I want to consider a particular kind of wrong within medicine and health promotion: epistemic injustice and its harms. My case study is obesity conceived of as a public health concern. However, the analytic framework I deploy may prove useful in ethically assessing many health promotion campaigns.
Individuals—both doctors and patients—are often provided with an impoverished set of conceptual tools for making sense of health and health behaviors, a set of tools that can lead to inappropriate individualization of responsibility and to unproductive attitudes towards health and which behaviors are health promoting. This is the case with obesity. Public health campaigns and clinical care of obese persons rely on a family of simplistic reductions.
The first reduction is that body size correlates reliably with health: witness the use of Body Mass Index (BMI) to diagnose obesity, and the medicalization of obesity as not just a risk condition but a disease in its own right. In June of 2013, the American Medical Association’s House of Delegates endorsed the notion of obesity as a disease defined primarily by BMI, joining the World Health Organization (WHO), U.S. Food and Drug Administration (FDA), and the U.S. National Institutes of Health (NIH). In the International Classification of Diseases (ICD-10), cases of obesity which are not caused by metabolic disorders or pharmaceuticals are classified as “hyperalimentation”: overeating.
This brings us to the second reduction in the conceptual toolkit available to doctors and patients: that obesity is caused by over-eating, and weight gain/loss is a simple calories-in-calories-out equation. This etiology shows up in public health campaigns, in the clinical recommendation that patients eat better and get more exercise, and in the widespread use of dieting in Western culture.
As I have argued in my 2015 IJFAB article, by focusing us on body size as a measure of health, and on calories-in-calories-out as both an explanation and a treatment for obesity, these two reductions create a third: the locus of responsibility for obesity falls upon the individual rather than on systemic features contributing to ill health. Consider, in the U.S., then-First Lady Michelle Obama’s “Let’s Move!” campaign which took little or no account of factors in the built environment which make it dangerous to exercise in many neighborhoods due to crime or traffic and which place residential areas often quite distant from workplaces and necessary errands, thus disincentivizing foot travel. “Let’s Move!” explicitly aimed to “solve” the epidemic of childhood obesity within a generation. While it included discussion of healthy foods in schools—an environmental factor—it also explicitly addressed “healthy moms” and “healthy families” thereby placing responsibility for health disproportionately onto women and individual family units, much as the framing of obesity places individual responsibility onto fat adults generally.
A fourth form of reductivism is well-documented in physician diagnosis of fat patients’ ills as originating in fatness, such that fat patients with joint pain will be met with directions to lose weight rather than, say, a consideration of rheumatoid arthritis or a recommendation for physical therapy. This contributes to misdiagnosis and undertreatment.
By providing clinicians, patients, and the general public with reductive frameworks, public health campaigns foster several forms of epistemic injustice. The first of these is hermeneutic injustice. As described by Miranda Fricker, this occurs when a knower is harmed because she lacks the toolset to make sense of her lived experience. It may be that, while both doctors and patients can be impoverished, power relations mean that only patients truly suffer injustice from insufficient toolsets. This is especially the case with dominant frameworks about obesity which foster a calories-in-calories-out reductivism, leading to widespread failure of weight loss regimes, and to damaging assertions of individual responsibility.
Interwoven with this is unjustified skepticism about patient testimony that contradicts simplistic conceptual frameworks. So entrenched are these reductions that physicians who see that patients have not lost weight often presume they have been non-compliant, and that fat patients who claim to eat well and exercise must be lying. Indeed, adjectives American doctors most associate with fatness include “noncompliant” and “lazy.” Fricker calls this form of epistemic injustice testimonial injustice, in which a knower is harmed because her testimony is unjustly discounted; the knower experiences a credibility deficit in relation to her audience based in part on irrelevant traits such as body size.
A third form of epistemic injustice occurs when fat patients stop going to the doctor because of testimonial and hermeneutic injustice. This is what Kristie Dotson calls testimonial smothering: a knower stays silent because she believes her testimony will be dismissed. When doctors attribute patient ills to obesity and discount patient testimony, physicians teach patients that seeking medical treatment will not in fact produce health.
The conceptual frameworks provided by health promotion are often simplistic, as with that for obesity. Kukla has shown some of these same features with breastfeeding campaigns. Epistemic injustice, a wrong in itself, occurs and in turn causes other forms of harm including patient withdrawal from medical care and devastating internalization of individualized responsibility. More nuanced frameworks can prevent such harms and in doing so can better accomplish the promotion of health.
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