Explaining epistemic injustice in medicine: tightrope walking, double binds, paths of least resistance and the invisibility of power positions to those who occupy them

Person-centered healthcare requires providers to appreciate the knowledge and perspectives of patients. Effective and appropriate care depends on such knowledge. Medical institutions can only function well when they acknowledge patients’ own experiences. Yet a range of evidence shows that professionals and organisations often ignore patients’ own knowledge about their condition and treatment. This article aims to explain why this epistemic injustice occurs and persists. (Epistemic: to do with knowledge. Justice, because professionals and organisations do wrong when they bypass or deny patients’ own knowledge.) The explanation focuses on problems of power and accountability. Illness is a disempowering experience, partly for bodily and psychological reasons, partly because the ill person depends on others for help, partly because professionals and organisations are specially empowered in order that they may help. Occupying a lesser power position, patients often walk a tightrope between conflicting demands and may be caught in double binds: situations where every possibility for action risks bad outcomes. By contrast, professionals need not notice their greater power position and how this opens up paths of least resistance, whereby it is easy to ignore or belittle patients’ knowledge. When it is hard for patients to voice their “complaints” (the details of their illness, their sense of being badly treated), accountability falters. Healthcare providers may see themselves as expert and responsible, even as they fail many persons they are meant to help.

Boys in Blue Camo: The 1033 Program

There’s a thin, often unclear line between a riot and a protest. Demonstrators perform a tightrope-walking act, balancing their outrage at controversial events with the knowledge that a single misstep can lead to total chaos. In some countries, that chaos manifests itself as military crackdowns by the ruling government, the goal being to jail problematic opposition leaders and scare people out of returning to the streets. The U.S. has a long history of replacing that military force with the presence of local police, but over time that line has become equally blurred. One need only look at the events of Ferguson, Mo. to see that ambiguity in action.