Epistemic injustice in healthcare: a philosophial analysis

Abstract

In this paper we argue that ill persons are particularly vulnerable to epistemic injustice in the sense articulated by Fricker (Epistemic injustice. Power and the ethics of knowing. Oxford University Press, Oxford, 2007). Ill persons are vulnerable to testimonial injustice through the presumptive attribution of characteristics like cognitive unreliability and emotional instability that downgrade the credibility of their testimonies. Ill persons are also vulnerable to hermeneutical injustice because many aspects of the experience of illness are difficult to understand and communicate and this often owes to gaps in collective hermeneutical resources. We then argue that epistemic injustice arises in part owing to the epistemic privilege enjoyed by the practitioners and institutions of contemporary healthcare services—the former owing to their training, expertise, and third-person psychology, and the latter owing to their implicit privileging of certain styles of articulating and evidencing testimonies in ways that marginalise ill persons. We suggest that a phenomenological toolkit may be part of an effort to ameliorate epistemic injustice.

This is a preview of subscription content, log in to check access.

Notes

  1. 1.

    This scene was observed by one of the authors (Carel), whilst shadowing a paediatrician consultant at a UK hospital (details redacted to ensure patient confidentiality).

  2. 2.

    These discourses may vary greatly; we are not suggesting that there is only one such discourse.

  3. 3.

    Perhaps it is also a sort of epistemic injustice to complain that a person’s style of testimony is no good (inarticulate, etc.) but do nothing to ameliorate this (e.g. by critically reflecting upon the reasons that one has for using these unhelpful formats rather than others). Epistemic injustice might arise because (a) one buys into epistemically unjust structures or because (b) one fails to challenge those structures.

  4. 4.

    For an engaging discussion of the relationship between epistemic injustice, standpoint, and solidarity, see Medina (2012).

  5. 5.

    See, for instance, Coady (2010) and Hookway (2010).

  6. 6.

    More generally, we are not denying the existence of epistemic asymmetries, but call for discussion on how these should be managed in those cases where they do exist and where clinicians are aware of them. We would agree that a teacher who dismisses students or talks down to them, on the basis of their epistemic inferiority, is not a very good teacher. Dialogical openness is compatible with epistemic asymmetry and can serve to address the imbalance. Distinguishing the stance adopted by a clinician from the perceived and actual epistemic status of claims made by clinician and patient might be useful. We thank an anonymous referee for emphasising this point.

  7. 7.

    The Baron Münchausen (1720–1797) was a German war hero who travelled around Germany describing his military adventures. There is no evidence that he feigned disease or duped people into caring for him. As Feldman (2004) notes, Rudolph Erich Raspe appropriated the Baron’s name for the title of a 1785 pamphlet of outrageous and patently false tales, Baron Munchausen’s Narrative of His Marvelous Travels and Campaigns in Russia.

  8. 8.

    http://www.kgh.on.ca/en/aboutkgh/Patient%20and%20Family%20Advisory%20Council/Pages/default.aspx (accessed on 10 June 2013).

  9. 9.

    Leslie Thomson, KGH Chief Executive, talk at King’s Fund on 8th November 2012.

  10. 10.

    These examples are taken from responses to a query we posted on a patient mailing list in 2012.

  11. 11.

    Self-censoring is another form of epistemic injustice, in which the negative stereotyping is internalised by the patient herself, leading her to downgrade her own testimony. .

  12. 12.

    See for example the work of organisations such as the King’s Fund and the Point of Care Foundation and, for the UK National Health Service, Coulter and Ellins (2006), Greener (2009), and McIver (2011).

  13. 13.

    A vivid and tragic example is the series of systematic failures which led to the death of hundreds of patients, uncovered by the Mid Staffordshire NHS Foundation Trust Public Inquiry, led by Sir Robert Francis in the UK. See: http://www.midstaffspublicinquiry.com/report (accessed on 10 June 2013).

  14. 14.

    The fact that the medical community has these forms of social and epistemic power does not, of course, entail that they always exercise that power in a robustly procedural manner (see Kidd forthcoming a).

  15. 15.

    Indeed, the issue of culpability for epistemic injustice is complex, for instance because it varies according to whether the particular form of injustice is agential or structural. See, further, the exchange between Riggs (2012) and, in reply, Coady (2012).

  16. 16.

    Many religious persons who experience depression will often consult persons they recognise as having spiritual authority—priests, say—as well as to psychiatrists and other mental health professionals (cf. Scrutton forthcoming and Kidd forthcoming b).

  17. 17.

    The case of some mental disorders, e.g. psychosis, would be different. In these cases the patient may be considered altogether irrational and unable to make true assertions at all.

  18. 18.

    These comments were collected during three consultative sessions: one with a group of GPs took place on 14 June 2012 and two patient group sessions took place on 14 and 21 September 2012, all in Bristol, UK.

References

  1. Anderson, E. 2012. Epistemic justice as a virtue of social institutions. Social Epistemology 26(2): 163–173.

    Article  Google Scholar 

  2. Beckman, H., and R. Frankel. 1984. The effect of physician behavior on the collection of data. Annals of Internal Medicine 101: 692–696.

    Article  Google Scholar 

  3. Biggs J. and N. Boulton 2011. Voices from the shadows. DVD documentary. UK.

  4. Dennett, D. 1981. Brainstorms. Cambridge MA: MIT Press.

    Google Scholar 

  5. Carel, H. 2008. Illness. Stocksfield: Acumen.

  6. Carel, H. 2012. Phenomenology as a resource for patients. Journal of Medicine and Philosophy 37(2): 96–113. doi:10.1093/jmp/JHS008

    Google Scholar 

  7. Carel, H. 2013. Bodily doubt. Journal of Consciousness Studies 20(7–8): 178–197.

  8. Cegłowski, M. 2012. No evidence of disease. http://idlewords.com/2012/09/no_evidence_of_disease.htm.

  9. Coady, D. 2010. Two concepts of epistemic injustice. Episteme 7(2): 101–113.

    Article  Google Scholar 

  10. Coady, D. 2012. Critical reply to “Culpability for epistemic injustice: Deontic or aretaic?”. Social Epistemology Review and Reply Collective 1(5): 3–6.

    Google Scholar 

  11. Coulter, A., and J. Ellins 2006. Patient focused interventions: A review of the evidence. London: The Health Foundation. www.health.org.uk.

  12. Emanuel, E.J., and L.L. Emanuel. 1992. Four models of the physician-patient relationship. Journal of the American Medical Association 267(16): 2221–2226.

    Article  Google Scholar 

  13. Feldman, M.D. 2004. Playing sick? Untangling the web of Munchausen syndrome, Munchausen by proxy, malingering, and factitious disorder. New York: Brunner-Routledge.

    Google Scholar 

  14. Frank, A. 2010. The wounded storyteller: Body, illness, and ethics. Chicago: University of Chicago Press.

    Google Scholar 

  15. Fricker, M. 2007. Epistemic injustice. Power and the ethics of knowing. Oxford: Oxford University Press.

    Google Scholar 

  16. Goldacre, B. 2012. Bad pharma. London: Fourth Estate.

    Google Scholar 

  17. Greener, I. 2009. Healthcare in the UK: Understanding continuity and change. Bristol: The Policy Press.

    Google Scholar 

  18. Heidegger, M. 1962 [1927]. Being and time. Oxford: Basil Blackwell.

  19. Hookway, C. 2010. Some varieties of epistemic injustice: Response to Fricker. Episteme 2010: 151–163.

    Article  Google Scholar 

  20. Husserl, E. 1999 [1931]. Cartesian meditations. D. Cairns (trans.). Dordrecht, The Netherlands: Kluwer.

  21. Kidd, I.J 2013. A pluralist challenge to ‘integrative medicine’: Feyerabend and Popper on the cognitive value of alternative medicine. Studies in History and Philosophy of Biological and Biomedical Science 44(3): pp.392–400.

  22. Kleinman, A. 1980. Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, CA: University of California Press.

    Google Scholar 

  23. Kleinman, A. 1988. The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.

    Google Scholar 

  24. Korsch, B.M., et al. 1968. Gaps in doctor-patient communication: Doctor-patient interaction and patient satisfaction. Pediatrics 42: 855–871.

    Google Scholar 

  25. Korsch, B.M. 1969. Gaps in doctor patient communication ii: patients response to medical advice. The New England Journal of Medicine 280: 535–540.

    Article  Google Scholar 

  26. Leontiou, J.F. 2010. What do the doctors say? New York: iUniverse.

  27. McIver, S. 2011. User perspectives and involvement. In: K. Walshe and J. Smith (Eds.), Healthcare management 2nd ed. (pp. 354–372) Maidenhead: Open University Press.

  28. Medina, J. 2012. The epistemology of resistance: Gender and racial oppression, epistemic injustice, and the social imagination. Oxford: Oxford University Press.

    Google Scholar 

  29. Merleau-Ponty, M. 1962 [1945]. Phenomenology of perception. New York: Routledge.

  30. NHS Constitution: http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-nhs-constitution-for-england-2013.pdf (accessed March 17, 2014).

  31. Patients Association: http://patients-association.com/Default.aspx?tabid=41 (accessed March 17, 2014).

  32. Patient Charter (1991/1995/1997) see: Department of Health (1991) The Patient’s Charter (London: HMSO) (accessed July 15, 2013).

  33. Ratcliffe, M. 2008. Feelings of being: Phenomenology, psychiatry and the sense of reality. Oxford: Oxford University Press.

    Google Scholar 

  34. Ratcliffe, M. 2012. Phenomenology as a form of empathy. Inquiry 55(5). doi:10.1080/0020174X.2012.716196.

  35. Riggs, W. 2012. Culpability for epistemic injustice: Deontic or aretaic? Social Epistemology 26(2): 149–162.

    Article  Google Scholar 

  36. Rosenbaum, L. 2012. How much would you give to save a dying bird? Patient advocacy and biomedical research. New England Journal of Medicine 367:1755–1759. http://www.nejm.org/toc/nejm/367/18/. doi:10.1056/NEJMms1207114.

  37. Saks, E. 2007. The center cannot hold. My journey through madness. New York: Hyperion.

    Google Scholar 

  38. Savino, A.C., and J.S. Fordtran. 2006. Factitious disease: Clinical lessons from case studies at Baylor University Medical Center. Proceedings of Baylor University Medical Center 19: 195–208.

    Google Scholar 

  39. Scrutton, A. (forthcoming) ‘Two Christian theologies of depression: An evaluation and discussion of clinical implications’. Philosophy, Psychiatry, & Psychology.

  40. Toombs, S.K. 1987. The meaning of illness: A phenomenological approach to the patient-physician relationship. The Journal of Medicine and Philosophy 12: 219–240.

    Article  Google Scholar 

  41. Toombs, S.K. 1999. The meaning of illness: a phenomenological account of the different perspectives of physician and patient. Amsterdam: Kluwer.

    Google Scholar 

  42. Wainwright, M., and J. Macnaughton. 2013. Is a qualitative perspective missing from COPD guidelines? The Lancet Respiratory Medicine 1(6): 441–442.

    Article  Google Scholar 

  43. Wanderer, J. 2012. Addressing testimonial injustice: Being ignored and being rejected. The Philosophical Quarterly 62(246): 148–169.

    Google Scholar 

  44. Wootton, D. 2007. Bad medicine. Oxford: Oxford University Press.

    Google Scholar 

Download references

Acknowledgments

This paper was written during Havi Carel’s British Academy Fellowship. She is grateful to the British Academy for enabling this period of research leave. Ian James Kidd wrote this paper during an Addison Wheeler Fellowship. We are also grateful to Miranda Fricker for her encouragement and to the men and women who generously shared their illness testimonies with us.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Havi Carel.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Carel, H., Kidd, I.J. Epistemic injustice in healthcare: a philosophial analysis. Med Health Care and Philos 17, 529–540 (2014). https://doi.org/10.1007/s11019-014-9560-2

Download citation

Keywords

  • Epistemic injustice
  • Illness
  • Patient experience
  • Phenomenology
  • Patient toolkit