This presentation outlines issues as it relates to discounting the lived experiences of patients in clinical encounters. This could be because patients belong to a marginalized group or represent a different sociodemographic cohort. Providers are instrumental in providing epistemic goods as part of the quality and value of healthcare. Micro inequities and micro aggressions are common and are as the result of implicit bias, value laden judgments and lack of insight the role of heuristics and incomplete assumptions. When not questioned, this has implications for the delivery of value care.

1. Epistemic injustice in clinical
encounters:
an axiological perspective
Dennis A. Velez, MD, MHA (candidate)
University of Missouri-Columbia

2. Objectives
To define epistemic injustice and outline the different kinds of epistemic
injustice.
To appreciate how epistemic injustice exists in the context of providing
healthcare.
To outline how deflating/dismissing patient’s accounts diminishes the
instrumental value (axiological perspective) of trust in the provision of
healthcare.
To generate a discussion around the tension that exists around this concept
in our current healthcare climate.

3. Miranda Fricker

4. Relevant definitions
 Epistemic injustice: a type of harm done to individuals or groups
regarding their ability to contribute to and benefit from knowledge.
 Distributive epistemic injustice: not having access to epistemic goods
such as information, education, expert advice including medical and
legal advice.
 Discriminatory epistemic injustice:
 Testimonial injustice
 Hermeneutical injustice

5. Discriminatory epistemic injustice
 Testimonial injustice: altered perception of the credibility of the
interlocutor/patient (deficit/excess) affected by prejudice of some kind
(ex: a female provider’s recommendations are less credible because she’s
a female)
 Hermeneutical injustice: due to insufficient shared concepts and one’s
experienced is thereby obscured from understanding due to prejudicial
flaws in shared resources for interpretation (ex: “sexual harassment”
before there was a concept to explain this experience by the knower).

6. The Wrong of Epistemic Injustice
 Primary wrong: a person or group is wronged in their epistemic capacity
(a knower, a questioner, a reasoner)
 Secondary wrong: more practical consequences: inability to get a job,
convince a jury, be misdiagnosed and be offered wrong treatment

7. Healthcare providers as epistemic agents
 Diagnostic and therapeutic processes are not merely clinical or technical
exercises-they are also social and political processes.
 Our descriptions of pathophysiological or experiential phenomena
depend on which clusters of signs and symptoms we see as constituting
a disease and which we interpret as irrelevant.
 Healthcare providers’ social environment, personal background,
worldview and other values influence how they observe patients, how
they investigate and interpret histories, what diagnoses they offer and
what treatment they recommend.

8. Medical axiology
 Medicine as a science is a value-free discipline.
 Are providers supposed to be value neutral?
 “A truly value-neutral doctor would have no patient-physician
relationship of significance” (Hoehner, 2006)

9. Pellegrino and Thomasma (1981)
 Three ways in which values function in medicine:
 “in being aimed at the good of health, in being a cognitive art evaluating
towards that good, and as a manifestation of a virtuous disposition
concerning that good.”

10. Trust and patient-provider relationships
 The provider-patient relationship is a “peculiar constellation of urgency,
intimacy, unavoidability, unpredictability and extraordinary vulnerability”
(Pellegrino, 1991).
 Trust is an instrumental value as it affects the emotional and
interpersonal aspects of this relationship.
 It is assumed that clinical encounters, “at baseline”, always respect issues
of autonomy, beneficence and non-maleficence.

11. Epistemic injustice and challenging medical
conditions

12. Correcting for prejudice
 If virtue ethics supports epistemic justice:
 Reflection: alone, peers,
 Self-correction: should not result in an administrative encumbrance.
 Epistemic humility
 Is there a role for practices such as mindfulness meditation
(Vipassana practice as outlined in the Theravada tradition of Buddhism)?

13. Deflation/dismissal of “pain behavior”

14. Sciatic pain and questions of value

15. Sciatic pain and questions of value

18. Expectations and
sources of information
regarding elective
lumbar spine surgery
Sources of expectations varied by
demographic and clinical
characteristics, severity of pain
related disability and prior
treatment including prior surgical
intervention.
Modifiable sources of expectations
can be developed that are
accurate and reliable and foster
discussions between patients and
surgeons and improve patient
outcomes.

19. Thanks for your attention!