The clinician’s narrative and the patient’s narrative are ontologically equivalent

Yuya Yokota is a GP and Assistant Professor in the Department of General Medicine at the Graduate School of Medicine, Dentistry and Pharmaceutical Sciences at Okayama University, Japan. He is on X: @Yokota_general

The clinical setting of general practice is a space of complex human experiences, where the pursuit of biomedical facts alone is insufficient. In this environment, the medical imperatives of diagnosis and treatment are deeply intertwined with the life stories and values of each patient. At this intersection, an ethical problem may arise: “epistemic injustice”. According to Miranda Fricker, epistemic injustice occurs when an individual is wronged in their capacity as a knower.¹

This injustice can manifest in two forms. The first, “testimonial injustice”, involves unfairly diminishing a patient’s testimony due to prejudices about their social identity. The second, “hermeneutical injustice”, occurs when patients’ narratives, including their suffering, are not fully understood because of a gap in shared conceptual resources.¹ Common examples in clinical practice, such as dismissing pain not visible in lab results as “psychogenic” or attributing an undiagnosed condition to “laziness”, demonstrate how deeply this injustice can be embedded.

While the need to correct epistemic injustice is often framed as an ethical imperative, the philosophy of Markus Gabriel offers a more fundamental critique.^2,3 I argue that his concept of “fields of sense” reveals this injustice to be not merely an ethical failing but an ontological error.

“Fields of Sense”

Gabriel’s “New Realism” fundamentally challenges our understanding of existence. He argues that a single, comprehensive “world” does not exist.^2,3 When we consider the “world” as the place where things exist, a larger “world” is necessary to make that “world” exist. However, if we set such a larger “world”, for that “world” to exist, an even larger “world” is necessary. Thus, the single, comprehensive world we generally imagine requires an external context in which it can appear, resulting in an endless logical puzzle (an infinite regress) and, therefore, cannot logically exist.

In Gabriel’s philosophy, “to exist” is to appear within a specific context, or a “field of sense”.^2,3 For example, the laws of physics exist within the field of sense of “physics”, while human rights exist within the field of sense of “law and ethics”. A crucial consequence of this philosophy is the plurality and equality of these fields of sense. There is no hierarchy in which the field of sense of “scientific discourse” is ontologically superior to the field of sense of “illness experience”.

This is distinct from relativism. While relativism might imply that all viewpoints are merely subjective opinions, Gabriel’s realism asserts that phenomena within different fields of sense, such as “scientific discourse” and the “experience of illness,” are equally real. The existence of multiple “fields of sense” allows for the existence of various ideas and meanings.

Ontologically overcoming epistemic injustice

From this ontological viewpoint, the hierarchy that privileges “objective, scientific knowledge” over “subjective, narrative knowledge” collapses. While the benefits of scientific medicine are immense, treating its framework as absolute can undermine the credibility of patient testimony that lacks objective data, dismissing it as “unscientific”. Gabriel’s philosophy asserts that the field of sense of medicine and the field of sense of patient’s experience, where a patient articulates their suffering, are ontologically equal realities. Therefore, disregarding a patient’s testimony is not simply a lack of empathy; it is an ontological error that denies the reality of an existing field of sense.

Similarly, hermeneutical injustice arises when the dominant medical field of sense lacks the interpretive resources to explain certain forms of suffering. Experiences that fall outside existing diagnostic categories are often treated as non-existent, effectively silencing the patient. Gabriel’s philosophy breaks this impasse by suggesting that new fields of sense can always be generated. The dialogue between a clinician and a patient is therefore not a mere exchange of information, but a co-creative process that can form a new “interpretive field of sense”, allowing previously unnamable experiences to be understood.

In conclusion, the philosophy of “fields of sense” compels us to see epistemic injustice in medicine as a fundamental ontological problem, not just an ethical issue of rights and power. This perspective provides an ontological grounding for narrative and dialogical medical practices. It affirms that the clinician’s narrative and the patient’s narrative are ontologically equivalent, urging us to respect the patient’s voice as legitimate knowledge and to co-create new frameworks for understanding experiences.

References

1. Fricker, M (2007). Epistemic Injustice: Power and the Ethics of Knowing. New York: Oxford University Press.
2. Gabriel, M (2015). Fields of Sense: A New Realist Ontology. Edinburgh: Edinburgh University Press.
3. Gabriel, M (2015). Why the World Does Not Exist. Malden: Polity.

Featured photo by Frank Vessia on Unsplash