Telling, Hearing, and Believing: A Critical Analysis of Narrative Bioethics

A critical and systematic literature review of epistemic justice applied to healthcare: recommendations for a patient partnership approach

Invalidation from healthcare practitioners is an experience shared by many patients, especially those marginalized or living with contested conditions (e.g., chronic pain, fibromyalgia, etc.). Invalidation can include not taking someone's testimony seriously, imposing one's thoughts, discrediting someone's emotions, or not perceiving someone's testimony as equal and competent. Epistemic injustices, that is, the disqualification of a person as a knower, are a form of invalidation. Epistemic injustices have been used as a theoretical framework to understand invalidation that occurs in the patient-healthcare provider relationship. However, to date, the different recommendations to achieve epistemic justice have not been listed, analyzed, nor compared yet. This paper aims at better understanding the state of the literature and to critically review possible avenues to achieve epistemic justice in healthcare. A systematic and critical review of the existing literature on epistemic justice was conducted. The search in four databases identified 629 articles, from which 35 were included in the review. Strategies to promote epistemic justice that can be applied to healthcare are mapped in the literature and sorted in six different approaches to epistemic justice, including virtuous, structural, narrative, cognitive, and partnership approaches, as well as resistance strategies. These strategies are critically appraised. A patient partnership approach based on the Montreal Model, implemented at all levels of healthcare systems, seems promising to promote epistemic justice in healthcare.

Five Coffin Nails to Informed Consent: An Autoethnography of Suffering Complications in Breastfeeding

This autoethnography describes an illness episode caused by breastfeeding complications. It focuses on informed consent processes accompanying this illness episode. Informed consent is a cornerstone of ethical medical practice and has to be obtained before a medical intervention can legally be implemented. It is therefore not trivial that in practice, informed consent processes often fail to achieve what they are set out to. With this autoethnography, I want to provide a review of how informed consent processes can fail in the context of breastfeeding, but also draw attention to what these situations can mean and feel like for those affected. I provide in-depth descriptions of five scenes from my illness episode each representing a different barrier to informed consent. The scenes were developed based on emotional recall and written to grant access to the emotional dimensions of my experience in the tradition of evocative autoethnography. As part of my story, I engage with various issues like practices of prescribing, communicative requirements in vulnerable situations to ensure understanding, the dual purpose of informed consent in the moral and legal realm, and the moralized breastfeeding discourse. Possible routes for change to abolish or reduce described barriers to informed consent are discussed.

Attending to the Moral Meaning of Pain

In addition to a physical and emotional experience, pain is also a morally infused experience with deep, often subconscious, meaning for many sufferers. Whether justified or not, for many people, pain may represent loss, judgement, unworthiness, abandonment, punishment, and even existential suffering and thoughts of death. The moral meaning of pain is what influences the associated experiences of stigma, loneliness, and guilt that contribute to suffering. It is why nurses and other healthcare practitioners have long adhered to a moral obligation to treat those with pain, implying a duty to attempt to make right the wrong of undeserved suffering. Yet the moral meaning of pain is rarely discussed and is often overlooked when establishing a relationship with and a treatment plan for a person with pain. It is the unattended moral meaning of pain that may contribute to unnecessary suffering, futile treatment, and even moral dilemmas in establishing care. In this paper, I explore the definition of morality itself, the moral meaning of pain, and its implications for care. I discuss how moral pluralism in contemporary society contributes to various moral perceptions that influence a person's pain experience and how their pain is treated. Finally, I make the case that using a narrative approach to intentionally look for moral meaning in an individual's pain story may reveal opportunities for more effective pain management options.

Bioethics and the Moral Authority of Experience

While experience often affords important knowledge and insight that is difficult to garner through observation or testimony alone, it also has the potential to generate conflicts of interest and unrepresentative perspectives. We call this tension the paradox of experience. In this paper, we first outline appeals to experience made in debates about access to unproven medical products and disability bioethics, as examples of how experience claims arise in bioethics and some of the challenges raised by these claims. We then motivate the idea that experience can be an asset by appealing to themes in feminist and moral epistemology, distinguishing between epistemic and justice-based appeals. Next, we explain the concern that experience may be a liability by appealing to empirical work on cognitive biases and theoretical work about the problem of partial representation. We conclude with preliminary recommendations for addressing the paradox and offer several questions for future discussion.

A stigmatizing dilemma in the labour room: Irrationality or selfishness?

Nowadays, a considerable number of women have a negative or outright traumatic birth experience. Literature shows that being involved in decision-making and exercising autonomy are important factors in having a positive birth experience. In this article, I explore the hypothesis that some views characteristic of the biomedical model of childbirth may hinder women's involvement in decision-making, leading them to what I have dubbed as a 'stigmatizing dilemma'; that is, to be perceived and treated as either irrational or selfish when trying to exercise their autonomy in the labour room. I suggest that such a stigmatizing dilemma arises when the following views are uncritically and unqualifiedly endorsed: (1) childbirth is a process fraught with risk, particularly to babies; (2) labouring women's reports are unreliable and their subjective perspective does not constitute a valuable source of information; (3) medical knowledge and procedures are the safest means to give birth. In a scenario where (1)-(3) are strongly endorsed, if birthing women act according to instrumental rationality and want the best for their babies, they will be expected to just leave decisions to medical experts. Thus, not following expert directions might lead women to fall under the stigma of either irrationality or selfishness: they could be perceived and treated as either irrational, since they may not seem to seek the best means to accomplish their goal; or selfish, since they may seem to pursue goals other than the baby's health. I examine these stigmas in relation to two ideals: that of disembodied rationality and that of selfless motherhood. I also explore different ways in which the views and prejudices underlying this stigmatizing dilemma could be challenged.