Race, Pain Management, and Epistemic Credibility
Yolonda Wilson (Howard University) is a 2019-2020 fellow at the National Humanities Center and a 2019-2020 Encore Public Voices Fellow. She holds a Ph.D. in Philosophy from the University of North Carolina at Chapel Hill. Her research interests include bioethics, social and political philosophy, race theory, and feminist philosophy. Professor Wilson has worked as a visiting scholar in the Department of Bioethics at the National Institutes of Health (NIH) in Bethesda, MD. She believes that the philosophic endeavor is enriched when diverse voices are at the table, and she is committed to broadening the discipline.
NOV. 14, 2019 CHAPEL HILL, NC -- Students, faculty, and guests gather in the Toy Lounge on the fourth story of Dey Hall on a cold day in November. The room bustles with conversation while trays of food are shuffled onto the center table. After the lines clear and seats are taken, the speaker for the afternoon is introduced.
Dr. Yolanda Wilson is a 2019-2020 fellow at the National Humanities Center and a 2019-2020 Encore Public Voices Fellow. In addition, having been a visiting scholar in the Department of Bioethics at the National Institutes of Health (NIH) in Bethesda, MD, she devotes her research to include bioethics, social and political philosophy, race theory, and feminist philosophy. Her talk on race, pain management, and epistemic credibility is an effort to understand and resolve crises in the healthcare industry, especially those involving race, prejudice, and oppression. Her talk is a glimpse into her upcoming book “Black Death: Racial Justice, Priority Setting, and Care at the End of Life.”
Dr. Wilson began by asking about pain: how do we relate our pain? How can we tell our physicians and providers that we are suffering and to what degree we are suffering? Moreover, how can we describe it in a way that others can understand? This is a recurring problem in healthcare relationships and is perpetuated by deep rooted fears and stereotypes and it is not easy to answer these questions. However, there are ways in which physicians try.
The Wong-Baker Scale was created as a way for children and adults to relate their feelings of pain to corresponding facial expressions which include smiling (no pain), grimacing (moderate pain), or crying (major pain). Expression of pain, as Dr. Wilson explains, can be explained using this scale or a variety of other scales that are numbered and correspond to different facial expressions. When somebody is in pain, we may notice their facial expression. If they grimace, they may be feeling pain. If they slightly wince, they may feel less severe pain. Depending on the patient’s reaction, we may gain insight into their well being.
Wong-Baker Scale (https://wongbakerfaces.org/)
When anyone explains that they are in pain and their physician/provider understands that they are feeling pain then, as Dr. Wilson explains, “we have a right to pain management.” Pain management may take different forms depending on the level and duration of pain that the patient may feel. However, if pain is left untreated then it may lead to worse outcomes. Therefore, to avoid unnecessary suffering, “we must have a right to accurate assessments of pain levels… Identification of clinical status and appropriate treatment… timely treatment and follow up as needed.”
While physicians may understand their patients are going through pain and are prepared to take the necessary steps to treat them, what happens when the physician and patient disagree on the pain that the patient is feeling? Dr. Wilson cites a study by Singer and colleagues in which they identify that physicians tend to over or underestimate the pain levels that patients express when using the Wong-Baker scale. Specifically, physicians overestimate non-black pain and underestimate pain in black patients. This is an “injustice” in the patient-provider relationship but, as Dr. Wilson exclaims, it is not always a conscious injustice but, in fact, can be a subconscious bias.
This bias may be studied through a discussion of opioid prescriptions given to black and white patients. Black patients are prescribed opioid painkillers less often than white patients. Dr. Wilson explains that conscious injustices result from “reasons which are complex and many” but include stereotypes that “black patients abuse drugs disproportionately than non-white patients… but the fact is that blacks don’t use more than other populations.” Even if they are given opioids to assist in pain management, black patients are more frequently drug tested for abuses in them.
Opioids may not be prescribed to black patients firstly on the basis that they do not feel as much pain as non-black patients. Dr. Wilson cites two studies: one by Kenneth and Mamie Clark in which young preschool children are given the choice between white and black dolls and are asked to rate them in a variety of ways; the other by Dore et al. in which children are asked to rate levels of pain they see between white and black children. In both studies it is shown that children show bias between white and black. While the study by the Clarks showed that children seem to have a preference for doll colors (white), the study by Dore et al. takes it a step further and asks children to determine what pain both white and black people seem to feel.
The study shows that both white and black children rate the levels of pain they think white people feel to be higher than that of what black people feel. This bias is seen to start at around age seven and becomes fully prevalent at age ten. While these studies show innate biases that start at an early age, they reinforce stereotypes that further separate black and white patients. Dr. Wilson identifies that this creates unique problems between the patient and the physician. Namely, stereotyping.
Epistemic Credibility + Stereotype
In the provider-patient relationship, the provider holds more power. Namely, the power to address the health concerns of the patient and to provide solutions that the patient then follows. The physician and provider has much more power over the patient than the patient does over his or herself. How, then, does a physician and provider respond if they believe that the patient lacks credibility in describing his or her pain?
Dr. Wilson explains that “who you are and who you show up as determines what you get.” Citing work on trustworthiness by Amanda Fricker and Kristie Dotson, she claims that patients may be determined by their physicians and providers as either competent and sincere or not, which influences if the provider and physician can give the patients concerns more or less weight over their own expertise.
Physicians and providers may trust patients more or less depending on the patients’ social status and associated stereotypes. “The less credible a patient seems, the more a physician will rely on racial stereotypes.” Dr. Wilson identifies that black patients come under stereotyping more often than non-white patients as they are seen as “drug sellers or drug abusers.” This lack of epistemic credibility, or the amount of trust a provider and physician has in the patients’ health claims, results in disparaging treatment between racial groups. It falls onto black patients to overcome negative stereotypes so that they may be considered as trustworthy as non-black patients. Similarly, it relies on the physician to combat stereotypes when distinguishing the trustworthiness of a patient when discussing their pain.
“Pain management is a gateway to thinking about black credibility and epistemic problems” according to Dr. Wilson. The problems that exist can only be solved after they are acknowledged. Understanding the biases and injustices perpetrated in the healthcare industry and in society at large can influence the way that we think about solving these problems. Dr. Wilson expressed to me that she believes a solution may lie in early childhood education before subconscious, racial biases are programmed into children.
The way in which children are raised to include the household, the community, schools, extra-curriculars, television, etc. influence the ways that they think about the world. Influencing children in the earliest years has a studied effect, as Dr. Wilson pointed to. They do not show preference for white or black people because of complicated, philosophical viewpoints. Much like they do not show affection to their mother and father because the costs of renting an apartment and buying food are too high. Dr. Wilson believes it is subconscious programming through the sources we expose children to that determines whether the child will grow to prefer one colored doll over another, and in turn, determine the understanding between the child and others. Dr. Wilson believes that if biases in early childhood education are not flushed out, they will persist in a cyclical pattern from one generation to the next. Children influenced by negative biases may go on to persist ineffective patient-provider relationships in medical settings or other settings, for that matter. The results of which may lead to catastrophic failures in bureaucracy like ineffective health care.
References
Garra, Gregory, Adam J. Singer, Anna Domingo, and Henry C. Thode. “The Wong-Baker Pain FACES Scale Measures Pain, Not Fear.” Pediatric Emergency Care 29, no. 1 (2013): 17–20. https://doi.org/10.1097/pec.0b013e31827b2299.
Clark, Kenneth B., and Mamie K. Clark. “Skin Color as a Factor in Racial Identification of Negro Preschool Children.” The Journal of Social Psychology 11, no. 1 (1940): 159–69. https://doi.org/10.1080/00224545.1940.9918741.
Dore, Rebecca A., Kelly M. Hoffman, Angeline S. Lillard, and Sophie Trawalter. “Childrens' Racial Bias in Perceptions of Others Pain.” British Journal of Developmental Psychology 32, no. 2 (February 28, 2014): 218–31. https://doi.org/10.1111/bjdp.12038.
Fricker, Miranda. Epistemic Injustice: Power and the Ethics of Knowing. New York, NY: Oxford University Press, 2010. https://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780198237907.001.0001/acprof-9780198237907.
Dotson, Kristie. “Conceptualizing Epistemic Oppression.” Social Epistemology 28, no. 2 (2014): 115–38. https://doi.org/10.1080/02691728.2013.782585.
Photo Citation: "Patient Talking With Doctor" by NIHClinicalCenter is licensed under CC BY 2.0
