Philosophy and the clinic: Stigma, respect and shame

Abstract Since its foundation in 2010, the annual philosophy thematic edition of this journal has been a forum for authors from a wide range of disciplines and backgrounds, enabling contributors to raise questions of an urgent and fundamental nature regarding the most pressing problems facing the delivery and organization of healthcare. Authors have successfully exposed and challenged underlying assumptions that framed professional and policy discourse in diverse areas, generating productive and insightful dialogue regarding the relationship between evidence, value, clinical research and practice. These lively debates continue in this thematic edition, which includes a special section on stigma, shame and respect in healthcare. Authors address the problems with identifying and overcoming stigma in the clinic, interactional, structural and phenomenological accounts of stigma and the ‘stigma‐shame nexus’. Papers examine the lived experience of discreditation, discrimination and degradation in a range of contexts, from the labour room to mental healthcare and the treatment of ‘deviancy’ and ‘looked‐after children’. Authors raise challenging questions about the development of our uses of language in the context of care, and the relationship between stigma, disrespect and important analyses of power asymmetry and epistemic injustice. The relationship between respect, autonomy and personhood is explored with reference to contributions from an important conference series, which includes analyses of shame in the context of medically unexplained illness, humour, humiliation and obstetric violence.

1 | PHILOSOPHY AND THE CLINIC: STIGMA, RESPECT AND SHAME Since its foundation in 2010, 1 the annual philosophy thematic edition of this journal has been a forum for authors from a wide range of disciplines and backgrounds, enabling contributors to raise questions of an urgent and fundamental nature regarding the most pressing problems facing the delivery and organization of healthcare. 2 Authors have successfully exposed and challenged underlying assumptions that framed professional and policy discourse in diverse areas, generating productive and insightful dialogue regarding the relationship between evidence, value, clinical research and practice. 3 These lively and inspiring exchanges have included important contributions to the 'great debate' about clinical reasoning and decision making, 4 advancing our understanding of the professional-patient interaction and our changing conceptions regarding objectivity, diagnosis, bias, judgement and power. [5][6][7] Recent editions have focussed on the ongoing discussions concerning shared decision making, person-centred care, patient expertise and value-based practice, 8,9 with authors building on earlier debates regarding the integration of health and social care 10 to advance new approaches to the clinical encounter and the developing interactions between technical and humanistic features of care. 11 These important themes are developed further in this edition, which includes a special section on stigma, shame and respect. This section includes papers aimed at identifying, understanding and addressing discrimination in clinical settings [12][13][14][15][16][17][18][19] and on respect and shame in healthcare and bioethics. [20][21][22] The edition opens with a number of papers that address core issues in health philosophy, which have been the preoccupation of the philosophy thematic editions of this journal for over a decade.
Authors raise pertinent and challenging questions concerning our understanding of the nature of health and disease, 23,24 diagnosis and the processes of clinical decision making. 25,26 These contributions are followed by several highly original articles addressing the relationship between evidence and practice in medicine and healthcare, [27][28][29] demonstrating the application of specific, philosophically informed approaches to causal reasoning with reference to some very practical contemporary health controversies. 30,31 Continuing debates on pressing issues we have emphasized in more recent thematic editions, authors explain and analyse different conceptions of 'patient-centred care' and 'patient expertise', 32,33 discussing the role of values in shaping our understanding of the mental and medical disorder, 34,35 and the relationship between epistemic risk and nonepistemic values in the end of life care. 36 The need to understand research, its implementation and interpretation in the broader social and political context is illustrated by a fascinating article on overdiagnosis. 37 The edition includes stimulating and provocative discussions of shared meaning making and health literacy, 38 precision medicine and its effects on medical epistemology, 39 and the need to rethink our conception of 'researcher bias' in health research. 40

| STIGMA, SHAME AND RESPECT IN HEALTHCARE
The concluding section of the edition focuses on the closely related concepts of stigma, shame and respect and how these have an impact on health and clinical practice. 12-22

| Stigma
Contemporary research on stigma is generally agreed to have been initiated by the publication of the sociologist Erving Goffman's now classic book Stigma: Notes on the Management of Spoiled Identity, which appeared in 1963. 41 In recent decades, stigma has become a prominent topic in healthcare, largely driven by stigma's status as a significant category of phenomena, which feature prominently in the areas of mental health, sexual health and human immunodeficiency virus (HIV).
Goffman identified stigma as a feature or attribute that is operationalized in interaction to be discrediting or degrading. The reference to interaction is important: an attribute might be unremarkable and inert in one situation, a source of pride in another, while being interactionally operationalized in yet another situation in a way that stigmatizes the bearer of the attribute by degrading or discrediting them. Furthermore, some prominent recent work on stigma 45,46 has sought to reorient the study of the stigma away from interactional study and phenomenological analyses of the lived experience of degradation and discreditation, and instead argued for and sought to provide structural theories of stigma. The argument underpinning such proposed reorientations is that stigma is a structural phenomenon and needs to be theorized as such. This is an ongoing discussion and one that will not be pursued here. In this special issue, the editors asked for the focus of the contributions to be on the interactional dynamics of stigma. The hope was that this focus would speak directly to health professionals, so as to help them understand these dynamics in a way that might prove useful in their own practice, and in the hope that patients' lived experiences of discreditation and degradation would take prominence over academic theories. The section includes papers designed to open up debates on understanding and addressing stigma in a range of contexts, from the labour room 17 to mental healthcare 16,19 and the treatment of 'deviancy' and 'looked-after children'. 15,18 Authors raise challenging questions about the development of our uses of language in the context of care, 12,[15][16][17][18][19] and the relationship between stigma and important analyses of power asymmetry 12 and epistemic injustice. 15,17

| Shame
While stigma has been extensively written on in the context of healthcare, the relationship between stigma and shame has been discussed much less. As Phil Hutchinson and Rageshri Dhairyawan noted in 2017, 47,48 while stigma is extensively discussed in the literature on HIV, relatively speaking shame rarely features as a topic for discussion. Hutchinson and Dhairyawan 48 went on to write that studying stigma in the absence of any discussion of shame 'is akin to proposing strategies and methods for studying the social phenomenon of "threats" while not undertaking, nor even talking about, the fear response to threats. Just as threats are of interest to us as social phenomena because of the impact they have on our lives through the responses they engender, so stigma is of interest to us because of the responses it engenders, the way it makes us feel and behave'.
In this issue, the papers by Luna Dolezal 13 and Phil Hutchinson 14 discuss the stigma-shame nexus. Stigma, or enacted discreditation and degradation, can serve as objects of shame. That means that it is part of what it is to experience this shame that one feels discredited or degraded in this way. A person who experiences a degrading interaction experiences this as shameful.
Where 'stigma' is a term which picks out a category of social  [56][57][58][59] Seeking to move beyond this debate, some recent accounts of emotion have emphasized the lived experience of emotions, 60 the enactive nature of emotion 61 or the way in which emotions are made witnessable and accountable in interaction. 59 While it can be tempting to think of this as a purely academic debate, of interest only to those contributing to it in the disciplines of philosophy and psychology, it would be a mistake to do so. Our conception of shame, what we take to be the nature of shame, will inform how we understand the production of shame in the clinic and how we select the best or most appropriate methods for studying shame.
One of the things we do know is that the person experiencing shame often seeks to withdraw or retreat from the social world. This is one of the reasons that understanding shame is important for healthcare practitioners. A person who feels shame might be more inclined to withdraw from engagement in a clinical encounter, either literally by leaving the clinic or figuratively by becoming 'closed', less responsive and less forthcoming with answers to (clinically) important questions. For example, questions about sexual history in a sexual health consultation might be less likely to be answered openly and honestly, if at all, by someone experiencing a pronounced shame episode. Appointments might not be attended owing to shame. These would be fruitful areas for further study, but such studies must be grounded in a good understanding of shame as a phenomenon.
A better understanding of the social dynamics of shame and stigma might help the clinician avoid shaming and the deleterious consequences of that.

| RESPECT AND SHAME IN HEALTHCARE AND BIOETHICS
We have already noted that stigma is a category term, and in his contribution to this section of the Philosophy Thematic issue of the JECP, Hutchinson says a little more about this: stigma is a category term, like the term emotion, and it brings together experiences of degradation, discreditation and discrimination.
This list is not exhaustive, and one could add to this list of members of the stigma category, (negative) bias and disrespect.
This last term, 'disrespect', is based on the idea that there are interactions which fail to be respectful or that are experienced as disrespectful.
One helpful way to understand 'respect' is that it 'necessarily has an object: respect is always directed toward, paid to, felt about, or shown for some object'. 62  Darwall and Cavell marked real progress, but more recent work in bioethics places the lived experience of the second person perspective centre stage, so it is not so much based on our conception of humanity (even if that is rich and nonreductionist), but on how a person experiences the interaction: Do they experience the interaction as respectful? Do they feel acknowledged as a person?
We might call this the phenomenological or existential turn in the respect for persons literature. This turn to basing respect for persons on the experiential aspect or the lived experience of being respected has been particularly significant in the context of thinking of respect for persons in healthcare encounters. 64  The contributions published here ground their analyses from diverse disciplinary frameworks with a focus on the experiential aspects, particularly from shaming, shame and humiliating experiences. The articles illustrate how these experiences complicate the practice of ethical principles such as 'respect for persons' within healthcare settings. While much work still needs to be done, we hope that these contributions will help to draw attention to the need for interdisciplinary engagement, for further understanding of these concepts and phenomena to advance both academic and healthcare practice debates.