Wednesday 24 May 2023

Should epistemic injustice matter to psychiatrists?

This post is by Eleanor Harris, Lucienne Spencer, and EPIC project investigator Ian James Kidd. Harris is a M4C funded doctoral researcher at the University of Birmingham, working on epistemic injustice and epistemic vigilance. Spencer is a postdoctoral researcher working on the Wellcome Trust-funded project ‘Renewing Phenomenological Psychopathology’ at the Institute of Mental Health, University of Birmingham. Kidd is a lecturer in philosophy at the university of Nottingham and works on epistemology, philosophy of illness and healthcare. 

Eleanor Harris

Does epistemic injustice matter in psychiatric contexts? Brent Kious and colleagues have recently argued ‘No’ (see paper in Psychological Medicine). While it is welcome to have our assumptions challenged, we think the answer should still be that epistemic injustice should matter to psychiatrists. (See our full response in Philosophy of Medicine).

Before addressing whether epistemic injustice is applicable to psychiatry, it’s important to briefly clarify what “epistemic injustice” is. Epistemic injustice is a broad and heterogenous category of wrongs. Very generally, epistemic injustices are those which harm someone in their capacity as a knower (as an epistemic agent). With this notion in place, we can focus on epistemic injustice in psychiatry.

Lucienne Spencer

When disputing the need for epistemic injustice, one has to have a good understanding of what it is. Our first worry is that Kious and colleagues have an overly-narrow conception of epistemic injustice as ‘unfairly discriminating against a person with respect to their ability to know things’. While this captures some important kinds of epistemic injustice, it does not include others, such as those involving the unfair and harmful distribution of epistemic goods (like credibility). Given the varieties of epistemic injustice, claims about whether or not it matters in a given context should be sensitive to the richness and diversity of the concept.

Secondly, Kious and colleagues dispute the prevalence of epistemic injustice, which we think overlooks the abundance of evidence for its enduring and widespread presence in psychiatry. Many patient testimonies report negative epistemic experiences – such as the feeling of not being listened to – which are interpretable as epistemic injustices. Indeed, such reports are common almost to the point of cliché. 

A related claim by Kious and colleagues is that even if there are a few localised instances of epistemic injustice, the psychiatric profession has existing tools and clinical standards to deal with these cases. However, this is unpersuasive, given that epistemic injustices are still being reported despite these tools and standards. Moreover, we worry that those tools and standards themselves could perpetuate epistemic injustices. Some apparent solutions might actually be part of the problem, and this is precisely the point raised by so many critical writers in the philosophy of psychiatry, mad studies, and elsewhere.

Ian Kidd

Kious, Lewis and Kim end their paper with a worry that the concept of epistemic injustice might encourage some psychiatrists to ‘act as though we believe everything patients tell us’. Even worse, patients might come to expect ‘uniform acceptance of their ideas about diagnosis and treatment’. We agree that neither of these outcomes is desirable, but we also think that no epistemic injustice scholar would endorse such exaggerated policies of epistemic credulity and acceptance. Uncritical acceptance of all testimony is not epistemic justice.

We think that epistemic justice does need appreciation of psychiatrists’ epistemic power, the intrinsic and contingent obstacles to interpersonal understanding in cases of psychiatric illness, and the serious consequences of epistemic injustice in this domain. The conceptual resources offered by epistemic injustice studies are vital for making progress in that direction.