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Epistemic injustice in “The Pitt”: How the hit show captures imbalances in healthcare 

by Kyr Goyette

“The Pitt” burst onto the entertainment scene last year when its first season aired on HBO Max and drew the attention of viewers craving the next hit medical drama. Set in Pittsburgh at the fictional Pittsburgh Regional Trauma Center (PRTC), the show’s references to various UPMC and Allegheny Health Network hospitals–Presbyterian, Mercy, West Penn, and Magee–ground it in the dense web of medical centers with which Pittsburgh residents are familiar. Each season covers just a single 12-hour-shift of a team that includes emergency room attendings, nurses, residents, medical students, and more, and each episode corresponds to an hour. Now in its second season, the show has received positive attention from healthcare workers–likely because medical professionals contributed to its writing and production–for its accurate representations of what it is like to work in an emergency room and how institutional pressures impact the quality of care that patients receive. Importantly, patients have also felt seen: the show reflects how individuals who find themselves in the ER–because of a freak accident, lack of primary care coverage, or an acute episode of a chronic disease–end up suffering because of overworked physicians and overcrowded rooms. 

A concept developed by philosopher Miranda Fricker in her 2007 book Epistemic Injustice: Power and the Ethics of Knowing can be used to help understand some of the challenges that patients face in “The Pitt” and in real life. Fricker works in the field of epistemology, a branch of philosophy concerned with how knowledge is created, shared, and passed from generation to generation. She coined the term epistemic injustice to describe an injustice done to someone in their capacity as a “knower” of information. According to Fricker, there are two main ways that someone can experience this kind of injustice: hermeneutical and testimonial.  

An individual may face hermeneutical injustice if there is a lack of existence of or access to concepts that would allow an individual to make sense of and/or communicate their experiences. This kind of injustice can result from linguistic inadequacies, such as the insufficiency of language to describe chronic pain, or systemic inequalities, such as when interpreting services are not offered to individuals who do not speak English. 

Testimonial injustice occurs when an individual’s credibility is downgraded unfairly because of prejudice or bias, which results in their testimony being undervalued by the hearer. Often, the testimonies of individuals with psychiatric illness are dismissed or considered less seriously because they are assumed to be unreliable narrators as a result of prejudices and stereotypes about mental illness. 

Epistemic injustice is distinguished from other forms of injustice by its attention to who has access to knowledge and who is seen as a provider of reliable information. Access to information and credibility are often but not always correlated with other forms of marginalization, so epistemic injustice may occur in tandem with other forms of injustice, like social or economic, or on its own. Since Fricker’s coinage of the term, other academics have worked to apply the term to healthcare contexts, and it has proven to be adept at articulating the consequences of subtler epistemic biases. 

“The Pitt” illustrates testimonial injustice by showing how doctors and nurses privilege or discount the narratives of different patients, often from biases that don’t necessarily reflect intentional malice. In the first season, medical student Dennis Whittaker’s experience of two patients seeking pain relief illustrates how assumptions learned in medical education can affect assessments of an individual’s credibility as a patient and knower of their own body.  

In episode 2, a Black woman in the midst of a sickle cell crisis is brought in by police, thrashing in pain and yelling for medication. The viewer sees that Whittaker has made a series of assumptions about her epistemic credibility. He seems surprised that Dr. Samira Mohan dismisses the police offers and quickly orders pain medication for the patient. She does this because she listens to the words that the woman, Joyce St. Clair, is screaming and is able to quickly ascertain that she is in the midst of a sickle cell crisis. Dr. Mohan’s subsequent explanation of how excruciatingly painful a sickle cell crisis is helps Whittaker–and the audience–to understand that the first-glance judgments he made obscured his ability to listen to the patient and see her pain in a context outside of what the police told them upon bringing her in.  

 In episode 10, a white male patient named Ivan Pugliesi presents with vomiting and diarrhea and makes an offhand comment about back pain acting up, for which he claims a previous doctor gave him opioid medication. Possibly because he was rightfully chastised by Dr. Mohan for his skepticism of their sickle cell patient or possibly because this patient is a composed white man, Whittaker is quick to list the many serious possible causes of the patient’s symptoms, but misses entirely that they line up perfectly with the symptoms of opioid withdrawal–which Dr. Mohan again points out. 

For reasons that are not always plainly malicious, healthcare professionals are taught certain strategies for treating patients when there is uncertainty surrounding their history or concern for the safety of the patient or others. In the wake of the opioid crisis, students are taught skepticism towards patients who ask for pain medications. Particularly in emergency rooms, healthcare workers are taught to be aware of patients that may pose a threat: a later episode where charge nurse Dana is physically assaulted by a disgruntled patient underscores the risk to healthcare workers in primary care settings. 

When listening to or observing a patient, medical professionals may downgrade the credibility of a patient because they seem combative, are immediately asking for pain medication, or are brought in by police. Students also hold their own assumptions from outside their medical education which they may apply to patients, including stereotypes about who is more likely to be dangerous or drug-seeking on the basis of race, sex, gender, or socioeconomic status.  

Fricker’s definition of epistemic injustice holds that it is necessarily unintentional: when testimonial injustice occurs, it is not because the listener wants the speaker to suffer or has decided they are lying. Rather, covert prejudices and biases operate to reduce the patient’s epistemic credibility without the doctor necessarily being conscious that this process is happening and affecting their actions. In discussing how individuals with psychiatric illness can be at greater risk of epistemic injustice, Kidd et. al note how “one’s capacity to conform to the socially standard kinds of practical comportment” can affect their perceived credibility. 

For example, a healthcare worker assumes that a patient screaming is not as rational as a patient who is talking normally. Therefore, they conclude that the screaming patient is less likely to be communicating any important information even if the words they are yelling are comprehensible and relevant to their treatment–as was the case for St. Clair during her sickle cell crisis. In showing these two cases, “The Pitt” illustrates how extreme pain can cause someone to behave–completely reasonably–in a manner that is judged to be non-standard and therefore suspect in a medical context.   

Epistemic injustice has been embraced by scholars in the fields of philosophy, gender, sexuality, and women’s studies, and disability studies for its applicability in understanding how subtler forms of prejudice can operate in the world. Analyzing episodes of “The Pitt” through this framework demonstrates how the show has highlighted the kinds of injustice that permeate American healthcare systems and relayed them in a way that resonates with audiences of healthcare workers and patients alike. It also displays the strategies that help to mitigate epistemic injustice, especially the testimonial form. One such strategy, articulated first again by Miranda Fricker, is called “virtuous listening.” To listen virtuously is to take the testimony with which one is presented seriously, regardless of whether there is some learned or reflexive reason to downgrade the credibility of the person who is speaking. It might seem surprising that the conclusion of this expansive philosophical analysis is for people to listen to others how they would want to be listened to themselves, but “The Pitt” shows us both how easy it is for testimonial injustice to happen–and how profoundly impactful a single person “listening virtuously” can be.