Intersectional Dynamics of Epistemic Injustices in Medicine
Kyle Sabater
Abstract
Following the concepts highlighted in Miranda Fricker’s “Evolving Concepts of Epistemic Injustice” (2017), the historical disregard for women’s concerns with their own bodies in medical contexts can be categorized as not only an issue of testimonial injustice, but also as an hermeneutical one. This paper intends to highlight the intersections between these variances of epistemic injustices in how they interact with one another, the implications their intersections carry for how these terms are understood, and what entails for victims of their dynamics. I argue that such obstructions in medical spaces, specifically between caregiver and careseeker interactions, invalidate their very purpose: alleviating sickness. For how can the intention to heal be exercised when a denial of a vulnerable person’s phenomenological accounts is imposed?
Introduction
Introduced in Miranda Fricker’s work “Epistemic Injustice: Power and the Ethics of Knowing” (2007), epistemic injustices are a categorization meant to delineate different types of wrongs committed against one’s capacity as a knower; of which she highlights two distinct types: testimonial injustices and hermeneutical injustices. As the invoking of the word “injustice” would imply, the purpose of these labels is to highlight the power dynamics present in epistemic interactions and represent forms of discrimination via denial of or to a target’s epistemic capacities. It is worth noting that these concepts are not mutually exclusive, and are thus able to interact with one another which itself bears troubling implications for the victims caught in their overlap. This is especially true in the dynamics present in the sensitive relationship between a doctor and patient; posing a great threat against the very purpose of these interactions:
identifying and alleviating sickness. If medical care was without justice, then the professional goal of providing these quite literally life-saving services would simply fail. The primary goal of this paper is to address the epistemic gap inherent to patient-doctor relations and discuss how injustices in this context not only impedes on diagnostic processes, but also results in a complete failure in providing care. In this work I will first define testimonial and hermeneutical injustices, outline their application in a diagnostic context, then discuss gender bias in diagnostics to then reflect on the disturbing implications of these injustices in medicine.
Defining Epistemic Injustices
To begin, we must introduce the injustices as they are plainly defined.[1] Testimonial injustices are the type invoked in a direct manner, such as through the denial of one’s credibility as a speaker. It is worth noting that this label is not to be used for instances where some denial of credibility is resultive of accidents or misunderstandings with regard to the speaker, for there is no one culpable in such situations. It is specifically used to describe the deliberate denial of credibility due to prejudices that the listener harbours against the speaker. While this may appear as contained within the instances where the injustice was imposed, the interaction may leave lasting effects on its victims. For example: if one’s contributions to discussions are consistently devalued by their peers, then they would have little reasons to continue participating. They would really have more reason to instead forgo participating in that circle’s activities, especially since they would then be carrying the knowledge that their peers view them as someone lesser to themselves. Fricker (2017) uses the term “downgraded epistemic status” to describe scenarios such as this. This social demotion of epistemic status is born of doubt to one’s capacities as a knower which may eventually result in their exclusion from whatever discussion is at hand, or from the group all together. A downgraded epistemic status applied before a discussion even really begins is also an issue. If one is dealing with some kind of mental disorder that others are inclined to believe disrupt their sense of reality, then whatever concern this person would have of their experiences or observations would probably be dismissed as them being crazy. The injustice here lies in how rather than be carefully considered with any sense of compassion or sensitivity from those around them, they are instead faced with an immediate dismissal resultive of this reduced status, leaving them in a position of not even being seen as a reliable interpreter of their own experiences. In a sense, they are alienated from their own experiences from not being accepted as someone capable of discussing them.
Hermeneutical injustices, on the other hand, are indirect and are the result of a problematic distribution of hermeneutical resources: “-Practices through which social meanings are generated” (Fricker, 2007, pg. 6). An example of this which Fricker points to the experience of sexual harassment in a culture that has not developed the concept. With the concept essentially absent from their culture’s social consciousness, victims of this offense would be without means to adequately recognize their victimhood. This category of epistemic injustice is meant to highlight the disparities between those who are epistemically empowered by their access to hermeneutical resources and those who are not. Those who are advantaged are considered so by virtue of their access to these resources, access to meanings for them to interpret which permits them a means of navigating their experiences. Those without are to be considered disadvantaged by their lack of access to the resources of the advantaged. The injustice of this type lies in victims’ comparative powerlessness to their counterparts through their denial to the social meanings that would permit them to make sense of the same concepts.
Application in Diagnostic Context
Nothing about these definitions of epistemic injustices indicate any sort of mutual exclusivity, and if anything, they leave plenty of room for overlap. Let us look at an example of epistemic injustice wherein a doctor disregards a patient’s account of their symptoms. Fricker points to situation of a doctor’s dismissal of a patient’s reports of their own phenomenological experience in “Evolving Concepts of Epistemic Injustice” (2017). The interaction between these two roles are typically led by the goal of understanding the patient’s symptoms or preferences for alternative treatments, but their exchanges may be led astray for a variety of reasons.
Doctors bear most, or some would argue all, the responsibility over the patient evaluation process. They must work under the pressure of the time allotted for their appointment to interpret someone’s symptomatic experiences comprehensively enough to understand the nature of their possible condition(s) and/or if they require further assessment. It is also important to acknowledge that by the nature of their role in this dynamic, patients are dependent on doctors, specifically their comparatively elevated epistemic status. Assuming that most patients are ordinary people who are unable to describe their symptoms using the technical language the doctor is accustomed to, it might actually impede on the accuracy of the assessment of their symptomatic experiences by presenting the problem of communicative gap. While this sort of issue is to be expected, again pointing to the epistemic gap inherent to the doctor-patient dynamic, this does nothing to change how, in the end, the patient must rely on the doctor to correctly assess their issues. But a wider gap does nothing to help the situation. It may actually make things actively worse. So much so that the patient’s testimony might end up working against them.
In the acknowledgement of both an epistemic and communicative gap, the doctor might work into it rather than bridge the distance. Rather than succeed in properly considering the patient’s accounts into their medical assessment, the doctor in question might instead find themselves either missing it entirely or outright dismissing it. This does not only disrespect the patient, the lack of credence to the patient’s communicated experiences turns them into weapons against them一in a sense. If the patient’s contributions to the exchange between themselves and their doctor are ignored, disregarded, then they might as well be made implicit in the doctor’s negligence.
Both testimonial and hermeneutical injustices are clearly invoked in such a scenario, in the doctor’s dismissal of their patient’s testimony and how this was founded in the doctor’s epistemic prejudices against the patient. It might appear as an exaggeration to label the latter as a matter of hermeneutical injustice, but we must understand that an imbalance in medicinal knowledge is inherent to dynamics between a doctor and patient. The very act of seeking advice from a medical professional implies a personal deficit in knowledge pertaining to the subject at large and demonstrates an acknowledgement of this disparity, of which said professional must respect and attend to in their dialogue with the patient.
The hermeneutical issue lies in the violation of this acknowledgement, as is exemplified in the previous example in the case that the doctor in question bases the discrediting of their patient’s accounts on this strange expectation that the patient somehow has access to the same language they are accustomed to using, to the same medical concepts as they understand. But if that were the case, then the patient would have little reason to seek consultation with a doctor to evaluate their problems beyond seeking a second opinion and/or having means to access diagnostic equipment. All this already presents a troubling situation to the patient as the dismissal from the authority they had sought to be guided by instead ultimately leaves their needs disrespected, unattended. This sort of predicament only gets worse for more vulnerable populations of care seekers.
Gender Bias in Diagnostics
Let us introduce an additional factor in this sort of sensitive interaction: the patient’s gender, then look to the evidence of gender bias in diagnostics.
Theresa Beery’s article titled “Gender Bias in the Diagnosis and Treatment of Coronary Artery Disease” (1995) discusses the exclusion of women from populations at high risk of CAD due to a multitude of issues that are rooted in different flavors of misogyny. This includes misinterpretations of womens’ symptoms to be indicative of psychiatric problems rather than physiological ones, the lesser likelihood for women to receive diagnostic referrals due to a downplaying of urgency regarding their symptomatic experiences, and a general lack of attention towards how symptoms of CAD might present differently in female sexed bodies. A common theme in these issues presented by Beery’s work is an element of neglect, a neglect of an epistemic sort. Women face not only testimonial injustice in the fact that their phenomenological accounts are often being dismissed for prejudices held against them based on their status as women, they also face hermeneutical injustices that are resultive of the lack of female representation in these diagnostic contexts.
The way these manifestations of injustice share a dynamic that informs and perpetuates one other is clearly apparent. If we begin with the dismissal of womens’ accounts of their symptomatic experiences, then we will inevitably find ourselves confronting where that neglect is coming from. When there simply is not enough data for how illnesses like those of CADs present in different bodies, the dismissal of their accounts come to be based on this lack. Should we examine this from the opposite direction, starting with this apparent lack of data, then we will find ourselves looking at the testimonial neglect once more, one informed by an absence of diverse information regarding these conditions, reinforcing these negative preconceptions of women not knowing their bodies. In this mutual perpetuation, women are left behind to bear their ills and the consequences born of their neglect alone.
When those who seek help for what they cannot solve on their own are cast aside, who benefits from it? It cannot be the doctors, those in a higher epistemic standing over the patients, for there is nothing of any actual value to be earned in the disregarding and neglecting of those they bear a prescribed responsibility to act in the best interests of. The neglect of one’s patients completely contradicts this purpose; there is no use for a caretaker disinterested in providing care. What befalls those caught in the intersection of these injustices is an act of violence against their well-being, both in an epistemic and physical sense, of which only functions to serve the interest of the discriminatory forces that exist at their roots. It does no good to the patients, the vulnerable; it does no good for those empowered by access to epistemic resources that the others are without. It only functions to enable and perpetuate the discriminatory ideals that are foundational to these acts of injustice that, if permitted to continue, could only lead to more and more people enduring this violence. This cannot continue.
Conclusion
It is clear that the dynamic between a medical professional and a patient seeking assessment is founded on an epistemic disparity in diagnostics and the obligation for the professional to, in such sensitive interactions, lead the reduction of this gap. But without the commitment to the patient’s well-being, to the sincere consideration of their experiences as part of the diagnostic process, then not only will the purpose of the interaction be left unfulfilled, but a vulnerable person’s hurts and concerns are left unattended, or even worse, left to fester.
Works Cited
Beery, Theresa A. “Gender Bias in the Diagnosis and Treatment of Coronary Artery
Disease.” Heart & Lung, vol. 24, no. 6, Mosby, Inc, 1995, pp. 427–35, https://doi.org/10.1016/S0147-9563(95)80020-4.
Carel, Havi, and Ian James Kidd. “Epistemic Injustice in Medicine and Healthcare.” The
Routledge Handbook of Epistemic Injustice, 1st ed., Routledge, 2017, pp. 336–46, https://doi.org/10.4324/9781315212043-33.
Fricker, Miranda. Epistemic Injustice : Power and the Ethics of Knowing . Oxford
University Press, 2007.
Fricker, Miranda. “Evolving Concepts of Epistemic Injustice.” The Routledge
Handbook of Epistemic Injustice, 1st ed., Routledge, 2017, pp. 53–60, https://doi.org/10.4324/9781315212043-5.
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Reflections 