Epistemic Microaggressions in Healthcare

In its relatively short history, the growing literature on epistemic injustice in healthcare has come a long way in highlighting the distinctly epistemic dimensions of medical encounters that can lead to a variety of injustices for patients. Such injustices are often the result of differences in relationships of institutional, professional, and social power (Kidd and Carel 2017, Freeman and Stewart 2024, Stewart and Freeman, 2022). 

This literature is mostly focused on how phenomena such as testimonial injustice and hermeneutical injustice render patients epistemically vulnerable. Additionally, it has helped to illuminate some of the ways in which patients from marginalized groups have their epistemic agency constrained, undermined, or ignored as they attempt to make claims about their bodies, identities, or health status to healthcare professionals. However, this literature has only recently started to attend to some of the more subtle, covert, and insidious mechanisms of epistemic dismissal.

 
In our recently published book, Microaggressions in Medicine, we engage with some of these seemingly subtler forms of epistemic (and other) types of injustice and harm in medical contexts. Let’s zoom out to mention the overall aims and goals of the book before zooming back in to focus on the epistemic dimensions of these injustices.

The two main theoretical aims of Microaggressions in Medicine are to reconceptualize how microaggressions have been understood by psychologists and philosophers and to introduce a new conceptualization of microaggressions that we call a harm-based account. 

Our harm-based account categorizes microaggressions according to the kind of harm that results for those who experience them. As such, we propose and argue for the following three kinds of microaggressions: epistemic microaggressions that result in epistemic harm, emotional microaggressions that result in emotional harm, and self-identity microaggressions that result in harms to one’s sense of self.

Microaggressions in Medicine (2024)

There are three applied aims of the book. 

• Using first-personal narratives, case studies, and testimonies of patients who are members of marginalized groups, we develop this harm-based account within medical contexts. 
• Analyzing these case studies, we illuminate the serious and enduring harms of microaggressions and argue that they can ultimately lead to delaying or avoiding medical care, damaged trust relations with healthcare professionals, and ultimately worse health outcomes for patients who experience them. 
• We introduce practical tools and strategies to help healthcare professionals reduce microaggressions in their practices and institutions, thereby diminishing harm caused to patients.

In what follows, and drawing on chapter 4 of the book, we focus on epistemic microaggressions, epistemic harm, and discuss why attending to epistemic microaggressions is an important part of the larger picture of epistemic injustice in healthcare.

In medical contexts, epistemic microaggressions are intentional or unintentional verbal or gestural slights made by healthcare professionals that dismiss, ignore, or otherwise fail to recognize claims that patients make about their bodies or health. Epistemic microaggressions result in epistemic harm to recipients (here, patients), namely, harm to them in their capacity as knowers. 

One example of an epistemic microaggression that we develop in the book is the story of what happened to the famous sociologist, professor, writer, and MacArthur “genius” award winner, Tressie McMillan Cottom. Despite her social standing and countless intellectual and academic achievements, as a self-described fat, Black (and at the time, pregnant) woman, Cottom knew that given her identity, she would face an array of discriminations. For this reason, she carefully chose her physicians. Or so she thought.

When she was four months pregnant, bleeding and experiencing acute pain, Cottom knew that something was terribly wrong. Yet when she and her then husband arrived at her doctor’s office, instead of being seen immediately or being sent directly to the emergency department, she was told to sit patiently in the waiting room. When she finally got to see her doctor, he looked at her and quickly said that she was probably just too fat and that for “women like her,” spotting was typical at this stage of pregnancy. She was sent home.

When, later that night, her pain escalated, the on-call nurse assured her over the phone that because the pain was in her bowel and not her lower back, that it was probably constipation and that she should try to go to the bathroom. After three days of such pain and no sleep, Cottom went to the hospital, where she was told that she’d probably just eaten something that was “bad” for her. 

After insisting that she get an ultrasound, it showed the fetus, in addition to two large tumors. Upon seeing this, the nurse scolded Cottom: “You should have said something” (Cottom 2019, 84). Soon thereafter, Cottom went into early labor. She gave birth to her daughter, who died soon after she was born (ibid., 85). While making plans for how to handle her daughter’s remains, another nurse said: “Just so you know, there was nothing we could have done since you never told us that you were in labor” (ibid.).

There are countless microaggressive harms that Cottom experienced. It’s important to underscore however, that the result of those microaggressions was nothing micro. Our analysis focuses on how racialized and gendered epistemic microaggressions combine in ways that are unique to Black women (what we call the misogynoir of microaggressions).

In this case, it was clear that Cottom knew that there was something wrong, tried to convey this knowledge to her healthcare team, and continued to be viewed as lacking credibility with regards to her knowledge of her body. As a result of the entrenched biases and stereotypes about Black women, Cottom experienced a panoply of racialized gendered epistemic microaggressions. 

As a pregnant Black woman who was bleeding and in pain, her bleeding was attributed to her fatness. Then, her pain in her bowel was dismissed as being the consequences of something “bad” that she’d eaten, where “bad” has racist undertones about the kinds of food that Black people eat. Finally, after the death of her newborn daughter, she was blamed for not having spoken up sooner, with the implication that the death was in part her fault and could have been prevented had she spoken up.

Cottom is powerless relative to the healthcare professionals.

Her knowledge of her body is ignored.

Repeatedly, healthcare professionals assumed they knew better.

On account of her race, gender, and body size, Cottom suffered the epistemic harm of not being recognized as a credible knower, the practical harms of severe physical pain, the death of her daughter, as well as the enduring trauma of the whole experience.

These consequences are macro and tragic. But we are most concerned with the epistemic racialized gendered microaggressions that contributed to them. Cottom’s credibility as a knower was denied due to her race, gender, and body size and as a result, her knowledge claims were ignored or dismissed.

The racialized gendered epistemic microaggressions that Cottom experienced are reflections of imbalances in epistemic and other sorts of social power that themselves mirror broader patterns at play both within and beyond healthcare contexts. Healthcare workers belong to an elite professional class. They’re assumed to have epistemic authority within and beyond that context. They often exert epistemic power over their patients by blocking them from making meaningful contributions to clinical exchanges. This epistemic situation both reflects and reifies assumptions about power in the epistemic domain. For example, it makes clear who creates, controls, and deploys knowledge and who doesn’t; who is “rational” or “objective” and who isn’t (cf. Code 1991).

The epistemic microaggressions on which we have focused, combined with more macro and explicit stereotypes and assumptions about Black women, result in epistemic harms to patients: they’re denied the full status of knower, which is central to human dignity and value (Fricker 2007; Pohlhaus Jr. 2017; Dotson 2011). 

Because the epistemic contributions of patients who are members of marginalized groups are routinely blocked, over time this can result in patients coming to doubt their own epistemic capacities, especially as microaggressions add up and their harms accumulate (Evans and Mallon 2020). As we saw and as we develop further in our book, epistemic microaggressions can also lead to harmful health and other consequences.

As Cottom’s case makes clear, epistemic microaggressions are harmful to the epistemic status and agency of marginalized patients. A complete understanding of epistemic justice and injustice in healthcare and the myriad ways they manifest must include attention to the subtle epistemic dismissals and indignities that epistemic microaggressions reflect.

Heather Stewart is Assistant Professor of
Philosophy at Oklahoma State University.

Lauren Freeman is a Professor of 

Philosophy at University of Louisville.

Female Sterilization and Epistemic Injustice

Hysterectomies, involving the removal of fallopian tubes, ovaries, or the cervix, are among some of the most common operations performed in the US and the UK. Often requested as a way of minimizing the pain associated with endometriosis, hysterectomies can also be lifesaving for women with cancer.

Recently, there has been a wave of op-eds and public accusations against medical professionals who refuse to perform these surgeries on young women, who are suffering from painful or even life-threatening conditions. 

These refusals are often justified by the concern that these young women might change their minds about having children, that their future husbands might be cheated out of parenthood or, in the case of non-binary patients, that their sexual identity might change. 

So far, these hysterectomy refusals have been criticized as denials of bodily autonomy and reproductive freedom. Yet, it is difficult to neglect that, in these interactions, some epistemic injustices might also be at play.

Uterus 

For one, the young women might be victims of testimonial injustice, which, according to Miranda Fricker, involves a speaker receiving an unfair deficit of credibility from a hearer owing to prejudice on the hearer's part. In this case, the patients’ assertions that they have understood and accepted all implications of such an operation (especially regarding the ability to procreate), are being dismissed in a way that amounts to an identity-prejudicial credibility deficit. 

Importantly, the medical professionals, deny credibility to patients based on an intersectional prejudice against young women, who are seen as immature, confused, or plainly mistaken about their reproductive decisions. They are not only denied epistemic agency, but othered, as they are viewed solely through the lens of patriarchal norms.

In addition to testimonial injustice, one might argue that young women who are denied hysterectomies also suffer from hermeneutical marginalization, wherein significant parts of lived social experience are obscured from understanding because of prejudices in collective resources for social interpretation. Historically, women, especially younger women, have been denied equal hermeneutical participation, and as a result, their lived experience of postpartum depression, sexual harassment and domestic abuse have long been obscured. 

In the case of hysterectomy denials, experiences of gynecological illness and authentic desires to remain childfree fail to be properly interpreted by the medical establishment, which functions here as a reinforcer of dominant norms linking a woman’s value to her ability to reproduce. Furthermore, these cases also indicate a compounded epistemic injustice, testimonial obfuscation, where an identity-prejudicial credibility evaluation an experience to remain unintelligible to the hermeneutically marginalized speaker. 

Thus, young women suffer a double epistemic harm – their experiences are obscured not only within the dominant discourse but also to themselves, in ways that distorts the construction of their selfhood. This explains why the denial of hysterectomies can make women doubt their own minds and desires and force them into submission to the dominant norms, regardless of the painful or life-threatening conditions they might endure.

It is my hope that considering these injustices will renew calls for embedding epistemic virtues within the medical establishment.

 

Dr Catalina Carpan is a Teaching Fellow in Political Theory at the University of Warwick. Her research explores epistemic injustice in relation to ideology and power, to show how its victims are disciplined and denied republican freedom.

Epistemic Injustice in Dementia

One of the most common mistakes people make when they hear the word “dementia” is to assume that it is the same for everyone. They assume that problems with memory are always the most prevalent symptom, that dementia is synonymous with “Alzheimer’s disease” or that it is not possible to live a good life with such an illness. 

All of these are contested; the first two by various informative webpages (e.g., Alzheimer’s Association), and the third by people with dementia themselves in the multitude of first-hand accounts I have uncovered during my research in which they readily voice their experiences of “living well” in spite of their symptoms (e.g., Mitchell, 2018, Bute, 2018).

Arguably the most harmful assumption about people with dementia is that “the impairment of cognitive function is severe and global; that the person has or will rapidly and inevitably become a ‘vegetable’.” (Crichton, Carel & Kidd, 2017:69). Although the progression of impairment is, to some extent, inevitable (given that there is no cure), cognitive decline does not occur in the same way or at the same pace for everyone. 

Furthermore, it is important, I feel, to note the effects of the language used. People with dementia have been referred to as “vegetables”, “shells”, and even “zombies” (Behuniak, 2011, Schweda and Jongsma, 2022). This kind of downgrading of their identity from a person to a “zombie” only perpetuates the stigma that a person with dementia is “crackers” (Langdon,et al 2007:994) and therefore not worth listening or speaking to.

The notion that a person with dementia is not worth conversing with is aptly referred to by Young et al (2019) as “pre-emptive testimonial injustice”. Testimonial injustice (TI) is a type of epistemic injustice in which a speaker is not given the credibility they deserve by a hearer, and so they are “wronged specifically in their capacity as a knower” (Fricker, 2007:1). Pre-emptive TI involves the hearer already assuming that the speaker is an unreliable testifier before they have even spoken. A clear example in which this is exemplified can be seen in a study by Larsson et al in which people with dementia were interviewed: 

“if you tell colleagues (about having dementia) then they change….they will put a mark (on) your forehead… dementia that’s no point… no point in telling him… that’s too complicated… he will never get it… or a joke or something funny… there’s no point… he won’t get it anyway… and… it’s not true… because you will” (Larsson et al, 2018:4). 

“Bob” (in a similar study) also expresses that his live-in carer frequently warns people that:

“it’s no good discussing it with him (Bob) because he wouldn’t know the first thing about it” (Langdon et al, 2007:996). 

In both of these examples, the person with dementia is clearly a victim of pre-emptive TI. It has unjustifiably been assumed that the person with dementia “won’t get it” and that they are therefore not worth engaging in communication with.

The stereotype above discussed by Crichton, Carel & Kidd is arguably doing a lot of the heavy-lifting in pre-emptive TI. Not everyone with dementia has “severe and global” cognitive impairment or is incapable of understanding. This is yet another instance of the harm that negative stereotypes can cause in testimonial exchanges and to epistemic agents (Fricker, 2007). 

In the words of the late Wendy Mitchell: “Dementia has to start somewhere…It doesn’t always mean the end stages, and I’m just an example of someone at the start of the journey” (Mitchell, 2018:179). We should bear Mitchell’s words in mind before we hesitate to speak to or listen to someone because they have dementia.

Sarah Wood

Sarah Wood is a PhD researcher in Philosophy at the University of York. Her research aims to provide a better understanding of the subjective experience of dementia by drawing upon ideas in the phenomenological tradition.

Will medical AI apps help us to achieve healthcare justice?

AI-powered healthcare apps promise to solve current problems, offering more efficient, unbiased and accurate care to users. According to these promises, AI Apps can diagnose mental disorders, tell patients if their moles are cancerous, and offer a more effective ear for disclosure since some patients report feeling more comfortable sharing their experiences with AI rather than with their clinician. Yet, as AI has been found to reproduce biases within training data, can it really be a departure from the long and difficult history of inequality in healthcare? 

Traditionally, women have been underrepresented in science, leading to conditions faced by half the world's population being ignored and women's symptoms being systemically underplayed and disbelieved. This resulted often in the lack of adequate understanding of female physiology. For decades studies on women’s healthcare have revealed how women’s pain is often misdiagnosed, psychologised, with women reporting having to work harder for their symptoms to be believed and addressed. 

Moreover, the history of psychiatry shows how diagnosing mental disorders has been used to oppress women. Today, we are facing great inequalities in the medical profession; for example, only one in ten surgeons in the NHS identify as female while patients with endometriosis need on average seven and a half years to receive diagnosis.

Reproductive health is a popular area for apps, with one subsection targeting users who suffer from symptoms compatible with endometriosis so they can track their pain and physical discomfort. Apps collect data that can then be presented to a physician, and via this process data seem more reliable and trustworthy. This type of app is presented as a solution for epistemic injustice because the data collection and visualisation of data points are seen as more objective and can thus accelerate diagnosis. The collected data can also be argued to power AI investigations into medical conditions, and, at the individual level, empower people by tracking their medical journeys.

The apps collect inputted information and present it to healthcare providers, aiming to alleviate epistemic injustice in the clinic though data visualisation. However, we contend that this ultimately shifts the burden of proof from the practitioner to the user rather than resolve the structural inequalities responsible for the phenomenon. The apps could ultimately increase the burden of proof for these conditions, requiring longitudinal self-tracking and interaction with the app interface, a labour cost to the individual who is seeking help. For those users who, for whatever reason, do not or cannot provide this information, then the barrier to healthcare will be further entrenched. Ultimately such apps could make epistemic injustice worse rather than alleviating it. The risk is that the issue will be obfuscated by techno-solutionism and that, ultimately, women are not to be believed without neatly packaged data.

Moreover, we are sceptical about the emancipatory role of such apps in improving healthcare for individuals who face epistemic injustice in the clinic. We are also concerned about the argument that the data these apps collect can truly empower research into conditions such as endometriosis. What is currently needed to advance understanding of the condition is more and better imaging and screening of those affected, which start with believing their symptoms. This is possible within traditional medical set-ups. So, before we get excited about the next toolkit, it is worth reflecting on why we expect technology to offer us solutions to deeply entrenched socioeconomic problems.

Dr Milena Ivanova is a philosopher of science interested in the relationship between science and art, creativity and the automation of discovery. She teaches medical professionals on the role of epistemic diversity in medicine and is interested in the presence of gender and racial bias in the history of medicine and psychiatry.

Dr Aisha Sobey is an interdisciplinary STS researcher, who is concerned with understanding the interaction of the digital systems and the human experience, especially concerning power structures.