Received: 24 October 2016 | Revised: 9 November 2017 | Accepted: 12 December 2017

DOI: 10.1111/bioe.12435

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SPECIAL ISSUE: MIGRATION, HEALTH AND ETHICS

Language barriers and epistemic injustice in healthcare settings

Yael Peled

Correspondence Abstract
Yael Peled, Institute for Health and Social Contemporary realities of global population movement increasingly bring to the fore the chal-
Policy, McGill University, Charles Meredith
lenge of quality and equitable health provision across language barriers. While this linguistic
House, 1130 Pine Avenue West, Montreal,
Quebec H3A 1A3, Canada. challenge is not unique to immigration contexts and is likewise shared by health systems
Email: [email protected] responding to the needs of aboriginal peoples and other historical linguistic minorities, the
expanding multilingual landscape of receiving societies renders this challenge even more criti-
cal, owing to limited or even non-existing familiarity of modern and often monolingual health
systems with the particular needs of new linguistic minorities. The centrality of language to
health beliefs, attitudes, practices, cultural scripts, and conceptual frameworks emphasizes its
pivotal role in the healthcare process, and consequently in the adverse effects of treatment
that is language-insensitive and unaware. Such an attitude on the part of medical authorities
risks considerable epistemic injustice in the form of a (mis)judgement of patients’ intelligence,
credibility, and rationality based on the language that they speak and the manner in which
they speak it, consequently impacting the quality and equity of care provided. This danger, I
argue, may be effectively countered by fostering among the participants in the healthcare pro-
cess a sense of epistemic humility through greater metalinguistic awareness. Outlining a range
of operative steps that can be used to facilitate this. I argue that the reality of language bar-
riers in the healthcare process, while not entirely eliminable, may nevertheless be successfully
addressed, in order to mitigate the challenge of quality and equitable healthcare provision in
multilingual societies.

KEYWORDS
epistemic humility, epistemic injustice, health communication, language barriers, linguistic
minorities

1 | INTRODUCTION impact on the quality of care that is received and its equitable
provision.1

Of the many challenges facing national health services and health The pivotal role of language in the context of healthcare is under-
standably linked, first and foremost, to the fact that any type of health
systems in an age of increased international migration, language is
arguably among the most significant ones. The equitable provision
of healthcare in (and to) increasingly multilingual societies is a com- 1
See for example, Bowen, S. (2000). Language barriers in access to healthcare.
plex task against the backdrop of a modern industrialized nation- Ottawa: Health Canada Ottawa; for detailed literature reviews on the impact of
state whose institutions primarily operate in a particular (or, at language barriers on health and healthcare access, see Timmins, C. L. (2002).
The impact of language barriers on the healthcare of Latinos in the United
most, in a limited number of) official language(s), whether de jure or States: A review of the literature and guidelines for practices. Journal of Midwif-
de facto. Given the centrality of linguistic interaction to health ery and Women’s Health, 47(2), 80–90; Jacobs, E., Chen, A. H. M., Karliner, L. S.,
Agger-Gupta, N., & Mutha, S. (2006). The need for more research on language
communication, the existence of language barriers between health
barriers in healthcare: A proposed research agenda. The Milbank Quarterly,
practitioners and service users can have a significant adverse 81(1), 111–133.

Bioethics. 2018;1–8. wileyonlinelibrary.com/journal/bioe V

C 2018 John Wiley & Sons Ltd | 1
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communication necessarily and inevitably involves a linguistic interaction the existence—and experience—of a language barrier just as intrinsic to
that cannot be reduced to a purely technical or nonlinguistic form. Each the linguistic human condition as the capacity for language itself.4 This
and every phase of the healthcare process, from diagnosis (e.g., reviewing implies that, in the context of healthcare, and particularly in multicul-
medical history) and treatment (e.g., the tailoring of treatment plans and tural democracies committed to principles of inclusiveness, equality,
communication with supportive care) to consultation (e.g., responding to and justice, ensuring effective communication between practitioners
questions concerning treatment plan and success) and eventually termi- and patients across language barriers is a public policy challenge that
nation of treatment (e.g., verification and monitoring), is reliant on effec- cannot be resolved on its own, for example, by delegating the task to
tive communication between practitioners and patients. The role of linguistic market forces.
language in healthcare, however, encompasses not only this relatively The challenge of language barriers in healthcare is by no means
overt dimension of linguistic interaction, but also a more covert dimen- unique to those countries with an established history of immigra-
sion that pertains to its epistemic nature, i.e., to the question of how the tion (e.g., the United States, Canada, etc.), whose policies reflect
very existence of language barriers between practitioners and patients the historical and continuous presence of linguistic minorities, abo-
potentially affects the perception of their respective epistemic standing in riginal and otherwise, in their territories. Current immigration
a manner that is often difficult to identify and respond to. trends further compound this challenge, particularly in the case of
In this article, I set out to identify and explore the challenge of host societies that receive significant numbers of new linguistic
healthcare provision across language barriers. I begin from the basic pre- groups. In quantitative terms, this often requires the health system
mise that there exists an unavoidable tension between a modern health and health services to expand the range of languages accommo-
system that operates primarily in an official language(s) on the one hand, dated through various means (e.g., interpretation services, trans-
and the existence of an expanding language barrier as a result of increas- lated documents such as medical protocols or information leaflets).
ing immigration bringing in new linguistic groups on the other hand. Tak- In more qualitative terms, a significant part of the challenges posed
ing that premise as my point of departure, I offer a general account of by language barriers stems from the more covert role that language
the complex relations between language and healthcare, and the manner plays in the meaning-making process of illness and well-being. Such
in which they are impacted—not necessarily positively—by the reality of
meaning-making process is unavoidably rooted in a particular cul-
English as a global political and scientific lingua franca. I then move to
tural setting, which acts as the epistemic backdrop against which
consider the ethical dimension of these complex relations from the view-
notions of health and illness are formed, articulated, and
point of epistemic justice as ‘the ethics of knowing’, as identified and
addressed:
developed by Fricker.2 More specifically, I argue that Fricker’s distinction
between testimonial and hermeneutical epistemic injustice succinctly cap- Culture can profoundly influence every aspect of illness
tures the ethical issues that stem from the overt impact of language bar- and adaptation, including interpretations of and reac-
riers on healthcare provision, corresponding respectively to the tions to symptoms; explanations of illness; patterns of
intralinguistic and interlinguistic communicative challenges in the health- coping, of seeking help and response; adherence to
care process in a reality of language barriers. This challenge, I argue, is treatment; styles of emotional expression and commu-
best addressed through the adoption of epistemic humility, which can be nication; and relationships between patients, their fami-
manifested through greater language sensitivity and metalinguistic aware- lies and healthcare providers.5
ness, particularly among those who are accorded greater epistemic
authority. I conclude by outlining a number of operative measures that An illustrating example of this is pain. Pain may be perceived as a
can be adopted by modern healthcare systems in order to better assess universal human experience rooted in biology rather than in particular
and respond to the health needs of linguistically diverse populations. cultural and linguistic environments. However, given the fact that a
direct measurement of pain is impossible (by contrast with other vital
2 | LANGUAGE AND HEALTHCARE: signs such as blood pressure or body temperature), and considering
COMPLEX DYNAMICS that self-reporting remains the ‘gold standard’ of pain assessment,

The fundamental challenge of healthcare provision in a linguistically

4
diverse society stems from the fact that while language is a human Peled, Y. (2018). Language ethics and the interdisciplinary challenge. In J.
Tollefson & M. Pe
rez-Milans (Eds.), The Oxford handbook of language policy
commonality, it paradoxically manifests itself in a particularistic manner,
(p. 141). Oxford, UK: Oxford University Press.
namely, through a diverse range of (natural) languages,3 thus rendering 5
Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J.,
. . . Pottie, K. (2011, Sep.). Common mental health problems in immigrants
2
Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. and refugees: General approach in primary care. Canadian Medical Associa-
Oxford, UK: Oxford University Press. tion Journal, 183(12), E963. Awareness towards the importance of meaning-
3
The word ‘language’ in health research is used in different ways and in making in illness more generally is a constitutive tenet of narrative medicine
service of different debates, for example in terms such as ‘medical language’ (e.g., Charon, R., & Montello, M. (2002). Stories matter: The role of narrative
in reference to a particular professional medical discourse as distinct from in medical ethics. New York, NY: Routledge; Charon, R. (2008). Narrative
‘plain language’. For the purpose of this paper, ‘language’ here is used mostly medicine: Honoring the stories of illness. Oxford, NY: Oxford University
in reference to ‘natural language’ (e.g., English, French, Welsh, Hebrew, etc.). Press.).
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understanding and treating pain critically depends on language,6 and six terms semantically equidistant, and not overlapping?
can be adversely affected when health communication is insufficiently Does it make sense to add, say, a 6 for pounding to a 2
aware of the complexities of cross-linguistic conceptualizations of pain. for exhausting in list 11, or are we summing two different
Examples include the lack of a clear distinction, in Russian, between entities? And this without venturing outside lexically-
what English speakers call pain and ache, or the semantic mismatch defined sets of descriptors taken as being context-,
between English and Korean pain categories.7 Another important and socially-, culturally- and communicatively neutral.11
equally overlooked feature of health communication concerns
language-specific medical cultural scripts, namely, the explicit and The significance of language barriers becomes even greater, how-
implicit ‘declarative knowledge structures that organize stereotypical ever, as we move from physical health to mental health. This is because
events, such as visiting a clinician. . . [which] provide a structure or scaf-
fold for meaning-making and memory’.8 For example, the Anglo dis- compared with more technological aspects of medical
course of discomfort may be confusing for patients from non-Anglo care, psychiatric practice is still highly dependent on the
cultural backgrounds.9 quality of the clinical relationship. Despite the ongoing
The dominance of English in fact plays a dual role in the ‘biologization’ of psychiatry, mental health practitioners
(mis)managing of healthcare provision across language barriers, particu- cannot function ethically or effectively without engag-
larly in cases where the health system itself is English-speaking. First, in ing essential aspects of the patient’s personhood, which
monolingual Anglophone health systems, the quality of care provided can be achieved only through a dialogical encounter
to linguistic minorities, including non-Anglophone immigrants, is poten- that explores and acknowledges each patient’s lived
tially compromised when minority language speakers are not fully profi- experience. Mental illness raises basic questions of the
cient in particular Anglo-English forms of thinking and talking about meaning of human vulnerability, suffering, loss, and limi-
pain in communication with mainly Anglophone health providers. A tations. In most societies, these crises are addressed
second issue arises from the prominence of English as a global language through fundamental cultural systems of meaning,
of science, and therefore its nearly default presence in diagnostic sys- including those of morality, religion, and spirituality.12
tems and instruments used (in translation) outside the English-speaking
world. Such dynamics seem to reflect an underlying, if unreflective, To illustrate this, consider the case of depression. Like pain,
belief that an English-specific conceptualization of pain may somehow depression is now seen as a major global public health concern,
be universally applicable. Recent critiques of English-based diagnostic referred to by the World Health Organization as a ‘global crisis’ that is
tools such as the McGill Pain Questionnaire (MPQ), however, have expected to become the foremost cause of global burden of disease by
called into question the MPQ’s capacity to capture adequately the 2030.13 The urgency of understanding and treating depression globally,
experience of pain in other languages.10 Even worse, perhaps, its utility however, is significantly challenged by the critical role of the dialogic
has also been questioned for assessing native English speakers encounter, which is, almost inevitably, situated in particular cultural and
themselves: linguistic settings. Indeed the very concept of depression has been
argued to be far from being universal, or easily and readily translatable
From a language specialist’s point of view the design of across linguistic and cultural barriers. This is the case not only between
the MPQ is fraught with problems [. . .]. To take just the linguistic communities that are far removed from each other, such as
six descriptors listed above from the first ‘sensory’ list: English and Pintupi and Pitjantjantjara (Australian aboriginal languages),
flickering, quivering, pulsing, throbbing, beating and pounding. but also between English and Russian.14 Furthermore, even when a
Is the ranking correct, from weakest to strongest? Are the translation supposedly exists, the assumption that the linguistic label
corresponds to the exact same meaning is highly problematic.15 This is
evident, for example, in the tendency of White Australians to describe
6
Wierzbicka, A. (2012). Is pain a human universal? A cross-linguistic and
depression as a personal misfortune, contrasted with the tendency of
cross-cultural perspective on pain. Emotion Review, 4(3), 307.
7 Somalian and Ethiopian refugees living in Australia to perceive
Ibid: 308.
8
Ryder, A. G., & Chenstova-Dutton, Y. E. (2015). Cultural clinical psychol-
ogy: From cultural scripts to contextualized treatments. In L. J. Kirmayer,
11
R. Lemelson, & C. A. Cummings (Eds.), Re-visioning psychiatry: Cultural phe- Sussex, R. (2009). The language of pain in applied linguistics. Australian
nomenology, critical neuroscience, and global mental health (pp. 405–406). Review of Applied Linguistics, 32(1), 06.5. Of course, English is by no means
Cambridge, UK: Cambridge University Press. unique in having such a gap between ordinary language and technical or
9
Wierzbicka, op. cit. note 6, p. 308. The notion of discomfort here involves biomedical language.
12
a downplaying of the patient’s pain (Coulthard, M., & Ashby, M. (1975). Kirmayer, L. J. (2011). Multicultural medicine and the politics of recogni-
Talking with the doctor. Journal of Communication, 25, 140–147, in Wierz- tion. Journal of Medicine and Philosophy, 36(4), 414.
13
bicka, Ibid). World Health Organization. Depression: A global crisis. World Mental
10
For comments on the validity of the Welsh version and a comparative dis- Health Day.
14
cussion on similarities with the Norwegian equivalent, see Roberts, G., Dowrick, C. (2009). Beyond depression: A new approach to understanding
Kent, B., Prys, D., & Lewis, R. (2003). Describing chronic pain: Towards bilin- and management. Oxford, UK: Oxford University Press, pp. 133–134.
15
gual practice. International Journal of Nursing Studies, 40(8), 889–902. Ibid: 130.
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depression ‘as an affliction that is collectively derived and experi- Intriguingly, however, attention to the role played by language in the
16
enced’. Religious affiliation, too, may play an important role in the healthcare process, and more specifically, to the inevitable reality of
experience and processing of depression, as shown, for example, by language barriers, remains to date limited and under-theorized. This is a
the perception among certain Islamic communities that depression may surprising state of affairs, given the fact that epistemic judgements are
17
show a lack of respect for God. often based on (mis)perceptions that arise in a communicative context
The linguistic challenge to the proper understanding and successful that relies primarily on linguistic interaction, such as discussing some-
treatment of depression, however, goes deeper than the requirement one’s medical history, describing complaints, responding to self-
for cross-linguistic (and cross-cultural) awareness. This is because reporting diagnostic tools, or giving consent. In the context of a multi-
depression itself is in many cases experienced as ‘indescribable’, 18
com- lingual society whose linguistic landscape is expanding as a result of
prising both inarticulacy (‘the difficulty of adequately communicating, increasing immigration, a closer consideration of language in the health-
sharing, or ‘getting across’ certain aspects of the experience of ill- care process suggests that the framework of epistemic injustice is par-
19 ticularly suitable for the task of identifying the impact of language
ness’) and ineffability (‘the sense that certain aspects of those experi-
ences cannot be adequately communicated to others through barriers on equitable healthcare provision. This is because the distinc-
propositional articulation because understanding is premised upon a tion that Fricker makes between testimonial and hermeneutical forms of
person’s having had the requisite bodily experience’). 20
In other words, epistemic injustice corresponds to the distinction between intralinguis-
the challenge of treating depression across language barriers is further tic and interlinguistic dynamics of health communication.
compounded by the added difficulty for patients to articulate their Let us begin with testimonial injustice, defined by Fricker as a ‘preju-
experience in their own native language(s) to begin with, before issues dice on the hearer’s part [that] causes him to give the speaker less credi-
of cross-linguistic conceptual equivalency and comprehensibility even bility than he would otherwise have given’.22 An illustrative example of

arise. In depression, therefore, as in pain, the pivotal role of language in testimonial injustice, according to Fricker, is accent. This is because ‘[n]ot

the process of sense-making and articulating the experience of illness, only does accent carry a social charge that affects how a hearer per-

whether physical or mental, renders language a critical element of the ceives a speaker (it may indicate a certain educational/class/regional

healthcare process, which significantly affects its equity and quality. background), but very often it also carries an epistemic charge’.23 In the
context of healthcare, linguistic testimonial injustice usefully maps on an
intralinguistic interaction that takes place when practitioners and patients
3 | LINGUISTIC EPISTEMIC INJUSTICE IN
do not necessarily share a certain language as their first language, and
HEALTHCARE
nevertheless have to communicate in it, for example, due to lack of trans-
lation and interpretation services. Instances of linguistic testimonial injus-
The epistemic dimension of the healthcare process, as managed by
tice therefore occur, for example, when a physician may unjustly
healthcare systems, has been the topic of increasing normative and
perceive a patient as less intelligent based on the fact that the patient
theoretical attention in the domain of public health ethics.21
speaks with an accent that is often associated with less educated popula-
16
Ibid: 130–131. tions.24 Linguistic prejudice, of course, is by no means confined to practi-
17
Goh, C. R., Lee, K. S., Tan, T. C., Wang, T. L., Tan, C. H., Wong, J., . . . tioners, and can be found, for example, in attitudes of patients who are
Schipper, H. (1996). Measuring quality of life in different cultures: Transla- native speakers towards foreign-accented physicians. However, the
tion of the Functional Living Index for Cancer (FLIC) into Chinese and Malay
greater epistemic authority accorded to practitioners in the healthcare
in Singapore. Annals of the Academy of Medicine, Singapore, 25(3), 323–334.
For contemporary work on Christian perceptions of depression, see Scrut-
process implies a greater share of the responsibility to ensure equitable
ton, A. P. (2015). Two Christian theologies of depression: An evaluation and treatment.
discussion of clinical implications. Philosophy, Psychiatry and Psychology, Another important form of intralinguistic communication that may
22(4), 275–289; Scrutton, A. P. (2015). Is depression a sin? A critique of
result in testimonial injustice stems from particular expressive choices
moralizing and medicalizing models of mental illness. Journal of Disability
and Religion, 19(4), 285–311; Scrutton, A. P. (2016). What might it mean to
on the part of the patient for whom the language of the medical con-
live well with depression? Journal of Disability and Religion, 20(3), 178–189. sultation is not their first language. Given the epistemic prestige of for-
18
Ratcliffe, M. (2017). Experiences of depression: A study in phenomenology. mal medical language, and owing to possible lack of competence or
Oxford, UK: Oxford University Press, pp. 1–2. confidence in one’s ability to employ medical cultural scripts in a non-
19
Kidd, I. J., & Carel, H. (2017). Epistemic injustice and illness. Journal of

s that clinicians judge to
native language, a patient may resort ‘to cliche
Applied Philosophy, 34(2), 172–190.
20
Ibid.
be too coarse or idiomatic to be of use, or feeling that they ought to
21
See, for example, Kidd & Carel, ibid; Carel, H., & Kidd, I. J. (2014). Episte-
22
mic injustice in healthcare: A philosophical analysis. Medicine, Health Care Fricker, op. cit. note 2, p. 4.
23
and Philosophy, 17(4), 531; Wardrope, A. (2015). Medicalization and episte- Ibid: 17.
24
mic injustice. Medicine, Health Care and Philosophy, 18(3), 350; Freeman, L. From a linguistic standpoint, it is worth emphasizing that there exists no
(2015). Confronting diminished epistemic privilege and epistemic injustice such thing as speaking without an accent, and that any kind of human
in pregnancy by challenging a “panoptics of the womb”. Journal of Medicine speech exhibits by default an identity related to one’s native language,
and Philosophy, 40(1), 44–68. A comprehensive bibliography of epistemic social class, geographical location, etc. See Moyer, A. (2013). Foreign accent:
injustice and illness maintained by I. J. Kidd can be found at https://sites. The phenomenon of non-native speech. Cambridge, UK: Cambridge University
google.com/site/dfl2ijk/res/epistemic-injustice-and-illness-bibliography. Press, p. 9, 20.
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employ formal medical vocabularies in which they know themselves to different conceptualizations of health and illness in different languages
25
be inexpert’, thereby further compromising their epistemic standing can result in a hermeneutical epistemic injustice when concepts from a
in the eye of the physician. While an interaction of this kind takes place different language are not recognized as valid information that may
in a language that is common to the physician and the patient, the contribute to the healthcare process.
unequal linguistic competence and power asymmetries between the Consider, for example, an Italian-speaking immigrant complaining
interlocutors, which exist even in the absence of a (natural) language about a colpo d’aria in consultation with an English monolingual physi-
barrier,26 nevertheless reflect a reality of a language barrier between cian. Colpo d’aria, literally meaning ‘hit of air’ caused by sudden fluctua-
native and non-native speakers that can potentially result in significant tion in temperature, is often recognized as the cause of a wide range of
testimonial injustice, and, consequently, compromised quality and health problems in Italian, from earache and backache, through sore
equity of care. throat and fever, and to headache, stomachache, and indigestion. The
If linguistic testimonial injustice is concerned with the (mis)judge- lack of a linguistically codified conceptual equivalent in English may
ment of how a person speaks, hermeneutical injustice is concerned with then result in linguistic hermeneutical epistemic injustice. More specifi-
the (mis)judgement of what a person says. Hermeneutical injustice is cally, in the event that the physician attempts to gather more informa-
defined by Fricker as a situation in which ‘a gap in collective interpre- tion on the meaning of the Italian expression, he or she may be
tive resources puts someone at an unfair disadvantage when it comes tempted, perhaps unconsciously, to search for the nearest English
to making sense of their social experiences’.27 For example, when one equivalent, namely, ‘catching a chill’. However, colpo d’aria and catching
‘suffers sexual harassment in a culture that still lacks that cultural con- a chill are not semantically equivalent (for example, the latter does not
cept’.28 In the context of health communication, cultural conceptual refer to indigestion while the former does), and therefore treating the
voids (wholly or partially) are an unavoidable result of the reality of a condition on the basis on what is essentially a mis-assessment is likely
language barrier, as the examples of ‘pain’ and ‘depression’ in the previ- to compromise the care that is provided. Alternatively, if the physician
ous section illustrate. The expectation that there somehow exists an is less language-sensitive, they may conclude that the belief that illness
objective conceptualization of the experience of health and illness is is caused by ‘being hit by air’ marks an individual as less intelligent or
certainly understandable, particularly under the epistemic influence of rational, thereby demoting the epistemic validity of an expression that
medicalized language and the reality of English as a global lingua franca does not have such credibility deficit in its own cultural and linguistic
of health research and communication. However, the attempt to neu- context.
tralize away particularistic elements such as culture and language29 The linguistic conceptualization of serious diseases is another
risks undermining the quality and equity of care provided to individuals important instance of the challenges raised by language barriers in the
when the healthcare process is either unable or is unwilling to recog- domain of health and illness. One particularly illustrative example of
nize the epistemic validity of medical knowledge originating in and con- this is cancer care. The conceptual void in this case is much more com-
ceptualized by a different language. In other words, the existence of plex, encompassing both lack of conceptual equivalents as well as (at
least in certain cases) taboo language and the use of euphemisms. With

25
regard to the former, some languages lack the concept entirely, and in
Carel & Kidd, op. cit. note 19, p. 531.
26 some contexts, such as South Africa, when such words do exist (e.g., in
Ibid. The question of shared decision-making (SDM) is an illustrative
example of power imbalances in healthcare settings (see, e.g., Frosch, D. L., Zulu, Swazi, and Xhosa), they ‘do not refer to a disease that could
May, S. G., Rendle, K. A., Tietbohl, C., & Elwyn, G. (2012). Authoritarian spread to other parts of the body or require any specific treatments to
physicians and patients’ fear of being labeled ‘difficult’ among key obstacles bring about cure’.30 Other forms of cancer-related lexical voids include
to shared decision making. Health Affairs, 31, 1030–1038; Joseph-Williams,
lack of a common name among traditional healers in Nigeria, and the
N., Elwyn, G., & Edwards, A. (2014). Knowledge is not power for patients: A
systematic review and thematic analysis of patient-reported barriers and existence of various terms referring to different types of cancers in dif-
facilitators to shared decision making. Patient Education and Counseling, ferent parts of the body.31 When there exists a word for cancer, it is
94(3), 291–309.) sometimes used rarely and reluctantly, often referred to as a ‘terrible
27
Fricker, op. cit. note 2, p. 1.
28
disease’, for example, in Italian32 and Hebrew. As in the case of colpo
Ibid.
29 d’aria, the use of euphemisms in the context of inter-linguistic cancer
I take culture and language to be strongly interdependent entities, rather
than either wholly distinct from one another, or largely interchangeable. I care may pose particular issues in the context of immigrant popula-
follow Kramsch in considering the relationship between the two as follows: tions, where such use reflects pre-migration health communication
language serves as an expression, embodiment, and a symbol of cultural expectations.33 Such attitudes, once again, can potentially portray
reality. Culture, on that account, is contrasted with nature, and denotes the
patients as irrational and uneducated in the eyes of physicians, thereby
particularity of a socially embedded set of meanings, conventions, assump-
tions, and expectations, that often give the impression that they are indeed
30
natural, and are articulated through language (Kramsch, C. (1998). Language Dein, S. (2005). Culture and cancer care. New York, NY: McGraw-Hill
and culture. Oxford, UK: Oxford University Press, pp. 3–7). In addition, my Education, p. 3.
31
conception of language here includes visual modality, incorporating not Ibid.
32
only sign languages but also the complex visual modality of expressive fea- Ibid: 25.
33
tures such as gestures and postures that shape the context in which utter- Dohan, D., & Levintova, M. (2007). Barriers beyond words: Cancer, cul-
ances are produced and understood (Blommaert, J., & Rampton, B. (2011). ture, and translation in a community of Russian speakers. Journal of General
Language and superdiversity. Diversities, 13(2), 3–21.). Internal Medicine, 22(2), 302–303.
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resulting in the ascription of credibility deficit to their perception and words, metalinguistic awareness involves the capacity for higher-order
understanding of their own illness. reflection over language and linguistic agency, as opposed to simply
It is important to note that the argument here is not that the epis- using a particular linguistic system (i.e., a particular language) to com-
temic validity of the knowledge and insights into the experience of ill- municate and interact with others. Drawing on the above-mentioned
ness provided by the patient is necessarily superior to that of the examples, metalinguistic awareness in healthcare implies, for example,
medical professional. Rather, the point is that the existence of a lan- awareness that ‘pain’ and ‘depression’ as conceptualized in English are
guage barrier may make patients who do not necessarily share a first by no mean human universals, particularly in the context of global out-
language with a physician more vulnerable to epistemic injustice, and reach campaigns; that the fact that a person speaks with a marked
consequently to compromised standards of equity and quality of care. accent or in a seemingly inappropriate register is not in itself a suffi-
The examples above illustrate that the challenge of language barriers in cient indicator of their intelligence, credibility, or rationality; and that
healthcare is not purely technical but rather encompasses a complex the human experience of health and illness cannot be sufficiently cap-
backdrop of health beliefs and attitudes, linguistic ideologies, cultural tured, understood, and processed using English-based medical termi-
scripts and even institutional experiences. A more epistemically just nology or, more broadly, non-linguistic (i.e., numerical) forms of
healthcare process, by contrast, is therefore a more epistemically aware evidence and indicators. As such, my argument here aligns with recent
healthcare process, which is capable of making sense of health commu- calls in medical humanities for greater attention towards phenomeno-
nication across linguistic and cultural boundaries, and capitalizes on logical research, particularly in mental health research.36
that awareness in order to provide better and more equitable care to Emphasizing the social and cultural situatedness of health and ill-
vulnerable groups. ness, of course, is an imperative for approaches that advocate the need
for cultural (including notions of intercultural and cross-cultural) compe-

4 | LINGUISTIC EPISTEMIC HUMILITY IN tence in medical education and practice. Some of the fundamentals of
HEALTHCARE cultural competence include ‘a culturally sensitive attitude, appropriate
cultural knowledge, and flexible enough skills to provide culturally rele-
Language barriers, I have argued above, are the unavoidable result of vant and effective care for the patients of diverse backgrounds’.37 Cul-
multilingual realities in a modern world, and particularly in immigra- tural competence may indeed be seen as commensurable with and even
tion contexts that involve new linguistic groups. In the domain of encompassing the notion of linguistic epistemic humility as defined
health, such linguistic realities may contribute significantly to both above, given the former’s emphasis on the idea that ‘[. . .] healthcare pro-
testimonial and hermeneutical epistemic injustice, by mis-assessing viders need to be aware of their own cultural beliefs and biases to be
the credibility, rationality, and intelligence of non-native speakers on cognizant of their own cultural sensitivity, and to examine the cultural
the basis of their linguistic behaviour. In this final section my purpose relevance of the healthcare service they provide’.38 At the same time,
is to suggest that linguistic epistemic injustice in health can be suc- the focus on ‘appropriate cultural knowledge’ presupposes some cultural
cessfully countered by cultivating an attitude of linguistic epistemic familiarity, which is a far more demanding condition in the case of lan-
humility, defined by Wardrope as ‘an attitude of awareness to one’s guage (as a holistic epistemic system, namely, a comprehensive and
own epistemic capacities, and an active disposition to seek sources potentially self-containing system of meaning) than in that of non-

outside one’s self to help overcome these shortcomings’. 34

Concern- linguistic behaviours, practices, or rituals relating, for example, to dress

ing the question of the role of language in the healthcare process, lin- and posture codes. Furthermore, such presuppositions seem aspirational

guistic epistemic humility can therefore be defined as an attitude of at best in immigration contexts, particularly those involving linguistic

awareness, on the part of those involved in the healthcare process, of communities with which national health systems have little previous

their own linguistic epistemic capacities in both intralinguistic and familiarity, if any. These are, of course, precisely the contexts in which

interlinguistic contexts, the recognition of their limitations, and the linguistic epistemic injustice in healthcare is more likely to occur.

active search for sources outside one’s own linguistic epistemic In relation to cultural competence, epistemic humility should there-

capacities to help overcome them. fore be viewed as exhibiting, or at least acknowledging, a greater

How may such cultivation of linguistic epistemic humility be real- degree of uncertainty in healthcare across language barriers. Such

ized? The key to that, I argue, is fostering among the participants in the uncertainty, I argue, ought to be viewed as a structural feature of the

healthcare process a sense of metalinguistic awareness, defined as ‘the healthcare process39 that requires (imperfect) mitigation rather than a

ability to reflect upon and manipulate the structural features of lan- 36

See for example, Ratcliffe (op. cit. note 18); Kirmayer et al. (op. cit. note 5);
guage itself as an object of thought, as opposed to simply using the lan-
Carel, H. (2016). The phenomenology of illness. Oxford, UK: Oxford Univer-
guage system to comprehend and produce utterances’.35 In other sity Press.
37
Tseng, W., & Streitzer, J. (2008). Cultural competence in health care: A
34 guide for professionals. New York, NY: Springer, p. 12.
Wardrope, op. cit. note 21, p. 350.
35 38
Zhou, M. (2000). Metalinguistic awareness in linguistic relativity: Cultural Ibid: p. 13.
and subcultural practices across Chinese dialect communities. In M. Pu €tz & 39
Schwab, A. (2012). Epistemic humility and medical practice: Translating
M. A. Verspoor (Eds.), Explorations in linguistic relativity. Amsterdam, the epistemic categories into ethical obligations. Journal of Medicine and Philoso-
Netherlands: John Benjamins, p. 346. phy, 11, jhr054.
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technical issue that may be successfully and permanently resolved. In rendering them easier not only for more general comprehension but
line with the above-proposed definition of linguistic epistemic humility, also for more straightforward translation into other languages.
particularly with regard to the awareness of one’s own epistemic limita- The availability of a diagnostic tool whose validity across different
tions, their recognition, and active search for outside sources in order languages is empirically supported may also assist in further addressing
to overcome them, one important element in the process involves the another gap that contributes to a state of epistemic injustice, namely
recognition of medical translators and interpreters as epistemic author- the routine exclusion of linguistic minorities from health research. This
ities, of the specialized knowledge that they bring to the healthcare means that the reality of a language barrier in healthcare results not
process as cultural brokers, and of their distinct contribution to it. This only in poorer health outcomes, but also in a more limited access to
can be done as part of broader guidelines for working with interpreters research, i.e., ‘in data that do not adequately reflect, and are thereby
and cultural brokers, such as discussing relevant etiquette and cultural not necessarily applicable to, the needs of the broad population’.44 This
expectations in the pre-interview process; making sure not to interrupt means that, in addition to denying individual minority language speak-
the interpreter during the interview; and asking the interpreter to ers the opportunity to participate in research (including access to
assess the patient’s degree of openness or disclosure in the post- cutting-edge treatments in clinical trials), their exclusion from research
interview stage.40 Each of these actions on behalf of the physician ‘presents a barrier to the generalization of clinical research findings’.45
reflects an awareness of one’s own (linguistic) epistemic limitations, The imperative of epistemic humility through metalinguistic awareness,
coupled with an active disposition towards overcoming them. therefore, holds the key for greater equity and quality in the research
At the same time, it is important for the physician to be mindful of process itself as it does for the practical delivery of healthcare. The
the fact that interpreters are not necessarily successful or even quali- importance of attention to language is pivotal for ensuring the availabil-
fied cultural brokers, for example, when the patient and interpreter ity, validity, and reliability of data,46 further offering significant payoffs
share a language but not a socio-cultural, ethnic, and/or religious back- such as the capacity to compare co-lingual populations across borders,
ground, which may lead to misunderstanding and consequently misin- including (but not limited to) comparing data on immigrant populations
terpretation. In other words, an attitude of linguistic epistemic humility with data on their countries of origin.
on the part of the physician (and, arguably, on the part of the patient One final consideration on the importance of epistemic humility
and interpreter as well) cannot be simply ‘switched off’ on the basis of through metalinguistic awareness pertains to the rapport that is estab-
the expectation that another party to the healthcare process assumes
lished between practitioners and patients in a healthcare setting char-
full responsibility to ensure communicative accuracy and efficiency.
acterized by a language barrier. The linguistic agency of the
Another way of cultivating epistemic humility through greater
practitioner, as an epistemic authority, can greatly influence the quality
metalinguistic awareness involves a more critical attitude towards the
and equity of care provided. Even when patients do not expect to be
linguistic particularities of diagnostic tools such as the above-
treated in their own language, there are nevertheless certain linguistic
mentioned MPQ. This implies greater awareness, for example, of the
actions that can contribute to a more positive rapport and therefore
fact that the MPQ’s semantically refined distinctions such as continu-
better care delivery, such as a bilingual greeting, the recognition of
ous/steady/constant, rhythmic/periodic/intermittent, and brief/momen-
one’s linguistic identity, the acknowledgement of language needs, and
tary/transient ‘belong to a register of English which is alien not only to
the effort of pronouncing a patient’s name correctly.47 The latter, in
many immigrants, but also to many monolingual speakers of English’.41
particular, embodies an important instance of epistemic humility, as it
The same equally holds for the list of MPQ pain descriptors, including
temporarily reverses the epistemic disparities between the practitioner
‘flickering, quivering, pulsing, beating, pounding, pumping, boring, drilling,
and the patient, signaling the practitioner’s willingness and commitment
or lacerating [that] are normally not used in colloquial English when
to listen and learn from the patient on a matter that greatly affects the
people try to tell others about their pain’.42 A more helpful approach,
patient’s sense of personhood and dignity.
by contrast, would be to reformulate the questions using much more
It is important to note that the suggestions outlined above do not
simple words, on a level that would be comprehensible by a child, such
presume to provide a comprehensive response to the question of how
as ‘where does it hurt?’; ‘does it hurt very much?’; ‘does it hurt so much
best to develop linguistic epistemic humility among practitioners,
that you can’t think about anything else?’; ‘does it hurt always in the
let alone how best to institutionalize it, for example, in terms of revising
same place?’; ‘does it hurt so much that you can’t do anything?’; and
medical curricula and other training programs. As I argue above, cultivat-
‘does it hurt so much that you think “I can die because of this?”’43 In
ing a sense of linguistic epistemic humility differs from cultivating a sense
addition to being more accessible to non-native (as well as native) Eng-
lish speakers, the specific lexical items comprising these reformulated 44
Gany, F., Diamond, L., Meislin, E., & Gonz
alez, J. (2008). Ensuring access
questions have empirically documented cross-linguistic equivalence, to research for nondominant language speakers. In M. B. Schenker, X.
~eda, & A. Rodriguez-Lainz (Eds.), Migration and health: A research
Castan
methods handbook. Oakland, CA: University of California Press, p. 456.
45
Gany et al., ibid: p. 460.
40
Kirmayer et al., op. cit. note 5, p. E964. 46
Gany et al., ibid: p. 475.
41
Wierzbicka, op. cit. note 6, p. 312. 47
Comisiynydd y Gymraeg/Welsh Language Commissioner. (2012). My
42
Ibid: 313. language, my health: Inquiry into the Welsh language in primary care.
43
Ibid: 312–313. Cardiff: Author, p. 51.
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of (inter)cultural competence, in that the former is less able to rely on at care offered to populations that are often already more vulnerable in
least some regular contact with a specific community (e.g., indigenous terms of their social, political, and symbolic capital.
peoples, ethnic and/or ethno-religious minorities, deaf communities, asy- The danger of linguistic epistemic injustice, I have argued, may be
lum seekers, and refugees), which enables practitioners to optimize their effectively countered by fostering a sense of epistemic humility
communicative efficiency when providing care. Furthermore, as recent through greater metalinguistic awareness in the healthcare process.
(and relatively rare) work on language awareness in healthcare shows, a Despite the reality of language barriers, there exists a range of opera-
more linguistically sensitive health communication requires efforts not tive steps, varying in nature and required resources, which may be
only on the part of the individual practitioner, but also on the part of the taken in order to reduce the extent of the challenge of healthcare pro-
organization as a whole. 48
This suggests that efforts to address vision across those barriers. Beyond its contribution to better individual
language-based healthcare access disparities, through the cultivation of health outcomes among minority language speakers, finally, a more
linguistic epistemic humility, must meaningfully involve the healthcare language-aware healthcare process can further advance the health of
system as a whole. Much of the precise workings of such efforts in vari- the general population in multilingual societies, ensuring that both
ous institutional, and national settings, however, is likely to require a research and practice are held to a higher standard, and are carried out
high degree of context-sensitive analysis, planning, and implementation. in a more equitable manner.

This is ought to be seen as a cornerstone of a more equitable healthcare

provision for linguistic minorities, especially given the current limited ACK NOWLE DGME NT S
49
research on language-awareness training in healthcare settings. The author wishes to express her sincere gratitude to Matteo
Bonotti, Ryoa Chung, Gabriele Badano, and two anonymous
reviewers for their thoughtful comments and suggestions.
5 | CONCLUSION

Contemporary realities of global population movement increasingly CON FLICT OF INT E RE ST

bring to the fore the challenge of quality and equitable health provision The author declares no conflict of interest.
across language barriers. While this linguistic challenge is not unique to
immigration contexts and is likewise shared by health systems respond- ORC ID
ing to the needs of aboriginal peoples and other historical linguistic Yael Peled http://orcid.org/0000-0003-0816-6366
minorities, the expanding multilingual landscape of receiving societies
renders this challenge even more critical, owing to limited or even non-
AUT HOR B IOGRAP HY
existent familiarity of modern and often monolingual health systems
YAEL PELED is a research associate in language and health at the Institute
with the particular needs of new linguistic minorities. The centrality of
for Health and Social Policy, Faculty of Medicine, McGill University.
language to health beliefs, attitudes, practices, cultural scripts, and con-
Her main research interests lie in the political ethics of language, with
ceptual frameworks emphasizes its pivotal role in the healthcare pro-
special interest in questions of linguistic justice, and moral agency and
cess, and consequently in the adverse effects of treatment that is
autonomy in language.
language-insensitive and unaware. Such attitude on behalf of medical
authorities risks considerable epistemic injustice in the form of a
(mis)judgement of patients’ intelligence, credibility, and rationality How to cite this article: Peled Y. Language barriers and episte-
based on the language that they speak and the manner in which they mic injustice in healthcare settings. Bioethics. 2018;00:1–8.
speak it. Such misjudgements, consequently, are likely to result in https://doi.org/10.1111/bioe.12435
poorer health outcomes, by compromising the quality and equity of

48
Irvine, F. E., Roberts, G. W., Jones, P., Spencer, L. H., Baker, C. R., &
Williams, C. (2006). Communicative sensitivity in the bilingual healthcare
setting: A qualitative study of language awareness. Journal of Advanced
Nursing, 53(4), 422–434.
49
Roberts, G. W., Irvine, F. E., Jones, P. R., Spencer, L. H., Baker, C. R., &
Williams, C. (2007). Language awareness in the bilingual healthcare setting:
A national survey. International Journal of Nursing Studies, 44, 1179.