Confronting Diminished Epistemic Privilege and Epistemic Injustice in Pregnancy by Challenging a...

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Confronting Diminished Epistemic Privilege and Epistemic Injustice in Pregnancy by Challenging a “Panoptics of the Womb”

LAUREN FREEMAN*University of Louisville, Louisville, Kentucky, USA

*Address correspondence to: Lauren Freeman, PhD, Department of Philosophy, University of Louisville, 313 Bingham Humanities Building, Louisville, KY 40292, USA.

E-mail: [email protected]

This paper demonstrates how the problematic kinds of epistemic power that physicians have can diminish the epistemic privilege that pregnant women have over their bodies and can put them in a state of epistemic powerlessness. This result, I argue, constitutes an epistemic injustice for many pregnant women. A reconsidera-tion of how we understand and care for pregnant women and of the physician–patient relationship can provide us with a valu-able context and starting point for helping to alleviate the knowl-edge/power problems that are symptomatic of the current system and structure of medicine. I suggest that we can begin to confront this kind of injustice if medicine adopts a more phenomenological understanding of bodies and if physicians and patients—in this case, pregnant women—become what I call “epistemic peers.”

Keywords: epistemic injustice, epistemic peers, epistemic privilege, Foucault, phenomenology, pregnancy

I. INTRODUCTION

This paper is concerned with exposing, exploring, and confronting a specific type of injustice that many pregnant women suffer, namely, an epistemic injustice.1 An epistemic injustice is an injustice that one suffers with regards to one’s status as a knower. Like any injustice, it is harmful to the one who suffers it. The type of epistemic injustice that concerns me here occurs when claims that pregnant women make about their bodies are not taken seriously; when their desires and requests are systematically undermined, overlooked, or ignored; when their agency fails to be recognized; and when, as a result

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of being unheard and ignored, they are demoted to occupy a position of powerlessness. When this occurs, women cease to have epistemic privilege over their bodies. For pregnant women’s epistemic privilege over their bod-ies to be taken away is harmful in that it precludes their ability to exercise agency in medical situations; it can result in their becoming alienated from their bodies (and thus, from themselves); and it can negatively affect their sense of self and hinder their initial ability (and sometimes, desire) to bond with their new baby. It can also have harmful practical consequences with regard to the kinds and quality of medical and clinical care they receive. Being recognized as a knower whose claims have legitimacy and are taken seriously and having the ability to exercise agency are basic human values that are necessary in order to navigate social, public, and private domains. When one’s claims are not taken seriously and when one is rendered power-less as a result, this constitutes an epistemic injustice.

The kind of epistemic injustice that I have outlined is directly related to the inflated and problematic epistemic authority that many physicians and medi-cal professionals have over patients in general and over pregnant women in particular. One factor that bolsters this problematic kind of epistemic author-ity that physicians and medical professionals have over pregnant women’s bodies and that can result in pregnant women suffering an epistemic injus-tice is what I am calling a “panoptics of the womb.” This phrase was coined in the late 1980’s by the Chief of Maternal and Fetal Medicine at a Boston hospital (Hubbard, 1984, 349). The aim of a panoptics of the womb, he stated, is “to establish normative behavior for the fetus at various gestational stages and to maximize medical control over pregnancy” (349). This claim conveys the discipline of and control over women’s sexual reproductive capacities as a core patriarchal practice. A “panoptics of the womb” also conjures up Foucault’s work on panopticism. Below I will discuss some of the Foucaultian echoes of this term. Before doing so, however, and for now, it is also necessary to note that I will be using the phrase “panoptics of the womb” to refer to the predominance of and reliance on a visual paradigm of knowledge within the domain of pregnancy, the normalized medical surveil-lance used within this domain, and the technologies on which such a visual paradigm depends. It is the result of a paternalistic trend within medicine, combined with an overuse of and overreliance on certain technologies, and it manifests itself in the power that physicians and medical professionals have over pregnant women.

My aim in this paper is to interrogate the ways in which physicians’ knowl-edge/power can trump, discredit, and invalidate the legitimacy of women’s sensory, embodied experiences, and the testimonies women provide based on those experiences and to emphasize the problems that arise as a result. The state of affairs that concerns me is symptomatic of a patriarchal tradi-tion that not only privileges vision as the most informative sense modality, but that also takes the knowledge derived from vision to be conclusive and

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superior to other kinds of knowledge, for example, those derived from other sense modalities.2 Although the source of power that physicians have can be traced back, at least in part, to the status of vision as the most reliable sense modality, my focus will be both on the knowledge but especially on the power derived from this sense modality and on the institutional context in which this power is exercised. Specifically, the kinds of knowledge and accompanying positions of social, professional, and epistemic power that result from a panoptics of the womb are ubiquitous within the institution of medicine. They manifest themselves in the attitudes and practices of physi-cians; they influence the extent to which claims that women make about their bodies are recognized and taken seriously; and they can threaten the relationships that women subsequently come to have with their bodies.

In this paper, I show how the problematic kinds of epistemic power that physicians have can diminish the epistemic privilege that pregnant women have over their bodies and can put them in a state of epistemic powerless-ness. The result, I argue, constitutes an epistemic injustice. A reconsideration of how we understand and care for pregnant women and of the physician/patient relationship can provide us with a valuable context and starting point for helping to alleviate the knowledge/power problems that are sympto-matic of a panoptics of the womb. I suggest that we can begin to confront this kind of injustice if medicine adopts a more phenomenological under-standing of bodies, and if physicians and patients3—in this case, pregnant women—become what I call epistemic peers.

To be clear, my project is not motivated by a desire for the wholesale rejec-tion of technology within pregnancy, nor am I suggesting that women’s epis-temic privilege be considered sacrosanct to the exclusion of the epistemic authority and medical expertise of physicians. Indeed, there are many cases in which medical expertise results in effective and advantageous care for preg-nant women. Rather, my main concern is when the delicate balance between the epistemic authority of physicians and the epistemic privilege that pregnant women have over their bodies is lost and when the former is taken to be defini-tive without considering and appreciating the latter. This can occur because of an overreliance on certain technologies, an accompanying paternalism, and/or an inflated degree of epistemic authority on the part of physicians. The con-sequence is that the epistemic authority of physicians eclipses the epistemic privilege that pregnant women have, which amounts to an epistemic injustice.

There are four sections to my paper. First, I draw two distinctions that are necessary for my argument: (a) the distinction between two different ways of understanding the body: understanding it as Leib versus understanding it as Körper and (b) the epistemic authority of physicians versus epistemic privi-lege that women have over their bodies. Second, I provide some examples of how a panoptics of the womb works by considering how ultrasounds are used in pregnancy and how fetal heart monitors (FHMs) are used in labor.4 Third, based on the examples considered in Section III, I consider how the

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kind of knowledge and power bolstered by a panoptics of the womb can result in an epistemic injustice for pregnant women and what some of the implications of such an injustice are. Fourth and finally, I suggest that under-standing the body as Leib, not Körper, and building a relationship of epis-temic peers between physicians and pregnant women can help to confront epistemic injustice in pregnancy.

II. SETTING THE FRAMEWORK

For the purposes of this paper, two important distinctions must be drawn. The first is between Körper (material or objective body) and Leib (experi-encing, living, lived, or animate body). This distinction was introduced by Husserl, rigorously analyzed by Merleau-Ponty, and more recently taken up by a range of scholars who work within the phenomenological tradition and specifically at the intersection of phenomenology and medicine (see Husserl, 1970; Zaner, 1970; Toombs, 1987; Husserl, 1989, Leder, 1992; Husserl, 1997; Svenaeus, 2000; Zaner, 2000; Merleau-Ponty, 2002; Zaner, 2006; Carel, 2011, 2012). Whereas Körper refers to the physical body as an object of natural sci-entific study; Leib refers to the lived body as a living subject, focusing on the experiential characterization of the body. To understand the body as Leib is to emphasize the fact that we are bodies (we don’t merely have them), and moreover, that we are living bodies existing in the world, who are directly involved with and embedded in our surrounding environments that hold significance for us. For the most part, science in general and medicine in particular understand and treat the body as Körper, not as Leib, and it is the body understood as Körper that is operative in a panoptics of the womb.

The second distinction is one between epistemic privilege and epistemic authority. Epistemic agent P has epistemic privilege over Q about P’s bodily states insofar as only P has first-personal access to P’s bodily states. Pregnant women have epistemic privilege over their bodies insofar as only they have first-personal, immediate access to their bodily sensations, and on the basis of this access, only they can refer to their sensations and give testimony as evidence in support of claims about their bodily states. Such first-personal access gives pregnant women privilege over their bodies in that they have a unique epistemic route to facts about their bodies. To hold that pregnant women have epistemic privilege over their bodies does not mean that they are infallible when it comes to making claims about their bodies. Indeed, pregnant women are susceptible to mistakes and subject to corrections even about claims pertaining to the nature of their own bodily states. For exam-ple, when a woman who is pregnant for the first time feels the slight pain and discomfort of early contractions and thinks that she is in active labor, a physician or midwife, based on his or her knowledge and experience, can tell that in fact she is still in pre-labor and is only experiencing Braxton Hicks


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contractions.5 To maintain that someone has epistemic privilege over her body is to maintain that the way her body feels to her is a legitimate source of evidence for making claims about it. On the other hand, the epistemic authority of physicians is based on third-personal, disembodied, indirect, yet practiced and experienced expert knowledge. Even though a pregnant woman has epistemic privilege over her body insofar as she alone has access to how her body feels; a physician can still have epistemic authority over her body insofar as he or she has expert knowledge to interpret, explain, and if necessary, diagnose, and treat what a pregnant woman is feeling.6

I would like to claim that in a best-case scenario, in clinical encounters, patients in general and pregnant women in particular are epistemic peers with their physicians. Two epistemic agents are epistemic peers if they can both make legitimate claims to knowledge about S, and if their respective claims are taken seriously by each of them. A pregnant woman is an epis-temic peer with her physician if her physician acknowledges that she can make legitimate claims to knowledge and offer testimony about her body on the basis of her bodily sensations and if the pregnant woman acknowledges that her physician can also make legitimate claims to knowledge about her body based on his or her knowledge, experience, and expertise. Such a relationship is based on mutual respect, open responsiveness, and strong communication between women and physicians. Physicians create a dia-logic space in a supportive environment in which women feel comfortable talking about how their bodies feel to them and about what they are experi-encing (physiologically, psychologically, emotionally), asking questions, and engaging in related discussion. Moreover, in this space, physicians take the time to listen carefully to women’s accounts and concerns and to respond, speak to, and treat them as credible in offering testimony based on their first-personal experiences of their bodies.7 This kind of relationship can break down, however, if physicians fail to take seriously or dismiss the claims that women make about their bodies, thereby misusing the epistemic, social, and professional power granted to them by the institution of medicine. It can also break down if women fail to take seriously, dismiss, or ignore the claims that physicians make. In what follows, however, I will be interested exclusively in instances and situations where the epistemic peer relationship breaks down on account of physicians misusing their epistemic authority in ways that take away, or even eclipse, the epistemic privilege that women have over their own bodies.8

III. HOW A PANOPTICS OF THE WOMB WORKS

Now that these distinctions are in place, we can consider the workings of a panoptics of the womb and how it results in a harmful imbalance of epis-temic power between physicians and pregnant women. Before doing so,


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however, and within the context of the theme of a panoptics of the womb, it is helpful to note the history of how ultrasound technology came to be used in pregnancies in the first place. Fittingly for my project, the technol-ogy that ultrasounds employ was originally developed for military use in World War I, specifically, to detect and monitor submarines. The application of this technology to obstetrics came almost by accident in the 1950s when Dr. Ian Donald and his colleagues in Glasgow had the original idea to use this technology as a diagnostic aid on mysterious tumors in women’s abdo-mens.9 Only later did it occur to them that “the commonest abdominal tumor in women is pregnancy” (Donald, Interview, cited in Oakley, 1986, 155). When asked about using military technology on women’s bodies, Donald responded: “There is not so much difference after all between a fetus in utero and a submarine at sea” (Donald, 1969, 618). As one commentator notes, since ultrasound imaging began, pregnant women have been repre-sented as objects of mechanical surveillance rather than recipients of antena-tal “care” (Oakley, 1986, 159). In order to consider the extent to which this is still the case, I examine testimonies of pregnant women, gathered by vari-ous anthropologists who have studied the culture surrounding ultrasound technology in pregnancy (see Sandelowski, 1994; Mitchell, 2001; Levesque-Lopman, 2010). The following four examples elucidate what I mean by a panoptics of the womb.10

(1) It is common for pregnant women to know the precise date of con-ception, yet not to be trusted in this knowledge. When it is a question of the woman’s word over the date obtained from the ultrasound meas-urements, the latter “more precise” date always trumps the former (see Sandelowski, 1994, 239; Kukla, 2005, Note 27, 140), which often does not even correspond to the date of sexual activity that led to conception (see Mitchell, 2001, 123). In such cases, the woman’s knowledge is referred to as an “unreliable source” or “poor substitute” for the ultrasound-generated knowledge (Mitchell and Georges, 1997, 379).11 Ultrasounds thus enable physicians to “dispense with mothers as…necessary informants on fetal status” (Oakley, 1986, 155). By using technological instruments that provide what has come to be considered otherwise unavailable data, physicians establish their epistemic authority—based on third-personal, indirect, quan-tifiable knowledge—that is considered to be more reliable and accurate than a woman’s knowledge of the date of conception and also than her immedi-ate, often unquantifiable feelings of her pregnant body. It has been argued that fetal ultrasonography preserves a patriarchal arrangement of power and authority where technological surveillance of pregnancy constitutes a new but not unfamiliar order of control over women (see Arney, 1982). Thus, whereas physicians’ (as well as sonographer’s and nurse’s) epistemic authority is bolstered by knowledge derived from objective, quantifiable, verifiable, often visually based measures, women’s epistemic privilege, their status as knower, is diminished.


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(2) More strongly, for almost all of the women followed by the anthro-pologists upon whose work I draw, the ultrasound images that enabled them to see the fetus were far more powerful with respect to their “knowing” that they were pregnant than their own embodied sensations (Mitchell, 2001, 147). As Michelle recounts: “Seeing the baby meant that it’s really there. I’m not imagining things. It’s been barely four months and you really can’t see any results. Yes, I’m nauseated and have sore breasts. I’m tired and my stom-ach is sticking out. But seeing an image of the child, it’s reality” (Mitchell, 2001, 147, my emphasis). Julie notes that before her ultrasound, she’d simply “felt” different since having become pregnant, but as it turned out, the reality of the ultrasound was far more persuasive to her than any of her own bodily sensations (148). With these two testimonies, we see how the widespread reliance (both social and medical) on ultrasound technology—specifically, the way that it has become normalized—serves to diminish women’s trust in their own embodied sensations. Such reliance favors visual images that make the pregnancy more “real” and it also creates a situation in which women require other parties to confirm what they might very well already know themselves. This is another way in which a panoptics of the womb and the accompanying power afforded to medical practitioners diminishes women’s epistemic privilege over their bodies by distancing, even alienat-ing, them from their own bodies and embodied experiences and sensations.

(3) A third and particularly salient example of how a panoptics of the womb privileges third-personal knowledge at a distance over first-personal bodily sensation, thereby diminishing women’s epistemic privilege (and increasing their dependency on medical experts) can be seen in the testi-mony of Teresa. She remarks: “We could see it [the fetus] moving and I told her [the sonographer] I had felt it when I was taking the Metro [subway]. She said that wasn’t it, that I couldn’t feel it until a few more weeks. I thought for sure the baby was moving, but I guess not” (Mitchell, 2001, 173).12

The importance of this example is not primarily the fact that Teresa is cor-rected, but rather is the way that she is corrected. That is, the sonographer fails to recognize Teresa’s unique access to her bodily feelings, on the basis of which she can make claims about her body and what she is experiencing. As a consequence, the sonographer diminishes Teresa’s epistemic privilege insofar as Teresa’s claims, based on her bodily sensations, are not treated as amounting to knowledge, nor are they taken seriously as legitimate tes-timony. Here, we see just how much pregnant women’s epistemic privilege depends on the recognition of medical professionals, the repercussions of which will become more salient below.

With regard to the case of Teresa, let me be clear that there is an important difference between (a) acknowledging that what she felt might have been the fetus but insisting that in all likelihood it was not and (b) discrediting and dismissing her claim altogether. It is only in (b) where, given that medical professionals often do not give enough validation to women’s perspectives


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on their own bodies (let alone even take the time to listen to them [see Wen and Kosowsky, 2013]), women’s immediate embodied experiences are undermined, their avenue to making claims about their bodies is discredited, thereby resulting in the invalidation of their status as knowers or as someone who can give valid testimony.

One might respond by stating that the sonographer was justified in dis-crediting and dismissing Teresa’s claim since the former has expert knowl-edge on the matter, whereas the latter does not. Such a response, however, is shortsighted. Suppose that the sonographer is correct that Teresa could not have felt fetal movement. Here, it is important to consider the type of evidence on which the sonographer relies in making such a judgment. Most likely, the sonographer is drawing such a conclusion based on studies of pregnant women showing that, at Teresa’s stage of pregnancy, women do not feel fetal movement. It is quite unlikely, however, that such studies were conducted without consulting pregnant women. It seems unreason-able, then, to assume that researchers could conclude that women do not feel fetal movement without consulting women themselves. Thus, even if the sonographer has good empirical evidence to support her verdict, the manner in which she corrects Teresa is indicative of her failure to recognize Teresa’s epistemic privilege over her own body and, I would say, is a misuse of her epistemic authority.

The exchange between Teresa and the sonographer could have opened up a positive space for them to exist as epistemic peers where Teresa’s epis-temic privilege would not have been discredited and where the sonographer would have used her epistemic authority appropriately. Instead of Teresa being corrected and silenced, a dialogue could have occurred in which the sonographer asked Teresa to describe in greater detail what she took to be fetal movement. In response, the sonographer could have taken seriously Teresa’s account, considered her description of her sensations more care-fully, and responded in a way that recognized that Teresa might indeed have felt something that resembled fetal movement, even if in all likelihood, at this stage in gestation, the fetus is still too small for its movements to be felt.

(4) Let us now consider how FHMs are used during labor. In so doing, we will see the strongest example of how the knowledge and epistemic author-ity based on technologically mediated, visual representations discredits and trumps laboring and birthing women’s first-personal embodied sensation and the kinds of knowledge and testimonies that they provide on the basis of their embodied sensations. In the next section, we will consider the impli-cations of the inflated epistemic authority of medical practitioners diminish-ing the epistemic privilege that pregnant women have over their bodies.

FHMs concurrently detect fetal heart movement and women’s contractions and create a visual record of both in the form of two graphs, printed side-by-side. Monitoring contraction patterns alongside fetal heart rates is important, because the latter is nearly impossible to interpret without knowing when


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a contraction is occurring. In order for the monitors to record continuous measures, two transducers must be strapped on to the laboring woman’s abdomen, which requires her to lie still and prone and which thereby ren-ders her immobile. These instruments are part of a larger trend of medical-ized surveillance in that they allow medical practitioners to keep constant and continual watch over multiple women concurrently, since the readouts from the monitor are simultaneously transmitted both to a printout next to the woman’s bed, and also to a centralized computer monitor in the nursing station.

When FHMs are used, women’s bodies and embodied claims to knowl-edge of the progression of labor tend to be discredited, dismissed, and often altogether ignored. This occurs for at least two reasons: first, because there is a time lag between a contraction and its uptake in the monitor and second, because the measures taken to be definitive are those of the moni-tor and not of the woman herself. It is extremely common for laboring and birthing women to describe an immediacy and certainty of knowing their bodies and, specifically, when it is time to push. Many women who have been hooked up to fetal monitors report that when they experience a strong contraction, and feel that labor is progressing and that it is time to push, the nurses tell them to “stop pushing!” Common is for nurses to continue: “We are not ready since by our clock, it’s not yet time” (Testimony cited in Louise Levesque-Lopman, 2010, 108). Once the monitor catches up to and records the woman’s contraction, however, she is then told that it is time to push.

In situations like this, two kinds of knowledge are in conflict. On the one hand, we have technologically mediated, visually based, third-personal knowledge of medical practitioners and on the other, we have first-personal, embodied sensations, and felt knowledge of laboring women. In situations where the two are in conflict, the former trumps the latter since the sen-sory, bodily experiences of pregnant women are considered to be less reli-able and less conclusive than more objective measures. There are, however, problems with this model.

Such strong trust in and reliance on FHMs not only literally directs attention away from the expectant woman toward the monitor, but it also mediates her experience of labor, since what becomes most important is document-ing, timing, charting, and measuring her contractions and not always paying as close attention to her behavior, experience of, and condition and feel-ing in the situation, all of which tend to tell us more about labor and its progression than quantitative representations and measurements (see Leslie Everest [doula], 2010a 2010b, personal correspondence). Iris Young writes: “Such instruments transfer some control over the means of observing the pregnancy and birth process from the woman to the medical personnel. The woman’s experience of these processes is reduced in value, replaced by more objective means of observation” (Young, 2005, 58).13 Thus, we see that instead of relying on women’s own embodied sensations and accounts of


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such sensations, the increased reliance on technologically mediated instru-ments and visual representations in pregnancy, labor, and birth can lead women to become alienated from their own experiences, from their bodies, and, ultimately, from themselves, since their first-personal experiences are supplanted with objective measurements of their experiences.

Not only is the way that FHMs work an example of visually based knowl-edge trumping embodied, felt knowledge, but the same technology that keeps surveillance over laboring women has two further consequences, both of which are related to the power of a panoptics of the womb and, relatedly, to the inflated epistemic authority of medical practitioners, and both of which further diminish the kind of agency (epistemic and otherwise) that women have in labor and birth. The first consequence is that the traditional use of FHMs renders laboring women to be literally passive in labor; the second is that it can lead to worse outcomes for women. Women become literally passive and powerless when FHMs are used in a traditional way, because in order to be continually monitored by such machines, they must lie prone and still so that the machine can take accurate readings. It is well known, how-ever, that lying prone and still is possibly the worst position for advancing labor, since it closes the pelvis by up to 30 percent and requires the fetus to work against gravity (Mendez-Bauer and Newton, 1986; Gardosi, Sylvester, and Lynch, 1989). Moreover, lying prone and being immobile slows labor down, which tends to result in worse outcomes for women; for example, it leads to longer, harder, often more painful labors, which then leads to a cas-cade of interventions (e.g., requiring Pitosin to speed up contractions, epidur-als, Caesarean sections). Thus, with FHMs, not only are women’s experiences of and testimonies about their bodies—their epistemic privilege—trumped by technologically mediated visual data and by the accompanying inflated epis-temic authority of medical practitioners, but the excessive use of such moni-tors further entrenches a kind of control and mastery over laboring women by rendering them to be passive and subject to all sorts of interventions that in other contexts would likely have been unnecessary.14

From these examples, we can draw three preliminary conclusions. On the basis of the inflated epistemic authority and accompanying power that medi-cal practitioners come to hold over women’s bodies which are supported and bolstered by a panoptics of the womb: (a) women tend to disappear from and not be trusted with respect to certain moments within their own pregnancies (e.g., dating), thereby diminishing their credibility; (b) women privilege seeing images of their bodies over feeling them as a basis for knowing them, which can result in their becoming alienated from their bod-ies and, thus, from themselves; (c) and most importantly, privileging images of (or data pertaining to) their bodies and the fetus over their own embod-ied sensations, along with the accompanying power of medical practition-ers, women are invalidated as knowers with respect to their own bodies. Moreover, with regard to the use of FHMs, women tend to become passive


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and powerless in their labors. Thus, a panoptics of the womb—and in partic-ular the power it confers on medical practitioners—trains women to distance themselves from their bodies in general and from their lived experiences of pregnancy and labor in particular by relying on medical interpretations of their experiences (based by and large on visual images and data obtained from them) over their own bodily sensations. The epistemic authority of physicians thus gains more credibility, thereby giving them more power and diminishing the epistemic privilege that women have over their bodies. These components further entrench medical control over pregnancy by (a) placing greater value on experience at a distance as opposed to direct bodily sensation and experience of the fetus and (b) increasing women’s depend-ency on medical experts and their technology.15 The point that I would like to reinforce is that the epistemic authority over women’s bodies increases at the expense of their own epistemic privilege over their bodies.

Let me repeat that my point is not that we should stop using FHMs.16 The problem is not with technology per se, but rather with the way that it is deployed and the motivation behind its deployment. In this context, my point is to highlight how the traditional ways in which the technology is used is a part of a panoptics of the womb, which aims to gain control over women’s bodies: the problem then is not restricted to the agential level of individual physicians but is also and perhaps more insidiously a structural problem within the institution of medicine. That is, this control must be seen within the broader context of systematic domination over women’s bodies, where women are rendered powerless—both physically and in terms of their capacities as knowers of their bodies. My main concern on which I focus in what follows is how such powerlessness can ultimately lead to women suf-fering an epistemic injustice. Another related concern that I discuss is that while existing in this powerless state, women can also suffer both physically and emotionally in terms of worse outcomes for their labors and births.

Before considering how a panoptics of the womb results in an epistemic injustice for pregnant women, I would like to elaborate a bit further on why I am using the Foucaultian framework of a panoptics. A panoptics of the womb, I want to claim, can be understood as a contemporary example of what Foucault calls panopticism.17 As Foucault recounts in Discipline and Punish, the major effect of the panopticon is to induce in the inmate a state of conscious and permanent visibility that assures the automatic functioning of power. With the shift to panopticism, power becomes ubiquitous in that “what are required are mechanisms that analyze distributions, gaps, series, combinations, and which use instruments that render visible, record, differ-entiate, and compare” (Foucault, 1995, 208). The key shift—one that is also operative in a panoptics of the womb—is that the multiple layers of power have their intensity precisely insofar as they have become institutionalized, normalized, and, as a result, internalized into the bodies under its control. One example of this is the way that ultrasound technologies—which render


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the fetus visible, record it, and “interpret, evaluate, and set the standards of normalcy for the various changes associated with the different stages of pregnancy” (Sherwin, 1992, 100)—have become normalized, so much so that getting ultrasounds is now considered to be an important part of preg-nancy. It is no longer even part of the standard medical discourse to discuss whether ultrasounds are necessary in low-risk pregnancies, nor do they fall under the domain of requiring informed consent (Mitchell, 2001, 5, 44).

Panopticism refers to a schema of generalized surveillance that is powerful precisely because it is not localized, but rather operates structurally in and through our bodies. We see this in the ways that women cease to trust their own first-personal experiences of their bodies and instead defer to medical experts who base much of their knowledge on technologically based, visual data. Moreover, much of the power—the epistemic privilege—that medical practitioners have gained is bolstered by their position vis-à-vis the institu-tion of medicine. That is, their power and its motives of mastery operate both agentially but also structurally, such that there is not necessarily any agent exercising it. Foucault writes: “The medical gaze was also organized in a new way. First, it was no longer the gaze of any observer, but that of a doctor supported and justified by an institution, that of a doctor endowed with the power of decision and intervention” (Foucault, 1994, 89). We can understand the panoptics of the womb to be an instance of panopticism insofar as with its emphasis on and use of quantifiable data derived primarily from visually based technologies, it too is “a power that insidiously objecti-fies those on whom it is applied; to form a body of knowledge about these individuals” (220). Through a panoptics of the womb, just as in panopticism, the formation of knowledge and the increase of power—both bolstered by technological advancements—reinforce one another. Now that we have seen how a panoptics of the womb can be understood as an instance of pano-pticism, we can spell out more explicitly one of its consequences, namely, that it can result in an epistemic injustice for pregnant women. Following this discussion, we can also consider some of the consequences of such an injustice.

IV. FROM A PANOPTICS OF THE WOMB TO EPISTEMIC INJUSTICE

As we have seen, a panoptics of the womb and the kind of epistemic power that it grants to medical practitioners discredits women’s lived bodily expe-riences insofar as, throughout pregnancy and during labor, their sensory experiences are invalidated as legitimate avenues to knowledge in favor of more “objective,” technologically mediated, visual, often quantifiable measures. The upshot is that women can experience diminished epistemic privilege over their bodies. One immediate consequence is that women are not epistemic peers with their medical practitioners. Instead, they exist in


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a state of epistemic powerlessness wherein they are demoted to passive as opposed to active agents in their pregnancies and labors, where their claims are not heard, and in a worst-case scenario, where they are silenced. Such a demotion, I would like to claim, is the result of what Miranda Fricker calls “epistemic dysfunction” (Fricker, 2007, 16) in testimonial exchanges: when the hearer makes an unduly deflated judgment of the speaker’s credibility, which results in the hearer missing out on knowledge of the speaker. In such cases, the hearer does something morally wrong in that the speaker is wrongfully undermined in her capacity as a knower on the basis of an imbalance of power.

On the basis of such epistemic dysfunctions, we have seen that preg-nant women can come to depend upon third-personal knowledge in order to understand and interpret their bodies, thereby becoming alienated from themselves. Demoted from agents (or knowers) to patients, they can enter into tenuous relationships with their bodies insofar as they require them to be constantly monitored and diagnosed by experts. As Maureen Connolly writes, “[w]hen a woman – or anyone – in a clinical encounter is placed in a situation of having to deny and distrust her felt sense of her own embodi-ment, then there is no ground for lived relation” (Connolly, 2001,190). It is precisely this lived relation to one’s own body that is threatened by a pano-ptics of the womb and, as such, contributes to women’s resulting diminished epistemic privilege.

Women who experience diminished epistemic privilege over their bodies and who exist in a state of epistemic powerlessness suffer an epistemic injus-tice: they are wronged in their capacity as knowers. By employing the broad term epistemic injustice, I am drawing more specifically on what Fricker calls “testimonial injustice” which refers to an injustice that occurs to a knower when her credibility fails to be recognized as she tries to advance a claim, idea, hypothesis, or even to persuade someone of something. For Fricker, testimonial injustice is an injustice suffered by a speaker when “prejudice causes a hearer to give a deflated level of credibility to a speaker’s word” (Fricker, 2007, 1).18

Developing and applying Fricker’s idea to the present context, we can say that the prejudice at work is rooted in the institutionalized practice of medicine combined with the fact that vision is considered to be the most reliable and credible sense modality. Such a prejudice also stems, in part, from the ubiquitous notion of body conceived as Körper, or mere object, operative within medicine (see Leder, 1992). Bodies understood as Körper are thought to be unintelligent matter and therefore are not considered to be reliable sources of information about themselves. Moreover, at play is a prejudice against women’s embodied knowledge, exacerbated by the tradi-tional idea of pregnant women as being particularly vulnerable. The preju-dice stems from the fact that pregnant women are not considered to know, to be in tune with, or to be able to “read” their own bodies, and for this


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reason require their bodies to be read and interpreted for them by means that are not direct or immediate.19 These prejudices are constitutive of and fuel a panoptics of the womb and the resulting inflated epistemic authority of medical professionals.

Undeniably, in many medical contexts—including certain contexts within pregnancy and especially in labor—some of what I have called “prejudices” can be true: many women indeed might not know what is going on with their bodies. More generally, it is often the case that medical patients are also unable to read, interpret, or diagnose changes, pains, or growths in their bodies; furthermore, there are often malignancies and symptoms that people cannot even feel or see (with our own eyes). This is why we go to, and put our trust in, physicians in the first place. There is then an important sense in which physicians’ exercise of epistemic authority is not always or necessarily a bad thing. The claims that I am making, therefore, are not meant to cover all medical contexts, nor even all contexts within pregnancy, for indeed there are many contexts in which we want our physicians to exercise their epistemic authority. Rather, with regard to suffering testimonial injustices in pregnancy, I am concerned with instances (like the ones discussed above) where women are in tune with and do know their bodies, yet because of the institutionalized power/knowledge structure in which a visual paradigm of knowledge is rooted, they are not taken to be credible in what they know. This loss of epistemic privilege is a common experience for many pregnant women, but it tends to be exacerbated for women of color, women of low socioeconomic standing, women from non-Western cultures, women who are not proficient in English, very young women, and women with cogni-tive or physical disabilities. When these women are seen through the lens of various stereotypes, it affects the ways they are treated by medical prac-titioners—specifically, the extent to which their claims are dismissed—and subsequently, the kinds of care they receive (see Sherwin, 1992, especially Chapter 11).

In case it is not clear how a panoptics of the womb, the related inflated epistemic authority of physicians, and their subsequent treatment of preg-nant and laboring women constitute an epistemic injustice, let me expand. A clinical medical encounter is supposed to be a context in which patients can be open and honest, can share what they are feeling or experiencing, and are listened to and taken seriously by medical practitioners. When a preg-nant woman—or anybody in a clinical encounter—feels something peculiar, painful,20 different (or even familiar, but potentially problematic), and relays this sensation to a physician who responds with skepticism or distrust, or who says that based on this test, this image, or this statistic, she is not feeling what she says she feels, or that she is not in pain—or even worse, if a physi-cian cuts off, interrupts, or dismisses the claim altogether—then it can deeply penetrate the psychology of the subject in a variety of ways. It can result in women feeling rejected, ignored, belittled, and ashamed (see Hoffman and


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Tarzian, 2001; Werner and Malterud, 2003); it can result in women feeling intimidated by and even afraid of the physician who becomes an unap-proachable figure of authority (Werner, Isaksen, and Malterud, 2004); and it can result in a lack of confidence and in emotional distress (Werner and Malterud, 2003). This is the case for a one-off occurrence, but it can be even more harmful when the dismissals, disbelief, and distrust occur on an on-going basis. In such instances, women must work extra hard just to be taken seriously, believed, and deemed credible by medical practitioners, and this is an injustice in the sense that it causes harm. It causes harm to the woman in that she cannot exercise her agency, since she is not taken seriously, not listened to, and not heard. It is especially an injustice within the context of health care, where physicians are supposed to treat, heal, and cure illnesses, and in the context of pregnancy, where physicians are supposed to ensure that woman are healthy, developing, and thriving.

By dismissing or ignoring what pregnant women say, physicians commit an epistemic injustice in that they fail to treat pregnant women as knowers. It is an epistemic injustice in the sense that pregnant women are not perceived by medical practitioners as being credible, nor are they even heard, with regard to claims they make about their own bodies. Specifically, their testi-monies and descriptions that legitimate the kinds of knowledge they have of their own lived bodies are put into question, deemed inaccurate, discredited, and often altogether ignored. They are thus devalued and deflated, wrong-fully undermined in the claims they make about their bodies, and, therefore, wronged in their capacity as epistemic agents. Such harms constitute an intrinsic epistemic injustice in that a privileged relation to and knowledge of one’s body is essential to one’s sense of self, which is an essential human value. Suffering an epistemic injustice of this sort can have serious implica-tions for one’s agency in pregnancy, labor, and birth; for one’s sense of self more generally; and for one’s existence as a new mother.

The following three testimonies in different ways provide examples of both the harm of suffering an epistemic injustice in labor and birth and also of how suffering an epistemic injustice can affect one’s role as a new mother.21 Reflecting on the birth of her son, SA reported feeling as though she was “assaulted” by aggressive doctors who not only ignored the claims that she was making about her body when she was in labor and during birth, but also took away any agency and control that she might have had during that time. Afterwards, she reported having violent post-partum nightmares in which she relived the trauma of feeling powerless against the words and actions of physicians. These experiences contributed to an already intensi-fied post-partum vulnerability and also to a heightened sense of disconnec-tion from her new baby (and also from her body and from her sexuality).

In another case, NS explicitly told the doctors and nurses (both verbally and in writing) that she wanted to hold her baby close right after she was born. Not only did the medical staff laugh at this request (as well as at all


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of her other requests) but they also did not comply with it (or any of the others). She described her situation as such: “No choices, no control, you are at the mercy of the doctor’s decisions” (NS, personal correspondence). Subsequently, she felt a deep sense of sadness, anger, and disappointment not only for having lost the first opportunity to connect with her new baby, but also for having been systematically ignored. She felt and was powerless in her situation.

In a third case, not only were VH’s birthing preferences systematically ignored, but none of the physical sensations that she reported to medical professionals were taken seriously. These factors, combined with the bad luck of being the victim of incompetence on the part of the medical pro-fessionals, resulted in a horrific and disorienting 7-day labor. VH reported feeling angry and depressed following the birth of her son, and these pro-found feelings deeply affected her relationship with her newborn for the first month of his life. Instead of being able to bond with him, she was focused on “the physical and psychological aftermath of the week of labor…[com-bined with] the internalized feelings of anger coming from self-blame” (VH, personal correspondence). Her testimony demonstrates in a very personal way the larger point I am making about the lasting effects on many women who suffer epistemic injustices in labor and birth. She writes:

The questions of why I did not listen to my body, why did I allow someone else to dictate my reality and why did I not act sooner and stand up for myself when it became clear to me that my health and well-being were not [the medical prac-titioner’s] primary concern plagued me for a while. The whole experience left me feeling disempowered…This feeling of disempowerment caused me to have a lot of self-doubt in terms of my capability as a new mother. I did not feel competent in nursing and caring for my baby and because of this, I felt alienated from my child. I felt more fear than joy… (VH, personal correspondence)

All of these examples illustrate ways in which epistemic injustices suffered by laboring and birthing women can not only cause immediate harm to them but also have an effect on their relationship to their newborn babies and impact their roles and feelings as new mothers.

As I have already discussed, on the basis of a panoptics of the womb that supports the inflated epistemic authority of physicians at the expense of women’s epistemic privilege over their bodies, in pregnancy, labor, and birth women can feel as though they are patients, not active agents in control of and in tune with their bodies. We have seen in particular how FHMs are used as a means of depriving women of control over and power in labor. This loss of agency with respect to such a personal and powerful experience can be damaging. It can cause women to no longer “hear” and therefore become alienated from their bodies, thereby becoming more (and overly) depend-ent on medical interpretations of their bodies.22 Being embodied—listening to and hearing one’s body—is fundamental to the way that we exist in the world, in that the body is the very basis of our existence: the point from


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which any interaction with the world occurs. Insofar as this is the case, such alienation from one’s body can be traumatic: specifically, if one becomes disjointed from one’s body and requires constant external validation that one is really feeling what one feels. Being alienated from one’s body can also have implications for feeling alienated from one’s sexuality, which can be an especially delicate issue after the birth of a child. Being pregnant is already emotionally and physically difficult and disorienting.23 Once preg-nant women become alienated from their bodies, their basic point of depar-ture for and attunement to the world and to others is shattered. Embodiment, subjectivity, perception, and action are all interrelated. More often than not, a change to (one’s relation to) one’s body can have serious implications for one’s sense of self and the way that one exists in the world and with others. Moreover, if pregnant women are no longer attuned to themselves, then it is difficult to attune themselves to a new baby and to navigate the world in this new and already disorienting role as mother.

V. CONFRONTING EPISTEMIC INJUSTICE IN PREGNANCY

How then to confront such an epistemic injustice? To conclude, I will sug-gest that there are at least two related ways of doing this. The first (following the work of S. Kay Toombs, Drew Leder, and more recently, Havi Carel) is for medicine to shift its conceptual and practical understanding of bodies from Körper to Leib; the second is for physicians and pregnant women to exist, relate to, and treat one another as epistemic peers.

We have seen how pregnant women’s epistemic privilege is diminished by a panoptics of the womb and the inflated epistemic authority of physi-cians, both of which are sources of a wider tendency toward epistemic injus-tice within the practice of medicine. For physicians to base their epistemic authority on privileging what is seen over what is felt is a consequence of the dominant concept of body that prevails in Western medicine, namely, that of Körper (see Leder, 1992). Material objects can be measured, quanti-fied, predicted, represented, reified, disciplined, surveilled, and controlled, all of which work in the service of a systematic domination that dimin-ishes and often revokes the epistemic privilege that women have over their bodies, thereby rendering them epistemically powerless. Shifting medicine’s understanding and treatment of the body from Körper to Leib and supple-menting visual knowledge and power with embodied knowledge derived from first-personal sense modalities will help to elevate the epistemic status of pregnant women insofar as bodies will not be understood and treated as mere objects which can always be best known in the third person. Rather, they will be understood and treated as living, animated, affective, credible beings in the world about which and whom legitimate information can also be derived first-personally.


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With this shift, women’s embodied experiences, though fallible, could be epistemically validated and recognized as reliable avenues to knowl-edge and not necessarily seen to be inferior to the mediated, visually based knowledge claims of physicians. In order for this conceptual and practical shift to occur, a major re-vamping of the way that physicians are trained is necessary, which is slowly beginning to happen in medical schools.24 Although pedagogical changes can begin to address the agential dimension of a panoptics of the womb and the inflated epistemic authority it grants to physicians, only over time can these changes to the agential dimension of problematically imbalanced power dynamics begin to infiltrate the structural dimension of the problem.

Treating a pregnant woman as Leib, however, is a necessary but not a sufficient condition for confronting this problem. Related to and building on this shift to understanding and treating bodies as Leib is the second way of challenging the epistemic injustice at stake: namely, that physi-cians and pregnant women become epistemic peers. One cannot become epistemic peers with an object (Körper). One can, however, become epis-temic peers with a living body, a person who exists in the world, whose claims to knowledge are deemed credible, taken seriously, and engaged with in a supportive, open, dialogic, and comfortable environment. The epistemic peer relationship overturns a more traditional, paternalistic understanding of the physician–patient relationship where the operative role that physicians tend to play is one of stranger (Childress and Siegler, 1984, 22), an expert who is never to be questioned and to whom patients defer all power. Traditionally, we think of patients putting themselves in the hands of physicians, who, in turn, tell them what is necessary, often not dialogically, and not in an environment that feels safe and open (22). The result of this traditional model is that patients in clinical encounters often feel intimidated, rushed, and uncomfortable to engage in dialogue and to voice their questions and concerns. Due to the asym-metry of power, patients tend to feel vulnerable and afraid that if they do voice their concerns, they will be dismissed. They tend to feel inhibited by physicians who occupy an authoritarian, rather than an authoritative role, and therefore who seem, as S. Kay Toombs has written, to exist in a different “world” (Toombs, 1987). Even if patients are not inhibited to voice their concerns, they often fear the consequences of becoming more assertive: that if they are, they will be labeled “difficult,” which could compromise the kind of care they receive.25 On this model, the extent to which physicians have epistemic authority is so great that it eclipses any epistemic privilege that patients could have over their bodies. This relation—where physicians have epistemic authority at the expense of the epistemic privilege that patients have over their own bodies—constitutes an inadequate exercise of power, yet it has become normalized so much so that we tend not to question it.


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To be clear, the problem is not that physicians have epistemic author-ity or use visually based technologies. Indeed, physicians are experts and we go to them precisely in order to benefit from their expertise. Moreover, and within the context of pregnancy, even insofar as physicians have epis-temic authority, pregnant women can still be epistemic peers with them, so long as physicians acknowledge that women have epistemic privilege over their bodies, and on that basis can make legitimate claims about their bodies that are taken seriously. However, the epistemic peer relationship can break down when visual, technologically mediated kinds of measure-ments or observations and the knowledge and power derived from them are assumed to be the only legitimate ways of obtaining knowledge about preg-nant women and when, as a result, pregnant women’s own testimonies or accounts are ignored, dismissed, or deemed non-credible. As we have seen, when this occurs women suffer a diminished epistemic status: their claims to knowledge are considered to be merely subjective, affective, unquantifiable, and therefore inconclusive. Whereas women should have epistemic privi-lege over their bodies, even if they lack epistemic authority, in the state of affairs with which I am concerned—which seems to be the majority of preg-nancies in North America—the epistemic authority of physicians eclipses and renders null and void the epistemic privilege that pregnant women have over their own bodies. When this occurs, there is no longer a foundation for being epistemic peers. That is, within a visual paradigm of knowledge that relies heavily on technologically mediated representations of our bodies on the basis of which knowledge claims are made and on the basis of which epistemic power is held, such visually based knowledge and the power that accompanies it trump the kinds of claims that are made on the basis of the first-personal, direct givenness of women’s embodied experiences. Because of this, medical professionals often do not give enough validation to women’s perspectives on their own bodies, which results in their suffering a diminished epistemic status.

Confronting the injustices that result from a panoptics of the womb and the related and problematic imbalance of power thus requires us to build a different kind of relationship between pregnant women and their physi-cians. One reason I am suggesting that this relationship can and should move in the following direction is because in the context of this discus-sion on pregnancy, we are (most often) not talking about the relationship between physicians and patients suffering from some pathology, where the patient does not know what is going on with them and thus cannot make claims to knowledge about their bodies that would help the diagnosis and treatment. Pregnancy is different in that pregnant women are not suffer-ing from a disease, and therefore, are not seeking a diagnosis or cure.26 Moreover, they often do possess valuable knowledge about their bodies that ought to be taken seriously. As we have seen, sonographic imaging can represent movements of the fetus and the woman’s contractions (but often,


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not accurately or adequately, as we saw with FHMs during labor); however, they cannot replicate the first-personal sensation of what the woman experi-ences with such movements. They cannot represent the body as lived. It is for these reasons that pregnant women’s words and testimonies are so valu-able and why they can and should be deemed credible (or at the very least, acknowledged) especially in the face of conflicting data from visually based technologies. In order for this to happen, pregnant women must exist as epistemic peers with their physicians. As I have shown, there are epistemic, pragmatic, and moral reasons why physicians and pregnant women should exist as epistemic peers.

In order to think through what it means to exist as epistemic peers, we can return for a moment to Fricker from whom we can borrow the notion of what she calls “testimonial sensibility,” which is a form of socially incul-cated rational sensitivity trained by numerous experiences of individual and collective testimonial exchange (Fricker, 2007, 5). I would like to suggest that becoming epistemic peers requires the professional virtue of testimonial sensibility on the part of physicians, in addition to the skill of being a com-passionate listener and empathetic responder. It requires physicians to take the claims of pregnant women seriously and treat them credibly. As Fricker writes: “This real life training [of testimonial sensibility] instills in the virtu-ous hearer empirically well-grounded habits of epistemically charged social perception, and thus reliable perceptual judgments of speaker credibility” (5). Becoming epistemic peers requires that physicians strive to achieve this virtue.27

My point is that if the first-personal, unmediated, sensed dimension of the experience of pregnancy is deemed more credible than it tends to be, and if it is considered to have more legitimacy than it currently does, then women can begin to regain epistemic privilege over their bodies. This will help them to exist as epistemic peers with medical practitioners. Taking these suggestions seriously could help to shift the context of physician–patient relations so that women’s claims are seen to be more credible and legitimate the epistemic privilege that they have over their bodies. It could also begin to offset the prejudice against the kind of embodied knowledge that I have been discussing. Women’s lived bodily experiences could be integrated into more holistic clinical dialogues between felt knowledge and technologically mediated, expert knowledge. This shift would not eliminate the use and importance of sonographic technology in pregnancy nor would it reject the epistemic authority of physicians. Rather, it would create a context in which both kinds of knowledge, authority, and privilege are integrated through openly responsive, respectful dialogue that enables women and physicians to exist as epistemic peers. Moreover, it would help to situate the way that we view images within a different paradigm of knowledge: one that is not wholly based in vision, but that recognizes that other sense modalities can be equally important. If this kind of relation becomes more common in clinical


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dialogue, then we can begin to confront, reduce, and perhaps even elimi-nate these kinds of epistemic injustices that pregnant women suffer. Existing as epistemic peers with their physicians, it is less likely that women’s epis-temic privilege will be diminished (at least in the ways we’ve discussed) and therefore less likely that they will suffer epistemic injustices (in these ways).

NOTES

1. For a robust account of epistemic injustice, see Fricker (2007), especially Chapter 2. In what follows, although I will be using several of Fricker’s terms, I will not always be using them in exactly the same ways that she does or in the ways that she necessarily intended them to be used.

2. Let me clarify how I’ll be using the term “knowledge” throughout this paper. In order for some-thing to count as knowledge in this context, one need not be certain that it is absolutely true. It might be better to think of what I mean by “knowledge” or “embodied knowledge” in these circumstances as a “feeling of knowing,” “articulable sureness,” or “phenomenological sureness.” In many instances, women experience a degree of certitude with respect to such claims. Often, what they are feeling is not ineffable and there is a kind of authoritative feeling of knowing, given that the subject of the claim is one’s own body. However, as embodied beings, we all know that when we claim to “know” something about our bodies, this kind of knowledge is quite different from knowing that it is raining or that the cat is on the mat. It is in the context of this murky area of embodied knowing that I will be using “knowledge.”

3. To further motivate the problem under consideration, it is worth considering the very fact that within a clinical setting we call pregnant women patients at all. We tend to think of patients as sick, injured, diseased, and often, frail, vulnerable, and incapacitated. For most healthy pregnancies, however, none of these states is a reality, at least most of the time. Thus, we can already see a conceptual problem insofar as we consider pregnant women to be patients. Another connotation with the term “patient” is that they are passive. As we shall see, the reality associated with this connotation is another part of the problem at hand, especially when we consider the kinds of power dynamics at work between pregnant women and physicians.

4. It is important to note that in no way do I mean to equate the two very different experiences of pregnancy and labor. For example, in labor women often do not know much of what is going on with them, and are often not in a position to make reasoned judgments about certain aspects of their situation (which is why many women hire birthing coaches or doulas to help them). The kinds of claims in which I am interested, however, are ones where women do know their bodies and are in a position to judge: for example, knowing when it’s time to push. This is not a judgment about a proposition, rather, it is another kind of judgment based on an embodied knowledge of what a woman’s body is “telling” her. The problem I will be concerned with is when this embodied kind of first-personal knowledge is discredited in favor of visually based third-personal data.

5. But even in examples like this one, it is often the case that physicians’ epistemic authority still requires women’s first-personal experience of her bodily state.

6. It is also the case that a pregnant woman can have both epistemic privilege and epistemic authority over her body if she has third-personal disembodied knowledge, for example, from reading about pregnancy or talking to other women who have been pregnant.

7. An article published in Health Affairs attests to the need for more relationships of this kind within medicine (cf. Frosch et al., 2012).

8. In this context, one might even say that at least sometimes pregnant women, and patients more generally, actively give up the epistemic privilege that they have over their bodies on account of the recognition they seek from physicians. This points to one of the many complex ways in which the power dynamic between physicians and patients operates, which is the result of the kind of power granted to physicians not only by the institution of medicine but also by their position in society more generally (see Wendell, 1996, Chapter 5). I’d like to thank Ami Harbin for her thoughts about the bidirectionality of this kind of relationship and about the power dynamics that transcend clinical encounters.

9. Fetal sonographic technology works by using high-energy sound waves that enter women’s bodies; reflect off of flesh, internal organs, amniotic fluid, and bone; and are converted into electrical sig-nals displayed as dots on a screen. It has developed to allow us to visualize and measure fetal anatomy,


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growth, and development; to detect fetal sex and a variety of fetal pathologies; and to predict the due date by measuring the fetus. In pregnancy, an ultrasound image is obtained by having a pregnant woman lie prone and still on an examination table and expose her abdomen. Conducting gel is squeezed onto her lower abdomen and a sonographer or physician rubs a transducer probe around in order to get a readable image of the uterus and fetus. As I’ve already said, in discussing ultrasound technology, my aim is not to reject it, since it can do much good. For example, many women need the technology for medical and/or psychological reasons. I have already mentioned the medical reasons for using this technology—also see Bliton (2001) for a discussion of many positive advancements in the technology. With regard to the psychological benefits, we can imagine a situation in which a woman has had a scare that she has miscarried. In this case, the ultrasound image can serve as reassuring confirmation to the fact the fetus is still alive and healthy. This is a clear case of a fruitful use of the technology in that it fosters bonding and quells the anxiety of the pregnant woman. Sandelowski (1994) discusses other cases of women who feel closer to their fetuses after their ultrasound examinations. On the other hand, recently in the United States, there have been many clear misuses of the technology, specifically, politically motivated require-ments for women who are seeking abortions to undergo transvaginal ultrasounds that have no medical benefit or use. Like all technology, ultrasounds can be used well or misused. There is much more to say on the politically motivated ways in which women’s reproductive freedoms are being taken away, but this topic falls outside the purview of this paper.

10. For the following testimonies, I refer to the women interviewed by their first names. 11. For a report that argues for the unreliability of maternal reports, see Kisilevsky, Stack, and Muir

(1991). 12. For another testimony that speaks to women coming to doubt their bodies, see Levesque-

Lopman (2010, 123). 13. In this section of the chapter, Young continues to describe a number of the problems associated

with the pregnant woman’s passivity in the face of technological devices (including FHMs) and standard obstetrical practices surrounding birth.

14. I say “excessive” use since it is entirely possible to take adequate and accurate readings of and chart fetal heartbeats intermittently (say, every 20 min or so), which would not require women to lie still and prone throughout their labors and which would allow them to be mobile, thereby helping to pro-gress labor, allowing women to be more comfortable, likely resulting in fewer interventions.

15. Susan Wendell makes a similar claim about medical patients in general: “[T]he cognitive author-ity of medicine in the doctor-client encounter gives far more weight to the doctor’s metaphysical stance, undermining the confidence of clients in the importance of their bodily experiences. When that happens, clients cease to expect acknowledgement of the subjective suffering or help in living with it. This can leave them not only isolated with their experience but feeling obligated to discount or ignore it, alienating them further from their own bodies” (Wendell, 1996, 120).

16. In fact, there are many ways in which the information they provide can be essential in some high-risk situations (i.e., for detecting fetal distress). I do think, however, that FHMs should be used dif-ferently so as to avoid these difficulties (as I mention in Note 14).

17. Thanks to Reviewer 1 for pushing me to develop this point. To be clear, by looking at the panoptics of the womb in this way, I am not claiming that there is an isomorphic relationship between Foucault’s idea of panopticism and a panoptics of the womb; rather, my claim is that this lens helps us to draw some important and insightful similarities between the two.

18. On testimonial injustice, also see “An Interview with Miranda Fricker” (Dieleman, 2012). 19. Although this is sometimes the case, it is by no means always the case. Recall the example of a

woman knowing that it is time to push but being told that she is wrong. 20. There is a huge literature on the differences in pain diagnosis and treatment for women and men

and the problem of women not being heard or taken seriously with respect to their experiences of pain. See, for example, Hoffman and Tarzian (2001), Werner and Malterud (2003), and Werner, Isaksen, and Malterud (2004). With respect to women’s claims not being taken seriously in clinical encounters more generally, see Lawrence and Weinhouse (1997).

21. These three testimonies are all taken from women with whom I had personal correspondences. I will refer to them by their first and last initials.

22. Indeed, in pregnancy but in particular in labor and birth, the trust women have of their bodies might come into question; nevertheless, in a best-case scenario, this can provide an opportunity for the epistemic peer relationship between physician and pregnant woman to thrive, in that when a woman is unsure of what is happening to her or of what she is feeling, physicians and other medical practitioners


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can listen, discuss, and try to figure out together what is going on and can come to conclusions together about what is going on and about what the best course of action might be.

23. For an excellent phenomenologically informed account of the kind of disorientations that many women experience, see Young (2005).

24. Important pedagogical changes in medical schools across the United States and Canada are occurring: changes implementing new approaches that speak to this conceptual and practical shift, even if they do not explicitly use the specific language of phenomenology. For example, emphasis is being put on the fact that patients are not mere specimens, Chen (2008); the emotions of compassion and empathy are being emphasized in medical training, Belkin, (1992); courses teaching communication skills between doctors and patients are being required of medical students, Belkin (1992); centers are also being set up that focus on this area, Johnson (2011); narrative medicine is being taught to help break down barriers between doctors and patients, Chen (2008).

25. All of these sentiments are taken from interviews with patients conducted by Frosch et al. (2012). 26. Here I am taking as my point of departure low-risk pregnancies of healthy women. I should note

that pregnancy has not always been and is still not always seen this way and can be treated as an illness, disability, or pathology of which women must be cured.

27. This discussion also opens up the question of how patients can become better in articulating and understanding their own embodied experiences and how they can become active members in fruit-ful dialogues with their medical practitioners. On this matter, I direct the reader to some fascinating and innovative work being done by Carel (2012). Carel develops a phenomenological toolkit that patients can use to become more in tune with and to better understand and deal with their illnesses. Although she does not discuss pregnancy in this context, her insights are relevant to a further development of the relationship of epistemic peers.

ACKNOWLEDGMENTS

There are many audiences and individuals I would like to thank for their invaluable comments on previous drafts of this paper. First, I would like to thank audiences at the 2012 meeting of the Society for Analytic Feminism (Vanderbilt University), the 2011 conference “Bodies in Crisis, Nordic Network Gender, Body, Health” (University of Iceland Reykjavik), and the 2011 conference “Bodies of Thought: Fleshy Subjects, Embodied Minds, and Human Natures” (University of Dundee/The Royal Society of Edinburgh). I would also like to thank audiences at University of Louisville, University of Memphis, Dickinson College, Concordia University, Boston University, and California State University Fullerton for their helpful questions and critical comments. Special thanks to Saray Ayala, Andreas Elpidorou, Ami Harbin, Brady Heiner, Jo-Jo Koo, Serena Parekh McGushin, Patrick Miller, Kate Norlock, Devora Shapiro, and to the anonymous reviewers at the Journal of Medicine and Philosophy for all of their careful read-ings and helpful conversations on drafts of the paper.

REFERENCES

Arney, W. 1982. Power and the Profession of Obstetrics. Chicago: University of Chicago Press.

Belkin, L. 1992, June 4. In lessons on empathy, doctors become patients. New York Times [On-line]. Available: www.nytimes.com/1992/06/04/nyregion/in-lessons-on-empathy-doctors-become-patients.html?pagewanted=all

Bliton, M. 2001. Imagining a fetus: Insights from talking with pregnant women about their deci-sions to undergo open-uterine fetal surgery. In Handbook of Phenomenology and Medicine, ed. S. K. Toombs, 393–416. Dordrecht, The Netherlands: Kluwer Academic Publishers.

Carel, H. 2011. Phenomenology as a resource for patients. Journal of Medicine and Philosophy 36:1–18.

———. 2012. Phenomenology and its application in medicine. Theoretical Medicine and Bioethics 32:33–46.


ecember 14, 2014


Dow

nloaded from

http://www.nytimes.com/1992/06/04/nyregion/in-lessons-on-empathy-doctors-become-patients.html?pagewanted=all

http://www.nytimes.com/1992/06/04/nyregion/in-lessons-on-empathy-doctors-become-patients.html?pagewanted=all


Chen, P. W. 2008, October 23. Stories in the service of making a better doctor. New York Times [On-line]. Available: http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=all

Childress, J. and M. Siegler. 1984. Metaphors and models of doctor-patient relationships: Their implications for patient autonomy. Theoretical Medicine and Bioethics 5:17–30.

Connolly, M. 2001. Female embodiment and clinical practice. In Handbook of Phenomenology and Medicine, ed. S. K. Toombs, 177–96. Dordrecht, The Netherlands: Kluwer Academic Publishers.

Dieleman, S. 2012. An interview with Miranda Fricker. Social Epistemology: A Journal of Knowledge, Culture and Policy 26:253–61.

Donald, I. 1969. On launching a new diagnostic science. American Journal of Obstetrics and Gynecology 1:609–28.

Everest, L. 2010a. On the subject of numbers. MotherWit [On-line]. Available: http://moth-erwitdoula.blogspot.ca/2010/01/and-while-were-on-subject-of-numbers.html (accessed May 15, 2014).

———. 2010b. Throw your clocks out the window. MotherWit [On-line]. Available: http://motherwitdoula.blogspot.ca/2010/01/throw-your-clocks-out-window.html (accessed May 15, 2014).

Fricker, M. 2007. Epistemic Injustice. Oxford: Oxford University Press.Foucault, M. 1994. The Birth of the Clinic. Trans. A. M. Sheridan Smith. New York: Vintage.———. 1995. Discipline and Punish. Trans. A. M. Sheridan Smith. New York: Vintage.Frosch, D. L., S. G. May, K. A. S. Rendle, C. Tietbohl, and G. Elwyn. 2012. Authoritarian

physicians and patients’ fear of being labeled ‘difficult’ among key obstacles to shared decision making. Health Affairs 31:1030–8.

Gardosi, J., S. Sylvester, and C. B. Lynch. 1989. Alternative positions in the second state of labor: A randomized controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology 96:1290–6.

Hoffman, D. E. and A. J. Tarzian. 2001. The girl who cried pain: A bias against women in the treatment of pain. Journal of Law, Medicine & Ethics 29:13–27.

Hubbard, R. 1984. Personal courage is not enough: Some hazards of childbearing in the 1980s. In Test-Tube Women: What Future for Motherhood?, eds. R. Arditti, R. D. Klein, and S. Minden, 331–55. Boston: Pandora Press.

Husserl, E. 1970. The Crisis of European Sciences and Transcendental Phenomenology. Trans. D. Carr. Evanston, IL: Northwestern University Press.

———. 1989. Ideas Pertaining to a Pure Phenomenology and to a Phenomenological Philosophy: Second Book. Dordrecht, The Netherlands: Kluwer Academic Publishers.

———. 1997. Thing and Space: Lectures of 1907. Trans. R. Rojcewicz. Dordrecht, The Netherlands: Kluwer Academic Publishers.

Johnson, D. 2011, September 22. A $42 million gift aims at improving bedside manner. New York Times [On-line]. Available: www.nytimes.com/2011/09/22/us/university-of-chicago-gets-42-million-gift-for-bucksbaum-institute.html

Kisilevsky, B. S., D. M. Stack, and D. W. Muir. 1991. Fetal and infant response to tactile stimu-lation. In Newborn Attention: Biological Constraints and the Influence of Experience, eds. M. J. S. Weiss and P. R. Zelazo, 63–98. Norwood, NJ: Ablex.

Kukla, R. 2005. Mass Hysteria: Medicine, Culture, and Mothers’ Bodies. Lanham, MD: Rowan & Littlefield.

Lawrence, L. and B. Weinhouse. 1997. Outrageous Practices: The Alarming Truth about How Medicine Mistreats Women. New Brunswick, NJ: Rutgers University Press.


ecember 14, 2014


Dow

nloaded from

http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=all

http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=all

http://motherwitdoula.blogspot.ca/2010/01/and-while-were-on-subject-of-numbers.html

http://motherwitdoula.blogspot.ca/2010/01/and-while-were-on-subject-of-numbers.html

http://motherwitdoula.blogspot.ca/2010/01/throw-your-clocks-out-window.html

http://motherwitdoula.blogspot.ca/2010/01/throw-your-clocks-out-window.html

http://www.nytimes.com/2011/09/22/us/university-of-chicago-gets-42-million-gift-for-bucksbaum-institute.html

http://www.nytimes.com/2011/09/22/us/university-of-chicago-gets-42-million-gift-for-bucksbaum-institute.html


Leder, D. 1992. The Body in Medical Thought and Practice. Dordrecht, The Netherlands: Kluwer Academic Publishers.

Levesque-Lopman, L. 2010. Listen and you will hear: Reflections on interviewing from a femi-nist phenomenological perspective. In Feminist Phenomenology, eds. L. Fisher and L. Embree, 103–32. Dordrecht, The Netherlands: Kluwer Academic Publishers.

Mendez-Bauer, C. and M. Newton. 1986. Maternal positions in labor. In Scientific Foundations of Obstetrics and Gynaecology, eds. A. Philip, J. Barnes, and M. Newton. London: Heinemann.

Merleau-Ponty, M. 2002. Phenomenology of Perception. London: Routledge.Mitchell, L. M. 2001. Baby’s First Picture: Ultrasound and the Politics of Fetal Subjects. Toronto,

Canada: University of Toronto Press.Mitchell, L. M. and E. Georges. 1997. Cross-cultural cyborgs: Greek and Canadian women’s

discourses on fetal ultrasound. Feminist Studies 23:373–401.Oakley, A. 1986. The Captured Womb: A History of the Medical Care of Pregnant Women.

Oxford: Basil Blackwell.Sandelowski, M. 1994. Separate, but less unequal: Fetal ultrasonography and the transforma-

tion of expectant mother/fatherhood. Gender and Society 8:230–45.Sherwin, S. 1992. No Longer Patient. Philadelphia: Temple University Press.Svenaeus, F. 2000. The Hermeneutics of Medicine and the Phenomenology of Health: Steps

Towards a Philosophy of Medical Practice. Dordrecht, The Netherlands: Kluwer Academic Publishers.

Toombs, S. K. 1987. The meaning of illness: A phenomenological approach to the physician-patient relationship. Journal of Medicine and Philosophy 12:219–40.

Wen, L. and J. Kosowsky. 2013. When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. New York: Thomas Dunne Press.

Wendell, S. 1996. The Rejected Body. New York: Routledge.Werner, A. and K. Malterud. 2003. It’s hard behaving as a credible patient: Encounters between

women with chronic pain and their doctors. Social Science & Medicine 57:1409–19.Werner, A., L. W. Isaksen, and K. Malterud. 2004. I am not the kind of woman who complains

of everything: Illness stories on self and shame in women with chronic pain. Social Science and Medicine 59:1035–45.

Young, I. 2005. On Female Body Experience: “Throwing Like a Girl” and Other Essays. Oxford: Oxford University Press.

Zaner, R. 1970. Toward a phenomenology of medicine. Journal of Medicine and Philosophy 1:3–4.

———. 2000. The phenomenon of vulnerability in clinical encounters. Human Studies 29:283–94.

———. 2006. Power and hope in clinical encounter: A meditation on vulnerability. Medicine, Healthcare and Philosophy 3:265–75.


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