Epistemic injustice: The hidden vulnerability of medicine

Abstract

Immortalised as a foundation of medical ethics, beneficence is often described as not taking advantage of another's vulnerability, particularly in hierarchical scenarios, or leader–follower relationships.¹ It is commonly referred to in relation to the doctor–patient duty of care and the inherent power imbalance of this relationship. However, to understand beneficence, one must also understand the concept of vulnerability; the shared human experience of our susceptibilities² and the likelihood that others will be less sensitive to our interests.³ In this issue of Medical Education, Nichol et al. explore the paradox of vulnerability through the experiences of resident doctors along the continuum of intrapersonal, interpersonal, and institutional dynamics.⁴ In doing so, they reveal resident doctors who are themselves vulnerable in the hierarchy and leader–follower relationships that construct the cornerstone of the medical institution.

Historically, Western medicine embodied the valorised, paternalistic, and infallible medical doctor, a portrayal which lingers today and eradicates the innate human quality of vulnerability. In modern-day experiences of resident doctors, this manifests a mutual exclusion between showing vulnerability and upholding professional competency.⁴ The authors reveal that residents expressing vulnerability were seen as undesirable by superiors and often met with humiliation, mistreatment or an erosion of professional relationships that stifled learning opportunities and career development.⁴ Thus, resident doctors 'eviscerated' themselves for ‘the culture of medicine’.⁴ Furthermore, residents discussed a conflation between vulnerability and weakness, which imposed a subsequent barrier to leadership positions.⁴ This is deeply disappointing, given that decades of evidence necessitates vulnerability in leader–follower trust,¹ and implicates it within the four primary characteristics of authentic leadership itself: self-awareness, balanced processing, relational transparency and an internal moral perspective.⁵ For an evidence-based profession, here lies the irony that core human attributes are negatively stigmatised among overwhelming evidence that both leaders and clinical preceptors who themselves model vulnerability create a positive symbiosis that strengthens trusting relationships,¹ institutional culture, learning and the quality of patient care.^{4, 6-8}

The stigma on vulnerability in medicine is met with well-known systemic failings through the form of pervasive hierarchies, bullying, untenable working hours⁹ and constant evaluation by superiors.⁴ In such environments, to even consider expressing vulnerability, residents Nichol et al's. study identified the dual challenges of first requiring the emotional bandwidth to do so, followed by the resilience to weather any negative consequences of their human expression.⁴ Already, a systemic cycle emerges where burn-out burns out vulnerability itself. Aptly, the authors cite Martha Fineman's ‘Vulnerability Theory,’ which advances that policies and regulation at an organisational level should be accountable and responsive to the conditions they impose.² In this case, the systemic and collegial hierarchies are both the cause and prohibition of vulnerability in residents. Fineman's theory equates dependence to vulnerability²; thus, patients are vulnerable to doctors, doctors are vulnerable to hierarchy, and hierarchy is vulnerable to the system. Therefore, in terms of power dynamics, vulnerability is a multifaceted, multilayered, cyclical entity in the medical sphere. This raises a question as to whether postgraduate medical education reflects a level of beneficence that understands vulnerability beyond the patient and extends this understanding to both fellow colleagues and their institution. Such an understanding should lead one to not only refuse taking advantage of each other's vulnerability, but also refuse to be the cause, prohibition or perpetuation of it.

On the concept of perpetuity, vulnerability itself is temporal by nature, and our past experience of it shapes both our present and future experiences.¹⁰ Residents highlight that, particularly for marginalised groups, expressing vulnerability brings the risk of negative repercussions, which may compound the already inequitable conscious or unconscious bias of their environment.⁴ This perpetuates the vulnerability of those already most vulnerable. As such, expressing vulnerability should neither be prohibited nor demanded but rather approached carefully, perhaps from a pluralist perspective that welcomes different concepts on humanity without being threatened by them; that is to say, vulnerability can be both positive and negative, both ontological and contextual and both relational and absolute.¹⁰ Anthropologically, we may share vulnerability as a human experience, but our social, cultural, environmental and institutional patterns greatly affect the associated distribution of risk subsequently encountered.¹⁰

Ultimately, it seems incongruous that vulnerability is discouraged within doctors, when the profession itself is innately vulnerable. To work in health care is to absorb a profound lesson which cannot be taught; the fragility of human flesh, human life and human experiences.⁸ And the paradox of being a doctor is that you are both an expert in your field as well as a perpetual student in an ever-changing health care landscape with dynamic interpersonal relationships. As one resident remarks, ‘this topic itself invites vulnerability’, and the authors highlight the need for its value to be embraced, while its risk is systemically mitigated.⁴ Yet, there continues to be layers of incompatibility between medicine's demand for perfection, its embargo on vulnerability and the contradiction of its prohibition within a profession full of exquisitely delicate human moments—times during the therapeutic alliance where vulnerability is itself most vulnerable. When considered with appropriate beneficence, vulnerability is essential for these human-to-human connections and the need for continuous reflective learning. Thus, the true paradox remains, that to deny a doctor's vulnerability is to stifle the embodiment at the very core of the profession and ignore its foundations as a profoundly relational term that is constant in the universal human condition.^{2, 8}

Joelle Winderbaum: Conceptualization; formal analysis; writing—original draft; writing—review and editing.