Creating Meaning Through Relationships

Rupal Shah, Sanjiv Ahluwalia, John Spicer.

This blog relates to the COIN meeting of March 2023 - https://www.youtube.com/watch?v=NkoW-EifvWk&t=4s 

A 55-year-old woman, Mrs M who is a refugee from Afghanistan is seen with an interpreter to discuss pain management. She complains of widespread body pain. She is offered the choice of a codeine/ paracetamol mix or physiotherapy and is signed off work.

A 25-year-old woman, Ms T has a diagnosis of Emotionally Unstable Personality Disorder (EUPD). There is an alert on her notes warning about aggression and impulsive behaviour. There is also a code on her medical records of childhood sexual abuse. Quetiapine is prescribed when pregabalin alone fails to stabilise her mood. 

Both Mrs M and Ms T have been given choice in the treatment they are offered. The doctor in each case has behaved kindly and suggested evidence-based treatment options. Nevertheless, we contend that Mrs M and Ms T have been treated unjustly. Although counter-intuitive, we propose that employing a traditional ethical framework does not detect or protect Mrs M or Ms T from a form of injustice which has been labelled epistemic injustice.

 Epistemic injustice describes the injustice inflicted on patients when their capacity as ‘knowers’ is denigrated, because the clinicians treating them cannot understand their experience of illness and also choose which parts of their medical narratives to take seriously. For example, ‘pain’ has a particular meaning when seen through a clinical lens.  For Mrs M, there may be a large overlap with suffering, which has been missed - and that matters, because almost certainly, her suffering is related to her pain. Mrs M’s case is an example of a patient’s experience of illness not fitting easily into medical categories that are created by doctors.  Without understanding Mrs M’s experience of pain, the options offered may not help her and although she is given the choice between different biomedical interventions, she is nevertheless the victim of epistemic injustice. Any decision she makes cannot be fully informed or autonomous because she is not being offered options that are likely to relieve her suffering.  

In Ms T’s case, the presence of the alert on her computer records may inhibit the formation of an engaged, authentic relationship between practitioner and patient which allows Ms T to understand the link between her childhood trauma and her current problems. The prescription of medications with the potential for significant adverse effects is potentially unjust, even though they may help to manage some of the manifestations of her distress. The prescribing clinician will have assessed her mental state, but in the absence of an on-going relationship will have been unable to understand her lived experience and the drivers for her behaviour. 

Both of the protagonists in the case studies above are therefore at risk of epistemic injustice and application of our usual ethical frameworks is unlikely to protect them. We argue that personalised care described in the NHS Long Term Plan as a statutory duty of healthcare providers is not possible without addressing epistemic injustice; and considering the contribution of relational care to its amelioration. 

Many consultation frameworks address only generic skills and largely ignore relational care – for example, the extent to which the clinician is able to establish a human connection, to understand what an illness means to their patient and to help them navigate through it. In previous articles, we introduced a new four domain model to describe the skills and approaches needed by clinicians in order to enable personalised care, by creating meaning for both patient and clinician (the hermeneutic window) –these include paying close attention, emotional engagement and awareness of one’s own biases and of power differentials.^1-5 Working within the hermeneutic window may help to ameliorate epistemic injustice.

In our view, a relational ethics framework may be more suited to primary care than a normative one. We propose that ethical decision making is enmeshed within and dependent upon the practitioner patient relationship.^6-7 A relational view like this incorporates internal and external influences on the decision making of both clinician and patient and the nature of the relationship between clinician and patient. This relationship surely influences autonomous decision making, which does not happen in isolation. We endorse a conception of autonomy that is relational, context specific and which cannot be considered independent of the protagonists involved in the process. Therefore, we conclude that the clinician- patient relationship is not distinct from ethical practice but is in fact integral.

1. Shah R, Clarke R, Ahluwalia S, et al. Finding meaning in the consultation: introducing the hermeneutic window. Br J Gen Pract. 2020;70(699):502–503.
2. Shah R, Clarke R, Ahluwalia S, et al. The hermeneutic Window in practice. Br J Gen Pract. 2022;72(715):83–84.
3. Shah R., Clarke R., Ahluwalia S. and Launer J. Finding meaning in the hidden curriculum – the use of the hermeneutic window in medical education, Education for Primary Care 2022, DOI: 10.1080/14739879.2022.2047112
4. Shah R., Clarke R., Ahluwalia S. and Launer J. Finding meaning in medical education – how the hermeneutic window can help primary care educators, Education for Primary Care, DOI: 10.1080/14739879.2022.2081936
5. Shah R., Clarke R., Ahluwalia S. and Launer J. Finding Meaning, Locating Hope. Br J Gen Pract. 2022 DOI: 10.3399/bjgp22x720845 
6. Spicer J., Ahluwalia S., Shah R. On challenges to respect for autonomous decision making in primary care, Clinical Ethics 2021 DOI: 10.1177/14777509211069908 
7. Spicer J., Ahluwalia S., Shah R. Moral flux in primary care: the effect of complexity, Journal of Medical Ethics 2021 DOI: 10.1136/medethics-2020-106149 
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