Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management.
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Atkins, K. 2000. Autonomy and the subjective character of experience. Journal of Applied Philosophy 17(1): 71–79.
Baier, A. 1986. Trust and antitrust. Ethics 96(2): 231–260.
Barry, D.T., K.S. Irvin, E.S. Jones, et al. 2010. Opioids, chronic pain, and addiction in primary care. The Journal of Pain 11(12): 1442–1450.
Beauchamp, T., and J. Childress. 2008. Principles of biomedical ethics. 6th ed. New York: Oxford University Press.
Biro, D. 2010. The language of pain: Finding words, compassion, and relief. New York: W.W. Norton & Company.
Boddice, R. 2015. Pain: A very short introduction. New York: Oxford University Press.
Bourke, J. 2014. The story of pain: From prayer to painkillers. New York: Oxford University Press.
Brodwin, P.E. 1992. Symptoms and social performances: The case of Diane Reden. In Pain as human experience: An anthropological perspective, edited by M.-J. Delvecchio Good, P.E. Brodwin, B.J. Good, and A. Kleinman, 77–99. Berkeley: University of California Press.
Brody, H. 1994. “My story is broken; can you help me fix it?” Medical ethics and the joint construction of narrative. Literature and Medicine 13(1): 79–92.
Buchman, D.Z., and A. Ho. 2013. What’s trust got to do with it? Revisiting opioid contracts. Journal of Medical Ethics 40(10): 673–677.
Buchman, D.Z., A. Ho, and J. Illes. 2016. You present like a drug addict: Patient and clinician perspectives on trust and trustworthiness in chronic pain management. Pain Medicine, ePub ahead of print.
Calnan, M.W., and E. Sanford. 2004. Public trust in health care: The system or the doctor? Quality and Safety in Health Care 13(2): 92–97.
Carel, H., and I.J. Kidd. 2014. Epistemic injustice in healthcare: A philosophical analysis. Medicine, Healthcare and Philosophy 17(4): 529–540.
Charon, R. 2006. Narrative medicine: Honoring the stories of illness. New York, NY: Oxford University Press.
Clarke, K.A., and R. Iphofen. 2005. Believing the patient with chronic pain: A review of the literature. British Journal of Nursing 14(9): 490–493.
Cohen, M., J. Quintner, and D. Buchanan. 2011. Stigmatization of patients with chronic pain: The extinction of empathy. Pain Medicine 12(11): 1637–1643.
Crowley-Matoka, M. 2012. No one wants to be the candy man: Ambivalent medicalization and clinician subjectivity in pain management. Cultural Anthropology 27(4): 689–712.
Daston, L., and P. Galison. 2007. Objectivity. New York: Zone Books.
Fiscella, K., and R.M. Epstein. 2008. So much to do, so little time: Care for the socially disadvantaged and the 15-minute visit. Archives of Internal Medicine 168(17): 1843–1852.
Foucault, M. 1994. The birth of the clinic: An archaeology of medical perception. Translated by A.M.S. Sheridan. New York: Vintage Books.
Fricker, M. 2007. Epistemic injustice: The power and ethics of knowing. Oxford, U.K: Oxford University Press.
———. 2012. Epistemic justice as a condition of political freedom? Synthese 190(7): 1317–1332.
Geppert, C.M. 2004. To help and not to harm: Ethical issues in the treatment of chronic pain in patients with substance use disorders. In Pain and depression: An interdisciplinary patient-centered approach, edited by M.R. Clark, and G.J. Treisman, 151–171.
———. 2008. Why psychiatrists should read the humanities. Psychiatric Times. February 1. http://www.psychiatrictimes.com/articles/why-psychiatrists-should-read-humanities. Accessed May 31, 2016.
Goldberg, D.S. 2010. Job and the stigmatization of chronic pain. Perspectives in Biology & Medicine 53(3): 425–438.
———. 2014. The bioethics of pain management: Beyond opioids. New York: Routledge.
Goldman, A. 2001. Experts: Which ones should you trust? Philosophy and Phenomenological Research 63(1): 85–110.
Govier, T. 1997. Self-trust and human communities. Montreal and Kingston: McGill–Queen’s University Press.
Green, C.R., K.O. Anderson, T.A. Baker, et al. 2003. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Medicine 4(3): 277–294.
Greenhalgh, S. 2001. Under the medical gaze: Facts and fictions of chronic pain. Berkeley, CA: University of California Press.
Hall, M. 2001. Arrow on trust. Journal of Health Politics, Policy and Law 26(5): 1131–1144.
———. 2005. The importance of trust for ethics, law, and public policy. Cambridge Quarterly of Healthcare Ethics 14(2): 156–167.
Halpern, J. 2001. From detached concern to empathy: Humanizing medical practice. Oxford, UK: Oxford University Press.
Hardwig, J. 1985. Epistemic dependence. The Journal of Philosophy 82(7): 335–349.
Heshusius, L. 2009. Inside chronic pain: An intimate and critical account. Ithaca: Cornell University Press.
Ho, A. 2009. “They just don’t get it!” When family disagrees with expert opinion. Journal of Medical Ethics 35(8): 497–501.
———. 2011. Trusting experts and epistemic humility in disability. The International Journal of Feminist Approaches to Bioethics 4(Fall 2): 102–124.
Hoffman, K.M., S. Trawalter, and J.R. Axt. 2016. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 201516047.
Honkasalo, M-L. 2001. Vicissitudes of pain and suffering: Chronic pain and liminality. Medical Anthropology 19(4): 319–353.
Institute of Medicine. 2011. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press.
Jackson, J.E. 1992. “After a while no one believes you”: Real and unreal pain. In Pain as human experience: An anthropological perspective, edited by M.-J. Delvecchio Good, P.E. Brodwin, B.J. Good, and A. Kleinman, 138–168. Berkeley, CA: University of California Press.
Jaillard, A., and A.H. Ropper. 2013. Pain, heat, and emotion with functional MRI. New England Journal of Medicine 368: 1447–1449.
Kleinman, A. 1988. The illness narratives: Suffering, healing, & the human condition. New York, NY: Basic Books.
———. 1992. Pain and resistance: The delegitimation and relegitimation of local worlds. In Pain as human experience: An anthropological perspective, edited by M.-J. Delvecchio Good, P.E. Brodwin, B.J. Good, and A. Kleinman, 169–197. Berkeley, CA: University of California Press.
Kwon, D. 2016. The battle over pain in the brain. Scientific American, April 28. http://www.scientificamerican.com/article/the-battle-over-pain-in-the-brain/. Accessed June 2, 2016.
Link, B.G., and J.C. Phelan. 2001. Conceptualizing stigma. Annual Review of Sociology 27: 363–385.
———. 2006. Stigma and its public health implications. Lancet 367(9509): 529.
Marbach, J., M.C. Lennon, B.G. Link, and B.P. Dohrenwend. 1990. Losing face: Sources of stigma as perceived by chronic facial pain patients. Journal of Behavioral Medicine 13(6): 583–604.
Martensen, R. 2004. The brain takes shape: An early history. New York: Oxford University Press.
Matthias, M. S., A.L. Parpart, K.A. Nyland, et al. 2010. The patient–provider relationship in chronic pain care: Providers’ perspectives. Pain Physician 11(11): 1688–1697.
McLeod, C. 2002. Self-trust and reproductive autonomy. Cambridge, MA: MIT Press.
Miller, J. 2007. The other side of trust in health care: Prescribing drugs with the potential for abuse. Bioethics 21(1): 51–60.
Moscoso, J. 2012. Pain: A cultural history. Basingstoke: Palgrave MacMillan.
Osborne, M., and J.A. Smith. 1998. The personal experience of chronic benign lower back pain: An interpretative phenomenological analysis. British Journal of Health Psychology 3(1): 65–83.
Ousager, J., and H. Johannessen. 2010. Humanities in undergraduate medical education: A literature review. Academic Medicine 85(6): 988–998.
Pellegrino, E. 1991. Trust and distrust in professional ethics. In Ethics, trust, and the professions: Philosophical and cultural aspects, edited by E. Pellegrino, R. Veatch, and J. Langan, 69–89. Washington, DC: Georgetown University Press.
Peterkin, A. 2008. Medical humanities for what ails us. Canadian Medical Association Journal 178(5): 648.
Pfeiffer, D. 2000. The disability paradigm. Journal of Disability Policy Studies 11(2): 98–99.
Rich, B.A. 1997. A legacy of silence: Bioethics and the culture of pain. Journal of Medical Humanities 18(4): 233–259.
Rhodes, L.A., C.A. McPhillips-Tangum, C. Markham, and R. Klenk. 1999. The power of the visible: The meaning of diagnostic tests in chronic back pain. Social Science & Medicine 48(9): 1189–1203.
Rogers, W. 2002. Is there a moral duty for doctors to trust patients? Journal of Medical Ethics 28(2): 77–80.
Sandman, L., and C. Munthe. 2009. Shared decision-making and patient autonomy. Theoretical Medicine and Bioethics 30(4): 289–310.
Scarry, E. 1985. The body in pain. New York: Oxford University Press.
Scheman, N. 2001. Epistemology resuscitated: Objectivity as trustworthiness. In (En)gendering rationalities, edited by N. Tuana and S. Morgen, 23–52. Albany, NY: SUNY Press.
Shapiro, J., E.H. Morrison, and J.R. Boker. 2004. Teaching empathy to first-year medical students: Evaluation of an elective literature and medicine course. Education for Health 17(1): 73–84.
Stempsey, W. 2000. Disease and diagnosis: Value-dependent realism. Dordrecht: Kluwer Academic Publishers.
The Good Stewardship Working Group. 2011. The “Top 5” lists in primary care: Meeting the responsibility of professionalism. Archives of Internal Medicine 171(15): 1385.
Toye, F., and K. Barker. 2010. “Could I be imagining this?”—The dialectic struggles of people with persistent unexplained back pain. Disability and Rehabilitation 32(21): 1722–1732.
Upshur, R.E.G., and E. Colak. 2003. Argumentation and evidence. Theoretical Medicine and Bioethics 24(4): 283–299.
van Hooft, S. 2003. Pain and communication. Medicine, health care and philosophy 6(3): 255–262.
Wager, T., L.Y Atlas, and M.A. Lindquist. 2013. An fMRI-based neurologic signature of physical pain. New England Journal of Medicine 368(15): 1388–1397.
Wailoo K. 1996. Negro blood as genetic marker: Thalassemia and sickle cell anemia in America to 1950. Journal of History and Philosophy of the Life Sciences 18: 305–320.
———. 2014. Pain: A political history. Baltimore: Johns Hopkins University Press.
Werner A., and K. Malterud. 2003. It is hard work behaving as a credible patient: Women with chronic pain and their physicians. Social Science & Medicine 57(8): 1409–1419.
Whitney S., and L. McCullough. 2007. Physicians’ silent decisions: Because patient autonomy does not always come first. American Journal of Bioethics 7(7): 33–38.
We would like to thank Nigel Hee, Research Associate at the Centre for Biomedical Ethics, Yong Loo Lin School of Medicine at the National University of Singapore, for his editorial support. We also thank our anonymous reviewers and editors for their very helpful suggestions.
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Buchman, D.Z., Ho, A. & Goldberg, D.S. Investigating Trust, Expertise, and Epistemic Injustice in Chronic Pain. Bioethical Inquiry 14, 31–42 (2017). https://doi.org/10.1007/s11673-016-9761-x
- Chronic pain
- Epistemic injustice