Mediation of Medical Distrust due to Racial Injustice: The Legacy of Nancy Dubler

AbstractMedical distrust is often the result of social injustices, discrimination, systemic racism, and the repeated experience of epistemic injustices. Signaling medical trustworthiness in this context requires not only demonstrating competence and caring but grappling with the source of distrust rooted in experience. While we should be wary of framing every unmediatable conflict as an issue of distrust, which may simplify a complex human experience to an identity-based response, we argue that a community-engaged intersectional approach to mediation can address conflicts rooted in distrust and is fundamentally aligned with Nancy Dubler's legacy of addressing power differentials. We present a case where traditional tools of mediation-including addressing informational and emotional gaps-were insufficient at reaching a "principled resolution." In this case, the distance between the family member's and the medical team's understanding of the facts was so profound that it could not be overcome. Far from being irrational or unreasonable, this outcome was a direct response to the perpetual unequal access to epistemic authority experienced by this Black family. Mediators often belong to social groups with more power, and this bias can impact mediation practices, communication norms, and assumptions about conflict. Inclusive mediation models rooted in conflict theory can build on Nancy Dubler's classical work. We argue that bioethicists must engage in risky conversations with local communities to "collaboratively imagine what a more trustworthy system might look like." We describe the inclusive mediation model and how it expands on Nancy Dubler's foundational work and honors her tremendous legacy.