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Investigating Trust, Expertise, and Epistemic Injustice in Chronic Pain

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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.
Investigating Trust, Expertise, and Epistemic Injustice
in Chronic Pain
Daniel Z Buchman &Anita Ho &Daniel S Goldberg
Received: 5 June 2016 /Accepted: 23 October 2016
#Journal of Bioethical Inquiry Pty Ltd. 2016
Abstract 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 re-
ceived 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 injus-
tice 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 testimo-
nial exchange in chronic pain management.
Keywords Chronic pain .Epistemic injustice .Trust .
Expertise .bioethics .Stigma
Trust underpins human relationships. When one trusts
another, one expects that the other is being honest and
has good intentions. The provision of healthcare is
grounded in trust and the trustworthiness of its profes-
sionals and institutions. In therapeutic relationships,
healthcare providers (HCPs) are sought based on their
epistemically privileged statustheir expert knowl-
edge, skills, and ability in addressing the health com-
plaint. Despite a shared identification of the goodthe
health of the patientthe epistemic asymmetries be-
tween a HCP and a patient make the patient, the trustor,
vulnerable to the HCP, the trustee.
The narratives of chronic pain sufferers provide help-
ful insights into the experience of pain at the juncture of
Bioethical Inquiry
DOI 10.1007/s11673-016-9761-x
D. Z. Buchman (*)
University Health Network, Bioethics Program, Joint Centre for
Bioethics and Dalla Lana School of Public Health, University of
Toronto, 399 Bathurst Street, McLaughlin Block, 8
Floor, Room
443, Toronto, ON M5S 2S8, Canada
A. Ho
Centre for Biomedical Ethics, Yong Loo Lin School of Medicine,
National University of Singapore and W. Maurice Young Centre
for Applied Ethics, University of British Columbia, Block MD11,
Clinical Research Centre, 10 Medical Drive, Singapore 117597,
D. S. Goldberg
Center for Bioethics and Humanities, University of Colorado
Anschutz Medical Campus, Fullginiti Pavilion Room 205, 13080
E. 19th Avenue, Aurora, CO 80045, United States
trust, expert knowledge, and the therapeutic relation-
ship. In a medical culture that increasingly relies on
objective indicators of disease processes, the clinical
assessment of pain is challenging, particularly when
the pathology, even if known, does not always corre-
spond to the reported severity by the pain sufferer. Such
subjectivity may prompt some HCPs to question the
truthfulness of the pain suffererstestimony,assymp-
toms may become viewed as embellished or contrived.
When issues related to opioid management arise, such
as addiction and overdose, pain sufferers may also be
considered suspicious and untrustworthy. Since HCPs
have the epistemic privilege to decide how patient nar-
ratives and symptoms should be managed, many pain
sufferers report that their testimonies about their pain
and experiences are discredited and considered
This unfair downgrading of credibility is what Mi-
randa Fricker (2007) calls epistemic injustice, a type of
harm that is done to individuals or groups regarding
their ability to contribute to and benefit from knowl-
edge. In particular, testimonial injustice happens when
a prejudice causes a hearer to give less credibility to a
speakers testimony and interpretations than they de-
serve. Since there are major inequities in the preva-
lence, treatment, and outcomes for chronic pain across
race, ethnicity, gender, and class, epistemic injustice
patterns of stigma and social injustices. This coupled
epistemicethical issue has received limited treatment
in bioethics.
Drawing upon the social science and medical human-
ities literatures, we examine how a climate of distrust in
pain management may facilitate epistemic injustice. We
critically interrogate the processes through which pain
sufferers are vulnerable to specific kinds of epistemic
injustice. We examine how healthcare institutions and
practices may privilege some kinds of evidence and
ways of knowing over others. We argue that HCPs
ought to avoid epistemic injustice by striving toward
epistemic humility as a form of epistemic justice. Being
epistemically humble means correcting for prejudicial
credibility judgements by recognizing that medical de-
cisions are almost always accompanied by uncertainty
and that the testimonies of pain sufferers can help com-
plete the clinical scenario. Importantly, an epistemically
humble approach recognizes patient testimony and ill-
ness interpretations as epistemically privileged in deter-
mining the best clinical management.
Trus t i n H ealthc a re
Trust is an essential feature of the therapeutic relation-
ship, given that the providerpatient relationship is a
Bpeculiar constellation of urgency, intimacy,
unavoidability, unpredictability, and extraordinary
vulnerability^(Pellegrino 1991, 84). As Annette Baier
(1986) explains, when we trust another, we expect that
the good will and competence of the other will govern
our interaction as appropriate for the relationship. Trust
is intrinsically important because it is a core character-
istic that affects the emotional and interpersonal aspects
of the physicianpatient relationship (Hall 2005). In
facing complex clinical information and navigating
through the healthcare system, many patients are
overwhelmed. They require assistance to understand
their situation as well as to restore or maintain their
functioning or well-being, and it is only when they trust
their HCPs that these professionals can help the patients
achieve their care goals (Ho 2011). As an instrumental
value, trust is widely believed to be essential for effec-
tive therapeutic encounters (Hall 2005). Without as-
sumptions of competence and goodwill, patients would
unlikely allow close physical contact or agree to recom-
mended treatments that may have significant side effects
and risks. Patients trust HCPs when they believe in these
professionalsqualification and motivations. Since
HCPs are often gatekeepers of resources and are the
only ones with the official credentials to treat patients,
if they are not trustworthy, patients would be vulnerable
to betrayal (Baier 1986; Rogers 2002). Motivations that
are not based significantly on patientswelfare or may
even counter their good are generally considered con-
flicts of interest that detract from the professionals
trustworthiness and undermine the fiduciary provider
patient relationship.
Trust and Medical Expertise
Trust in the therapeutic relationship is often taken for
granted partly because of two forms of epistemic hier-
archy. First, professionalsspecialized training bestows
on them a substantial body of knowledge and skills in
their clinical domain; the resulting epistemological gap
gives prima facie reasons for patients who cannot ade-
quately assess the evidence in this domain to accept
HCPsjudgement about such data (Goldman 2001).
Healthcare providers of all professional backgrounds,
by virtue of their intensive and ongoing education and
Bioethical Inquiry
practice, presumably have superior ability to accurately
diagnose and determine a range of possible solutions for
various medical problems. Laypersons generally lack
comparable levels of specialized training or knowledge.
Epistemic dependence in this context of Bintra-method^
epistemic hierarchy (Ho 2011)isarguablyrationalor
even the responsible choice (Hardwig 1985).
Second, clinical methods have traditionally and sys-
tematically been seen as the most reliable methods in
determining medical management strategies, creating
and reinforcing an Binter-method^hierarchy by directly
or indirectly conferring more credibility upon those who
practice the privileged approach(es) (Ho 2011). In the
age of evidence-based medicine, medical experts can
arguably predict the respective health consequences
from the use of various technologies or medications by
appealing to systematic reviews of double-blind,
placebo-controlled trials and meta-analyses. They can
also utilize their knowledge and clinical skills to help
prevent or reverse symptom progression. Lay patients
beliefs in specialized areas are relatively uninformed,
unreliable, and untested according to rigorous scientific
standards (Hardwig 1985, 340). With both forms of
epistemic hierarchy, HCPs are considered to be more
credible than their patients to decide what medical op-
tions would be in the lattersbestinterests.
When formalized or institutionalized, HCPsepiste-
mic hierarchy also solidifies their social authority on the
matter (Ho 2009). Medical expertsopinion on health-
related matters, including how chronic pain is to be
diagnosed and treated, hold power to persuade individ-
ual and court decisions, public opinions or expectations,
and healthcare policies. Being the authority on the mat-
ter, experts also have the prerogative to reject patients
claims as not credible according to the formerschosen
scientific frameworks. While many well-intended pro-
fessionals would also consult their patients regarding
their needs and perspectives as part of process of
obtaining informed consent, they are not bound to pro-
vide patients their desired interventions if they conflict
with HCPsclinical judgement (Whitney and
McCullough 2007). Their expert status bestows them
the authority to override patientsself-reported experi-
ence or preferred methods of management.
There are good prima facie reasons to entrust profes-
sionalsclinical expertise in making treatment and relat-
ed social decisions. Healthcare providers are members
of the helping professions, and because the bioethical
principles of respect for autonomy, non-maleficence,
and beneficence are generally accepted in Western bio-
ethics (Beauchamp and Childress 2008), we take HCPs
good will and commitment to use their epistemic ad-
vantage to patientsbenefit for granted. We generally
trust HCPs, assuming that they would not subject pa-
tients to any unnecessary harm, and that they would
diagnose and treat patients competently according to
the latters interests (Hall 2001). At a social level, the
ethical principle of distributive justice suggests that
physicians also have a responsibility to allocate limited
social or public resources based on sound evidence in
manners that are fair and equitable (The Good
Stewardship Working Group 2011).
Nonetheless, the processes of naming pain condi-
tions, diagnosing patients, and determining appropriate
interventions, even when employed by experts, are val-
ue-laden. Diagnostic and therapeutic processes are not
simply clinical or technical exercisesthey are also
social and political processes. Our descriptions of path-
ophysiological and experiential phenomena depend on
which clusters of signs and symptoms we see as consti-
tuting a disease and which we choose to interpret as
irrelevant (Stempsey 2000,98100). Healthcare pro-
viderssocial environment, personal background,
worldview, and other values also influence how they
observe their patientssymptoms, how they investigate
and interpret their histories, what diagnoses they offer
for reported and observed symptoms, and what among
the increasing number of treatment options they recom-
mend. It is within this complex combination of social
and institutional structure, historical and economic real-
ities, medical advances, as well as power relations that
medical experts define issues and goals.
As respect for patient autonomy and informed con-
sent become the ethical foundations of western
healthcare, there is an increasing attention to patients
own competence and role in contributing to treatment
decision-making (Sandman and Munthe 2009). Since
patients are the ones who experience their own symp-
toms and ailments, and generally have the most to lose
in times of sickness, their assessment of their overall
illness context and goals are now accepted asessential in
shared decision-making, raising questions of how we
should balance trust in HCPsexpertise and trust in
patientsown perspectives and experience. Patients
and others are expected to trust the expertscompetence
and goodwill but not vice versa. Even though doctors
generally assume that their patients are providing a
relatively accurate account of their concerns, some
Bioethical Inquiry
feminist bioethicists have pointed out that the latters
reports and motives may be distrusted (McLeod 2002),
especially if their symptoms such as pain do not have a
corresponding and accepted physical sign (Rogers
2002). Even as medical professionals generally attend
to patients under highly specific circumstances (e.g., in
clinics and hospitals) for very short periods of time, their
Bobjective^assessments are often considered categori-
cally superior to patientsown accounts. Patients who
do not follow the HCPs clinical recommendations to
overcome or manage their symptoms and conditions are
often considered noncompliant and untrustworthy and
may lose eligibility to financial or even medical assis-
tance (Pfeiffer 2000,98).
Chronic Pain and Epistemic Hierarchies
Epistemic issues are at the core of what it means to
experience pain. As Scarry (1985)famouslynoted,pain
is simultaneously the mostprivately certain and publicly
doubted phenomena. Undoubtedly, the difficulty pain
sufferers experience in expressing pain is part of the
problem (Biro 2010). Although pain can be shared
intersubjectively (van Hooft 2003), it also has enormous
capacity to destroy language and to silence it (Scarry
1985). Pain sufferers frequently report difficulty in com-
municating their pain to others, which, in the case of
HCPs, can exacerbate the trust problems noted above.
Ethnographies and qualitative studies of chronic pain
in Western contexts make clear that doubt and scepti-
cism regarding the existence, scope, and legitimacy of
pain are common and persistent. Such doubt flows from
all participants in cultures of pain: HCPs, caregivers,
fellow pain sufferers, and even pain sufferers themselves
(Goldberg 2010). Although there are almost certainly
multiple reasons why pain is a nexus of doubt and
incredulity, pain studies scholars, providers, and pain
sufferers themselves all identify the subjectivity of pain
as a core factor.
But what does subjectivity mean in this context? The
respective concepts of objectivity and subjectivity at
play here have been insufficiently theorized in pain
studies. The idea of objectivity itself has an important
history, and its meaning in present parlance can be read
according to that history and its influence on contempo-
rary understandings. Here we track Daston and
Galisons(2007) influential historical taxonomy of the
idea of objectivity in the early modern and modern
West. The particular model that seems most directly to
apply to assertions of the subjectivity of pain is what
Daston and Galison identify as mechanical objectivity.
This model has two central features: first, knowledge
produced via natural investigation has its truth status
determined by the extent to which the investigators
subjective influence is removed from the knowledge-
making process; and second, the primary goal of the
investigator is to represent the scientific object just as it
appears in its most natural stateno matter how imper-
fect that object may be in such a state.
How does this apply to pain? We can see ideals of
mechanical objectivity in the epistemic anxiety that
stakeholders voice as to pain. Especially in chronic pain
discourse, the natural object does not always reveal the
truth of the assertion: the patientssymptomsdonot
correlate with any visible scientific object. Thus, pain
defies the process of clinical correlation that is central to
the anatomo-clinical method. When a person injured in
a motor vehicle accident reports being unable to put
pressure on their leg, and the HCP sees the fracture on
the X-ray, the persons complaints can be clinically
correlated with a dysmorphology. But chronic pain often
frustrates this processmany, if not most kinds of
chronic pain cannot be correlated with any underlying
pathology. The epistemic structure ofWestern allopathic
medicineits claims to truth and veracitydepends on
frameworks of clinical correlation and pathological
anatomy. As physician-historian Robert Martensen
(2004) explains, the Bcentral reliance on anatomical
learning is Western medicines most distinctive
knowledge-making characteristic.^When chronic pain
impedes the production of clinical knowledge by defy-
ing the easy objectification that is at the core of the
epistemology of Western biomedicine, it becomes sub-
ject to doubt and scepticism. Epistemic agents cannot
see the visible pathologies that correlate with this par-
ticular illness complaint. Often enough, this epistemic
problem leads to metaphysical doubt regarding the ex-
istence of the illness itself.
Perhaps unsurprisingly, then, significant resources
continue to be expended on efforts to visibilizepain
in the natural objects inside the body, those below what
Foucault (1994)termedBthe tissual surface.^For exam-
ple, a team lead by Tor Wager earned international
headlines in 2013 for a study in which functional mag-
netic resonance imaging of the brain was deployed to
successfully predict acute pain among the participants.
Of course, Wager et al. cautioned that the study featured
Bioethical Inquiry
a small sample, evaluated only acute pain stimuli, and
was not remotely close to clinical validation (Wager
et al. 2013). An accompanying editorial directly refer-
enced the frames of subjectivity and objectivity noted
above and highlighted the epistemic significance:
We comprehend our own pain only as a subjective
phenomenon and recognize that the experience
and affective display of pain differ from person
to person and from culture to culture. Physicians
are flummoxed by pain because of a paucity of
objective manifestations and are reduced to using
clinical instruments, such as the visual-analogue
scale to quantitate pain. (Jaillard and Ropper 2013)
The authors of the editorial, however, contend that ulti-
mately the pain sufferer remains the authority on the
existence and nature of pain; another neuroscientist
studying pain and neuroimaging voiced concern over
the danger of an attempt to Brule out that somebody is in
pain^(Kwon 20162underBBeyond the Blobs^). We
submit that whatever utility may eventually be derived
from the use of neuroimaging techniques as to pain, the
true problem lies in continuing to legitimize the very
epistemic processes that seem to fuel so much scepti-
cism and doubt as to pain (Goldberg 2014). That is,
finding the holy grail of an imaging technique that
enables us to objectify pain merely reinforces the pro-
cesses of objectification that are in part responsible for
the epistemic injustice so many pain sufferers experi-
ence in their capacity as knowers.
Epistemic Injustice
Fricker (2007, 2012) argues that a distinctively episte-
mic type of injustice occurs when peopleindividuals
or social groupsmay be wronged in their capacity as
transmitters of knowledge. This kind of epistemic injus-
tice is discriminatory and can occur in one of the fol-
lowing two ways. First, discriminatory epistemic injus-
tice can occur when a personsorgroupscapacityas
knowers is unfairly downgraded. A hearers prejudicial
stereotyping causes the listener to attribute a reduced
level of credibility to a speakers testimony than they
otherwise would have given if the prejudice was not
present. This does not mean that the speaker is always
disbelieved but rather is taken less seriously. This unfair
accusation is referred to as testimonial injustice. Second,
discriminatory epistemic injustice can happen when
there is a gap in the economy of collective interpretive
resources that disadvantages the speaker when they are
trying to make sense of their experiences. This herme-
neutical injustice occurs at a prior stage when someone
experiences an event, such as sexual harassment, in a
culture that lacks that concept. Fricker (2012) notes that
epistemic injustice may also be of the distributive kind,
where this is an unfair distribution of epistemic goods in
society. We only focus on discriminatory epistemic in-
justices in this paper.
The Relationship Between Epistemic Injustice, Trust,
and Chronic Pain
Epistemic injustice, trust, and trustworthiness are
closely linked. Kleinman (1988) observes,
[i]f there is a single experience shared by virtu-
ally all chronic pain patients it is at some point
those around themchiefly practitioners, but also
at times family memberscome to question the
authenticity of the patients experience of pain. (57)
Such questioning is associated with concerns about
certainty as it relates to objectively unverifiable symp-
toms. Scheman (2001) refers to this phenomenon in
relation to scientific objectivity as trustworthiness: ob-
jective judgements of clinical medicine are understood
as judgements that can be rationally trusted. In the pain
management context, the operation by which mechani-
cal objectivity is mobilized as the primary criterion for
trustworthiness raises questions about who or what
should be trusted and under what circumstances.
Given the epistemic significance of the framework of
mechanical objectivity, where pain does not necessarily
have a corresponding and accepted physical signal, the
pain sufferers testimony may not be considered episte-
mically competent. This is particularly likely in cases
where the perceived severity of pain as reported by the
patient seems far from a reliable account (e.g., the HCP
suspects that the patient is malingering). Where uncer-
tainty exists, HCPs may feel unconfident to address the
patients pain needs or may be suspicious of the patients
motivations for seeking care. Providers may resort to
distrust of patients whose pain symptoms cannot be
objectively verified. Where their experience is perceived
to lack credibility, the pain sufferer might perceive the
presumed scientific objectivity of medicine to be valued
Bioethical Inquiry
more than their own lived experience (Rich 1997;
Honkasalo 2001). These negative interactions may con-
tribute to the perception by pain sufferers that they are
being questioned as a trustworthy source of information
(Marbach et al. 1990;OsbornandSmith1998).
Chronic Pain, Trust, and Identity-Prejudicial Credibility
In the clinical encounter, a pain sufferer is vulnerable to
the expert HCPs actions that can have an impact
positive or negativeon their welfare. For example, a
pain sufferer may be accused of lying about diverting
prescribed opioids despite the lack of counter-evidence
that demonstrates that diversion occurred. This illus-
trates the central case of testimonial injustice, what
Fricker refers to as an identity-prejudicial credibility
deficit. For this specific prejudice to occur, heuristics
are invoked to assess the trustworthiness of another
individual. An identity-prejudicial credibility deficit
might unfavourably bias the HCPs judgement of the
pain sufferers narrative. If a pain sufferers believe that
they have been given less credibility than they deserve,
the pain sufferer may feel unfairly distrusted. This testi-
monial injustice is particularly problematic as it may
impair the pain sufferers ability to negotiate certain
aspects of their care in the future.
People living with chronic pain have been considered
systematically less credible in clinical encounters as
compared to medical experts. Green et al. (2003)have
documented that the credibility of the patientsreportof
pain is more likely to be questioned in socially margin-
alized populations, thereby raising questions of social
justice. It is well established that the burden of chronic
pain is greater for persons from disadvantaged socio-
economic groups than for persons from more privileged
socioeconomic groups. Some HCPs may be more sus-
picious of certain requests of persons from marginalized
populations, such as requests for an increased dose of
opioid medications (Barry et al. 2010). Likewise, a
person from a marginalized population may be suspi-
cious about what the HCP thinks of a request and how
his or her moral character is assessed (Govier 1997).
This may be particularly relevant for pain sufferers who
in previous healthcare encounters were accused of ex-
aggerating their pain or malingering. Pain sufferers may
feel confused and doubtfuland both partiesmay be wary
of the other, fostering mutual distrust (Miller 2007).
People living with painespecially those without
concurrent substance use problemsmay not have ex-
perienced a distrusting therapeutic relationship when
they first began to receive treatment. Given the climate
of distrust in pain management, pain sufferers may
quickly learn that their identity as a trusted patient in
other healthcare relationships may not translate to the
pain management context (Buchman, Ho, and Illes
Narrative Accounts of Pain Sufferers
The interrelatedness of trust and discriminatory
epistemic injustice in chronic pain management is
supported by past humanities and social science
research associated with trust and integrity of
testimony. A study on public trust in healthcare by
Calnan and Sanford (2004) suggests that a major influ-
ence of trust in the patientprovider relationship is the
patient perception that healthcare providers take their
testimony to be credible. It has been shown previously
that not being believed or taken seriously is a common
experience among those living with chronic pain
(Jackson 1992; Clarke and Iphofen 2005; Toye and
Barker 2010). Kleinman (1992)writes,whatis
B[a]bsolute private certainty to the sufferer, pain may
become absolute public doubt to the observer. The up-
shot is often a pervasive distrust that undermines family
as well as clinical relationships^(5). A desire to avoid
Bpervasive distrust^may be what really matters to per-
sons living with pain, as they strive for their claims to be
considered credible and their character considered
Werner and Malteruds2003 study of female muscu-
loskeletal pain sufferers provides a particularly salient
example of distrust and epistemic injustice in the context
of pain. The informants
invested much work, time, and energy before
or during the encounters in order to be perceived
as a credible patient. By trying out various strate-
gies such as appropriate assertiveness, surrender-
ing, and appearance, they attempted to fit in with
normative, biomedical expectations of what was
Bjust right.^(1412)
Ethnographic research suggests that patients will rely on
such strategies or Bsocial performances^(Brodwin
Bioethical Inquiry
1992, 72) in order for their testimonies to be perceived
as trustworthy.
The effort to behave like a credible patient is only
necessary where there is a substantial risk of being
perceived as lacking credibility. Despite significant ef-
fort, the informants Brepeatedly find themselves being
questioned, particularly by doctors, and judged to be
either not sick or suffering from an imaginary illness^
(Werner and Malterud 2003, 1414). In this way, a lack of
credibility is associated with a lack of trustworthiness.
Of course, the fact that the informantspain defies
objectification is a crucial part of what creates the cred-
ibility gap to begin with. Playing the credibleand
trustworthypatient is almost certainly easier where
discrete, visible pathologies can be correlated with an
illness sufferers complaints (Rhodes et al. 1999).
Moreover, this scrutiny and the efforts involved are
also highly gendered, a vulnerability that is at the core of
Frickers framework: some identities render individuals
and communities more or less likely to be subject to
testimonial injustice. Historians of pain uniformly agree
that only some voices and narratives of pain tend to be
heard in any given time and place (Moscoso 2012;
Bourke 2014;Boddice2015). When it comes to pain,
the voices of marginalized groups such as women, chil-
dren, and people of colour (Wailoo 1996,2014)have
long been silenced or ignored. These and other disad-
vantaged social statuses are therefore important markers
of trust and epistemic injustice as to pain. Moreover, as
Joanna Bourke puts it, the question of
Bwhose pain is heard^is not only correlated
with power differentials between groups pa-
tients considered to be Btruly^in pain are also
directly constituted by those differentials. The be-
lief that not every person-in-pain suffers to the
same degree is intrinsic to hierarchical systems
generally. (Bourke 2014,230)
Pain frustrates dominant models of mechanical ob-
jectivity within biomedical cultures. It evades the clinical
gaze that stands as a powerful truth-making criterion in
such cultures. For example, in her pain autopathography
Lous Heshusius (2009) questions whether she might
derive any benefit in being truthful to physicians about
her pain. She narrates, Bwe fear the doctor will not
really believe us anyway, for how can we convincingly
tell of this pain they can neither see nor measure?^
(2009, 78). Two narrative examples from HCPs that
reinforce this view come from Buchman, Ho, and Illes
study of trust and pain management. One physician
participant stated, Bwhen I see a patient who has,
you know, a pathological fracture on a X-ray if theres
something objectively definable it does change the way
that I approach the patient^(7). Another physician re-
ported, Bwe have all had experiences where theres
been a discrepancy between what [patients] report and
what we see [on imaging]. And, unfortunately, it is a
very distrusting relationship inherently^(Buchman, Ho,
and Illes 2016, 7). It is therefore unsurprising that so
many chronic pain sufferers have for so much of the
modern era been wronged in their capacity as knowers,
been subject to testimonial injustice. Moreover, like
many instantiations, this form of epistemic injustice
tracks closely social power structures, suggesting that
already-disadvantaged groups are increasingly likely to
have their pain delegitimized and doubted.
In addition, the link between epistemic injustice and
patterns of domination and oppression suggest concep-
tual overlap with stigma; a phenomenon that is unfortu-
nately all too common an experience for pain sufferers.
Link and Phelans model of health stigma (2001,2006)
emphasizes the close connections between social power
and patterns of stigma: Which groups are most likely to
be stigmatized? And how severe will that stigma expe-
rience be? Link, Phelan, and colleagues working on
their model have even taken to using the term Bstructural
stigma^to emphasize the robust evidence suggesting
that already-marginalized groups are disproportionately
likely to experience stigma. Although obviously not all
pain sufferers are marginalizedsome would no doubt
reject the labelmany of the groups most likely to have
their pain treated poorly are already subject to structural
oppression. In the United States, for example, the elder-
ly, women, veterans, and African-Americans are only a
few of the social groups who endure worse treatment for
their pain than members of dominant groups (Institute of
Medicine 2011). Racial pain inequalities are particularly
evident and troubling in the United States, resting on a
long history in which Black bodies were regarded as
subhuman and insensible to pain (Wailoo 1996,2014;
Hoffman, Trawalter, and Axt 2016).
Toward Epistemic Humility in Pain Management
We believe that the participation of pain sufferers in the
therapeutic dialogue has both epistemological and
Bioethical Inquiry
ethical importance. We also argue that HCPs ought to
repair damaged or lost trust with pain sufferers and
correct testimonial injustices, by striving toward a dis-
position of epistemic humility. We believe that respon-
sibility for epistemic humility is situated with the HCP
more so than the pain sufferer given the power hierarchy
in the therapeutic relationship. However, we also con-
tend that pain sufferers, as participants in a relationship,
also have responsibilities to demonstrate veracity and
In the healthcare context, epistemic humility is an
approach that calls for partnership and dialogue be-
tween patient and HCP in a deliberative decision-
making process (Ho 2009,2011; Buchman and Ho
2013). Epistemic humility requires HCPs to adopt a
disposition, or an attitude, that allows room for
balancing clinical evidence, professional judgement,
and patientsperspectives. Epistemic humility is inten-
tionally collaborative, as Bboth the HCP and patient are
counting on each other in investigating a full picture of
the patients experience and determining the most ap-
propriate management strategies^(Ho 2011,117).
While HCPs possess expert knowledge in pain man-
agement, they do not have direct access to their pa-
tientsexperiences. In search of the most appropriate
clinical approach, epistemic humility requires an inqui-
ry into the patient experience. For example, the HCP
can invite the patient to tell her story and embrace a
willingness to incorporate the patients narrative into
her professional worldview (Atkins 2000).
Epistemic humility does not reject clinical expertise.
Rather, epistemic humility encourages HCPs to consider
the limits of clinical expertise, especially where there is
uncertainty or incomplete knowledge about a clinical
situation. Moreover, striving for epistemic humility does
not require HCPs to trust all patients at all times
trusting unreflectively can be harmful. Instead, episte-
interest and inquiry into the patient experience, critical
reflection about the assumptions made about the trust-
worthiness of pain sufferers, as well as prejudices that
shape credibility judgements. Accordingly, epistemic
humility is a commitment to continuous responsiveness
to the patients experience and recognition of the limi-
tations of applying clinical expertise to different forms
of clinical decision-making (Upshur and Colak 2003;
Ho 2011). It is a process and practice that allows for the
repair of damaged trust and the demonstration of pro-
fessional trustworthiness.
Given that structural and psychosocial characteris-
tics of the patient may influence HCP judgements
about the claims of pain sufferers, a curious, morally
self-reflective stance is critical to epistemic humility.
By acknowledging the value of the pain sufferers
perspectives and providing patients with a constructive
means of participating in their care decisions, a com-
mitment to epistemic humility may help to minimize
the power asymmetry in the therapeutic relationship
and help minimize other forms of injustices that pain
sufferers may face.
Epistemic Humility as Epistemic Justice
Miranda Fricker (2007) defines epistemic justice as a
hybrid epistemicethical virtue that a hearer possesses in
order to counterbalance the impact of prejudice in their
credibility judgements. Like most intellectual virtues,
epistemic justice is acquired through repeated efforts
of critical reflection. The virtuous hearer is Bsomeone
whose testimonial sensibility has been suitably
reconditioned by sufficient corrective experiences so
that it now reliably issues in ready-corrected judgments
of credibility^(Fricker 2007, 97). Epistemic humility,
then, may be the kind of disposition required to correct
the harmful prejudices that might arise through testimo-
nial exchange in chronic pain management.
Epistemic humility requires HCPs to critically eval-
uate the implicit assumptions inherent in the anatomo-
clinical method, especially as this method categorically
privileges certain kinds of knowing over others (e.g., the
objective MRI results over the subjective patient testi-
mony). Greenhalgh (2001) observed in her pain
autoethnography that even though HCPs are not the
experts about the patients own complex illness narra-
tives, they generally place their scientific and medical
narratives in an epistemically higher position than pa-
tientsnarratives. Indeed, Fricker (2007) points out that
marginalized populations exist in an epistemically
privileged position with regard to their own experiences
of domination and oppression; as such, silencing their
narratives strips already-disadvantaged groups of anoth-
er form of agency and dignity. This is particularly crit-
ical insofar as pain management practices regard as
virtually axiomatic the notion that the pain sufferers
subjective self-report is the most important tool in diag-
nosis. Perpetuating the established epistemic hierarchy
and neglecting the lived expertise of the pain sufferer
may communicate the message that painsufferers do not
Bioethical Inquiry
have an epistemically and morally equal claim in
negotiating their care. Howard Brody (1994) has argued
persuasively that one of the most powerful ways in
which HCPs can wield their greater social power for
good is by answering the illness suffererscry:BMy
story is broken; can you help me fix it?^Other scholars
of narrative medicine such as Kleinman, Frank, and
Charon have argued that creating space for illness suf-
ferers to tell their stories can reduce power imbalances
that nurture epistemic injustice.
In addition to acknowledging pain suffererslived
experiences, a HCP who aims for epistemic humility
can also reconsider the concepts and paradigms that
drive the discourse and practice of pain management,
including underlying epistemic and ethical assumptions.
These discursive concepts include binary terms often
used pain management such as objective/subjective,
legitimate/illegitimate, real/unreal, and normal/abnor-
mal. Healthcare providers can also examine how con-
tinued use of such binary terms may continue to deflate
the credibility of pain sufferers. One important part of
contesting the use of these binary terms in clinical
practice is for HCPs to be cognizant of how such terms
may work as explanatory tools to prematurely discredit
the patients testimony and dismiss the patientscredi-
bility as a trustworthy informant (Fricker 2007;Cohen,
Quintnan, and Buchanan 2011). By recognizing that the
line that separates binary terms is blurry, HCPs can
critically evaluate and modify mistaken dichotomies
Challenges to Epistemic Humility
We have identified three potential challenges in moti-
vating HCPs to adopt an attitude of epistemic humility
in chronic pain management. The first challenge relates
to the conflicting obligations HCPs face in providing
care for patients living with pain, especially when the
pain sufferer is also living with addiction and mental
illness. As Geppert (2004) explains, many physicians
struggle to treat chronic pain and prevent iatrogenic
addiction in the midst of mixed messages from the
government, professional organizations, and the media.
What is more, the increasing public health crisis in-
volving prescription opioids further complicates HCP
duties and obligations. Such uncertainty about how to
address risks associated with opioids challenges HCPs
to provide both compassionate and adequate treatment,
while also preventing harms. These conflicting duties
pose a problem for epistemic humility when a HCP
may be inclined to adopt a default position of distrust
with all patients after being Bburned^by a deceptive
patient (Crowley-Matoka, 2012; Buchman, Ho, and
Illes 2016).
The second challenge is that epistemic humility re-
quires the HCP to be empathic and compassionate in
inviting the pain sufferer to tell their story. Physicians,
for example, have historically been taught that empa-
thya subjective attitudewas an impediment to clin-
ical diagnosis, an objective exercise (Halpern 2001).
Bearing witness to patient stories of pain and being
responsive to them requires training and skill (Charon
2006), and even well-intentioned HCPs may not have
the necessary clinical-emotional competencies. Recom-
mendations to enhance empathy in medicine range from
increasing humanities content in undergraduate medical
education (Geppert 2008; Peterkin 2008)toexposing
first-year medical students to classical texts, poetry, the
arts, history, and philosophy (Shapiro, Morrison, and
Boker 2004). However, these programmes have shown
limited evidence of beneficial long-term impacts
(Ousager and Johannessen 2010).
A third challenge in motivating epistemic humility
is that caring for patients with pain can be demand-
ing. Many providers are overworked and
overburdened (Matthias et al. 2010). Opportunities
to hold compassionate and empathic dialogues regard-
ing the patients pain concerns in an emotionally
charged context can be limited. In short office visits,
Bphysicians are expected to form partnerships with
patients and their families, address complex acute
and chronic biomedical and psychosocial problems,
provide preventive care, coordinate care with special-
ists, and ensure informed decision-making that re-
spects patientsneeds and preferences^(Fiscella and
Epstein 2008). Taken together, these factors may
present obstacles in HCPs being able to possess epi-
stemic humility.
Not all pain sufferers desire to be active participants
in their care, and not all pain sufferers will be capable of
contributing testimony in the way we have described.
Since both the pain sufferer and the HCPsperspectives
are necessary in constructing appropriate care plans, the
pain sufferers lived experience ought to be in an epi-
stemic equilibrium with the expertise ofthe HCP. If such
epistemic justice can be achieved, patients and HCPs
may be able to engage in a bilateral and collaborative
approach to pain management.
Bioethical Inquiry
This paper critically explored the juncture of trust, ex-
pert knowledge, and pain management, by highlighting
how a specific form of epistemic injustice called testi-
monial injustice has become endemic to the care expe-
riences of many pain sufferers. We argued that epistemic
injustice may characterize the experiences of pain suf-
ferers when they try to have their voices heard by expert
HCPs, describe their lived experiences, or disclose their
values and treatment preferences (Carel and Kidd 2014;
Buchman, Ho, and Illes 2016). Concerns about the
apparent subjectivity of pain and the tendency of such
pain to frustrate processes of objectification that literally
underpin the epistemic foundations of Western biomed-
icine also likely contribute to epistemic injustice of pain
sufferers as well as a climate of distrust in pain
Ethically, it is critical that the discourse and practice
of pain management do not continue to marginalize the
voices of those who are considered to reside outside of
the accepted epistemic community. If HCPs demon-
strate a willingness to listen to and amplify the stories
of pain sufferers, it may signify a commitment to epi-
stemic humility, trust, and demonstrate that these indi-
viduals are valued members of the epistemic communi-
ty. If HCPs correct for prejudicial credibility judge-
ments, it may be one way to demonstrate trustworthi-
ness and good will and ultimately epistemic justice in
pain management.
Acknowledgements We would like to thank Nigel Hee, Re-
search 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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Bioethical Inquiry
... For instance, clinicians often assumed that they had to resolve uncertainty by getting patients 'on board' with the scientific information, or acknowledged they lacked skills to communicate effectively when navigating uncertainties well with a patient. These attempts to create certainty (e.g., manipulating patients' beliefs so they align with clinicians' views, or not communicating with people from low socio-economic backgrounds) are likely to create epistemic injustice, a common issue in pain management (Buchman et al., 2017). Epistemic injustice refers to situations in which medical experts exert power to persuade individuals using their chosen scientific frameworks and reject patients' claims (Buchman et al., 2017). ...
... These attempts to create certainty (e.g., manipulating patients' beliefs so they align with clinicians' views, or not communicating with people from low socio-economic backgrounds) are likely to create epistemic injustice, a common issue in pain management (Buchman et al., 2017). Epistemic injustice refers to situations in which medical experts exert power to persuade individuals using their chosen scientific frameworks and reject patients' claims (Buchman et al., 2017). Such scenarios may be particularly problematic when contextual factors such as the lived experience and determinants of health are not considered. ...
... Such scenarios may be particularly problematic when contextual factors such as the lived experience and determinants of health are not considered. Buchman et al. (2017) argue that clinicians should avoid epistemic injustice by striving toward epistemic humility. Being epistemically humble means correcting for prejudicial credibility judgements by recognising that medical decisions are almost always accompanied by uncertainty and that individuals' perspectives can enhance understandings of the clinical scenario. ...
Despite clinicians being important actors in the context of uncertainty, their experiences navigating uncertainty remain largely unexplored. Drawing on a theory-driven post-qualitative approach, we used Mol's logic of choice/care as a lens through which we made sense of interviews with 22 clinicians who work with patients who experience low back pain (LBP). Our analysis suggests that uncertainty is ubiquitous in LBP care and not limited to particular domains. Clinicians navigated uncertainty when considering patients' personal and social contexts; making therapeutic decisions; navigating emotions and mental health; communicating with, and educating, patients, among others. These uncertainties are intertwined with clinical aspects such as treatment choices and evidence-based education about LBP. At times, clinicians resolved these uncertainties by producing certainty at the cost of attending to human aspects of care. We argue that epistemic shifts, theorisation and practical engagement with theory in training, research and clinical practice may prompt clinicians to embrace uncertainty and enact the logic of care. In the logic of care uncertainty is chronic, and additional arguments cannot hope to alter this. You do what you can, you try and try again.…ultimately the result is not glorious: stories about life with a disease do not end with everybody ‘living happily ever after’ (Mol, 2008, p. 78, p. 78).
... At the level of healthcare encounters, the concept of epistemic injustice has been discussed in connection with manifold issues such as chronic fatigue syndrome (Blease et al. 2017), chronic pain (Buchman et al. 2017), children's testimony (Carel and Györffy 2014), mental health and illness (Carver & Morley 2017) ; Crichton et al. 2017;Scrutton 2017), clinical communication and language barriers (Naldemirci et al. 2020;Peled 2018), as well as medicalisation (Wardrope 2015). At the institutional level, the concept has been applied to issues such as psychiatric classification systems (Bueter 2019), treatment protocols for intersex people (Merrick 2019), and evidence-based healthcare policy (Michaels 2021;Moes et al. 2020). ...
... Some argue, for example, that healthcare professionals ought to become better aware of how their behaviour contributes to pathocentric epistemic injustices and correct these by cultivating virtues such as epistemic humility (e.g. Buchman et al. 2017;Peled 2018;Wardrope 2015) or that justice is fostered by healthcare professionals fulfilling their epistemic duties such as eliciting patients' experiential knowledge (Drożdżowicz 2021). Others, in their proposals to counteract epistemic injustices, emphasise the collective dimension of generating knowledge in healthcare. ...
... To overcome such epistemic injustices, some have called for doctors to exercise more epistemic humility and to acknowledge that patients' epistemic contributions are essential to healthcare delivery (e.g. Buchman et al. 2017;Peled 2018;Wardrope 2015). For healthcare professionals to demonstrate epistemic humility means to acknowledge that the knowledge of both the doctor and the patient is relevant for a proper understanding of the patient's condition. ...
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In this article, I apply the concept of solidarity to collective knowledge practices in healthcare. Generally, solidarity acknowledges that people are dependent on each other in many respects, and it captures those support practices that people engage in out of concern for others in whom they recognise a relevant similarity. Drawing on the rich literature on solidarity in bioethics and beyond, this article specifically discusses the role that epistemic solidarity can play in healthcare. It thus focuses, in particular, on solidarity’s relationship with justice and injustice. In this regard, it is argued (1) that justice and solidarity are two equally important and complementary values that should both be considered in healthcare practices and institutions and (2) that solidarity often arises in unjust situations and can be a means to bring about justice. I transfer these ‘general’ insights about solidarity to knowledge practices in healthcare and link them to the discussion about epistemic injustices in healthcare and how to overcome them. I argue that epistemic solidarity can play an important role in overcoming epistemic injustices as well as—and independently from its contribution to justice—in knowledge production in medicine more generally. To demonstrate how epistemic solidarity can add to our understanding of collective knowledge practices, I discuss two examples: patients sharing their medical data for research purposes and healthcare professionals’ engagement with patients to better understand their afflictions.
... Most importantly from our perspective, as these diagnostic odysseys lengthen, patients find that their status as reliable reporters of their symptoms is questioned. Writing from the perspective of applied philosophy and ethics and drawing on the experience of the chronically ill, this consequent downgrading of one's moral status has been described by various researchers (see Blease et al., 2017;Buchman et al., 2017;Fricker, 2017;Kidd & Carel, 2017) in terms of epistemic injustice. These authors advocate for various forms of epistemic humility from medical professionals, who are urged to listen to the lived experiences of their patients and acknowledge the limits of their expertise. ...
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While we know a lot more about Long Covid today, patients who were infected with Covid-19 early on in the pandemic and developed Long Covid had to contend with medical professionals who lacked awareness of the potential for extended complications from Covid-19. Long Covid patients have responded by labeling their contentious interactions with medical professionals, organizations, and the broader medical system as “gaslighting.” We argue that the charge of medical gaslighting can be understood as a form of ontological politics. Not only do patients demand that their version of reality be recognized, but they also blame the experts who hold gatekeeping power over their medical care for producing a distorted version of said reality. By analyzing results from an online survey of Long Covid patients active on social media in the United States (n = 334), we find that experiences of contention and their reframing as “gaslighting” were common amongst our respondents. In short answer responses about their experience obtaining medical care for Long Covid, our respondents described encountering medical professionals who dismissed their experience, leading to lengthy diagnostic odysseys and lack of treatment options for Long Covid. Even though we are limited by characteristics of our sample, there is good reason to believe that these experiences and their contentious reframing as medical gaslighting are exacerbated by gender, class, and racial inequalities.
In this paper, I take seriously calls for public engagement in human genome editing decision-making by endorsing the convening of a "Citizens Jury" in conjunction with the International Commission on the Clinical Use of Human Germline Genome Editing's next summit scheduled for March 6-8, 2023. This institutional modification promises a more inclusive, deliberative, and impactful form of engagement than standard bioethics engagement opportunities, such as comment periods, by serving both normative and political purposes in the quest to offer moral guidance on gene editing. In examining evidence from the Australian Citizens' Jury on Genome Editing convened in 2021, I argue that Citizens' Juries should work in tandem with governing institutions to preserve the role of expertise while ensuring that the diverse views of the public are incorporated into their final reports as well. First, early inclusivity allows "the people" to hold agenda setting power through helping to set resource priorities. This also makes a downstream deliberative event, such as the called for Global Citizens' Assembly, both more likely to occur and more influential on policy. Second, Jury's diverse composition promises substantive contributions to the Commission's work. Third, Citizens' Juries could help to cultivate the Commission's trustworthiness.
Objective It is increasingly recognized that when healthcare staff fails to give adequate credence to patients' illness-related knowledge work, this epistemic injustice undermines person-centered care. Therefore, we set out to examine the experiences of people with long-term conditions with knowledge work in healthcare settings to identify changes needed to strengthen person-centred primary care. Methods We designed a qualitative study and recruited people with long-term conditions in the UK. We conducted individual interviews (analysed using interpretive phenomenological analysis) and focus groups (analysed using thematic analysis), then integrated findings from both methods through an approach focused on their complementarity. Results Particpants described how successful person-centred consultations were characterised by a negotiation between patient and doctor and moments of broad exploration, reflexive listening, and reciprocal inquiry, which allowed for epistemic reciprocity. Conclusions Epistemic reciprocity is a core component of person-centred clinical consultations, fostering the co-creation of new knowledge of patient experience and need through the interactive knowledge work of patient and doctor. Practice Implications Medical education could benefit from initiatives that develop knowledge use and integration skills across primary care professionals. Accommodating for patient’s and doctor’s knowledge work during clinical practice requires redesigning the consultation process, including timing, headspace, pre-consultation, and post-consultation work.
Introduction Persistent low back pain (PLBP) is the biggest global cause of disability. Persons with PLBP experience biographic disruption and existential crisis. Guidelines recommend a biopsychosocial approach to management, with the emphasis on coping strategies. Purpose However, there is a paucity of research exploring the lived experience of persons who self-identify as coping with PLBP. Method The study used an interpretive phenomenological approach, analyzing transcripts from 1:1 interviews with six persons who self-identify as coping with PLBP. Poetic language was used to elicit empathic, embodied relational understanding and convey a richer understanding of the phenomenon that authentic quotations might not able to reveal. Findings and Conclusion Participants’ descriptions conveyed the sense of a journey, starting with the loss of a sense of self as they engaged in the pain battle, followed by a transition toward a new ‘normal,’ in which time, acceptance and trust in their own intuition were meaningful components. Although anxiety and fear were a continued presence, but they became more manageable. Society’s role in the coping process was significantly meaningful and is something which requires reflections from therapists’ and more widely.
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Drawing on original qualitative research, I argue that the concept of ‘epistemic injustice’ proposed by the feminist philosopher Miranda Fricker, and located within a long genealogy of Black feminist scholarship, can be used sociologically to help understand the lived experiences of asexual people. I show how participants’ accounts of their asexual subjectivities were frequently denied, dismissed and over-written. However, I argue that these experiences were heavily gendered, in that asexual women were subject to epistemic injustices to a degree and in ways that their male counterparts were not, and that this must be understood within the power relations of hetero-patriarchy. These epistemic injustices revolved around old yet prevailing constructions of femininity and womanhood as ‘naturally’ asexual, passive, and lacking agency. When asexual men experienced epistemic injustice, this was rooted in familiar understandings of masculinity as necessitating an active and desiring sexuality. Using Fricker’s elucidation of hermeneutical and testimonial forms of epistemic injustice, I show how asexuality remains a culturally unfamiliar hermeneutical frame in a context of ‘compulsory sexuality’ but also how stories of asexuality are ‘heard’ based on the gendered (and unequal) distribution of testimonial credibility.
Purpose Low back pain (LBP) directives provide information about how LBP should be managed, communicated and navigated in complex health systems, making them an important form of policy. This study aimed to examine how LBP is problematised (represented) in Australian directives. Materials and methods We employed an analysis of discourse of LBP directives drawing on Bacchi’s “What’s the problem represented to be?” policy problematisation approach. Results Our analysis suggests that LBP is problematised as a symptom that tends to improve when individuals take responsibility for themselves, but may require care at times. The way in which LBP is represented in the directives excludes important aspects, such as the uncertainties of scientific knowledge, paradigms other than (post)positivist, multimorbidity, social and structural determinants of health. Conclusion LBP directives may benefit from problematisations of LBP that consider the ongoing nature of LBP and broader contextual factors that impact on both LBP outcomes and care, beyond individual responsibility. Consideration of a wider range of paradigms and expanded evidence base may also be beneficial, as these are likely to enable individuals, clinicians and the Australian healthcare system to address LBP while dealing with its complexities, enabling real-world changes to lessen the LBP burden.
In 2012, a Venn diagram appeared on the blog The Kitchn detailing the characteristics of what it called the “worst dinner guest ever.” This maligned guest is not only vegan but also gluten and lactose intolerant and allergic to nuts and eggs. While a few commenters agreed with the implication that dietary constraints indicate a failure of appropriate guest behavior, most echoed what Lisa Heldke and Raymond Boisvert (2016) suggest is the dominant American view: hosts are generally obliged to accommodate the dietary restrictions of their guests. For Heldke and Boisvert, this is most obviously true when guests have food allergies and serious harm can be easily avoided by a change in menu. In this essay I argue that epistemic barriers can obscure hosts’ perception of these ostensibly obvious cases, preventing them from fulfilling their obligations. Specifically, I argue that guests with food allergies and other “gut issues” can be subject to testimonial injustice that undermines their credibility, leading hosts to doubt or disbelieve their need for accommodation. Such guests may also be subject to testimonial smothering, discouraging them from disclosing their dietary restrictions in the first place. I argue that these forms of epistemic injustice raise multiple moral concerns and that hosts have a responsibility to practice epistemic humility regarding guests’ reports of gut issues. Overall, this paper aims to enable hosts and guests with gut issues alike to recognize and overcome epistemic obstacles to good hospitality—the importance of which extends far beyond the dinner table.
The biopsychosocial model (BPS) of chronic pain aspires to be comprehensive, incorporating psychological and social factors omitted from biomedical models. Although psychosocial factors are viewed as highly influential in understanding behavioral and psychological responses to pain, these factors are usually viewed as modifiers of biological causes of the experience of pain itself, rather than as equal contributors to pain. To further advance the BPS model, we re-examine a classic 1994 paper by Wilbert "Bill" Fordyce, "Pain and suffering: what is the unit?" In this paper, Fordyce suggested that pain-related disability and suffering should be viewed as "transdermal", as having causes both inside and outside the body. We consider Fordyce's paper theoretically important because this concept allows us to more fully break free of the medical model of chronic pain than customary formulations of the BPS model. It makes it possible to place psychological and social factors on an equal footing with biological ones in explaining pain itself and to remove distinctions between pain mechanisms and pain meanings. The brain's salience network now offers a platform on which diverse influences on pain experience-from nociception to multisensory indicators of safety or danger-can be integrated, bridging the gap between impersonal nociceptive mechanisms and personal meanings. We also argue that Fordyce's article is practically important because this concept expands the BPS model beyond the bounds of the clinical encounter, opening the door to the full range of social, psychological, and biological interventions, empowering patients and non-medical providers to tackle chronic pain.
Chronic pain, which affects 70 million people in the United States alone-more than diabetes, cancer, and heart disease combined-is a major public health issue that remains poorly understood both within the health care system and by those closest to the people it afflicts. This book examines the experience of pain in ways that could significantly improve how patients and practitioners deal with pain. It is the first volume of a new collection of titles within the acclaimed Culture and Politics of Health Care Work series called How Patients Think, intended to give voice to the concerns of patients about their own medical care and the formulation of health policy. Since surviving a near-fatal car accident, Lous Heshusius has suffered from chronic pain for more than a decade, forcing her to give up her career as a professor of education. Inside Chronic Pain, based in part on the pain journal Heshusius keeps, is a stunning memoir of a life lived in constant pain as well as an insightful and often critical account of the inadequacies of the health care system-from physicians to hospitals and health insurance companies-to understand chronic pain and treat those who suffer from it. Through her own frequently frustrating experiences, she shows how health care providers often ignore, deny, or incorrectly treat chronic pain at immense cost to both the patient and the health care system. She also offers cogent suggestions on improving the quality and outcome of chronic pain care and management, using her encounters with exceptional medical professionals as models. Inside Chronic Pain deals with pain's dramatic and destructive effects on one's sense of self and identity. It chronicles the chaos that takes place, the paralyzing effect of severe pain, the changes in personality that ensue, and the corrosive effects of severe pain on the ability to attend to day-to-day tasks. It describes how one's social life falls apart and isolation takes over. It also relates moments of happiness and beauty and describes how rooting the self in the present is crucial in managing pain. A unique feature of Inside Chronic Pain is the clinical commentary by Dr. Scott M. Fishman, president of the American Pain Foundation. Fishman has long tried to improve the lives of patients like Heshusius. His medical perspective on her very human narrative will help physicians and other clinicians better understand and treat patients with chronic pain.
The germs of the ideas in this book became implanted in me during my experience as a resident in clinical pathology at Boston University Medical Center. At the time, I had inklings that the test results churned out by our laboratories were more than scientific facts. As a philosophically unsophisticated young physician, however, I had no language or framework to analyze what I saw as a deep philosophical problem, a problem largely unrecognized by most physicians. The test results provided by our laboratories were accurate and of great practical importance for patient care. However, most of the physicians who relied on our test results to diagnose and treat their patients either did not have the time or interest to consider the philosophical issues inherent in diagnosis, or, like me, had inadequate means to further analyze them. It was more than ten years later that I began doctoral studies in philosophy, and I was fortunate to find a faculty that was supportive ofmy efforts to address the problem. This book began as my doctoral dissertation in the Department of Philosophy at Georgetown University. I would like to acknowledge the assistance of my mentor, Robert Veatch, Ph. D. Our conversations during my Georgetown years led me in new and often fascinating directions. I would also like to acknowledge the help of Kenneth Schaffner, M. D. , Ph. D.
The germs of the ideas in this book became implanted in me during my experience as a resident in clinical pathology at Boston University Medical Center. At the time, I had inklings that the test results churned out by our laboratories were more than scientific facts. As a philosophically unsophisticated young physician, however, I had no language or framework to analyze what I saw as a deep philosophical problem, a problem largely unrecognized by most physicians. The test results provided by our laboratories were accurate and of great practical importance for patient care. However, most of the physicians who relied on our test results to diagnose and treat their patients either did not have the time or interest to consider the philosophical issues inherent in diagnosis, or, like me, had inadequate means to further analyze them. It was more than ten years later that I began doctoral studies in philosophy, and I was fortunate to find a faculty that was supportive of my efforts to address the problem. This book began as my doctoral dissertation in the Department of Philosophy at Georgetown University. I would like to acknowledge the assistance of my mentor, Robert Veatch, Ph. D. Our conversations during my Georgetown years led me in new and often fascinating directions. I would also like to acknowledge the help of Kenneth Schaffner, M. D. , Ph. D.
Halfway between history and philosophy, this book deals with the historical forms that have permitted the understanding of human suffering from the Renaissance to the present. Representation, sympathy, imitation, coherence and narrativity are but a few of the rhetorical recourses that men and women have employed in order to feel our pain.