Hermeneutic Justice and Medical Practice

Takeaway: The societal dominance of biomedical narratives requires physicians to practice medicine with epistemic humility and in a deeply collaborative manner.

 

How medical explanations shape our self-understanding individually as well as collectively has increasingly been on my mind, and over time I have become acutely aware of medicine’s complicated relationship with epistemic justice. According to philosopher Miranda Fricker, epistemic injustice occurs when someone is wronged “specifically in their capacity as a knower.” (1) This comes in two forms, testimonial and hermeneutic injustice. Testimonial injustice happens when a person is assigned lower credibility due to prejudice and not based on any reasonable concerns about the testimony. The person belongs to a certain negatively stereotyped social group, and this creates a credibility deficit for members of that group. A common example would be not taking the testimony of someone as seriously as is warranted because they are of a certain gender or race. Another important group consists of individuals who are ill or require healthcare services.

Hermeneutic injustice occurs when “the prejudicial flaws in shared interpretive resources prevent the subject from making sense of an experience which it is strongly in her interests to render intelligible.” (1) That is, when individuals do not possess the conceptual resources – the concepts, vocabulary, perspectives, etc. – which they need in order to make sense of their own experiences and their own identities. Hermeneutic justice is a collective and structural problem; it results from a deficiency of conceptual resources available to a particular group. This could be because the relevant conceptual resources have not yet been developed (Fricker gives the example of a victim of sexual harassment in a society where the concept of “sexual harassment” does not yet exist), resources exist but are not accessible to those who need them (for instance, a concept has been discussed but exists only in academic journals), or because the concepts exist and are accessible to the vulnerable group, but those concepts have not yet been acknowledged as valid or worthy of respect by the rest of society.

I am convinced that medicine on the whole has historically been on the side of hermeneutic justice. Medicine has created conceptual resources that have allowed individuals with various states of distress and disability to make sense of their experiences and access much-needed help. Furthermore, the medical framework has also saved vulnerable individuals from self-blame as well as societal blame by showing that the states in question are not under the ordinary control of the individual. Imagine, for instance, a society in which the medical concept of addiction does not exist, and the only way addiction can be understood is in moral or religious terms. Fricker herself gives the example of postpartum depression and refers to the story of a woman from the history of US women’s liberation movement who realized after a group discussion that she had been blaming herself and her husband had been blaming her for failings which were in fact a product of postpartum depression, a psychiatric condition, and realized that it wasn’t her personal deficiency (2).

The situation, however, is not that simple. The medical framework has acquired tremendous social power over the last half-century or so. This power also comes with a danger of displacing and suppressing non-medical narratives that may be necessary for self-understanding and without which individuals may be left “troubled, confused, and isolated.” (1) Consider, for instance, an individual with autism who has no access to the notion of “neurodiversity” and the only way she can think of herself is in terms of abnormality or deficit. Or consider an individual who has been told that his depression is a meaningless product of faulty neurochemistry and has no access to conceptual resources to contextualize his distress and understand his depression as meaning-laden.

Such instances of epistemic injustice are not inherent to the medical framework. They arise when medical explanations are privileged to such an extent that other modes of understanding become inaccessible, or when medical perspectives are incorrectly assumed to be complete and exclusive descriptions of the reality of the phenomena. Recognizing this as one source of the problem also suggest a possible solution: epistemic humility. Alistair Wardrope describes it as “an attitude of awareness of the limitations of one’s own epistemic capacities, and an active disposition to seek sources outside one’s self to help overcome these shortcomings.” (3) He notes that this awareness is not merely a private acknowledgement but a public expression of epistemic limits. “The epistemically humble agent is one who is aware of the perspectival, pragmatic nature of their interpretations of given phenomena, and actively seeks out information and perspectives that may highlight shortcomings in such interpretations.” (3)

The problem of epistemic injustice becomes even more complicated when both physicians and patients have to deal with unresolvable uncertainty. For many medical diagnoses there is no “hard” data in terms of pathological markers or neuroimaging; we must rely on patient histories, clinical examination, and clinical judgments. In addition, many medical diagnoses, such as chronic fatigue syndrome, are “conceptually impoverished” (4); their scientific nature is murky and unclear, such that both offering and not offering the diagnosis presents different challenges (see an insightful discussion by Eleanor Alexandra Byrne (4)). This means there will be situations where there is epistemic vulnerability to injustice but no clarity on whether epistemic injustice has or has not occurred.

Epistemic justice, in such situations, can only be ensured by a deep collaboration between stakeholders that epistemically empowers both patients and physicians (4-5). Recognizing that clinical work immerses us in epistemic challenges is the first step in being able to deal with those challenges; by practicing medicine in a collaborative, humanistic, and pluralistic manner, we can avoid the pitfalls of epistemic injustice.

 

References:

1. Fricker, M. Epistemic Injustice: Power and the Ethics of Knowing. 2007. Oxford University Press.

2. Hewitt, S. Hermeneutical injustice and mental disorder. 2020. https://www.simonhewitt.org/uploads/7/4/0/9/74091063/herminjustice.pdf

3. Wardrope A. Medicalization and epistemic injustice. Medicine, Health Care and Philosophy. 2015;18(3):341-52.

4. Byrne EA. Striking the balance with epistemic injustice in healthcare: the case of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. Medicine, Health Care, and Philosophy. 2020;23(3):371.

5. Crichton P, Carel H, Kidd IJ. Epistemic injustice in psychiatry. BJPsych bulletin. 2017;41(2):65-70.