Shame-Sensitive Public Health.

In this article, we argue that shaming interventions and messages during Covid-19 have drawn the relationship between public health and shame into a heightened state of contention, offering us a valuable opportunity to reconsider shame as a desired outcome of public health work, and to push back against the logics of individual responsibility and blame for illness and disease on which it sits. We begin by defining shame and demonstrating how it is conceptually and practically distinct from stigma. We then set out evidence on the consequences of shame for social and relational health outcomes and assess the past and present dimensions of shame in the context of the Covid-19 pandemic, primarily through a corpus of international news stories on the shaming of people perceived to have transgressed public health directions or advice. Following a brief note on shame (and policymaking) in a cultural context, we turn to the concept and practice of 'shame-sensitivity' in order to theorise a set of practical and adaptable principles that could be used to assist policymakers in short- and medium-term decision-making on urgent, tenacious, and emerging issues within public health. Finally, we consider the longer consequences of pandemic shame, making a wider case for the acknowledgement of the emotion as a key determinant of health.

Shame, health literacy and consent.

This paper is particularly concerned with shame, sometimes considered the 'master emotion', and its possible role in affecting the consent process, specifically where that shame relates to the issue of diminished health literacy. We suggest that the absence of exploration of affective issues in general during the consent process is problematic, as emotions commonly impact upon our decision-making process. Experiencing shame in the healthcare environment can have a significant influence on choices related to health and healthcare, and may lead to discussions of possibilities and alternatives being closed off. In the case of impaired health literacy we suggest that it obstructs the narrowing of the epistemic gap between clinician and patient normally achieved through communication and information provision. Health literacy shame prevents acknowledgement of this barrier. The consequence is that it may render consent less effective than it otherwise might have been in protecting the person's autonomy. We propose that the absence of consideration of health literacy shame during the consent process diminishes the possibility of the patient exerting full control over their choices, and thus bodily integrity.

Emotions of the pandemic: phenomenological perspectives.

This article provides an introduction to the special issue "Emotions of the Pandemic: Phenomenological Perspectives". We begin by outlining how phenomenological research can illuminate various forms of emotional experience associated with the exceptional circumstances of the COVID-19 pandemic. In addition, we propose that a consideration of pandemic experience, in all its complexity and diversity, has the potential to yield wider-ranging phenomenological insights. We go on to discuss the thirteen contributions that follow, identifying common themes and points of complementarity.

What is affective technotouch (and why does it matter)?

This Editors' Introduction defines the theme of 'affective technotouch' as referring to multidimensional embodied encounters with technologies which can trigger emotional and affective responses, while also being concerned with social, political, cultural and ethical dimensions of technological touch. With reference to neuroscience and developmental studies, we outline how touch is foundational in human experience. We then discuss contemporary technologies, such as haptic gadgets and care/companion robots, which illustrate the complexities of affective technotouch. Finally, we offer critical outlines of the six contributing articles to this Special Issue on Affective Technotouch.

A Sartrean analysis of pandemic shaming.

In this paper, we analyse the particular phenomena of COVID-19 pandemic shaming. We examine Sartre's account of the undifferentiated other in the experience of 'the look', and his insistence on shame as a foundational relational affect, in order to give a robust theoretical frame to understand how pandemic shaming circulated both online and offline, in targeted and diffuse manners. We focus on two features of pandemic shaming. First, we draw attention to the structural necessity of an audience in acts of pandemic shaming, where the shamer acts on behalf of a community of others, the audience, to perform and enforce a set of standards, values or norms. We turn to the we-experience and collective emotions literature and discuss how the shamer believes themselves to be 'speaking' on behalf of a community who share their outrage along with their values. Second, we discuss how the presumption of a collective emotion was frequently mistaken in acts of pandemic shaming, where shaming frequently led to shame backlashes, where the audience revealed themselves not to share the emotion and values of the shamer, consequently shaming the shamer. We argue that Jean-Paul Sartre's voyeur example is usefully illustrative of the tripartite structure of (1) shamed, (2) shamer and (3) shamer of the shamer that occurs in iterative processes of pandemic shaming, which are accompanied by shaming backlashes. We conclude by reflecting on the socio-historical context for Sartre's accounts of shame and 'the look', namely the German occupation of Paris and Sartre's experience of the French Resistance movement, and how these yield a particular socio-historical framing that makes evident how the extraordinary pseudo-wartime conditions of COVID-19 rendered atmospheres of distrust and suspicion prevalent.

Fat shaming under neoliberalism and COVID-19: Examining the UK's Tackling Obesity campaign.

This article explores the dynamics between fat shaming, neoliberalism, ideological constructions of health and the 'obesity epidemic' within the UK, using the UK Government's recent Tackling Obesity campaign in response to Covid-19 as an illustration. We draw attention to how fat shaming as a practice that encourages open disdain for those living with excess weight operates as a moralising tool to regulate and manage those who are viewed as 'bad' citizens. In doing so, we begin by outlining how the ideological underpinnings of 'health' have been transformed under neoliberalism. We then consider the problematic use of fat shaming discourses that are often used as tools to promote 'healthy' lifestyle choices by those who view it as not only an acceptable way of communicating the health risks associated with obesity but also a productive way of motivating people with obesity to lose weight. Drawing on Graham Scambler's theoretical framework regarding shame and blame (2020), we discuss how 'heaping blame on shame' has become a 'wilful political strategy' under neoliberalism, particularly as it relates to individuals with obesity, and how the Tackling Obesity campaign leverages concerns around 'choices' and 'costs' as a means through which to encourage normative models of self-care and self-discipline.

The Horizons of Chronic Shame.

Experiences of shame are not always discrete, but can be recurrent, persistent or enduring. To use the feminist phenomenologist Sandra Lee Bartky's formulation, shame is not always an acute event, but can become a "pervasive affective attunement" (Bartky, 1990: 85). Instead of experiencing shame as a discrete event with a finite duration, it can be experienced as a persistent, and perhaps, permanent possibility in daily life. This sort of pervasive or persistent shame is commonly referred to as "chronic shame" (Pattison, 2000; Nathanson, 1992; Dolezal, 2015). Chronic shame is frequently associated with political oppression and marginalization. In chronic shame, it is the potentiality of shame, rather than the actuality, that is significant. In other words, the anticipation of shame (whether explicit or implicit) comes to be a defining feature of one's lived experience. Living with chronic shame has important socio-political consequences. Thus far, chronic shame has eluded simple phenomenological analysis, largely because chronic shame often does not have a clear experiential profile: it is frequently characterised by the absence rather than the presence of shame. The aim of this article is to provide a phenomenology of chronic shame, drawing from Edmund Husserl's formulation of the 'horizon' as a means a to discuss structural aspects of chronic shame experiences, in particular how chronic shame is characterised by structures of absence and anticipation.

The effects of shame and stigma on patient care.

Stigma in healthcare has been associated with a range of negative outcomes, such as delays in seeking treatment, avoiding clinical encounters and mental distress. This editorial discusses the experience of stigma and argues that understanding shame anxiety and adopting 'shame-sensitive' practice is beneficial in healthcare.

Philosophy and the clinic: Stigma, respect and shame.

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.

Beyond a trauma-informed approach and towards shame-sensitive practice.

In this article, we outline and define for the first time the concept of shame-sensitivity and principles for shame-sensitive practice. We argue that shame-sensitive practice is essential for the trauma-informed approach. Experiences of trauma are widespread, and there exists a wealth of evidence directly correlating trauma to a range of poor social and health outcomes which incur substantial costs to individuals and to society. As such, trauma has been positioned as a significant public health issue which many argue necessitates a trauma-informed approach to health, care and social services along with public health. Shame is key emotional after effect of experiences of trauma, and an emerging literature argues that we may 'have failed to see the obvious' by neglecting to acknowledge the influence of shame on posttrauma states. We argue that the trauma-informed approach fails to adequately theorise and address shame, and that many of the aims of the trauma-informed are more effectively addressed through the concept and practice of shame-sensitivity. We begin by giving an overview of the trauma-informed paradigm, then consider shame as part of trauma, looking particularly at how shame manifests in post-trauma states in a chronic form. We explore how shame becomes a barrier to successful engagement with services, and finally conclude with a definition of the shame-sensitive concept and the principles for its practice.

Shame anxiety, stigma and clinical encounters.

Stigma has been associated with delays in seeking treatment, avoiding clinical encounters, prolonged risk of transmission, poor adherence to treatment, mental distress, mental ill health and an increased risk of the recurrence of health problems, among many other factors that negatively impact on health outcomes. While the burdens and consequences of stigma have long been recognized in the health literature, there remains some ambiguity about how stigma is experienced by individuals who live with it. The aim of this paper is to elucidate the phenomenology of stigma, or to describe how it is that stigma shows up in the first-person experience of individuals who live with stigma and its burdens. Exploring the relationship between shame and stigma, I argue that shame anxiety, or the chronic anticipation of shame, best characterises the experience of living with a health-related, or health-relevant, stigma. Understanding the experiential features, or phenomenology, of shame anxiety will give healthcare professionals a greater sensitivity to stigma and its impacts in clinical settings and encounters. I will conclude by suggesting that 'shame-sensitive' practice would be beneficial in healthcare.

Shame, Guilt, and Medical Error in Ann Patchett's State of Wonder.

Medical error can be a devastating experience for medical practitioners who are often called the "second victims" of medical mistakes. The emotional toll medical error takes on doctors is not well understood, with few studies investigating shame and/or guilt in response to making mistakes. This essay considers how fiction and medical nonfiction might contribute to this understanding, by exploring the relation between shame, guilt, and medical error in Ann Patchett's novel State of Wonder (2011) alongside Danielle Ofri's autobiographical reflections in her essay, "Ashamed to Admit It: Owning up to Medical Error," later reprinted as part of a chapter entitled "Burning with Shame" in What Doctors Feel (2013).

Shame, Stigma and HIV: Considering Affective Climates and the Phenomenology of Shame Anxiety.

The affective climate often associated with HIV prevention and care practices is often dominated by negative emotions such as shame, fear and suspicion which arise because of HIV's historical stigma. This article explores the experiential consequences of this affective climate and the continued stigma associated with HIV, through a focus on the experience of shame anxiety which can be understood as the chronic anticipation of shame or shameful exposure. Exploring first-person narratives of gay men living with HIV, the article gives an account of how shame anxiety is central to understanding how stigma causes harm, especially in experiences of chronic illnesses such as HIV. Using a philosophical framework, through phenomenology, it will be demonstrated how shame anxiety manifests in bodily lived experience through the structure of the "horizon". The article will finish with reflections on how shame anxiety can act as a barrier to the effective delivery of health services for those with stigmatised chronic illnesses and, furthermore, why the experience of shame anxiety might be useful to consider when delivering health services.

Health-related shame: an affective determinant of health?

Despite shame being recognised as a powerful force in the clinical encounter, it is underacknowledged, under-researched and undertheorised in the contexts of health and medicine. In this paper we make two claims. The first is that emotional or affective states, in particular shame, can have a significant impact on health, illness and health-related behaviours. We outline four possible processes through which this might occur: (1) acute shame avoidance behaviour; (2) chronic shame health-related behaviours; (3) stigma and social status threat and (4) biological mechanisms. Second, we postulate that shame's influence is so insidious, pervasive and pernicious, and so critical to clinical and political discourse around health, that it is imperative that its vital role in health, health-related behaviours and illness be recognised and assimilated into medical, social and political consciousness and practice. In essence, we argue that its impact is sufficiently powerful for it to be considered an affective determinant of health, and provide three justifications for this. We conclude with a proposal for a research agenda that aims to extend the state of knowledge of health-related shame.