By Mark Satta and Lacey J. Davidson
In recent years philosophers concerned with epistemic, moral, and political matters have identified many different types of epistemic injustice. Epistemic injustice refers to “forms of unfair treatment that relate to issues of knowledge, understanding, and participation in communicative practices.”
We are particularly concerned with epistemic injustices in the public health context and the consequences such injustices have for those most marginalized within our current society. When powerful entities act badly, individuals and communities justifiably distrust those entities. This distrust then guides individuals and communities in making decisions with respect to these entities, often causing them to avoid the entities in question. We are concerned with cases in which the distrust is harmful to the individual, even when it is justified. We think this circumstance is particularly common and troublesome in the public health context.
Here’s a hypothetical story offered to help explain what we mean.
Lisa is a 34-year-old Black woman living in North Carolina. Lisa has undiagnosed cervical cancer. If Lisa were going to a gynecologist regularly, her odds of having her cervical cancer caught in time for effective treatment are fairly high. However, Lisa strongly distrusts doctors and gynecologists in particular. Lisa hasn’t been to a doctor in several years, despite having decent health insurance. Lisa’s distrust is rooted in the fact that Lisa’s aunt was one of many poor women of color who was sterilized without giving her consent.
After learning she had been sterilized without her consent, Lisa’s aunt was distraught for many years. Lisa’s memories of her aunt’s pain made a strong impression on Lisa. Lisa would like to have children one day and thus avoids doctors whenever she can out of fear that she too will be sterilized. Lisa’s distrust is epistemically justified given her experiences, but the consequences of having her cervical cancer remain undiagnosed as a result are deeply harmful to Lisa.
Here are some features to note about Lisa’s condition. First, because of the information Lisa has about her aunt’s sterilization, she is epistemically justified in some degree of skepticism and distrust of doctors and the medical profession.
Second, it is the bad past actions of the medical profession, which in many places in the United States (including North Carolina) allowed and encouraged coerced sterilization of poor women of color, that is the source of Lisa’s distrust.
Third, Lisa’s skepticism and distrust—while reasonable—are harmful to her well-being because her cancer is spreading and remains undiagnosed.
Lisa is a victim of what we are calling pernicious epistemically justified distrust. By that, we mean that Lisa has beliefs that are justified by the bad past actions of others, but now result in harm to her. Thus, Lisa deals not only with the injustice of the coerced sterilization of her aunt. But, she is now also facing additional downstream harmful consequences from the wrongful actions of the medical professionals responsible for the force sterilization. While Lisa’s story is fictional, situations like this are sadly all too real.
Pernicious epistemically justified distrust is a public health problem, because it has provided those already socially and economically marginalized—especially poor people of color—with well-justified skepticism of doctors, public health initiatives, and the medical profession. There are of course plenty of real and current problems with the medical profession’s treatment of poor people of color, as is evidenced by disparate health outcomes. But, if we assume that, despite these problems, people are generally better off receiving medical care than not receiving it, medical professionals and public health officials have a responsibility to try and rectify pernicious epistemically justified distrust.
Because the issue is one of justified distrust, the task set before public health officials seeking to rebuild trust is a challenging one. The best (perhaps only) means of success will require public health officials to repair abused and broken relationships. Steps public health organizations can take include publicly acknowledging past actions, showing ways in which policies, practices, and commitments have been altered, and actively supporting individuals who are members of communities previously harmed by those bad past actions in pursuing health related careers.
While there is much work to be done, we are hopeful that the recognition of pernicious epistemically justified distrust may serve as a useful first step in rectifying such injustices.
Mark Satta is a 2018-2019 Petrie-Flom Center Student Fellow.
Lacey J. Davidson is a PhD Candidate in Philosophy at Purdue University.
Your argument, which I understand focuses on epistemology rather than culture or affect, would be strengthened if it made explicit the basis for your claim that “Lisa’s skepticism and distrust [are] reasonable” and that it is “justified” (as you say in bold face). Clearly some moral outrage and affective distrust would be understandable (and maybe those reactions could understandably directed at contemporary physicians who were not even practicing at the time of the injustices). But those reactions are not epistemic claims that in fact there is a substantial likelihood that “she too will be sterilized.” I’d encourage you to test the implicit proposed justificatory steps against other scenarios where there were historic injustices perpetrated by other persons (e.g., Jews encountering German soldiers today; all patients encountering physicians given that they historically withheld information paternalistically, all car buyers today since carmakers made dangerous cars in the 1960s).
Also, in your scenario, its not clear whether Lisa is aware of the legal/institutional changes 40+ years prior. If not, is making her aware then sufficient to eliminate the justification/reasonableness of her belief (if she maintains such belief)?
Finally, does anything really hang on whether her belief is strictly justified or reasonable, if it is false and inimical to public health?