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SHE Pod Season 4 Episode 7 Supriya Subramani

Catherine Sanderson36min

Diego Silva

00:06

Hello and welcome to the She research podcast. As always, I'm your host Diego Silva. Before introducing our guests, I want to acknowledge that we're recording on the unceded territory of the Gadigal people of the Eora nation. This is and will continue to be Aboriginal land, want to pay my respects to those who have and continue to care for country. Today I'm joined by none other than Supriya Subramani Lecturer in bioethics here at Sydney Health ethics to discuss her paper that she's co-written with Nikola Biller-Adorno Revisiting Respects for Persons: Conceptual Analysis and Implications for Clinical Practice. We can find this in the Journal of Medicine, healthcare and philosophy. We'll have this paper linked in the actual podcast that you're listening to right now. Supriya, welcome.

Supriya Subramani

00:53

Thank you, Diego. This is really a pleasure talking to you. And I'm looking forward to this conversation.

Diego Silva

00:58

So just to get us started Supriya hoping you could provide us with a summary of your paper.

Supriya Subramani

01:03

So to give you a quick summary, I'm trying to understand this is a paper which I wrote with Nikola as Diego was suggesting, which dovetails from my earlier works on micro inequities and moral habitus. So what it means is, of course, as with the conversation, I'm happy to go more closer or critically into these concepts. But this paper is basically trying to get an understanding of what respect means, especially from an experiential point of view, and what's its implications for clinical practice, within the larger bioethics discipline. And most of the discussions within respect for autonomy and respect for persons is what is acknowledged within the mainstream bioethics debates. So the key question, which one if wants to read and look in closer is about behaviors play a huge role in the understanding of attitude of respect for persons? Yeah.

Diego Silva

01:57

So what what's the argument that you guys make? What What are your conclusions in the paper? And you mentioned, this idea of micro inequities are inequalities? Can you tell us a little bit about that? And how that functions within what you're arguing for?

Supriya Subramani

02:13

Great, thanks for that question, because micro inequities is something which I have been working on for a while based on my doctoral work, which I did in India, in southern part of India, it's Chennai did an ethnographic research in two hospitals. One is a government hospital and a private hospital. And when I started doing research on informed consent, which was very much, you know, the concept which everyone has done research, there's so much of publications, 1000s and 1000s. So I did take this concept to look through within Indian context, what does it mean? And how do we understand not just from the clinical practice point of view, but also from the legal point of view. And I was looking at, taken for granted notion of informed consent, basically. And the more I continue to do my fieldwork, I realise most of the discussion when we're talking about informed consent is about, you know, the ethical value is autonomy. So autonomous decision is one of the key focus when we talk about informed consent. But the key question, which hit me through when I was doing my fieldwork, when I was talking to patients and family members in two different hospital settings, as I said, is how, when a person is not even respected, I mean, the sense of moral recognition, like if I don't even see you as a person, and in that clinical interactions, or within that particular social interaction, if I don't even acknowledge you with my embodied experience, you know, showing you the due respect, which I need to give through the recognising you as a person, how do I even think and talk about decision making as a capacity arguments. So I'm not saying these two are two different things. But what I would argue in my earlier works, and even this paper with along with Nikola is that, respect for autonomy is not just enough, we need to also look at the larger experiential aspect of how it is practiced within the everyday clinical encounters.

Supriya Subramani

04:07

And that's a switch and in order to do that, what I was looking at is looking at disrespect. So while we are talking about respect for persons looking through the lens of disrespect, is what I was trying to argue and push for. And the concept which helped me is micro inequities. And what is micro inequities, micro inequities in a simplest sense, which I bought from organisational behavior and feminist scholarship around that. And what they try to look is most of the scholars it's a subtle and it's a small and subtle harms, if I want to put it as little acts of disrespect, which sometimes is like for example, if you're not doing an eye contact or if you're just silent when I'm asking you questions, I can't pick a fight over that with you like Hey, why did you not this? I mean, you know, you constantly keep questioning, because a person who is experiencing this micro inequities are is always when is it happening because of my background Is it because of my gender? Is it because I belong to a certain minority group? So there is a question of is it happening because of this or that, the intersectional factors? But at the same time, we also worry people who are at the receiving end wonder, is it because is it intentional person? Is it targeting me because I belong to a certain marginalised community? And then the third characteristics of micro inequities, which some of the scholars say it's always intentional or it's because of implicit bias. What I would argue in my earlier paper and in upcoming paper, which I'm also working on is what is the moral wrong of that argument, which I'm trying to build is the micro inequities is even though it can be unintentional or not targeted intentionally in that sense, but it becomes normalised, both by the I mean I want to use the word perpetrators or victims in both ways, it's a strong terminologies, but I still see because of the power asymmetry, I still use these terms. So for example, a doctor who is from upper class or upper caste or a dominant ethnic group member who belongs to who is talking to a person who is from marginalised community, let's say a woman from a lower caste community, if a person is talking, who is teasing and you know, like not really acknowledging their worthiness as a person, that is there is disrespect through this micro inequities, like, maybe I roll eye not even do an eye contact, let's say, the person who is at the receiving end feels Wait, this has happened to me, because I'm marginalised committee and this is not like once or twice it's a pattern, it's because of the historical context or the marginalised community have this experience, you recognise that pattern, but you don't see it as that, oh, it's unintentional. You see, okay, this, I am normalised. I'm aware of this, but I don't pick a fight right now at this time. So that's how the micro inequities play out. And especially in hospital settings, it plays out so strongly. And that goes back to the question of how we as people in power, or people who don't have power in that particular context, navigate and negotiate that particular clinical clinical encounters in hospital settings is a very interesting dynamics. And that plays out very directly to the how a person feels respected or disrespected. And because of it becomes normalised or not, is a big push towards. Not necessarily, we need to always talk about outright discrimination or outright any kind of overt indignity, situations or behaviors. But these subtle and small harms are also which add select accumulative effect, of course. So that's something is what I would like to drop, you know, when we are talking about micro inequities. Did I answer your question?

Diego Silva

07:52

Yeah, absolutely. So, I want to pick up on this idea of perception in a second. But before that, I'm actually curious as to how you came across this as a topic of research in the first place, both for your doctoral and postdoctoral research. And, and now, you know, we hear a lot about discrimination. And usually we think about it in its worst forms, which we ought to, and we think about it sort of in a binary way, and one of the things I like about your work is that you point out the degrees and the sort of the continuum of and what this means for bioethics. So, I was hoping you could just tell us a little bit about how did you get to this question in the first place?

Supriya Subramani

08:37

Right, thank you. So, to answer that, I think I would like to share my personal stories about it actually. Because I mean, I my identity is very difficult within the Indian context, but if I want to position myself I belong to a lower caste identity per se in and my dad is it's a hilltribe community. So and also within Indian context, the questions around Indigenious who is Indigenous is also very much questioned and my dad belongs to that community which within the larger caste dynamics in India has been playing out, okay they don't belong to Indigenious type, but they belong to other backward community which I find that I know listeners may not be able to comprehend in these the caste questions or the identity questions within the particular place where I come from, but to give you a quick overview, I belong to a lower caste communities as simple as it is that means the discrimination I have experienced because of my caste identity, but also because of my, of course gender and then colorism in India, especially in the southern part of my place, where I come from, has been like lived reality for me. And that has always been there but I never had the vocabulary. Like when I was growing up and as I was in, yeah, even during my PhD too like couldn't really comprehend certain things which was happening for me. As I was reading certain feminist scholarship, that's when I started getting this vocabulary, right. And then this experience of micro inequities has happened to me. But at the same time, it has been outright and I have been witnessing also, it's not just happening to me, but I've been witnessing and have witnessed so many encounters. Of course, the larger discrimination practices like caste discrimination outright, but also the subtle ways it becomes normalised. So that's something which I was aware, but I never knew this is what micro inequities is, right? Because I was not exposed to these concepts. But when I started doing my research and PhD in India, in it's one of the institutions, which I did well, it's an elite institution in India. And that makes it much more interesting. Now, if I think about it, because the way we capture the practices, you are much more critically reflecting on how this plays out as a social researcher within academia. But also, when you go out whether you meet bureaucratic institutions like government offices and health a hospital settings is also a larger institution in itself. So when I started doing my fieldwork, whatever I was familiar with so many years of lived experiences, made me when I started witnessing within the hospital settings as I was talking, like when a patient is trailing behind, I think, in my works, which I use this example very often is a patient or a caretaker who is stealing behind a person who is powerful, usually the doctor or nurse, which is like a common sight, because people in power who just keep walking in front of you and the people who are not necessarily have a power enough, you know, your tail behind them. And one of the patient get the caretaker well, you know, it talks about it. I mean, these people don't even stop and talk to me, they don't even stop turn and so it is so embodied, right? I mean, and this experience has happened so many times in my life. And when I was reading, as again, I'm an interdisciplinary scholar and more curious with concepts happening. You know, there's concepts which are at different, you know scholarship, so when I was reading some Harvard discrimination and implicit bias, I came across micro inequities within the organisational behavior and feminist scholarship on microaggressions. But then, I did not want to use micro aggressions, because micro aggression is one part of the larger umbrella of micro inequities in my the way I would see this. And that's, that's how I started looking into micro inequities. And also to an extent of many times when we talk about outright discrimination, it's easier to because you have very clear thought process, and people give you more weightage, as you also rightly pointed out. But when it is a subtle ways it is happening. That's worse, I feel because you don't even have a sense of how do I make sense for myself? So the question of it's like, you know, a person can feel much more epistemically we end up questioning everything about ourselves. About is it happening because of my inability to not handle this situation? Or is it has it ever happened in this situation? So it's both my personal experiences, but at the same time as a researcher going into the field, the field which I'm very much familiar with, and in my other works in non methodology in one of the paper on practice and reflexivity, I talk about how my personal stories has influenced my own methodology and the theory construction within when when I make the case in my papers on respect.

Supriya Subramani

13:33

So, these personal experiences draws more attention towards the way we capture the lived experiences and at the same time, I think it is not much discussed in bioethics, while many feminist scholars do talk about power, right power vulnerability, and the way the disrespect has been acknowledged. It certainly scholars have worked, but the way it has to be unpacked and also demonstrating how it happens with you know, ethnographic details or the lived experience as a narrative, I felt it was lacking. And that's where I think this micro inequities and also the other concept of moral habitus, that is how bodily dispositions are normalised, I mean, the normalisation part, right? It's so much like we all know how to navigate a particular institutions or certain interactions, but it is so much part of historical socialisation part and within hospital settings, hidden curriculum. Doctors, and like, you know, patients, nurses, everyone we pick up and we play a certain role like most of the times we patients play a role of passive patients, right and the moment you want to deviate that your questioned again, how dare you question my authority? So these, these things play out very strongly and, and I would think in my work, I want to also look at the agency and structure divide, which usually the sociology as a discipline or anthropology as a discipline or philosophy the way we try to look through, I did not want to see this as a dichotomous thing, but it both draws our attention to how we as humans are social beings, of course, we constantly evaluate each other. And the way we evaluate is always sometimes explicit. Going back to the one we were talking about perception, we constantly, we perceive each other in a sense of our own understanding of how to be good, how to be bad, but wait, did I do something wrong? So we that's what I mean, like, we are constantly evaluating each other. And we also try to see whether should be good or bad is also part of this process. And micro inequity is something which we need to be aware I feel especially people in power that is, let's say healthcare professionals, because the chances of being discriminated or people experiencing disrespected within marginalised communities much more harm in using. Yeah.

Diego Silva

16:00

So one of the things that what your scholarship in general, that's kind of stood out to me, and it's in this paper as well. So you give sort of very practical examples like the the tailing example of the patient walking behind the healthcare worker. So much of the work that you do is about inhabitation, or I'm not even sure that's a word but sort of inhabiting a space or a place, and the role of physicality and location. I was hoping or I was wondering what you would think about bioethics and bioethics concepts, in how we do or we don't think about space and place and embodiment. And what does that mean, then for sort of broader bioethics scholarship?

Supriya Subramani

16:53

Right? This is something which I have been thinking about for a while. I mean, very recently, because in my postdoctoral work, I'm doing a project I mean, which, in which I'm still continuing on immigrants healthcare experiences, and use phenomenological method basically, phenomenological analysis, and embodiment within when we look at phenomenological understanding is very central. And so even though in my earlier work on micro inequities, I do talk about stereotyping, and how body dispersion is very important. But I never unpack in my earlier papers, what's embodiment and how it plays a role for ethics. And my current work and my future work is slowly you know, trying to head towards how do we unpack and what it means, why embodiment matters to ethics is a bigger question, which I'm also thinking through. And for now, I mean, the way I'm thinking is the dichotomy of reason versus emotion, body versus mind, which of course, we know, even many biotech scholars do acknowledge this. But when we are talking about it, especially in the ethical theory and ethical arguments, we don't directly address it. And when, for example, when I mean, in one other one of my project on breastfeeding, I mean, I keep because this is one of my pet project in itself. And I keep looking how breastfeeding and discussion in public health interventions whenever public health interventions are planned, they forget that. I mean, at least the way that I'm looking at the RCT is a number of RCTs, you know, looking through it, feminist scholarship so much they talk about maternal autonomy and lived experiences, but public health interventions or public health professionals when they're planning these interventions, if they acknowledge the maternal autonomy is important to value autonomy, let's say the ethical value of autonomy, they have to listen to the lived experiences and embodiment is part and parcel of that, right? Because the way a person lives and situates the body and engages oneself is, is of course, the subjective experiences. But the subjective is not like we can't say it's relativist understanding. Again, going back to the larger ethical arguments, we always is absolutes versus relative as this we end up in this kind of conversation. But in our everyday life, we don't do that and what it means for bioethics conversation as the moment we embrace or acknowledge embodiment is part of ethical being and as evaluated persons. I think that contributes so hugely to the way we think of ethical values and principles. And also of course, its implications to both public health ethics are to the larger mainstream medical ethics conversations too. For example, if I feel ashamed or when I feel humiliated with because of let's say, a micro inequity or even outright discrimination when I feel that plays a huge role on how I question myself and because it certainly questions my self respect, and it makes me think about how do I, when I go out again, like today, I experienced shame or humiliation from X- person. When I go back to another, next day to an office or to a healthcare institution, of course, that my past experience of feeling ashamed and humiliation plays a huge role in how I act or how I behave, how I communicate, right. And this is something again, which feeds back to how even healthcare professionals experience these emotions. So much of my psychological studies clearly shows that. But at the same time, how do we make sure we breach that within the ethical theory and the discussion with an ethical values? Is not it flushed out I feel? There are scholars, phenomenologist who do talk about this, but how much it has given in emphasis or the way we, you know, use it to talk about larger mainstream bioethics conversation is yet to be done very much. I feel, hopefully, I'll contribute more. I mean, so far, I still feel like, I've not done a good job of unpacking it. Hopefully, in future. I'll keep doing this unpacking more clearly.

Diego Silva

21:03

Yeah, I think I think you're well on your way, in terms of unpacking these very complex ideas. There's a couple of things from the actual paper that I want to kind of draw attention to our listeners and sort of get a little bit more details from you and kind of some more thoughts. One of the things you do in your paper is you you talk about how doctors and healthcare workers that it's not just about having the attitude of respect towards their patients. So you know, the intention to act in a way that's respectful, but that should actually behave in a way that is respectful of patients and particularly given existing norms in the locations where they're practicing. So going back to this thing that you mentioned a moment ago, about the absolute, the relative, the universal and the relative, one of the things that you and Nikola talk about in your paper is precisely this idea of instantiations of universals. And that the instantiation of respect, behave in a respectful way, is sort of taking seriously these social norms that exist. So you give the examples of various sorts about how even things like teasing a patient which may seem innocuous at first, can be disrespectful, again, sort of internalised. And I guess when I was reading this, the question that came up for me is, what are the limits of what we can expect from doctors and healthcare workers? Maybe another way of putting it is like, to what extent can we hold doctors responsible for how someone interprets, experiences, preceives, an interaction is respectful or disrespectful?

Supriya Subramani

22:47

Yeah, this is a very complicated question, right? I mean, this is something which I mean, basically, this hits to the question of whether the person intended the intentionality versus the perception, because when I witnessed to individuals who are just standing and shaking their hands, and I might interpret that as, Wait, are they really shaking? Are they angry me with because of the way I perceive their body language in itself? So going to your question of how what are the limitations, right? I mean, how much the doctors should think about, did they mean it did they intend, I mean, if the person has misinterpreted. The way I would put it, more based on my understanding of my learning over the last few years is about, within a particular social context. And also given the history of marginalisation, history of how people who are from who are from vulnerable socio-economic background community who have been experiencing discrimination. When we listen to the, the narratives and experiences, these these experiences, like, as I describe in all the works, which I do show is like, it's not actually too much to ask kind of a question it comes across, but then for a doctor, wait, I mean, I didn't intend to do this. They miss, I mean, I was busy, maybe when I did it, but I'm still busy, I don't have much resources to sit and talk through I give all the attention. So my overall observation of my studies, when I was looking at in ethnographic studies, the same doctor, when they are talking to a patient right, there is always a categorisation which we all do, I mean, not just doctors, we all do this. We just categorise people we constantly have our own certain perceptions, how to talk how to navigate, right we, based on social markers, that how we dress how we talk all this, and this is exactly what doctors also doing. I mean, I'm not blaming them in any way. But then the moment when they divide their care or the attention which they give based on the social markers, because of this larger socio economic or caste or gender all these factors playing out. That's the moment for me to reflect back and think through Wait, if I'm a person with power, that is usually the healthcare professionals, I would want them, Am I doing injustice? Or like, am I being unfair for a certain group of community or a certain group of people, because I mean, I may not basically think through at that moment, but what I do want as a researcher, or that's what I'm heading towards is making them reflect. Stop and think how we are socialised how our hidden curriculum plays out within the hospital settings, and also how we as humans generally do this, the prejudice and stereotyping certainly play out, like even myself, I'm sure I would be having all this. But what I'm do asking for myself as a researcher doing this work, and also people in power, is about, okay, let's stop and think how we are socialised how this power asymmetry is very part and parcel of medicine, and how that also plays a huge role in our interactions with patients and how it could discriminate people who are much more marginalised and vulnerable group of people. So that's what I would try to head towards and make the doctors think through.

Supriya Subramani

26:14

I'm not prescribed, like, it's not prescriptive, hey, you need to behave like this, like this in this context. And that's the reason the social norms play a huge role, the habitus plays a huge role, right? So and in my fieldwork, many of the patients actually especially people from, you know, patients from government hospital, they were having great empathy for doctors, actually. They were much more generous with the interpretation of the doctors, but at the same time, they do acknowledge wait maybe because I am belong to this this in this, you know, the marginalized community of group or individuals, they are behaving but I still acknowledge they're doing service, you know, there is this altruistic value of doctors who are in especially in the public hospitals, the patients do acknowledge that. The the problem I feel is, how much do we want the doctors to be a good person, like, it's not just good doctor, we also want them to be a good person. It's interesting. Like ethics teaching is also something around that. I mean, when we mean good doctors, we are trying to cater towards when you need to be a good person or good. I mean, that's a big ask, of course, right? So I think being aware of how disrespectful experiences are experienced by marginalised community or individual community members or individuals, I think that's something is a starter, that means being sensitive to the subjective experiences of people who have been at the receiving end for so many, so many years, which continues for various different reasons, right. So so I feel people with power and people with privilege should be aware that subjective experiences of people who are marginalised and and then start with questioning how we navigate this inter subjective space. And that's what I would hit towards. Yeah.

Diego Silva

28:06

So you've already mentioned education, and who we want doctors to be. So I think this is a fascinating question that I struggle with, which is, and I know many of our listeners do, too. One of the things bioethics face and bioethicists face when we're teaching medical students isn't actually the medical students themselves. It's the Medical program saying, Why does ethics matter? Or they might know why ethics matter? But why should we spend time teaching ethics when they could be learning about biological process X Y, Z? So when you're speaking about the importance of teaching reflexivity, of teaching respect for patients, and starting in the medical school, and so you and your co authors sort of make this argument in the paper. How would you answer the administrator about how you balance and why this is something that should be on the curriculum? And what this means for medical students?

Supriya Subramani

29:12

This has been like even for a very long time, I keep thinking about this ethics teaching. Does it make us ethically better humans? Right? I mean, of course, there was some studies right in 2010, or something or 13. I'm not sure there was a huge study that was said that moral philosophers not necessarily our ethical,

Diego Silva

29:36

yeah, well, there's a lot of history of moral philosophers behaving badly.

Supriya Subramani

29:40

Exactly, so I mean, of course, giving this context and the larger things but still I do value. Maybe I believe maybe I want my job to believe. But no, I'm serious note. I do think that ethics teaching is much more for making us reflect even as facilitators. I mean, rather than I would see teachers, I would see much more as a facilitators to think through, hey, these are the ethical theories, but then it's not about like a shopping thing. Right? Okay. You I mean, of course, we give these different different the knowledge or the way, it's a toolkit kind of, of course, when we are teaching. But then is it enough is something which I also keep thinking is, is that what part of bioethics teaching or the larger ethics teaching is for? Or sometimes I do wonder, is it are we trying to make going back to the other question, which was like, you know, good doctors are good human beings, that means we are focusing on virtuous or, you know, certain characteristic building. If that is the case, then we need to think through very differently of our ethics curriculum or the teaching methods, right? I mean, the way so for me as a person, the way I would see, based on my own research, work is much more about making students reflect their own ethical commitments, their own ethical positionality, or like, what values and it is, we all keep learning and unlearning over the years and the students first year students, especially, let's say, medical students will have a different kind of ethical vocabulary or the ethical concepts at the hand. And it is, of course, influenced by their own religious values, beliefs, or the social context where they come from the histories which they come from, right? Like, of course, even the way I would see even myself, but the ethical training, of course, as far as the way we reason, like why this decision or that, but I think it's not just enough, it should also push our boundaries to become much more reflective of our commitments, again, to reemphasise that and also to question, we have uncertainity, like, we constantly, you know, grapple with this uncertainty. And the larger society we live in is also ideologically, we have to reflect critically about the current ideology and value system which we live in. And we navigate this. So I would say the ethics teaching or bioethics teaching, especially when we are engaging with technology, medicine, at intersections would help myself and students to see how best we can navigate these ethical values or conundrum sometimes when we end up with and just stop and reflect and then live as best with plurality and being nice. I mean, I know I'm not sure whether that's the right word to be. Yeah, I like to be respectful with the plurality of values, but at the same time, be aware and comfortable with the ethical commitments which one has to.

Diego Silva

32:48

So with an eye of wrapping up, you mentioned a few of the things that you're working on, but I was hoping you could just tell us what we can expect for you and what papers we'll be reading from you soon.

Supriya Subramani

32:58

Great. Thank you. So for last four years, I have been working on a paper, which is on micro inequities, the moment I finished my paper on moral significance of micro inequities, which is basically ethnographic work, which I did in India. After that, whenever I did go and present my work with philosophers is applied philosophers specially, they did ask me a lot of times why it's important, why it matters? So I have written a paper now as submitted to a journal, which has been taking forever. It has went for many iterations with many other journals. But let's see how that goes. So that's something which I'm looking forward, hopefully, it'll come out soon. So that's basically a little less of disrespect, why it matters to healthcare ethics. That's something which I'm trying to work on. But other than my current papers, which is this, which is like a pet project, for a while it has been is my work on ethics of belonging, which is based on my postdoctoral project, which I did in Zurich, where I looked at immigrants healthcare experiences, especially from South Asian, Middle Eastern, and then African community members. It's very much an phenomenological work, which is very grounded within a small exploratory qualitative study. And there's something which I did focuses on how we do we understand belonging, what it what it means to belong to a particular community, but then not just from the idea of immigrants point of view, but more about how suffering plays a huge role in how we make sense of the world and how we navigate with each other, and how we become ethical towards others. So the way I'm connecting is if I'm feeling ashamed or humiliated, like as I was talking about, which is basically a continuation of my work. If I feel discriminated constantly, does that make me much more a good human being to another person who has been marginalised and discriminated. So basically, as an immigrant, if I'm meeting another immigrant who has experienced a similar kind of discriminatory experiences this suffering would help us to have a solidarity or the way we make sense of our belonging to each other, and how love plays a huge role. So that is something which is a long project. I mean, it's a huge project in itself, but that's where I'm heading towards. Yeah, thanks

Diego Silva

35:19

Yeah, that's awesome. I think it's really exciting and new ground that you're that you're going through. So good luck and looking forward to reading that. I want to thank you the listener for listening to this podcast of the SHE research podcast. You can find the paper as I noted at the beginning that we discussed linked in this episode's notes, along with the transcript of today's conversation. SHE pod is produced by SHE network and edited by Regina Botros. You can find our other episodes on Spotify, radio, public anchor, wherever you get your podcasts of quality. Thanks again for listening. Good bye.

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