SHE research pod Siun Gallagher_mixdown.mp3
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Kate MacKay:
Hello, everyone, and welcome to the SHE Research Podcast. I'm your host, Kate MacKay. And today I'm joined by Siun Gallagher.
Kate MacKay:
Hello Siun,how are you?
Siun Gallagher:
I'm good, thank you.
Kate MacKay:
So today Siun has joined me to talk about her paper, 'Testimonial Injustice: Discounting Women's Voices in Health Care Priority Setting', which is published in the Journal of Medical Ethics and was co-authored with Miles Little and Claire Hooker. Is that right Siun?
Siun Gallagher:
Yes, that's correct.
Kate MacKay:
Cool. So, I wonder if you can give our listeners just the kind of elevator pitch summary of your paper.
Siun Gallagher:
Yeah, happy to. I guess the bottom line is that the paper makes the case that the chances of a fair allocation of health care resources, especially to disadvantaged and marginalized groups, are reduced by the tendency of resource allocation procedure to discount the voices of women. And so the paper describes the nature of this discounting, just testimonial injustice, and explores its effects. And then we make some suggestions as to how the problem might be addressed.
Kate MacKay:
So what is testimonial injustice in a nutshell?
Siun Gallagher:
It's a bias or an injustice that arises from the bias of some hearers against the input of certain types of participant in the deliberation. And this bias arises from their negative perceptions of the speaker's social identity. So we often find it associated with women or with people of color, with people of lower educational attainment. So their voices are less likely to be taken on board. Now, I can give you a bit of a kind of a plain English version that we use in the paper, which was how Julie Bishop, who was Australia's previous foreign minister, experienced it in the cabinet room, of all places. This is what what she said in her retirement interview. She said, "if I spoke in a room of 20 men, if I would put forward my idea, there was a sort of a silence. It was as if I hadn't spoken. And then somebody would say precisely what I had said or come up with precisely the same idea. And then they'd say. Oh, that's a great idea. Why don't we do that?"
Kate MacKay:
Hm.
Siun Gallagher:
So, that's in a nutshell what it feels like to experience testimonial injustice. And so the primary harms then I felt by the person because they feel terrible. They feel that they've been disrespected as a person, and regardless of how much knowledge they have. That is not valued in the process that they're being part of. And that is really pretty terrible. And there are secondary disadvantages as well as secondary harms. And they are to the people who are deprived of the knowledge. So obviously, those actively depriving a person of credit for the knowledge are disadvantaged because they're missing a whole piece of knowledge that might have helped them to make a better evaluation or better decision. But the recipients at the end point of the decision are also disadvantaged because the process is faulty, because lack of relevant information being brought to bear on the problem.
Kate MacKay:
So were some of these negative outcomes the motivating factors for writing the paper?
Siun Gallagher:
Yes. What we had we had done an empirical bioethics interview study where we wanted to understand the ethical dimensions of being involved in macro allocation from the perspective of doctors who engage in it. Macro allocation is the same thing as priority setting, but at the level of populations or patient groups rather than at the bedside. And it's kind of it's a bureaucratic process that often gathers people together from different stakeholder groups and from different technical expert groups in order to provide the sort of information based on knowledge and expertise that's necessary for making the right decision. Doctors are big players in this. So the type of process I'm talking about includes things like the clinical councils of local health districts or equivalent regional authorities, and, in Australia, the Pharmaceutical Benefits Advisory Committee, which is a national committee. We had studied the issues that participants thought were ethically significant. And by and large, most people, male and female amongst our 20 participants, had come up with the same range of issues on fairness and opportunity to participate in political decision making: overriding their input or their decisions, and overall, a general lack of support for the effort that they put in. But there was one thing that women came up with that was unique to the women in the group, although I hadn't really thought that we would be analyzing by subgroup, they reported this feeling of having their or an experience of having their input discounted, ignored or being made to feel that they didn't belong in the process. And this obviously resonated with Miranda Fricker's idea of testimonial injustice. And we made reference to it in our paper, but wanted to return to it. And the impetus really to come back to it, at a more theoretical level, was this Julie Bishop interview, which made really quite a big impression. And the other thing that was going on at the time was a bit of a focus on bias against women generally in medicine. And the Lancet in particular had an issue around the general topic at the same time. So we thought that this was a good chance to highlight the issue in this particular dimension, which is macro allocation, with the involvement of medical professionals in the allocation of health care resources and to bring forward the significance of that, not just for the individuals concerned - those who experience the primary harms - but the broader implications for healthcare, resource allocation and its fairness and the people who bear the consequences of the decisions down the line.
Kate MacKay:
So is your paper primarily focused on these sorts of harms?
Siun Gallagher:
No, it's equally probably divided in its attention between the primary harms and the secondary harms. In the area of primary harms, we obviously draw out the general harms to women, but we also highlight a few specific areas, including the idea that, like it or not, participation in macro allocation is an opportunity to create reputations and even to attract resources to your own service. This is, as I said, not necessarily desirable, but there's no particular reason why that should be allowed to accrue in the case of men, but not in the case of women, or in the case of any advantaged group over a disadvantaged group. So that also has a potential to cause women to opt out of macro allocation long-term and potentially experience negative impacts on the flourishing of their career. And then potentially, as role models, to discourage participation of future women in future processes.
Siun Gallagher:
So that was sort of broadly how we outlined the primary and the secondary harms that arise from the differences between men and women's practice. But by that, I mean, well I actually mean two things. One is their practice in deliberation, and that women are have a different style. They have different, give different moral weight to different issues. They're more likely to champion the needs of marginalised and disadvantaged people. And so if you're selectively tuning that out, those people don't get to be represented, and those issues don't get to be represented. Now, the other aspect of practice is that women do actually congregate in some specialties more than in others. And so they're more likely to be representing some of the lower status medical specialties and areas of health care endeavor. And so this means that it's systematically embedded that these voices, or the champions for these issues, are not heard. Then we will continue to have resources allocated to the traditionally powerful specialties.
Kate MacKay:
Mm hmm. Mm hmm. So did you face any particular challenges while you were writing the paper or while you were collecting the data?
Siun Gallagher:
The focus of this paper was more on the marriage of theoretical with they the idea that this is a problem. And I guess that was probably the hardest thing, establishing it as a problem, because there's not much research at all into the personal aspect and the interpersonal aspects of a macro allocation procedure. So apart from our own paper, which describes this, there really wasn't anywhere to go to say definitively that women doctors in macro allocation experience testimonial injustice. So, I had to draw from a broader palette of women in policymaking generally and in macro allocation generally experiencing testimonial injustice and then to marry that with the theoretical literature on testimonial injustice. That was probably the biggest challenge.
Kate MacKay:
Mm. Yeah. So what would you say is your final sort of recommendation? Because I know in the paper you proposed some remedies.
Siun Gallagher:
We proposed three remedies. The first one is selective, or affirmative, recruitment to macro allocation deliberation panels, and the basis for this is contested. But it is that if you're not in the room, you're not going to find your issues represented. If you want to redress the balance, we have to make sure that the people who can represent the full gamut of issues are present in the room. So that would be a rationale for it. I think another is that it makes you think of overall how you might improve recruitment to these panels because they're often just based on emminence, and knowledge. Well, there are other characteristics that people in macro allocation deliberations need to have, and that's a willingness to deliberate. And certainly you could build into the criteria the idea that one must be willing to interrogate one's own biases and those of one's collaborators in the deliberation room. So that was probably our first and simplest idea. The second idea was to harness the idea of a deliberative expert, which is an idea put forward by Fisher. The deliberative expert is sort of oil between the cogs in the deliberative process, they have whatever particular expertise in making sure that the interpersonal aspects, the interactions in deliberation, are adequately attended to in macro allocation procedure. Now, this seems sort of a bit of a luxury, and we adapted it a bit to say, well, look, if somebody, and it's often a policy analyst or a senior bureaucrat or combination thereof, somebody is responsible for bringing together panels and taking input. It would seem reasonable that if they want to do the job right, which they generally do, they would have to extend their care within the procedure beyond the usual sort of principles that would apply, to actually tend to this issue of bias and testimonial injustice and provide leadership for that so, both by actively engaging with the discussion, but also by making the procedure safe, by designing it effectively. So the final one really was to harness this idea that was used by women in the Obama administration in the U.S. and I think they called it amplification. And so what we did, in a systematic sort of a way, was when women made contributions to the deliberation to repeat them.
Kate MacKay:
Mm hm.
Siun Gallagher:
Repeat them. Draw the attention onto the person who spoke in them in the first place so that there was no chance of the issue being lost or the issue being appropriated by somebody else. The idea being appropriated, rather, by somebody else.
Kate MacKay:
Wonderful. Well, thank you so much, Siun. That's really interesting. And it's great to hear about your research and about this paper. Any interested listeners can find the paper linked at the bottom of this episode's notes. And thank you so much for speaking on the SHE Research podcast. It's been great to have you.
Siun Gallagher:
You're very welcome, Kate. I enjoyed it.
Kate MacKay:
Excellent. Thanks for listening, everyone. And if you'd like to hear more of our SHE Research podcasts, you can find us on Anchor or Spotify or wherever you find podcasts of quality. Thanks for listening. Bye.
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