Testimonial Injustice and Its Harms in Hemodialysis Patients in Japan: A Qualitative Study.

Objective This study explored testimonial injustice and its associated harms arising from prejudices experienced by patients undergoing hemodialysis and examined implications for bioethics. Methods We conducted semi-structured interviews with 23 patients undergoing hemodialysis for one year or more. The interviews focused on the patients' experiences of prejudice, how they addressed the prejudice, and the effects of the prejudice. We analyzed the interviews by content analysis using Krippendorff's method. Results The analysis identified multiple forms of prejudice across both clinical and non-clinical settings. Patterns consistent with testimonial injustice were also observed, including situations in which patients were not believed or were not given opportunities to speak. In response, some participants adopted anticipatory strategies to avoid prejudice, such as withholding or modifying their testimony. These accounts correspond to testimonial smothering, in which individuals suppress their own statements in anticipation of negative evaluation. The harms identified in the data were primarily medical disadvantages, such as delayed examinations and treatment, which affected patients' access to appropriate care. Conclusion This study demonstrated that testimonial injustice can occur among individuals with internal disabilities whose conditions are not outwardly visible. Some patients anticipated this injustice and engaged in avoidance behaviors, such as concealing their treatment status, thereby forfeiting opportunities to be recognized as legitimate subjects of knowledge. The harms associated with these experiences included both primary and secondary forms: primary harms were identified as "invisible harms" that may threaten patients' dignity and warrant consideration under the principle of nonmaleficence, while secondary harms raised concerns from the perspective of formal justice. Addressing testimonial injustice in bioethics may help clarify how patients are harmed when their words are not taken seriously and encourage healthcare professionals to reflect on how they listen to and respond to patients.