Epistemic Injustice and Chronic Pain Reports

This post is by Veronica de Souza Campos and Daniel De Luca-Noronha who recently published a paper in the Journal of Applied Philosophy, entitled: Misunderstanding Epistemic Injustice: The Case of Chronic Pain Reports.

Migraine

Our article critiques the prevalent tendency to interpret inadequate medical responses to chronic pain reports primarily through the frameworks of testimonial and hermeneutical injustice. While these approaches—drawn largely from Miranda Fricker’s influential work—illuminate important aspects of the problem, they overlook a crucial dimension: what we term inquisitive inertia. 

Inquisitive inertia refers to the failure of healthcare professionals to actively investigate patients’ reports of chronic pain, defaulting instead to prescribing analgesics and dismissing the case. As we argue, this constitutes a form of distributive epistemic injustice, in which patients are denied access to a vital epistemic good: the right to a thorough and sustained inquiry into their condition.

Our article opens with first-person accounts of chronic pain sufferers who report years of misdiagnosis, dismissal, or inadequate treatment. Many scholars interpret such cases as instances of testimonial injustice (where a speaker is discredited due to prejudice) or hermeneutical injustice (where gaps in collective interpretive resources render certain experiences unintelligible). While these forms of injustice are undoubtedly present, the authors contend that they are insufficient to fully explain the epistemic harms experienced by chronic pain patients.

Testimonial injustice certainly plays a role, particularly for women and racial minorities, who are disproportionately undertreated due to implicit bias. However, chronic pain poses distinctive epistemic challenges that go beyond identity-based credibility deficits. Chronic pain often lacks clear aetiology, resists objective measurement, and disrupts narrative coherence. This makes it difficult to describe, even for patients who are believed, because the phenomenon itself strains linguistic expression. As such, even an attentive and impartial listener may fail to grasp the full significance of the patient’s testimony.

Back pain

Hermeneutical injustice also falls short in some respects. Although the development of richer conceptual resources for pain is important, this alone does not resolve the expressive limitations inherent in chronic pain experience. The highly individual and often ineffable nature of chronic pain resists neat categorization, and the dominant biomedical framework, which assumes a direct correlation between tissue damage and reported pain, fails to accommodate cases where no such correlation exists.

We introduce inquisitive inertia as a distinct and under-recognized form of epistemic injustice in healthcare. This occurs when healthcare providers, despite medical indications, refrain from pursuing further inquiry into the patient’s condition. Instead of investigating, they prescribe and dismiss. Such inertia is reinforced by systemic pressures: fragmented care, short consultation windows, and bureaucratic constraints that discourage deeper engagement.

Addressing epistemic injustice in chronic pain requires more than correcting biases or expanding conceptual resources. It demands structural reform that enables and obliges healthcare professionals to take chronic pain reports seriously and to investigate them with the epistemic diligence they deserve.

Veronica Campos is an assistant professor at the Federal University of Minas Gerais (Brazil) and research fellow at the Jesuit School of Philosophy and Theology (Brazil). Her main areas of interest are epistemology, philosophy of pain, and philosophy of religion. 

Daniel De Luca-Noronha is an associate professor at the Jesuit School of Philosophy and Theology. His areas of interest include philosophy of pain, philosophy of emotions, and philosophy of religion. 

Playfulness for Justice in Chronic Pain Care

"How many squats/lunges can you do before you want to die?"

I suggest that we consider how to encourage playfulness in chronic pain care. Drawing on the framework provided by feminist philosopher Maria Lugones, I conceive of playfulness as an attitude, not an activity. Playfulness requires a) openness to co-creation and improvisation – a willingness to engage with others in a flexible and unscripted manner, b) openness to surprise – being receptive to unexpected outcomes and expressions, rather than striving for control of the situation, and c) openness to being a fool – rejecting perfectionism and expertise and allowing oneself to be vulnerable. Taken together, playfulness builds increased sensitivity to the world’s differences. Honing this attitude can safeguard against the injustices faced by people living with chronic pain.

Two common themes throughout the scholarship on pain are invisibility and un-shareability. The first, invisibility, refers to the idea that the pain of another is, in principle, inaccessible. The second, unshareability, refers to the challenges involved in expressing pain - bringing it out of concealment so that it might be accessed. These two themes are linked, and they create a lacuna, a lack of vocabulary with which to express and understand how chronic pain feels, what it does, and how it changes people’s lives. 

Medical paradigms and their associated technologies play a massive role in this perennial problem. Thus, these are examples of pathocentric epistemic injustice: injustices that are sustained by dominant medical systems and the theoretical conceptions of health that underpin them. Biomedical approaches to chronic pain mobilize a specific theoretical understanding of pain, and these understandings shape who is thought to be a credible speaker and what forms of expression and speech are intelligible. According to this framework, conceptions of health themselves can be unjust.  

While the field of pain studies has made progress in complicating narrow biomedical explanations of pain, as Patsavas (2014) notes, these communicative norms have yet to find their way into popular understandings of pain. For example, adjectives found on the McGill pain questionnaire, the most frequently used questionnaire for the multidimensional assessment of pain, have crept into the common lexicon. We may ask our friends to describe their pain with these familiar qualifiers, such as burning-, tingling-, or shooting-. We might also ask our friends to rate their pain on a scale of zero to ten, drawing on the Visual Analogue Scale used by medical professionals. 

But what if the person experiencing pain wants to describe their pain as a wave or a colour? What if I want to express my pain by making a long, guttural sound? In her creative non-fiction titled “The Pain Scale”, Eula Bliss reflects, “Although the distance between one and two is finite, it contains infinite fractions”. When patients are unable to express more than pain intensity, this may lead to guilt, shame, and alienation, all of which should be understood as affective determinants of health. That is, these emotional experiences can make one’s pain worse. Pain relief comes not only in the form of excising pain (should this be possible) but also in understanding it. There is thus a pressing need to carefully consider how we might expand, invent, and promote new modes of creative expression.

Field notes that capture participants' emphasis on laughter and play

My paper draws on fieldwork conducted at a somewhat unconventional chronic pain clinic located in Toronto, Canada. Instead of offering one-on-one interactions (between a ‘credible’ pain expert and ‘less-credible’ patient in pain), the clinic operated more as a support group. No pain was measured, and no medicines were prescribed. Instead, patients showed up to talk about how their pain was affecting them spiritually, physically, and existentially. They laughed, they opined, they meditated, and they moved around the room doing silly strength- and mobility-building exercises. 

At the beginning of my observations there, I was mesmerized by the playfulness and levitous mood of the clinic. Mastery was eschewed by the physician (Dr. C) – he frequently reminded participants that they, not him, were the masters of pain. From dark jokes to improvised seating arrangements to casual coffees afterward, this landscape marked a notable departure from biomedical contexts that contribute to pathocentric epistemic injustice in chronic pain care. I characterize MB clinic as imbued with the playful attitude described by Lugones, which is antithetical to the rigid and expert-driven models of healthcare.

This approach may serve as a potential reform that emphasizes patient participation and emotional well-being. In the future, I am interested in exploring how medical educators might encourage this sensibility in training, as well as how playfulness might be better incorporated into the tools that are used in diagnostic and therapeutic encounters. 

Michelle Charette is a PhD candidate in the Science and Technology Studies Program at York University. Her work draws on science studies, phenomenology, and feminist theory to consider how bodies and technologies interact. Her doctoral project examines e-health approaches to chronic pain care, and how these tools (games, applications, virtual reality) introduce novel issues and questions about chronic pain, technology, and ethics in medicine.

When patients hold back: Tactical choices and epistemic agency

Relationships between healthcare professionals and patients often involve an imbalance of power. Medical professionals are very often the gatekeepers of diagnosis, treatments and other support services. Patients on the other hand, typically lack the institutional markers of authority that come with medical qualifications and position. We’ve seen how epistemic injustices can occur in these settings as a result of the biases and prejudices of medical professionals who fail to appropriately recognise the reliability of their patients as sources of information or structural defects of healthcare systems. 

I’m interested in exploring the ways in which patients might respond. How do those seeking diagnosis or treatment navigate tricky relationships with medical professionals?  What epistemic strategies do patients develop? What forms can epistemic resistance take? One approach that is taken by some patients is a tactical one – being careful about what information they share and how they share it. U.S. based researcher Ann Neville-Jan describes her own relationships with doctors and other medical professionals in her long and often demoralising search for an explanation for her chronic pain and effective pain relief. 

Like many who experience chronic pain, Neville-Jan found herself fighting against the view that her pain was ‘just in her head’ – a perspective not uncommon amongst healthcare professionals who view patients with chronic pain as being unreliable in their understanding of the extent and cause of their own pain. As a researcher herself, Neville-Jan was able to play an active role in investigating her condition, leading to a breakthrough: she came across reports of the effectiveness of the use of the drug Paxil for pain relief. The treatment was effective and also provided an insight into the cause of her pain: a ‘hardwiring’ of pain signals in the brain, similar to phantom limb pain.   

Whilst she was successful in finding effective pain relief, Neville-Jan still had to navigate encounters with healthcare professionals. Given the prevailing “just in your head” attitude, Neville-Jan reasoned that if she shared the information regarding her treatment, healthcare professionals would be likely to appeal to psychosomatic interpretations that better fits their narrative, especially because Paxil could also be used to treat depression. The information that her pain does have a physical cause and is effectively manageable with Paxil may be deemed implausible or even unintelligible to some healthcare professionals. So as a result, she chose to limit what she tells them, holding back the information which she thinks they will be less open to. 

This is an example of a practice which feminist philosopher Kristie Dotson calls ‘testimonial smothering’ in which a speaker ‘truncates’ their testimony – withholds certain information, avoids presenting it in a particular way, or doesn’t share it at all – because they believe that their audience will not find it plausible or intelligible. This practice is often the result of bad experiences: attempts to share information where audiences were found to be incredulous or tended to misinterpret or resist the information being shared. Of course, the practice carries with it numerous negative consequences. It restricts what the speaker is able to share and means that they are unable to challenge the misconceptions of their audience. In Neville-Jan’s case it had specific drawbacks – she had important information regarding the cause and treatment of her pain which can help those involved in her care. She had done a significant amount of research and had knowledge about her condition which she was unable to share. In some sense, this limited her agency. Despite all her work in researching treatments, she was not able to fully engage in discussions about her health.

The problem is that holding back on sharing this information can be a sensible tactical choice for someone in Neville-Jan’s position. By presenting only what is viewed as plausible and intelligible, they ensure that they remain seen as a reliable and intelligible source of information in the eyes of medical professionals.

What does this kind of tactical choice tell us about what it means to have agency in the generation of knowledge? Neville-Jan can be seen as being coerced into holding back information because of the power that healthcare professionals have over her access to treatment. But the intentional negotiation of these relationships through her careful choice of words, suggests a resistant form of agency. She is neither a powerless victim of silencing nor wholly free, but she finds a way of having some control over her situation despite the difficult relationships she must navigate with healthcare professionals. She ‘bargains’ with an unjust system by sacrificing one good (being able to share all information about her treatment) for another (being seen as a reliable source of information). Even though it involves testimonial smothering, a practice of silencing, this is an expression of a resistant form of epistemic agency. 

Alice Moneypenny completed her PhD at Nottingham on safe spaces and epistemic practices, before becoming a Teaching Fellow. Her research focuses on epistemic virtues and vices in a non-ideal world, philosophy of education and epistemic agency.