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Ans presentation narruhn 31520 with text in notes
- 1. Epistemic Injustice APhilosophical Analysis of Women’s Reproductive Health Care in a Somali-American Community by Robin Narruhn & Terri Clark Robin Narruhn PhD MN RN
- 2. Genesis of Article Witness to the philosophical differences between a biomedical system and a specific community Miscommunication Critical Event Birth inequities
- 3. Ways of Knowing ~Patternsof Knowing~ includes empiric, personal, aesthetic, ethical, and emancipatory knowledge, defines the different types of knowledge and how they relate to each other.
- 4. Ways of Knowing •Personal Knowing- refers to the knowledge we have of ourselves and what we have seen and experienced. This type of knowledge comes to us through the process of observation, reflection, and self-actualization • Aesthetic Knowing -Aesthetic knowing makes nursing an “art.” • Empirical Knowing -knowledge from research and objective facts. • Ethical Knowing -knowing helps one develop our own moral code; our sense of knowing what is right and wrong. • Emancipatory Knowing -critical framework to learn how to advocate for social justice and to question structural barriers that result in healthcare inequity.
- 5. Miranda Fricker Epistemic Injustice- a formof injustice that harms a person in his or her capacity as a knower.
- 6. Epistemic Injustice Testimonial injustice-occurs when a prejudice causes a hearer to give a deflated level of credibility to a speaker's world. Hermeneutical injustice- (hermeneutic = method of interpretation) occurs when a gap in collective interpretive resources puts someone at an unfair disadvantage when it comes to making sense of their social experiences. (Fricker, 2007)
- 7. Epistemic Injustice &Birthing • Informed Consent- full consent (short/long term, diagnostic/curative) • Constructed – “Maternal Fetal Rights” Paradigm (Cartesian split vs union) • Risk Discourse i.e. disease state/medicalization vs physiological process • Power Differentials esp. in relation to Intersectionality i.e. multiple categories of identity • Discordant & Obscured but Privileged Values i.e. Physiologic vs a Technological Interventionist Birth • Differing Conceptualizations of Autonomy i.e. individual vs relational/communitarian • Legitimacy of Specific Knowledge Systems aka Authoritative Knowledge
- 8. Authoritative Knowledge “When equallyand legitimate parallel knowledge systems exist . . . people move easily between them using them sequentially or in parallel fashion for particular purposes. But frequently one knowledge system gains ascendance and legitimacy. A consequence of legitimization of one kind of knowing as authoritative is the devaluation often the dismissal of other ways of knowing. Those who espouse alternative knowledge systems then tend to be seen as backward, ignorant, and naïve, or worse, simply as trouble makers." Jordan, 1997 (p56)
- 9. Case Studies • Inthis article we illustrate how these concepts are manifested in the clinical setting by providing several case studies.
- 10. Recommendations (1) a morecritical use of technology with attention paid to the unintended consequences, (2) a culturally safe and patient-centered approach to care, (3) a physiologic approach to birth that is more consistent with the values of the Somali community, or of any person's relevant community, (4) full, nonbiased disclosure of the various options regarding technology, (5) a fully-informed consent process regarding routine use of prenatal screening, diagnosis, and perinatal assessment technology, (6) translation of research on social determinants of health into action in the clinical context, (7) an approach to pedagogy and disparity reduction that uses a structural competency lens, and (8) legitimizing the use of epistemic diversity
Editor's Notes
- #2 My name is Robin Narruhn and I am honored to have an article I co-authored with my colleague and friend, Dr. Terri Clark featured in Advances in Nursing Science. Narruhn, R., & Clark, T. (2019). Epistemic Injustice: A Philosophical Analysis of Women's Reproductive Health Care in a Somali-American Community. ANS. Advances in Nursing Science, 43(1), 86-100.
- #3 The genesis of this research came about as a result of a critical incident in my workplace involving a mother from Somalia having her first baby. The incident involved mother who did not understand, nor trust the health care system, a newborn with severe neurological anomalies, reproductive disparities in her community, a disengaged health care system, a malpractice suit and stakeholders who viewed the court proceedings as a “win”. What ensued for me was moral distress and a drive to understand what happened, which compelled me to earn my PhD. I questioned what had happened in that case to make things go so awry. It was the catalyst for my studies and this article. In the article we outline four case studies to illustrate how these concepts intersect with epistemic injustice to affect birthing outcomes and experiences.
- #4 I had noted that different knowledge systems and ways of knowing were at work in this critical event. Chin’s and Kramer’s book, Knowledge Development in Nursing provided a framework to think about what was happening in the clinical setting.
- #5 Chin and Kramer explain there are 5 ways of knowing: Personal, Aesthetic, Empirical, Ethical and Emancipatory, Empirical Knowledge was being privileged by health care providers almost exclusively in this clinical event. The use of Ethical or Emancipatory ways of knowing may have led to different conclusions, practices and outcomes.
- #6 Miranda Fricker’s book, Epistemic Injustice further influenced my thinking’ Fricker defines Epistemic Injustice as a form of injustice that harms a person in his or her capacity as a knower This mother, like many mothers, did not have history of experiences that matched the expectations of the providers who were using a biomedical paradigm. Miranda Fricker’s idea of epistemic injustice is relevant to the scenario of giving birth in highly technical settings.
- #7 There are two types according to Fricker; testimonial injustice and hermeneutical injustice. Testimonial injustice is a prejudicially deflated degree of credibility from a hearer; it wrongs the subject in his capacity as a giver of knowledge. Hermeneutical injustice is an injustice occurs at a prior stage, when someone is trying to make sense of a social experience but is handicapped in this by a certain sort of gap in collective understanding. .
- #8 Epistemic Injustice is a factor that affects the clinical encounter between a helath care worker and mother in all of these areas. In the article we provide case studies that illustrate how this can occur in the clinical setting.
- #9 Fricker’s conceptualization of epistemic injustice resonated with Barbra Jordans ideas of authoritative knowledge which occurs “When equally and legitimate parallel knowledge systems exist . . . people move easily between them using them sequentially or in parallel fashion for particular purposes. But frequently one knowledge system gains ascendance and legitimacy. A consequence of legitimization of one kind of knowing as authoritative is the devaluation often the dismissal of other ways of knowing. Those who espouse alternative knowledge systems then tend to be seen as backward, ignorant, and naïve, or worse, simply as trouble makers." Jordan, 1997 (p56) Too often we often exclusively privilege one knowledge system over another when making clinical recommendations, most often privileging empiric knowledge over ethical, personal, aesthetic or emancipatory (see Chin and Kramer’s Integrated Theory and Knowledge Development in Nursing). By dismissing patient’s values, which are developed and expressed in knowledge systems such as ethical or emancipatory knowledge systems, we miss the opportunity to provide patient centered, culturally safe care. Jordan B. Authoritative knowledge and its construction. In: Davis-Floyd R, Sargent C, eds. Childbirth and Authoritative Knowledge. Berkeley, CA: University of California Press; 1997.
- #10 Both types of epistemic injustice were a factor in the reproductive health care setting that compelled me to explore these concepts. The more I thought about it, the more I realized that epistemic injustice is a factor in many women’s and parent’s birth stories from consenting to, diagnostic testing, childbirth classes, and socialization to the hospital environment, to recommendations for care. Theorists such as Miranda Fricker, Peggy Chin and Maeona Kramer, Robbie Davis Floyd and Barbara Jordan all influenced my thinking. In the article, we apply these concepts to case studies to illustrate how the concepts manifest in the health care setting.
- #11 These are our recommendations. We hope that you find these theoretical concepts as compelling as we did!