastically curtails such opportunities. The geographical concentration of limited facilities in major cities creates a stark urban-rural divide that violates principles of equal access [11]. Thirdly, Libertarian perspectives emphasize individual rights and minimal state intervention, suggesting that healthcare is a commodity to be purchased. This reflects the reality of cancer management in Nigeria, where most patients pay out-of-pocket for treatment within the public and private healthcare facilities. It directly impacts and contributes to the increasing cancer mortality as it fails to address the moral implications of allowing the ability to pay to determine access to life-saving treatment, especially when poverty is widespread and systemic [12]. Lastly, the Capabilities Approach, championed by authors Sen (2009) and Nussbaum (2011), shifts the focus from resources themselves to what individuals can be and do [13, 14]. Health is considered a fundamental capability (Table 1). From this perspective, the Nigerian system fails catastrophically, as lack of adequate access to cancer care severely diminishes individuals’ capabilities to live a life they value, to work, to parent, and to participate fully in society. The exorbitant costs mean that even potentially treatable cancers often lead to premature death or debilitating poverty, representing a profound failure to enable basic human capabilities. The practical reality in Nigeria often involves implicit or explicit rationing based on one’s ability to pay, connections, or geographic location, rather than on consistent ethical principles. This lack of a transparent, ethically grounded framework for resource allocation exacerbates feelings of injustice and despair among patients and families [15].

Collectively, these theories demonstrate that distributive justice is not merely a framework for diagnosing inequities in cancer care but a moral guide for determining how scarce healthcare resources ought to be allocated. What this framework requires is that access to cancer prevention, diagnosis, treatment, and palliative care be governed by fairness rather than by wealth, geographical location, or social influence. A utilitarian perspective supports prioritising cost-effective interventions that maximise population health benefits, particularly prevention, early detection, and essential treatment services. Egalitarian principles require equitable access to quality oncology services through strengthened universal health coverage, decentralisation of specialised facilities, and the removal of financial and geographic barriers to care. Although libertarian approaches recognise individual choice and private sector participation, the widespread poverty and market failures that characterise the Nigerian healthcare system make greater public investment and financial risk protection ethically indispensable. Similarly, the Capabilities Approach requires policies that expand individuals’ real opportunities to achieve and maintain good health by strengthening cancer services alongside investments in education, social protection, and other social determinants of health. Together, these perspectives require a transparent and ethically defensible system of resource allocation that balances efficiency with equity while safeguarding human dignity and enabling every individual to attain the basic capabilities necessary for human flourishing.

Social justice and social determinants

Beyond healthcare access, social justice perspectives highlight how broader societal structures influence cancer risk and outcomes. Poverty, low educational attainment, exposure to environmental toxins, poor nutrition, and lack of access to clean water and sanitation are social determinants of health that can increase cancer risk and hinder access to care [16]. In Nigeria, these factors disproportionately affect marginalized communities. For example, the prevalence of Hepatitis B and C, major risk factors for liver cancer, is linked to socioeconomic conditions and limited access to vaccination and safe healthcare practices [17]. Similarly, low awareness about cervical cancer screening and HPV vaccination, particularly in rural areas, contributes to high mortality rates [18]. Addressing the cancer burden justly requires tackling these underlying social inequalities, moving beyond a purely medical focus to encompass public health interventions, poverty reduction, education, and environmental protection. What this framework requires is recognition that achieving justice in cancer care extends beyond expanding clinical services to addressing the social and economic conditions that shape health and illness. It is because poverty, inadequate education, environmental degradation, poor living conditions, and unequal access to preventive services substantially influence cancer risk and outcomes, ethical responses must target these structural determinants. This requires sustained policies that promote poverty reduction, employment opportunities, quality education, environmental protection, expanded vaccination and preventive health programmes, and equitable access to clean water, sanitation, and primary healthcare. Reducing these underlying inequities is not merely a public health objective but a moral imperative for ensuring that all members of society have a fair opportunity to attain and maintain good health, irrespective of their socioeconomic circumstances.

Knowing and believing: epistemology, stigma, and trust

Epistemology, the philosophical study of knowledge and belief, offers insights into how cancer is understood (or misunderstood) in Nigeria, the role of trust in healthcare interactions, and the devastating impact of stigma. Knowledge sources are diverse and often conflicting:

Sources of knowledge and belief

• Biomedical Information: usually disseminated through healthcare providers, public health campaigns, and media. However, access to reliable information is uneven, and understanding can be hampered by low literacy and technical jargon.

• Traditional Beliefs: Cancer may be attributed to spiritual causes, witchcraft, curses, or moral transgressions [19]. These beliefs shape how individuals interpret symptoms, whether they seek conventional care, and how they and their families cope with the illness.

• Misinformation and Rumours: Widespread misinformation about cancer causes (e.g., linking it solely to lifestyle choices perceived as western or immoral, cultural apprehension toward western healthcare practices) and cures (e.g., miracle cures offered by unregulated practitioners) circulates through communities and online platforms, often hindering timely diagnosis and evidence-based treatment [20–22]. This complex epistemic landscape means that a patient’s understanding of their illness is shaped by a mixture of scientific facts, cultural interpretations, and potentially harmful falsehoods.

Epistemic injustice

Frickers (2007) concept of epistemic injustice, particularly testimonial injustice (where a speaker’s testimony is given less credibility due to prejudice) and hermeneutical injustice (where individuals lack the conceptual resources to understand or articulate their experiences due to societal gaps) [23], is relevant. Cancer patients in Nigeria, especially those who are poor, less educated, or female, may find their accounts of symptoms dismissed or downplayed (testimonial injustice). Furthermore, the lack of widespread public discourse and understanding of cancer can leave patients struggling to make sense of their illness and communicate their needs effectively (hermeneutical injustice). Stigma contributes significantly here, silencing patients and preventing shared understanding.

Stigma

The Social Weight of Belief: Stigma surrounding cancer in Nigeria is pervasive and deeply damaging [24–26]. It often stems from fear, misinformation about contagiousness, beliefs linking cancer to immoral behaviour or curses, and the association of cancer with inevitable, painful death. This stigma manifests in:

• Secrecy and Denial: Patients may hide their diagnosis from family, friends, and employers for fear of rejection, discrimination, or pity.

• Delayed Help-Seeking: Fear of diagnosis and social repercussions prevents individuals from seeking medical attention for suspicious symptoms until the disease is advanced.

• Social Isolation: Patients and their families can face ostracism, loss of social support, and even abandonment.

• Impact on Treatment: Stigma can discourage adherence to treatment regimens or participation in support groups.

Addressing stigma requires not just providing information but also tackling the underlying epistemic failures and fear-based beliefs. It necessitates public education campaigns that normalize cancer, share patient stories, and challenge harmful myths grounded in an understanding of the cultural and epistemic contexts in which these beliefs thrive.

Trust in the healthcare system

Epistemic trust – trusting the knowledge and competence of healthcare providers and institutions – is crucial for adequate care. However, experiences with under-resourced facilities, perceived indifference by staff, high costs, and communication breakdowns can erode trust in Nigeria’s formal healthcare system [27]. This lack of trust can lead patients to delay seeking care, prefer alternative healers, or disengage from treatment, further exacerbating the cancer burden. Building trust requires systemic improvements in quality of care, communication, transparency, and accountability.

What this framework requires is the creation of an epistemic environment in which individuals have equitable access to reliable health information and are treated as credible knowers of their own experiences. Ethical cancer care therefore requires health education strategies that promote evidence-based biomedical knowledge as the primary foundation for clinical decision-making while engaging respectfully with cultural and spiritual belief systems. This obligation extends beyond correcting misinformation to fostering trust through culturally sensitive public education, meaningful collaboration with community and traditional leaders, and patient-centred communication that acknowledges and respects patients’ lived experiences. Addressing epistemic injustice further requires empowering patients to participate meaningfully in healthcare decisions, ensuring that their voices are heard without prejudice, and guaranteeing equitable access to accurate, understandable, and trustworthy health information. Only by strengthening both knowledge and trust can healthcare institutions reduce stigma, promote timely care-seeking, and support ethically informed decision-making.

Facing finitude: existential dimensions of cancer in Nigeria

Beyond the physical and social challenges, a cancer diagnosis forces patients and families to confront fundamental existential questions about suffering, meaning, mortality, and the nature of a worthwhile life. Existentialist philosophy provides tools to explore these profound human experiences.

Suffering and meaning-making

Cancer often involves significant physical pain, emotional distress, and psychological suffering. Existentialist thinkers Albert Camus, (1942/1955) explored the absurdity of suffering in a seemingly indifferent universe [28]. Yet, others like Frankl (1959), based on his experiences in concentration camps, argued that even in extreme suffering, humans have the freedom to choose their attitude and find meaning [29]. In the Nigerian context, the search for meaning amidst cancer suffering is often framed by religious and spiritual beliefs [30]. Faith can provide solace, hope, a framework for understanding suffering (e.g., as a test, a path to spiritual growth), and a connection to a supportive community. However, it can also lead to existential crises if prayers seem unanswered or if the illness challenges deeply held beliefs. Fatalism, the belief that events are predetermined and unavoidable, is also prevalent and can influence coping strategies, sometimes leading to resignation rather than active engagement with treatment or palliative care [31, 32].

Confronting mortality

A cancer diagnosis brings mortality into sharp focus. Existentialism emphasizes the importance of confronting our finitude to live authentically Heidegger (1927/1962) [33]. In Nigeria, cultural attitudes towards death and dying vary, but the reality of limited treatment options often implies that patients face end-of-life issues sooner and more starkly than in high-resource settings. The lack of access to adequate palliative care, including pain management, means that this confrontation with mortality is often accompanied by unnecessary physical suffering [34, 35]. Philosophical reflection can help individuals, families, and healthcare providers grapple with these complex realities, fostering conversations about end-of-life preferences and legacy and finding value in the time remaining.

Freedom, responsibility, and identity

Existentialism stresses radical freedom and the responsibility that comes with it Sartre (1943/1956) [36]. While systemic constraints severely limit the choices available to many Nigerian cancer patients, they still face choices regarding treatment adherence, disclosure, coping mechanisms, and how they relate to their illness. Cancer can profoundly disrupt a person’s sense of self and identity – their roles as workers, parents, and community members. The physical changes caused by surgery or treatment (e.g., mastectomy, hair loss) can impact body image and self-esteem. Patients must navigate the challenge of integrating the illness into their identity without being solely defined by it, striving to maintain a sense of agency and purpose despite the limitations imposed by the disease and the healthcare System. Understanding these existential dimensions is crucial for providing truly holistic care that addresses not just the physical disease but also the patient’s psychological, spiritual, and existential needs, supporting their search for meaning and dignity in the face of profound adversity (Table 1).

What this framework requires is that cancer care recognise patients not merely as recipients of medical treatment but as persons confronting profound questions of suffering, identity, meaning, and mortality. Ethical care therefore extends beyond curing disease to preserving dignity, supporting meaning-making, and alleviating suffering throughout the illness trajectory. This requires the integration of palliative, psychosocial, and spiritual care into routine oncology services, including effective pain management, counselling, and culturally sensitive spiritual support. Healthcare institutions also have a moral obligation to create safe spaces for open and compassionate conversations about prognosis, suffering, mortality, and end-of-life preferences, enabling patients and their families to make informed and meaningful decisions. Furthermore, patient-centred care should safeguard individuals’ agency, dignity, and sense of identity despite the constraints imposed by illness and limited healthcare resources. By affirming the intrinsic worth of every person, this framework demands that quality of life and human dignity remain central ethical goals of cancer care, even when cure is no longer possible.

Agency under pressure: autonomy, paternalism, and consent

The principle of respect for autonomy

Recognizing an individual’s right to self-determination in decisions about their own body and healthcare – is a cornerstone of modern bioethics [37]. In Nigeria, multiple institutional and legal mechanisms exist to ensure that patients are treated fairly in both research and routine clinical contexts. Human Research Ethics Committees (HRECs), including the National Health Research Ethics Committee (NHREC), play a critical role in overseeing research — protecting participants’ autonomy and guarding against coercion, manipulation, or therapeutic misconception [38]. However, applying this principle in the Nigerian cancer context poses significant challenges.

Informed consent

Obtaining truly informed consent requires providing adequate information about diagnosis, prognosis, treatment options, risks, and benefits, and ensuring the patient understands this information and can make a voluntary decision. Ethics obliges practitioners to obtain informed consent, maintain confidentiality, and clearly communicate the risks and benefits of proposed treatments [39]. While this framework exists in Nigeria, several factors complicate the process of ensuring patients give their informed consent:

• Low Health Literacy: Limited understanding of complex medical terminology and disease processes can make it difficult for patients to grasp the implications of their diagnosis and treatment choices [40, 41].

• Communication Barriers: Language differences between healthcare providers and patients, particularly in diverse linguistic settings, can hinder effective communication. Time pressures in understaffed clinics often preclude detailed discussions.

• Cultural Factors: In many Nigerian cultures, decision-making is often a familial or communal affair, rather than purely individualistic. Family elders or spouses may play a dominant role, potentially overriding the patient’s own preferences [42]. While respecting cultural norms is essential, it must be balanced against the patient’s fundamental right to be informed and involved in decisions concerning their own health.

• Information Withholding: Sometimes, families may withhold a poor prognosis or the full extent of the diagnosis from the patient, believing it is kinder to protect them from distressing news (a form of paternalism) (Table 2). While potentially well-intentioned, this undermines autonomy and prevents the patient from making informed choices about their remaining life, including seeking palliative care or settling personal affairs.

Table 2.

Overview of analytic domains and their relevance to the Nigerian cancer care context

Domain	Major points	Relevance to cancer management in Nigeria	Possible talks/interventions
Distributive Justice and Resource Allocation	Resource scarcity of diagnostics, treatment and palliative care; urban–rural concentration; rationing by ability to pay or connections	Determines who gets timely diagnosis and curative therapy; drives late presentation and catastrophic expenditure	Policy dialogue on transparent priority-setting; develop equity-weighted triage frameworks; decentralize diagnostics; financing reforms; equity metrics
Social Justice and Social Determinants	Poverty, low education, environmental exposure, low vaccination/screening uptake; social determinants increase risk and hinder access	Affect prevention and early detection contribute to advanced-stage presentation and higher mortality	Scale up HBV/HPV vaccination; intersectoral policy addressing environment and education; mobile screening; community outreach
Agency Under Pressure: Autonomy, Paternalism, Consent	Low health literacy, language barriers, family-centered decision-making, information withholding, and alternative medicine influence	Compromises informed consent, leading to poor adherence and delayed or inappropriate care	Training on culturally sensitive consent, health literacy campaigns, patient navigators, and family-inclusive consent models
Knowing and Believing: Epistemology, Stigma, Trust	Competing knowledge sources; misinformation; epistemic injustice; pervasive stigma and loss of trust in the health system	Stigma and misinformation drive secrecy, delayed help-seeking, nonadherence, and use of unproven remedies	The public should be encouraged to prioritize scientific and biomedical explanations of cancer over misinformation, traditional misconceptions, or unverified beliefs. However, care must be taken not to eliminate traditional beliefs, but improve health literacy and promote evidence-based decision-making while respecting cultural context. Public sensitization which could be through community dialogues with traditional/religious leaders; clinician training on testimonial justice; survivor storytelling; transparent service reporting
Facing Finitude: Existential Dimensions	Existential distress, meaning-making, fatalism, identity disruption, limited palliative care and pain management	Psychological and spiritual needs affect QoL, adherence, and dignity at the end of life	Integrate palliative care, psychosocial and spiritual support, advance care planning, and bereavement programs
Collective Failure and Collective Response	Systemic underfunding, absent national strategy, insufficient workforce and infrastructure; global inequities	Structural deficits explain gaps in prevention, diagnosis, treatment and palliation	Advocate for national cancer control plan and budget; capacity building; strengthen NGOs; global partnerships for fair pricing and tech transfer

Paternalism vs. autonomy

Medical paternalism occurs when healthcare providers make decisions for patients based on what the provider believes is in the patient’s best interest, potentially overriding the patient’s wishes. Desperate financial situations faced by cancer patients, low health literacy, and limited treatment options in Nigeria can increase the risk of both intentional and unintentional paternalism. This can manifest as patients receiving suboptimal cancer treatment alternatives due to a lack of availability or access to optimal options. In addition, the patient’s values and family pressuring patients into treatments they may not fully desire may contribute to paternalism. Balancing the ethical principle of beneficence (acting in the patient’s best interest) with respect for autonomy remains a constant challenge in Nigeria, particularly when resources are scarce, and options are limited [43].

The influence of alternative medicine

Many Nigerians utilize Complementary and Alternative Medicine (CAM), including traditional or spiritual healing alongside or instead of conventional medicine [44]. Patients may feel autonomous in choosing these paths, but questions arise about the informed nature of the decision if it is based on misinformation about conventional treatments or on unrealistic promises from alternative practitioners. The stigma surrounding cancer can also push patients towards secretive traditional remedies, delaying potentially effective conventional care. Respecting patient choice here requires careful navigation, ensuring patients are not unduly influenced by misinformation while respecting their right to integrate different belief systems into their healthcare journey. True respect for autonomy in the Nigerian cancer context requires concerted efforts to improve health literacy, foster culturally sensitive communication, ensure adequate time for counselling, and empower patients to participate meaningfully in decision-making, even within challenging systemic constraints (Table 2).

The normative implication is that respect for patient autonomy should be understood as a substantive ethical obligation rather than a procedural requirement. Patients should be enabled to make informed and voluntary decisions about their care despite the practical constraints of the Nigerian healthcare system. This requires improving health literacy, promoting culturally appropriate communication, and strengthening informed consent processes that recognise the important role of families while preserving the patient’s right to participate meaningfully in decisions affecting their own health. Healthcare professionals also have a moral duty to minimise unnecessary paternalism by providing accurate, comprehensible information, discussing available treatment options honestly, and supporting shared decision-making. Respect for autonomy is therefore realised not merely through obtaining consent, but by creating the conditions that enable patients to exercise genuine agency, preserve their dignity, and make choices that reflect their own values and preferences.

Collective failure, collective response: social responsibility and community

The immense burden of cancer in Nigeria cannot be solely attributed to individual misfortune or biology. It reflects systemic failures and raises questions about collective responsibility (Table 2).

State responsibility

Political philosophy debates the extent of the state’s responsibility for the health of its citizens. From perspectives emphasizing a social contract or human rights, the state has a fundamental obligation to protect and promote health. The Nigerian government’s chronic underfunding of the health sector (often falling far short of the Abuja Declaration’s target of 15% of the national budget) represents a failure to meet this responsibility, particularly in addressing non-communicable diseases such as cancer [45]. This includes the responsibility to:

• Invest in prevention (e.g., HPV vaccination, hepatitis control, tobacco control, health education).

• Establish robust screening programs to detect early.

• Build and equip adequate diagnostic and treatment centres nationwide.

• Train and retain sufficient oncology specialists.

• Implement policies to make cancer care more affordable and accessible, such as strengthening national health insurance schemes to comprehensively cover cancer treatment.

Although cancer-specific mechanisms have been established, notably the Cancer Health Fund (CHF) and the National Institute for Cancer Research and Treatment (NICRAT), the resources remain very limited. The 2025 budget provides just ₦150 million for the CHF, a figure that cancer advocacy groups and clinicians deem grossly inadequate [46]. NICRAT, established by Act in 2017, is tasked with national leadership on cancer research, treatment, prevention, policy, and coordination [47]. However, NICRAT faces constraints: its 2023 Impact Review highlights persistent financing gaps, limited infrastructure, insufficient oncology workforce, and difficulties scaling its Cancer Health Fund [48]. In recent years, public–private and government–private collaborations have emerged to try to mitigate these gaps. For example, the Federal Ministry of Health (FMH) partnered with the Nigeria Sovereign Investment Authority (NSIA) on an Oncology Initiative, committing ₦37.4 billion to upgrade or build oncology and nuclear medicine facilities in six teaching hospitals [49]. Another high-profile effort is the Innovative Cancer Medicines (ICM) initiative, a collaboration between the Clinton Health Access Initiative (CHAI), the Parker Institute for Cancer Immunotherapy, NSIA, and pharmaceutical companies (Roche, Bristol Myers Squibb) to pilot immunotherapy (nivolumab) in Nigerian oncology services [50]. Despite these efforts, the financial burden on patients remains profound. A recent study found that more than 70% of Nigerian cancer patients borrow money to afford treatment, underscoring how existing funding mechanisms (like CHF) are insufficient to meet real-world needs [51].

Community solidarity and social capital

While state action is critical, communities also play a role. Communitarian philosophy emphasizes the importance of shared values, social cohesion, and mutual support. In Nigeria, family and community networks are often the primary sources of support for patients, providing emotional, practical, and sometimes financial assistance [52]. However, stigma can undermine this solidarity. Strengthening community-based support groups, involving religious and traditional leaders in awareness campaigns, and fostering a culture of empathy can help counter stigma and bolster social capital for cancer patients and their families. Civil society organizations and NGOs also play a vital role in advocacy, patient support, and service delivery, filling gaps left by the state, but their reach is often limited.

Global health equity

The disparities in cancer outcomes between Nigeria and high-income countries raise questions of global health equity. Access to essential medicines, technologies, and research funding is unevenly distributed globally. Philosophical arguments for global justice suggest that wealthier nations and international bodies have ethical obligations to support low- and middle-income countries in strengthening their health systems and addressing significant health challenges, such as cancer [53]. This includes fair pricing for cancer drugs, technology transfer, support for research capacity building, and development aid directed towards sustainable health system strengthening. Addressing the cancer burden in Nigeria requires a multi-pronged approach founded on a recognition of shared responsibility – from the individual making healthy choices (where possible), to the community fostering support and combating stigma, to the state fulfilling its obligation to ensure access to care, and the global community working towards greater health equity. This framework requires recognition that responding to cancer is a shared moral responsibility rather than an individual burden. The Nigerian state has an ethical obligation to provide accessible and affordable cancer prevention, diagnosis, treatment, and palliative care through sustained investment in health infrastructure, workforce development, and financial protection mechanisms. Communities, civil society organisations, and international partners likewise share responsibilities for reducing stigma, supporting patients, strengthening advocacy, and promoting global health equity. Effective cancer control therefore depends upon coordinated action across all levels of society.

Structural violence and biopolitics: the politics of neglect

The ethical burden of cancer in Nigeria can be illuminated through the concepts of structural violence and biopolitics. Structural violence, in Galtung’s (1969) sense, refers to the slow, organized harm produced by social systems that restrict people’s ability to meet basic needs. Cancer care in Nigeria reflects this harm strongly [54]. Outside a few urban centers, such as Lagos (LUTH, LASUTH), Abuja (National Hospital), Enugu (UNTH), Ibadan (UCH), and Port Harcourt (UPTH), there are few functional oncology units, and radiotherapy machines frequently break down for months at a time. Large regions, including much of the North-West and North-East, have no comprehensive cancer centers, forcing patients to travel hundreds of kilometers or to forgo treatment altogether. This uneven geography of care is not accidental; it is produced by decades of underinvestment and policy neglect.

Michael Foucault’s concept of biopolitics offers an additional perspective on this issue. Biopolitics involves the ways modern states govern their populations by managing health, distributing resources, and deciding whose lives are protected [55]. Nigeria’s health priorities, where malaria, HIV, and TB receive ongoing attention while cancer is marginal, reflect what Foucault (1976) called the power to “make live and let die” [56]. Cancer patients, especially women, rural residents, and the poor, are effectively excluded from the circle of state protection. Their suffering is normalised within a political system that has not yet recognised non-communicable diseases as urgent public concerns. This neglect carries ethical implications. Drawing on Farmer (2004) [57], the poor outcomes experienced by Nigerian cancer patients, such as late diagnosis, catastrophic out-of-pocket spending, and preventable deaths, are not simply medical failures but consequences of political will and political decisions. The absence of national cancer registries, unreliable data, and fragmented financing renders cancer patients biopolitically invisible. The Nigerian cancer crisis is therefore not only a biomedical issue but a moral and political one. While Structural violence explains how suffering is produced through institutional arrangements, biopolitics reveals how power determines whose suffering matters. A just response must challenge the conditions that make cancer care scarce, bring neglected populations into political visibility, and reorient the state toward a politics of care rather than abandonment. This framework requires deliberate efforts to dismantle the institutional conditions that systematically disadvantage cancer patients. Addressing structural violence demands equitable distribution of oncology services, increased public financing, stronger national cancer registries, and policies that reduce dependence on catastrophic out-of-pocket expenditure. From a biopolitical perspective, the state must recognise cancer as a public health priority deserving sustained political commitment rather than allowing vulnerable populations to remain invisible within health planning. Justice therefore requires transforming healthcare institutions so that every citizen is afforded equal moral concern and protection.

Care ethics and the relational dimensions of suffering

To understand the human dimensions of cancer in Nigeria, it is important to complement structural and political analyses with the perspective of care ethics. Care ethics, developed by thinkers such as Carol Gilligan (1982), Nel Noddings (1984), and Virginia Held (2006), emphasizes the moral significance of relationships, vulnerability, and the responsibilities that arise from human interdependence. This framework is particularly relevant in contexts where illness profoundly affects not only individuals but the families and communities that surround them. Cancer in Nigeria unfolds within relational worlds that are already strained by economic uncertainty and weak health infrastructure [58–60]. For reasons that most functional oncology centres are concentrated in Lagos, Abuja, Enugu, Ibadan, and Port Harcourt, many families must travel long distances for treatment. These disruptions carry emotional and relational costs. Care ethics helps to illuminate this relational suffering, showing that illness affects the social fabric as much as the body. In a healthcare system marked by scarcity, families shoulder much of the caregiving burden. Relatives often perform tasks ordinarily handled by trained professionals; tasks such as feeding, washing, and administering basic comfort, because hospitals lack adequate staff or resources. This informal care reflects the cultural commitment to communal responsibility found in African moral philosophy. Scholars like Thaddeus Metz (2010) emphasize that personhood is expressed through supportive relationships; yet cancer places immense strain on the very networks relied upon for care. Caregivers themselves experience a distinct form of suffering. They often experience the emotional exhaustion of witnessing decline in patients, the anxiety of financial pressures, and the moral distress of being unable to secure adequate treatment. These burdens remain largely invisible within public health discourse, even though they shape the lived reality of cancer. Care ethics draws attention to these overlooked dimensions and shows that moral evaluation must include the quality-of-care relationships and the pressures placed upon them.

By foregrounding relational life, care ethics challenges an exclusive focus on individual autonomy. Many treatment decisions in Nigeria are made collectively by families, reflecting relational rather than strictly individual moral agency. This perspective offers a more culturally grounded understanding of how people navigate illness and suffering. In this way, care ethics deepens our interpretation of the cancer experience in Nigeria. It reveals that suffering is not merely biological or structural but relational, as it is embedded in the bonds that sustain life and the ruptures that illness creates. A more just and humane cancer response must therefore attend not only to clinical needs but also to the emotional, relational, and cultural worlds in which patients and care-givers dwell.

Care ethics requires that healthcare systems recognise the relational nature of illness and the moral significance of caregiving. Beyond treating disease, cancer services should support the emotional, psychological, and practical needs of patients, families, and caregivers who often bear enormous burdens under conditions of scarcity. Policies should strengthen counselling services, caregiver support programmes, multidisciplinary palliative care, and patient-centred communication. By valuing relationships as essential components of healthcare, this approach promotes compassion, dignity, and shared responsibility throughout the cancer journey.

Ubuntu philosophy and the moral demand for communal solidarity

Any ethical interpretation of cancer in Nigeria must ultimately take account of the African philosophical heritage that frames personhood, suffering, and responsibility in profoundly relational terms. One of the most influential frameworks is Ubuntu, often captured in the expression “umuntu ngumuntu ngabantu,” meaning “a person is a person through other persons.” This phrase foregrounds a conception of the human being whose identity and dignity emerge from participation in a community bound by mutual care, recognition, and solidarity. Ubuntu, therefore, provides a powerful ethical lens for assessing the relational and moral failures visible in Nigeria’s cancer landscape. In his paper, “Ubuntu Philosophy and the Surge of Traditional Medical Practices in 21st Century Africa,” Oseni Afisi (2017) describes Ubuntu as a normative tradition in which the self is fundamentally embedded within a network of social relations and moral obligations [61]. For Afisi, Ubuntu stands in contrast to Western liberal individualism, which tends to privilege autonomy, self-sufficiency, and private decision-making. African moral life, by contrast, is grounded in communal belonging, empathy, and shared humanity. Illness, therefore, is not merely a biomedical phenomenon affecting isolated individuals; it is a disturbance of the ethical fabric that binds people together. When cancer disrupts families, forcing patients to travel long distances to Lagos, Abuja, Enugu, Ibadan, or Port Harcourt, Ubuntu helps us see this disruption as a communal injury, not just a personal tragedy.

Thaddeus Metz (2011) further deepens this ethical outlook by articulating Ubuntu as a moral theory centred on promoting harmonious relationships. According to Metz, an action is morally right to the extent that it fosters identity and solidarity with others; it is wrong if it undermines social harmony or disrespects our shared humanity [62]. Applying Metz’s interpretation to the Nigerian cancer context reveals sharp ethical tensions. A health system that leaves large populations without accessible oncology centres, fails to establish reliable cancer registries, and burdens families with overwhelming caregiving responsibilities cannot be said to promote social harmony or collective well-being. It fractures relationships rather than sustaining them, thereby falling short of Ubuntu’s moral demand. The convergence of Afisi’s normative account and Metz’s relational ontology underscores a unified ethical critique. It means that cancer care in Nigeria reflects a profound erosion of communal solidarity. When families are forced to shoulder the emotional, financial, and logistical burdens of care with little institutional support, the communal ethics of Ubuntu are compromised. The suffering of cancer patients becomes doubly painful, not only because of the disease but also because the community, in its extended sense (society, the state, the health system), fails to uphold the reciprocity and mutual aid that Ubuntu requires. Moreover, Ubuntu stresses that human dignity is realized through compassionate engagement and shared moral responsibility. Afisi emphasizes that Ubuntu is built upon moral attitudes such as kindness, empathy, and collective care, which should guide how societies respond to suffering. Metz similarly argues that Ubuntu places an ethical duty on social and political institutions to create conditions in which communal relationships can flourish. Under these frameworks, the uneven distribution of oncology services across Nigeria and the lack of accessible palliative care represents not merely administrative shortcomings but violations of the communal ethos that affirms each person’s humanity through collective support. Ubuntu, therefore, enriches the moral analysis of cancer in Nigeria by shifting emphasis from the clinical to the communal. It highlights that health justice is inseparable from the quality of relationships within society, and that a genuinely humane response to cancer must foreground solidarity, shared vulnerability, and collective responsibility. If “umuntu ngumuntu ngabantu” expresses the ideal of personhood realised through community, then a just cancer care system must embody this ethic, ensuring that no person confronts illness in isolation, and that the burdens of suffering are shared rather than abandoned. What this framework requires is that cancer care be organised around the moral principles of solidarity, compassion, and shared responsibility that lie at the heart of Ubuntu philosophy. If personhood is realised through relationships with others, then no individual should bear the burden of cancer in isolation because of poverty, geography, or institutional neglect. This requires the development of active community-based care networks that provide continuous support for patients and their families, alongside policies that reduce isolation through equitable access to care, caregiver support programmes, and culturally grounded interventions that strengthen communal participation in caring for the sick. By affirming our shared humanity, Ubuntu demands that illness be recognised not merely as a private misfortune but as a collective moral concern requiring coordinated action from families, communities, healthcare institutions, and the state.

Vulnerability and moral luck

Understanding the ethical landscape of cancer in Nigeria requires attending to the interplay of human vulnerability, moral luck, and the deprivation of basic capabilities. As Fineman (2008) argues, vulnerability is a universal human condition, but its impact depends on the strength of social institutions designed to buffer life’s contingencies [63]. In Nigeria, the weakness of these institutional supports, such as scarce radiotherapy machines, limited oncology centres outside Lagos, Abuja, Ibadan, Enugu, and Port Harcourt, and heavy reliance on out-of-pocket payments, magnifies the vulnerability of those already disadvantaged by geography or poverty. Vulnerability is therefore not merely biological; it is socially produced.

The concept of moral luck, developed by Nagel (1979) and Williams (1981), further clarifies how a person’s health outcomes depend on factors entirely outside their control [64, 65]. A patient who happens to live near a functioning cancer centre is luckier than one born in a region with no oncology services. Survival may hinge not on choice but on the “luck” of timing, whether the radiotherapy machine is functioning, or the misfortune of being born into a family unable to absorb catastrophic treatment costs. Moral luck exposes the ethical inadequacy of narratives that attribute outcomes purely to personal responsibility. It highlights the arbitrariness underlying many cancer deaths in Nigeria.

Taken together, vulnerability theory and moral luck show that many cancer deaths in Nigeria are ethically unacceptable because they result from preventable structural conditions rather than unavoidable misfortune. A more just health system must reduce unnecessary vulnerability, limit the role of luck in determining survival, and expand the substantive capabilities individuals and communities need to flourish. This requires stronger public investment, equitable distribution of oncology services, and social protections that uphold the dignity and agency of those confronting illness. This framework requires reducing the extent to which survival from cancer depends on circumstances beyond an individual’s control. Ethical healthcare policy should minimise avoidable vulnerability by ensuring equitable access to oncology services irrespective of socioeconomic status or place of residence. This requires stronger public investment, social protection mechanisms, and fair geographical distribution of specialised cancer facilities. A just society cannot eliminate vulnerability altogether, but it has a moral obligation to ensure that preventable inequalities and arbitrary luck do not determine who lives and who dies.

Discussion and synthesis

The application of philosophical concepts illuminates the Nigerian cancer burden in ways that purely empirical data cannot. The lens of justice reveals that the high mortality and suffering are not merely medical facts but consequences of profound, systemic inequities in resource distribution and social structures. The inability of most Nigerians to access basic cancer care is a fundamental injustice, violating principles of fairness, equal opportunity, and the enablement of core human capabilities. It is also a structural failure, shaped by the slow violence of institutional neglect and the political abandonment of those who fall outside the narrow circles of national health priority. Examining autonomy highlights the complex interplay between individual agency, cultural norms, communication barriers, and systemic pressures. While the ideal of informed consent remains crucial, achieving it requires navigating deep-seated cultural practices, addressing low health literacy and challenging paternalistic tendencies within a resource-constrained system. Empowering patients requires more than just information; it demands systemic changes that foster trust and enable meaningful participation. The epistemological analysis underscores how beliefs about cancer, shaped by diverse and often conflicting sources of knowledge, directly impact behaviour and outcomes. It is an epistemic failure, sustained by misinformation, stigma, and the erasure of patients’ voices, that distorts public understanding and undermines timely access to care. Addressing the cancer burden necessitates tackling not just the disease but also the epistemic environment – combating misinformation, building trust, and challenging the prejudices that lead to epistemic injustice and social exclusion. Existential reflections bring the human core of the crisis into focus. The experience of cancer constitutes an existential crisis, marked by fear, uncertainty, the search for meaning, and the disruption of identity and relationships. Beyond the statistics are individuals grappling with suffering, searching for meaning, confronting their mortality, and striving to maintain dignity and identity in the face of devastating illness and societal indifference. Recognizing these existential dimensions is essential for developing compassionate care models that address the whole person, including palliative care that alleviates suffering and supports patients and families through end-of-life transitions. Finally, the crisis is a communal and global responsibility, one that demands renewed solidarity within Nigerian society and greater international commitment to health equity and global justice. Viewed together, these dimensions reveal cancer not as an individual misfortune but as a profound moral problem demanding coordinated ethical, social, and political responses.

Conclusion

The burden of cancer in Nigeria is a complex tragedy woven from threads of biological misfortune, systemic failure, social inequality, cultural belief, and profound human suffering. While biomedical advancements are crucial, this paper has argued that a philosophical lens is indispensable for fully grasping the weight of this burden and for formulating ethically sound responses. Concepts of justice demand urgent action to address the stark inequities in access to prevention, diagnosis, treatment, and palliative care. Respect for autonomy necessitates culturally sensitive approaches to communication and decision-making that empower patients amidst systemic constraints. Epistemological insights call for robust public health education to combat misinformation and stigma and systemic reforms to build trust in the healthcare system.

Recognizing the existential dimensions of cancer requires integrating psychosocial and spiritual support into care, ensuring dignity and meaning are central concerns, particularly when a cure is not possible. Finally, the principle of social responsibility underscores the need for collective action – demanding greater state commitment, fostering community solidarity, and promoting global health equity. Ignoring these philosophical dimensions leads to policies and interventions that may be technically sound but ethically lacking, failing to address the root causes of suffering and injustice. By integrating ethical reflection and philosophical analysis into cancer control planning, policymaking, clinical practice, and public health initiatives, Nigeria can move towards a future where the response to cancer is not only more effective but also more just, equitable, and compassionate, honestly acknowledging the human value and dignity of every individual facing this devastating disease.

Author contributions

Conceptualization: Omolara. A Fatiregun; Methodology: Omolara. A Fatiregun; Formal analysis and investigation: All Authors; Writing - original draft preparation: Omolara. A Fatiregun; Writing - review and editing: All Authors; Resources: Omolara. A Fatiregun, Oseni. T Afisi and Boluwatife. L Borisade; Supervision: Omolara. A Fatiregun.

Funding

No funding was received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

All authors have given consent to publish.

Competing interests

The authors declare no competing interests.