Testimonial injustice in healthcare – an alternative diagnosis

The common patient complaint of not feeling listened to is familiar to many and well tracked throughout various channels. Whether it be the UK governments 2020 report on endometriosis care that describe women who speak of the difficulty of getting healthcare professionals to take their pain seriously and not “think[ing] you are over exaggerating” or anecdotal stories of our friends and family feeling frustrated at not feeling like their doctor listened to their testimony in the clinic; it is a familiar complaint and one of concern considering the impact it has on patients’ subjective experience of clinical care and the potential detrimental side effects on patients health outcomes. The question I address here, is how best to understand the mechanisms that lead to this patient experience.

This phenomenon has been interpreted by many to be instances of what philosopher Miranda Fricker originally termed testimonial injustice, a form of the wider category of epistemic injustices. While epistemic injustices refer generally to instances where an individual is harmed in their capacity as a knower (as opposed to their capacity to feel pain, say), testimonial injustice refers to instances where one is in harmed in their capacity as a knower due to “prejudice causes a hearer to give a deflated level of credibility to a speaker’s word” (Fricker, 2007, p.1).

As recognisable (to some more intimately than others) example of testimonial injustice, consider the case of an individual woman going to their doctor with complaints of excessive menstrual pain as a classic. A woman is experiencing severe menstrual pain that is leaving her bed bound for days on end. She goes to her doctor to discuss this pain and explore the possibility of an underlying cause, such as endometriosis, only to be met with scepticism about her claim and the sense that the doctor thinks she is over exaggerating. After many appointments where doctors dismissed her claims to pain as being dramatic and lots of convincing, she finally has a series of examinations that show she has endometriosis.

It doesn’t take much to convince someone that there is something problematic in the case described and more generally with testimonial injustices. In the first place, wrongly being treated as not being a credible source of information can lead to all kinds of negative secondary effects. But also, testimonial injustices do more than cause avoidable secondary harms. They also harm the speaker in their capacity as a knower which, according to Fricker, is to harm someone in a way essential to being human, thus to “degrade them to being less than fully human” (Fricker, 2007, p.45). Essential to being a social person is being able to contribute knowledge to shared inquiries. Where our contributions are blocked by prejudicial attitudes, we are wronged in a way that is essential to being social persons. The wrong of testimonial injustice is thus great, with far reaching harms and negative side effects.

In some healthcare contexts, such as endometriosis care, this interpretation of the claim of not feeling listened to as a case of testimonial injustice seems apt. The claim that prejudicial attitudes towards women might lead to some doctors not treating their complaints as seriously as they should does not seem controversial and is, in fact, incredibly important in figuring out how to avoid cases like the endometriosis case (for example, anti-bias training may lead to physicians offering more consideration to what women patients say). The question here though, is this the best way to generally understand the common patient complain of not feeling heard?

According to Havi Carel and Ian James Kidd, it is. They offer a series of anecdotes that they claim are evidence of testimonial injustices in the clinic and claim that the perception of patients as being ’dramatic’ or ‘gripped by anxieties about mortality and morbidity such that they can’t think straight’ causes credibility deflations and thus grounds the diagnoses of these cases as testimonial injustice. Carel & Kidd are not alone in this interpretation of patients not feeling listened to, with an extensive corpus of literature emerging on the various parts of healthcare that are plagued by instances of testimonial injustice.

To give proper due to this ever-growing corpus of literature our question here would require a deep examination into the social epistemology of clinical encounters and the common attitudes of physicians. However, perhaps before we carry out this examination, we could also consider other explanations of cases of not feeling listened to, thus pushing back on the common trend in the literature to rely exclusively on the concept of epistemic injustice broadly to make sense of them.

Imagine a patient who goes to A&E after cutting their wrist. They see a doctor who tells them they need stitches and quickly proceeds to get the required equipment and, with the patient’s consent, starts the procedure. The patient, during the procedure tells the doctor that they are in a lot of pain and asks for pain killers. The doctor replies saying ‘no, there is no need, this is almost done’. The patient, understandably, leaves the situation feeling that their doctor was not listening to them, but this scenario does not necessarily indicate that the clinician is not taking the patient to be credible. Perhaps the clinician knows the pain will be short lived and that the pain killers won’t help. They accept that the patient is in pain and therefore take the patient’s testimony to be true but also know there is nothing that can be done. The patient’s testimony in this case is not necessarily being dismissed as not credible – the doctor conceivably believes that the patient is in pain -, but instead, is not being properly acknowledged by the doctor.

Had the physician communicated to the patient that they understood that the patient was in pain but there was nothing that could be done at that moment to ease the pain and that the procedure would be finished shortly etc. then the patient may not have felt like they were  not listened to. The point being that feeling listened to requires more than simply being believed. We depend on some sort of acknowledgement from the people we speak to that indicates that they hear and believe what we are saying. Simply, not feeling listened to does not necessarily indicate that the speaker is not being treated as a credible source of information.

Perhaps instead, patients not feeling listened to is a sign of a different dysfunction in the endeavour to properly listen to people. If we accept that listening requires more than making an appropriate credibility judgement, then in turn being listened to requires more than being believed to be credible.

Now, this is not to say that there is not an issue in healthcare considering the extensive reports of patients feeling not listened to or that, as mentioned, some of these cases are genuinely cases of testimonial injustice. It is instead to offer an alternative diagnosis and therefore propose that the treatment required is different to the treatment required for a testimonial injustice. What a diagnosis of ‘lack of acknowledgement’ requires is that healthcare professionals improve their communication skills. Whereas the treatment of testimonial injustice is to improve those attitudes which may be deeply rooted in bias. Improving the patients’ subjective experiences and avoiding these types of cases requires consideration of communication techniques as well as considerations of underlying bias. And generally, the diagnosis of testimonial injustice needs to be more thoughtfully applied, taking into account the possibility of poor communication (which, albeit may be a distinct form of injustice in itself) as opposed to the unjust treatment of an individual’s testimony.

• Carel, H. & Kidd, I. J. (2014) “Epistemic injustice in healthcare: a philosophical analysis”, Med Health Care and Philos 17:529–540
• Carel, H. & Kidd, I. J. (2017) “Epistemic Injustice & Illness” Journal of Applied Philosophy, Vol. 34, No. 2
• Fricker, M. (2007) “Epistemic Injustice: “Epistemic Injustice: Power & the Ethics of Knowing”, Oxford University Press

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