Beyond health literacy: Addressing epistemic injustice in patient-provider communication.

Abstract

This study reexamines patient-provider communication difficulties that have traditionally been attributed to patients' low health literacy, highlighting instead the role of epistemic injustice-structural and epistemological imbalances that shape whose knowledge is considered credible and whose experiences are understood. Adopting a conceptual and theoretical approach, this study reviews previous studies on health literacy and its limitations, introduces Miranda Fricker's framework of epistemic injustice, and reinterprets qualitative studies on patient-provider communication. The analysis focuses on two forms of epistemic injustice-testimonial and hermeneutical-and incorporates the related concepts of epistemic legitimacy and epistemic asymmetry. Findings suggest that communication breakdowns often labeled as "health literacy deficits" are more accurately understood as manifestations of epistemic injustice. Testimonial injustice arises when patients' accounts are preemptively discredited due to negative identity prejudice, resulting in credibility deficits. Hermeneutical injustice occurs when patients lack the interpretive resources needed to articulate or understand their experiences, leading to structural exclusion from meaning-making processes. These dynamics reflect systemic power asymmetries in which healthcare providers disproportionately control epistemic legitimacy, constraining patients' ability to speak, be heard, and be understood. Reframing communication difficulties through the lens of epistemic injustice reveals that these barriers often stem not from patients' cognitive limitations but from structural biases and unequal epistemic power in healthcare. Achieving epistemically just communication requires recognizing patients as epistemic agents whose voices and silences are equally meaningful and credible. Addressing epistemic injustice in healthcare demands interventions at clinical, educational, and organizational levels, including fostering epistemic humility, creating narrative spaces for patient expression, incorporating patient narratives into medical records, promoting peer support, and enhancing organizational health literacy.