Why are sexism and racism ethically wrong

What can the concept of discrimination do for medical ethics? - An analysis

Summary

Hardly any other concept in the ethical debates in recent years has seen such a boom as the concept of discrimination. A comparative discussion of the concept, including its conceptual nuances and its ethical significance for the health care system, has so far been lacking. The aim of this article is to develop a differentiated understanding of discrimination on the basis of the philosophical and sociological literature against the background of ethically relevant medical and nursing scenarios. Using practical examples from the health sector, we discuss the specifics of direct, indirect and statistical discrimination, we examine the meaning of intentions and the role of collective actors. We also discuss which social groups can be discriminated against and which role forms of epistemic injustice play in this. It is argued that the concept, despite its complexity, offers significant added value because it allows to identify forms of disadvantage that go beyond the violation of individual specific rights or interests. As a knowledge-based system with great social influence, the health care system has a number of characteristics that can encourage discrimination. Recognizing this is essential in order to be able to counter discrimination effectively.

Abstract

Definition of the problem

Few concepts in recent ethical debates have enjoyed as much popularity as the concept of discrimination. However, a comparative discussion of the concept, including its conceptual nuances and its ethical significance for health care, has been so far lacking. The aim of this paper is to develop a nuanced understanding of discrimination based on the philosophical and sociological literature against the background of ethically relevant medical and nursing scenarios.

Methods

Using practical examples from health care, we discuss direct, indirect, and statistical discrimination; we examine the importance of intentions and the role of collective actors. In addition, we analyze which social groups may experience discrimination and the respective importance of forms of epistemic injustice.

Conclusions

We argue that despite its complexity, the concept offers significant added value because it allows us to highlight forms of disadvantage that go beyond the violation of individual specific rights or interests. As a knowledge-based system of great societal influence, health care exhibits some characteristics that can foster discrimination. Acknowledging this fact is essential in order to effectively address discrimination.

Discrimination as a subject of medical ethics - an introduction

Discrimination is a concept that is often used in medical and bioethics. The UNESCO Universal Declaration on Bioethics and Human Rights states in Article 11: "No individual or group should be discriminated against or stigmatized on any grounds, in violation of human dignity, human rights and fundamental freedoms" (UNESCO 2005). For example, US bioethics is currently discussing intensively under the heading “Black Bioethics” whether and in what way not only health care, but also bioethics as a profession People of Color systematically discriminated against and how that could be prevented (see Ray 2020).

It is all the more important to grasp the meaning and scope of this philosophically demanding term as precisely as possible. So far, this has been done in a number of individual studies. In the ethical professional world, the topic of genetic discrimination has been discussed for a long time (see Rehmann-Sutter 2005; Lemke and Liebsch 2015), and the question of whether people with disabilities are discriminated against by prenatal and pre-implantation diagnostics has been a concern for several years controversial debates (see Gen-ethisches Netzwerk e.V. 2014; Graumann and Koopmann 2018; Merkel 2019). In the work on human dignity, too, reference is made to discrimination and its moral reprehensibility (cf. Stoecker 2011; Schaber 2012). In public health ethics, for example in the field of health communication (cf. Loss and Nagel 2009), discrimination is discussed as an important challenge, and in 2007 Florian Steger bundled articles on stigmatization and discrimination in psychotherapy and sex science in an anthology. The focus is usually on the specific effects in the field being examined. A discussion of the concept of discrimination in its cross-thematic and cross-context ethical significance for the health care system has so far been lacking. The aim of this article is to undertake such an analysis.

What exactly is it about when people talk about discrimination in the healthcare sector? According to our starting point, discrimination can be understood not only as an individual violation of interests or rights, but as a phenomenon that is embedded in social contexts and thus raises its own normative questions. It is able to affect people's lives across all areas of life due to their group membership (s) and can have different manifestations such as racism, sexism, Ableism or Ageism accept.

In view of the variety of contexts of use, it seems appropriate to come to an understanding of a sufficiently differentiated understanding of the term and thus create a basis for further discussions. To this end, we will present the relevant philosophical literature and discuss it in the light of examples from the medical and nursing context. The aim of this article is to process the philosophical debate in such a way that it is conducive to medical and bioethical debates.

For this we have structured the article as follows. We will begin with an account of prominent philosophical positions on the question of what is morally wrong with discrimination. Then we discuss direct and indirect discrimination and ask whether it takes an intention to discriminate. Finally, in this chapter we address the concept of statistical discrimination, which is discussed as a special case in philosophical analyzes and should not be disregarded in the medical context due to the frequent use of statistical data. Along with the ideas of organizational discrimination, we will shed light on which ethically relevant knowledge can be gained from looking at collective actors separately. This distinction is particularly relevant for the health care system because the individuals involved operate in a system that is heavily pre-structured by rules. Then we come to a key debate: Who can be discriminated against? We present different approaches to this question and develop a practicable position for the application-related issues of medical and bioethics. Finally, we examine what stimuli the concept of epistemic injustice offers for an ethical debate about discrimination in a knowledge-based system like medicine. In a final chapter we summarize the essential findings.

Moral relevance

In philosophical literature there is between a generic and one normative Discrimination term differentiated. In the generic sense, the term means a value-neutral distinction and accordingly a different but non-judgmental treatment of peopleFootnote 1. If it is used in a normative sense, then discrimination means "differential treatment plus something else" (Lippert-Rasmussen 2018, p. 2) and is associated with ideas of equality and justice. If we speak of discrimination in the following, we will only use the term in its normative, morally relevant sense. This use of the term is not only more widespread in German-speaking countries, it is also the central starting point for ethical discussions, because one of the key questions revolves around “something else”. What is it and how can it be conceptualized? Or to put it another way: what makes discrimination morally wrong?

Depending on the underlying ethical theory, different interpretations of the evil caused by discrimination can be distinguished. Consequentialist positions represent the damage caused by discrimination (harm) (Lippert-Rasmussen 2006, 2013; Thomsen 2011, 2013, 2015) into the center. According to Moreau (2010), however, discrimination is morally condemned because it violates civil liberties (deliberative-freedoms account). Others (see Eidelson 2015; Hellman 2008), on the other hand, see the main evil in disregard (disrespectFootnote 2), which is expressed with discrimination and with which the moral status of the individual is devalued.

Let us consider an example from medicine. Until 2017, the guidelines of the German Medical Association (BÄK) stipulated that in vitro fertilization should only be carried out in heterosexual couples (see BÄK 2006). This has been criticized as discriminating against lesbian couples. But what moral evil does a lesbian couple who want to have children experience in the situation outlined above? Representatives of the harm-based approach focus on the consequences. The damage can be seen in the fact that women cannot have a child of their own biologically. Moreau (2010) would argue that inequality is morally wrong because it restricts freedoms to which those affected are entitled; in this case it is freedom of procreation or the right to start a family. For example, the National Academy of Sciences and the Union of German Academies of Sciences criticize that encroachments on freedom of reproduction are generally considered to be "highly in need of justification" (2019, p. 25) and unequal treatment based solely on gender or sexual orientation is not legitimate (National Academy of Sciences, Union of the Academies of the National Academy of Sciences and Union of the Academies of Sciences 2019, p. 29). Representatives of one disrespect approach, on the other hand, would be the reduction of the lesbian couple: These women are told that their way of life does not have the same status as a heterosexual marriage and that their desire to have children is not worth supporting in the same way. This would degrade them as people.

While with one on the immediate damage or the Restriction of freedom oriented approach, the focus is more on the consequences of the action, moves in disrespect- Approach the nature of the action at the center (cf. Boshammer 2008). Both approaches were again criticized. Some authors argue that not all cases of discrimination can be covered by these two interpretations, and suggest that the injustice in the restriction of the equal opportunity (see Knight 2018). Mediating positions argue that through discrimination both harm caused as well disrespect can be expressed (Scanlon 2008, p. 73). The underlying moral-philosophical debate cannot be presented comprehensively at this point. For the practical issues of medical ethics, we think it makes sense to look at all conceivable damage potentials from discrimination. A pluralistic approach is most appropriate for this.Footnote 3 Such an understanding is therefore the basis of the further explanations.

Forms of discrimination

Direct and indirect discrimination

In most philosophical work will be direct and indirect Discrimination differentiated from each other. Direct discrimination is used when unequal treatment can be directly traced back to a characteristic relevant to discrimination (“disparate treatment”, Klonschinski 2020, p. 142). For example, the BÄK's hemotherapy guideline directly and unequivocally excludes people from donating blood for one year, “whose sexual behavior entails a significantly higher risk of transmission of serious infectious diseases such as HBV, HCV or HIV that can be transmitted through blood, compared to the general population” (BÄK 2017, p. 18). This only applies to heterosexual men and women if they have frequently changing partners, but for all men who have sexual intercourse with men, regardless of their individual way of life, thus also for a monogamous gay couple. This blanket exclusion of homosexual men is criticized as discriminatory (Antidiskriminierungsstelle des Bundes 2017, p. 280; Deutsche Aidshilfe 2020) because it evaluates the sexual behavior of gay men indiscriminately as negligent, risky and therefore negative. In this way the gay way of life and every homosexual man are devalued.

Indirect In contrast, discrimination occurs when distinctions based on an apparently neutral criterion result in the interests of certain groups being systematically disadvantaged (cf. Lippert-Rasmussen 2006, p. 170). With it, behaviors and regulations are recorded, the discriminatory content of which only comes to light in the sometimes seriously different consequences for the affected individuals (“disparate impact”, Klonschinski 2020, p. 142). For example, it has recently been criticized that the recommendations on triage for ventilation of corona patients: inside (see DIVI 2020) discriminate against people with disabilities, because the criterion of the prospect of success proposed there is only apparently neutral. In fact, it is based on a frailty scale, the application of which would give people with disabilities generally poorer opportunities (see Association for Equal Opportunities and Human Rights for the Disabled e.V. (NW3) and Interest Representation Self-Determined Living in Germany e.V. (ISL) 2020). . The use of algorithms in medicine can also lead to indirect discrimination based on supposedly neutral criteria. For example, an in Science published study found that an algorithm often used in US hospitals, the need for treatment of People of Color systematically assesses it as too low because he makes decisions based on the supposedly neutral criterion of the average treatment costs incurred in the past. The lower costs are not justified by the lower need for medical treatment, but by socially-related poorer treatment opportunities (Obermeyer et al. 2019).

Discriminatory intent

According to a widespread view, direct discrimination is associated with an intention to discriminate and indirect discrimination with their absence (cf. Boshammer 2008, Section 2.2). This is obvious, because indirect discrimination occurs more often when the interests of certain groups of people are systematically neglected. The fact that something is neglected already implies that it does not necessarily require an intention.

Investigations carried out in the Critical Philosophy of Race are to be located, show, however, that the lack of consideration, at least in the light of Ignorance or indifference is to be discussed.

For example, illustrations in dermatological textbooks are selected for their clarity. This can be used as a neutral distinguishing criterion when selecting an image. Although the appearance is not less skin diseases People of Color can deviate, images of diseases on light skin are predominantly published.Footnote 4 The lack of representation on dark skin can lead to inadequate specialist knowledge of the medical staff, misdiagnosis and, in the worst case, dramatic consequences for the health of People of Color have as a consequence. The moral problem here does not lie in the choice of the criterion, because the criterion of clarity is neutral and meaningful. It arises when it is little differentiated and thus ignorant or indifferent to the interests of People of Color is implemented.

Lippert-Rasmussen (2006, p. 172) also argues that the connection between intentions and more direct Discrimination is also less clear than assumed. Like direct discrimination without own discriminatory intent of the acting person may be possible, requires further explanation. The following case applies to this: There are no medical staff with a migrant background working in a private clinic. The responsible clinic management rejects a discrimination allegation on the grounds that they only considered the interests of the patients: they would not like to be treated by people who appear strange to them. By referring to the attitude of third parties, the clinic management wants to underline that it is not pursuing any discriminatory intent with its recruitment policy. According to Lippert-Rasmussen (2006, p. 172), the determination of the form of discrimination is not, however, decisive with which direct intention is acted, but rather which distinguishing criterion is used. It is irrelevant whether the clinic management itself has racist intentions or whether its actions are guided by the racist attitudes of third parties.

It is also pointed out that prejudices and stereotypes also work unconsciously and can influence actions (implicit bias).Footnote 5 In the health sector, for example, this would be the case if a: e medical: r specialist: r is always friendly and patient when making an appointment by telephone, but is curt and impatient with people with a strong accent because they are people whose mother tongue is not German is, unconsciously rejects.

In the formal-logical sense, according to Lippert-Rasmussen (2006, p. 173), a reflected intention does not have to be a prerequisite for direct discrimination. Furthermore, this raises the explosive and lively debated question of whether moral responsibility can or must be assumed for actions based on unconscious prejudices (see Brownstein 2019). A distinction is made between different forms of assumption of responsibility, which cannot be discussed in detail here. It is discussed, for example, whether there is at least a moral responsibility to become aware of one's prejudices and, if possible, to remedy them in the future.

It is important to note that, contrary to popular belief, equating direct and indirect discrimination with the presence or absence of intentions does not go far enough in many cases. In any case, intentions are not decisive for whether there is discrimination, especially since the reasons of the counterpart are seldom apparent to the person concerned and unintentionality does not necessarily reduce the damage that occurs.

The intentions of the agent (s) are relevant for an ethical discussion of discrimination in medicine, however, in order to determine a continuum of responsibility and to be able to differentiate moral conclusions. If there is intentional discrimination, this must in any case be condemned, while a person cannot be held accountable in the same way for an unintentional act. The findings are particularly relevant when measures are developed to counteract discriminatory acts. It makes a major difference whether an event format pursues the goal of reflecting on unintended discriminatory actions in order to be able to better avoid them in the future, or whether intentional and reflected discriminatory attitudes are to be changed.

Statistical Discrimination, a Special Case?

In the debate on discrimination, various sides proposed a distinction between statistical and non-statistical discrimination (Schauer 2018). For example, the above-mentioned distinction between heterosexual and homosexual people in the haemotherapy guideline is based on the higher prevalence of communicable infectious diseases such as AIDS or hepatitis in the group of homosexual men. On the one hand it is about the existence of a legitimate interest - the containment of the spread of communicable infectious diseases - and on the other hand about a statistical correlation of belonging to a group and the presence of one of the relevant infectious diseases. Therefore - so the argument - the unequal treatment is not based on the discrimination-relevant characteristic per se, but on the same increased probability.

Statistical correlations are regularly guiding actions in medicine and are regularly used to justify unequal treatment. However, with a view to the risk of discrimination, it is always important to check whether the unequal treatment of a person is factually justified or not because of belonging to a statistically recorded group. If supposedly homogeneous group characteristics are assumed (“the homosexuals”, “the Muslims” etc.), discriminatory behavior can result, as the exclusion of homosexual men from blood donation impressively illustrates. The concept of statistical discrimination continues to ask from an ethical point of view whether and under what circumstances the conclusions drawn from statistical correlations can lead to individual individuals being degraded as a person or disadvantaged in some other way.

The concept of organizational discrimination

The actions of healthcare personnel are governed by numerous regulations, such as: B. laws or treatment guidelines, framed. They are therefore often heavily pre-structured. In democracies, such regulations are usually not the product of individual but rather collective actors such as governments, corporations under public law, specialist societies or commissions. If a collective actor acts in a discriminatory manner, this can be described as organizational discrimination (cf. Altman 2020, Section 2.3). In the following we want to show what added value this differentiation offers for medical ethics.

It is not uncommon for cases of organizational discrimination to affect questions of fair access, for example when it can be determined that certain groups are denied access to medical services or made difficult. In addition, this differentiation is analytically relevant for the medical context because the decisions of various collective actors pre-structure the scope of action of the health staff. This is particularly true of formal regulations. If, for example, doctors or nurses refuse a homosexual man to donate blood, it seems absurd against the background of the current version of the haemotherapy guideline to hold individuals responsible for the moral evil. Even those who consider the rejection of a homosexual man morally reprehensible have only limited options due to the regulation.

From an ethical point of view, it would be important in such cases whether there is room for maneuver that can be used responsibly by the individuals involved. In this respect, the concept of organizational discrimination is suitable for specifying the scope of moral responsibility of individuals. How much the individual's room for maneuver is restricted by regulations by organizations or institutions must be taken into account in the moral assessment.

Who can be discriminated against?

For a differentiated understanding of the term, the question is who can be discriminated against, centrally. Two approaches can be identified for this. A first approach consists in the identification of characteristics relevant to discrimination. These characteristics are used to construct groups that can be affected by discrimination. A second assigns particular importance to the consideration of power relations. The term intersectionality criticizes the fact that abstractly constructed groups suggest a homogeneity of living conditions that does not exist empirically. We will explain the two approaches and the intersectional criticism of them in the following sections.

Features relevant to discrimination and the socially salient group

A feature-centered understanding is based on the legal concept of discrimination, evident from the fact that Article 3 (3) of the Basic Law of the Federal Republic of Germany emphasizes specific features. There it says: “Nobody may be disadvantaged or preferred because of their gender, their origin, their race, their language, their homeland and origin, their beliefs, their religious or political views. Nobody should be disadvantaged because of their handicap. ”What all listed characteristics have in common is that they are to be understood as characteristics of social groups. According to Lippert-Rasmussen (2006, 2013) it cannot be arbitrary characteristics that make up such groups. The decisive factor is that it is socially salient.Footnote 6 It is characteristic of a socially salient trait that it structures interactions across situations (Lippert-Rasmussen 2006, p. 169). This then also applies to the possibly disparaging stereotypes associated with the characteristic and the corresponding group, as is often the case with people with disabilities, those who have fled or very fat people.

With the concept of socially salient group Thus, reference is made to a tendency towards the repetition of discriminatory experiences across all areas of life and situations (cf. Lippert-Rasmussen 2013, p. 34). Typically, people who have one socially salient group a shared history and, moreover, share experiences in the current structure of social conditions.

An example from the medical context: a doctor, accompanied by a nurse, conducts rounds on a ward in the hospital. In the hospital rooms, however, the doctor is repeatedly addressed as "sister" and the attending nurse as "doctor". This situation can be addressed using the concept of socially salient group classify. The patients perceive the doctor as a member of the socially salient group of women and on this basis locate her stereotypically in a helping professional group within the hierarchically organized professional field of the medical professions. It can be assumed that the doctor will experience recurring situations in her life in which her expertise is not recognized and her status is not recognized.

The idea of socially salient group is widely accepted, as the above-mentioned Basic Law article shows. Thomsen (2013) brings up two main points of criticism. He takes the view that a convincing group criterion must be linked to a damage threshold and that it is also circular. It is only convincing if it can explain for each hypothetical case why unequal treatment due to belonging to a socially salient group is morally more important than when it is due to another characteristic, such as e.g. B. the color of the eyes, be done. For this, a threshold must be identifiable from which the additional damage caused by the repetition of discriminatory acts across situations is morally more serious (Thomsen 2013, pp. 128–140). However, he disregards the fact that damage is not only caused by the factual repetition. A good life can also be interpreted as one that is free from the well-founded fear of (repetitive) degrading, damaging or equal opportunities inequality. The expectation of repetition, with which the members of a socially salient group affected by discrimination have to live, can already have damaging effects of its own. A well-known problem is, for example, that members of groups who fear discrimination in the health care system often avoid medical facilities and therefore show a poor general state of health.

Another problem is that the social salience of a characteristic is understood in an essentialist way by critics such as Thomsen, Lippert-Rasmussen or Heinrichs (2015, p. 27). They assume that social salience is a characteristic such as B. is inherent in gender. On the other hand, from a constructivist point of view, one can argue that the cross-life meaning of a characteristic is largely produced socially. This is why the sociologists Lemke and Liebsch urge, in the context of genetic discrimination, “to make the social construction of norms and distinctions itself the subject of analysis” (Lemke and Liebsch 2015, p. 172).

From a sociological perspective, it is considered relevant which meanings powerful social actors such as medicine ascribe to a characteristic. They have a discourse-defining influence in the sense of a Foucaultian “biopower”. In general, it can be formulated that the attributions of medicine are problematic when it generally assigns a disease value to an expression of human diversity, thus stigmatizing it as “deficient” and charging it morally. Since medicine enjoys a high social reputation and is widely accepted, it has a considerable influence on who is considered normal in a society and who is “undesirably different” (Goffman 1975, p. 13). This is criticized in connection with a number of characteristics, such as disability as an unjustified "pathologization" (cf. Schidel 2020).

This results in a mutual dependency of characteristics relevant to discrimination and social production processes (Vehmas and Watson 2014). This inevitably increases the complexity of the ethical problem, since it raises the question of the responsibility of medicine for the maintenance and production of the social significance of a characteristic, especially since these develop their effectiveness beyond the boundaries of health care.

Social status and power

Hellman assumes that the question of who can be discriminated against cannot be conclusively answered with a characteristic-based approach (Hellman 2018, p. 100). She therefore suggests including the social status of the actors involved and focuses on the analysis of power relations.

Power differences are omnipresent in medicine. Some are easy to see because they are laid down in sets of rules (e.g. in hierarchical professional regulations). However, these are not the only differences in power to consider in an ethical debate about discrimination in health care. Also power differences, such as between the sexes or between People of Color and white people, who are relevant to society as a whole, have an impact in the health care system and structure the interactions between staff and patients.

As already stated, Hellman sees the central evil of discrimination in the degradation of the individual. This requires a certain position of power (Hellman 2018, p. 103). According to Hellman, a person with sufficient power has the power to use his words or actions to harm another person. The easiest way to understand a person's social status is when formal rules such as laws define the roles of the interaction partners. Here is an example. If a transgender person in Germany wants to change their civil status, this is tied to two positive psychiatric reports. If the reports are negative, she must continue to live with an official gender entry that does not correspond to her gender identity. According to the law, the reviewers are in a powerful position to decide on the gender identity of the reviewed person. You also have the power to demean that person.

Other authors, however, do not see power asymmetry as a necessary condition for discrimination (Blum 2002; Lippert-Rasmussen 2006, p. 173). Blum (2002) is not concerned here with a fundamental invalidation of the meaning of power, but with a differentiation. He states that it can only be used to assess the “moral seriousness” (Blum 2002, p. 39) of an action.

The health care system is a place where organizational and social power differences act simultaneously and influence one another. This entanglement makes the subject even more explosive and should not be left out of a differentiated debate on discrimination in medicine.

Intersectionality

The one-dimensionality of the approaches mentioned above is criticized from an intersectional perspective. Crenshaw (1989) argued that the members of the group of “women” are very different because they belong to other socially salient groups (e.g. “blacks” or “whites”) or because of other dimensions of inequality, such as socio-economic background make social experiences. Some combinations can reinforce, others defuse. In the context of genetic discrimination, Lemke and Liebsch therefore also demand to investigate “how forms of genetic discrimination combine with sexist and racist practices and, if necessary, reinforce them mutually” (2015, p. 172).

The importance of the intersectional view can be seen in the following example: A gynecologist in Germany who reveals herself to be a Muslim through her headscarf regularly learns that her expertise is not recognized by her colleagues. From an intersectional perspective, your social position is determined by both factors, for example in a consultation with colleagues. The colleagues take her as a member of the group of women and of persons of the Muslim faith. So it is conceivable that her scientific advice is not only taken less seriously because of its assignment to the group of women, but that it is also reflexively viewed as a traditionalist image of women, supposedly with the wearing of a headscarfFootnote 7 being expressed. It is important that it is not about the addition of negatively connoted properties of different groups, but about the specific position of an individual. Phenomena such as sexism, racism or ableism are not to be understood alongside one another, but as interlinked with one another. It should be noted that the intersectional criticism does not invalidate core ideas such as the repetitive character of discrimination; only the limits of one-dimensional approaches are shown in this way (cf. Stoljar 2018, p. 77).

Conclusions

In this chapter we have highlighted two different approaches to the question of who can be discriminated against. Although each emphasizes their own aspects, they both come to the conclusion that not just any person, but only certain People may be affected by discrimination. These can be understood as members of socially salient groups who have little social power and therefore occupy a subordinate social position in society. The concept of intersectionality encourages one to look at the situation-structuring meaning of group membership in the light of processes that sometimes reinforce and sometimes cancel one another, in order to obtain a more differentiated picture.

In our opinion, the approaches presented do not contradict each other, but are together indispensable in order to understand what characterizes discrimination. It is the expectability of the repetition of the degrading or otherwise damaging behavior that has a significantly negative influence on the self-image and lifestyle of the person concerned. It prevents a life free from fear of repetitive degrading, damaging or equal opportunities inequality. It is essential not to understand socially salient characteristics in an essentialist way, but rather as the result of the interaction of biological and social discourses. Medicine as a powerful social authority is involved in giving characteristics a meaning and thus giving social groups social salience in the first place. If these meanings are negative, this solidifies their subordinate social position in the structure of social power relations in the long term.

Epistemic injustice

Medicine is a knowledge-based system of great social importance. Whoever speaks in the name of medicine can generally claim not only scientific but also social authority. Explicit and implicit orders of knowledge have an impact on who is heard in a society, whose voice counts, who can claim credibility and who cannot. Differences in power and social stereotypes influence the position of the public speaking in health care and distort the process of cognition. According to Miranda Fricker (2007), this can be described as epistemic injustice. Some authors see this as their own form of discrimination, so-called epistemic discrimination (see Puddifoot 2018), which is why it should be discussed in more detail here.

Fricker essentially differentiates between two forms of epistemic injustice: “testimonial injustice” (Fricker 2007, chapter 2) and “hermeneutical injustice” (Fricker 2007, chapter 7). A person experiences “testimonial injustice” when their credibility is degraded because of their social group affiliation. Your positions will then not be heard, put into perspective or not taken seriously. This is morally questionable because it is generally denied the ability to generate knowledge and to be able to pass it on to others. In the words of Fricker, she is degraded as a knower and thus also as a person (Fricker 2007, p. 44). Such situations are particularly common when the audience is guided by stereotypical generalizations about the epistemic status of the members of a social group. One example is the anamnestic examination of a sick ten-year-old child who is accompanied by his parents and who communicates exclusively with the parents. Parents are not wrongly regarded as a more reliable source of information than the sick child in the case of childhood illnesses, but their views are generally treated as irrelevant because they belong to the group of children, according to a “testimonial injustice”.

It is important that “testimonial injustice”, like discrimination, is characterized by repeated occurrences across life areas. Probably the most significant long-term consequence can be that those affected lose faith in themselves, their intellectual abilities and their development potential (Fricker 2007, p. 58).

If the credibility of the members of a socially salient group is permanently degraded due to the sovereignty of dominant social groups or actors, this can lead to the entire collective lacking the terms to interpret negative experiences as such (Fricker 2007, p. 159 ). They then experience “hermeneutical injustice” (Fricker 2007, Chapter 7). This can be exemplified by the situation of intersex people who suffer from the consequences of sexually unambiguous operations in childhood. Over a long period of time, these measures were presented and carried out as having no alternative and as medically necessary. Due to the interpretative sovereignty of medicine, those affected lacked concepts to classify, communicate and ultimately criticize their negative experiences with this approach.

Fricker's concept of epistemic injustice is suitable for demonstrating the potential for damage caused by discrimination, which is of particular importance for the context of medicine as an institution of high social standing. The power asymmetry that this creates affects not only the concrete conversation between the doctor: in and patient: in, but also in general whether and how the point of view of those affected is perceived and respected. It is important for employees in the healthcare sector to be sensitive to these dangers, because this is the only way to hear all of the voices relevant to the knowledge process.

Summarizing considerations

Discrimination is a concept that can be applied to medicine at a profit. In our opinion, a pluralistic understanding is appropriate for the practical issues of the health care system. Discrimination is therefore morally relevant because it harms individuals, curtails their freedoms, demeans them or impairs their equal opportunities. Damaging effects come from the expectation of repetition, with which the members of a socially salient group affected by discrimination have to live. For example, those who are not free from the fear of repetitive degrading treatment in the healthcare system may avoid contact with doctors for this reason alone. Since medicine is a knowledge-based system, forms of epistemic disadvantage (“not being heard” or “not being taken seriously”) must also be taken into account.

Only members of socially salient groups with a lower status in the structure of social power relations can be discriminated against. The cross-situational meaning of the characteristic is predominantly produced socially. As a powerful social actor, medicine is able to exert lasting influence on such processes in both negative and positive respects, for example on who is considered normal in a society and who is undesirably different.

However, it must be taken into account that every person can be assigned to different social groups. They all influence which social position an individual assumes, for example in a conversation.

The distinction between direct and indirect discrimination helps in particular to identify less obvious forms. Direct discrimination, that is, the obviously unfounded unequal treatment of people based on a socially salient characteristic such as “skin color”, is the problem that is usually better known and is now likely to be rare in the healthcare sector. Indirect discrimination on the basis of seemingly neutral criteria, on the other hand, is much more difficult to identify and is not uncommon in the healthcare sector. In particular, the use of statistical correlations with regard to socially salient groups should be questioned against this background for discriminatory effects.

Intent is not a necessary condition for discrimination. However, the reference to the acting person's intention is important in order to determine the specific form of responsibility required in each case. In the context of dealing with discrimination in the health care system, this plays a major role, because the individual professional individuals generally act with benevolent intent, but sometimes with discriminatory effects. The moral responsibility is to be sensitive to such forms and to prevent their occurrence as much as possible. Forms of organizational discrimination are particularly common in complex organizational structures such as the healthcare system. Institutional and legal requirements limit the room for maneuver and thus also the extent of the moral responsibility of the actors (doctors, nurses, etc.). Nevertheless, the individuals acting individually bear a certain responsibility to reflect on the respective status of the institution or organization and, if necessary, to look for ways out of an ethically responsible approach.

The findings of social psychological and sociological research make it possible to better understand the underlying social mechanisms and to grasp the complex causes of discrimination in a society. As a knowledge-based system with great social influence, the health care system has a number of characteristics that can favor discrimination. Recognizing this is essential in order to be able to counter discrimination effectively.

Notes

  1. 1.

    "Discriminare" (Latin) = to distinguish.

  2. 2.

    For an overview of different interpretations of disrespect (see Beeghly 2018, p. 86).

  3. 3.

    Klonschinski (2020, p. 139) also assumes that only a pluralistic approach is promising. Whether such a plural understanding of the term can unite the competing approaches without contradicting itself, however, would have to be examined further. There is no consensus in this regard in the philosophical debate.

  4. 4.

    The “Mind the Gap” initiative took up this and published a medical handbook on the appearance of skin diseases on darker skin online (cf. Mukwende et al. 2020).

  5. 5.

    For a systematic analysis of the literature on the subject of implicit prejudices among health care professionals, see Fitzgerald and Hurst (2017).

  6. 6.

    Heinrichs (2015, p. 27) gives an overview of further views on how characteristics relevant to discrimination can be understood and groups defined.

  7. 7.

    For an insight into the arguments of Iranian women's rights activists see Armipur (2003), for a study on the meanings of the Muslim headscarf see Sahin (2014).

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