The Role of Curiosity in Healthcare

Empathy, kindness, and trustworthiness are among some of the virtues commonly associated with physicians and other healthcare professionals. However, might the virtue of curiosity also have a role to play in medicine?

Lisa Bortolotti and Kathleen Murphy-Hollies (2023) offer an extensive and thoughtful treatment of how curiosity can be a virtue in healthcare, especially within the physician–patient relationship. They describe curiosity as a disposition to attain new information, with it manifesting as a moral virtue when it helps one to view others as speakers with a valuable perspective. Importantly, they argue that when curiosity is directed towards the experiences of others, it becomes a form of caring, encouraging one not to dismiss the experiences of others.

Girls being curious about botany

Curiosity in Healthcare

Curiosity may thus have a crucial role to play in healthcare, “opening us to questions and, if fortunate, knowing more deeply both patient and disease” (p. 138). It may help physicians to practice a more patient-centered care and to ensure that the perspectives and experiences of patients are not lost or dismissed even when views differ. Moreover, it may be particularly fruitful in situations where testimonial injustice is common, such as the doubting or discrediting of a patient’s pain, or the disbelieving of female reproductive symptoms.

However, it is also important for physicians to not stray into inappropriate curiosity, which can take the form of question-asking solely to satisfy the personal interest or curiosity of the physician. This inappropriate curiosity can lead to patients being subjected to intrusive questions irrelevant to their medical care, or breaches of privacy and the violation of patient confidentiality.

Barriers to Curiosity and Ways Forward

Although it may play a valuable role, several barriers may prevent or hinder the practice of curiosity in healthcare. Practically, the decreasing time for physician–patient encounters presents a logistical barrier—to what extent can one exercise curiosity in another’s life within the short span of 5 to 10 minutes?

Another obstacle to the cultivation of curiosity is what Martyn Evans calls the “foreseeable, unremitting, and unsung”” (p. 125). These, for a physician, may be patients with unremarkable or routine symptoms and stories that provoke little surprise. In these situations, “curiosity is dulled by familiarity”. However, even if medically unremarkable, such patients are still deserving of sustained moral attention. To combat this, , Evans proposes adopting an attitude of openness to wonder, potentially allowing a physician to see the patient in a new and extraordinary light, and thereby facilitating the exercise of curiosity.

People looking quizzical

Overconfidence and a lack of epistemic humility can also be an obstacle to curiosity, as physicians may sometimes be reluctant to acknowledge uncertainty or ignorance to their patients or peers. For this, medical education and institutions can help by emphasizing a culture of curiosity, and fostering an environment where physicians can constantly learn and adopt the perspectives of others, even post-graduation.

With these obstacles in mind, working towards the practice of curiosity in healthcare may contribute to broadening one’s perspectives and contribute to a more empathetic and well-rounded practice of medicine that includes the experiences of all.

Katherine Cheung

Katherine Cheung is a PhD student in Bioethics and Health Policy at Johns Hopkins, and previously worked as a Health Science Policy Analyst on data sharing, stationed with the NIH. Her current work focuses on bioethical issues related to psychedelics, such as the value of the psychedelic experience and the place of meaningfulness in medicine.

Jodie Russell joins EPIC!

Welcome to Jodie Russell who will be joining project EPIC, working in Birmingham with Matthew Broome and Lisa Bortolotti. Here Jodie replies to some questions about her research.

Jodie Russell

Hi Jodie! What are your main research interests?

Hello there! I’m interested in the ways in which talking about and researching mental disorder shapes the very experience of mental disorder itself. I would describe myself as part philosopher of mind, philosopher of psychiatry and phenomenologist. 

Early in my PhD I was strongly inspired by Ian Hacking’s work in looping effects; he describes how the act of labelling a person can influence their behaviour, which in turn can change the meaning of the label. This also applies in the case of mental disorder categories, and I used my PhD project to try and get at the bottom of why and how this happens. 

My hypothesis is that looping effects are as a result of people trying to understand one another, where labelling is a way of learning about other people. When we label, I suggest, we (intentionally or unintentionally) encourage another’s behaviour to conform to certain norms and expectations about that label. 

For example, by labelling someone as a friend, that might come with expectations that they should do me certain favours (like keeping a secret). They could refuse, of course, but that might challenge the legitimacy of the label ‘friend’ and whether I actually understand the nature of our relationship! This is how social cognition works, according to the mind-shaping hypothesis; we understand each other’s minds through the norms and expectations we conform to. My contribution, however, is to describe how scientists and patients themselves ‘shape’ the minds of those with mental disorder, for good or for bad.

Why do you think it is important to study epistemic injustice in healthcare?

My research thus far has led me to the conclusion that the kinds of concepts and labels someone has access to can greatly influence how they behave. This can have good and bad effects; a mental disorder concept that implies that one must suffer if one has a mental disorder might lead to a person expecting a poor quality of life, which may itself lead to experiences of suffering and despondency. However, a concept of a particular mental disorder that captures a significant aspect of how it feels might make people feel understood and less alienated in society.

Identifying cases of epistemic injustice, I think, helps us steer away from the negative effects of social labelling and understanding, and steer our cognitive tools towards those concepts which not only help reduce the suffering of people with mental disorder but are also informed by their experiences directly. 

Studying epistemic injustice in healthcare not only helps us identify where particular concepts have been overlooked and where testimony has been excluded in cases of mental health, but the principle of epistemic justice can help rectify some of the historic harms of an overly narrow approach to healthcare where patients traditionally did not have much say in how they were treated and understood.

What are you working on right now?

Now I have completed my PhD, I’m developing its insights further in my current work to consider how mental disorder concepts overlap with other facets of our identity (such as race, gender, and age) where concepts may similarly apply in order to shape someone’s behaviour. My goal is to establish an intersectional, feminist approach to psychiatry that highlights how other aspects of one’s identity impact disorder experience, and vice versa.

I feel that in order to effectively tackle cases of epistemic injustice we should also consider the nuances of people’s identity; two people with psychosis, for example, will never have the exact same experience as they take up different roles and positions in the world. A young person with psychosis will face different kinds of challenges and may require different tools for understanding their experience than someone middle-aged, for instance. My goal is to capture these nuances and to make a case for this more intersectional approach.

The Scope of Epistemic Injustice in Psychiatry

In this post, Themistoklis Pantazakos and Sarah Arnaud argue that the concept of testimonial epistemic injustice has been too broadly used in psychiatry, leading to confusion and doubts about its usefulness. They suggest that once the concept is properly focused on phenomenology, these issues are largely resolved.

In broad terms, to do an epistemic injustice is to harm somebody in their capacity as a knower (Fricker, 2007). The concept has taken the world of philosophy of psychiatry by storm, with a surge of academic articles and presentations over the past decade. However, many fundamental aspects of the concept remain unclear. For instance, it is often ambiguous what type of knowledge mental health service users contribute, or why and when psychiatrists should listen to them. “Listening to the voice of the marginalized (service users)” has become a common go-to phrase for finding a remedy to epistemic injustice, however it remains too vague. Overall, there is a pressing need for accounts that clarify the mechanisms and specifics of epistemic injustice with an eye to making it clinically useful.

In our recent article in Philosophical Psychology, we address these questions, beginning with a recent debate in philosophy of psychiatry, focusing specifically on the testimonial strand of epistemic injustice, which involves the information provided by service users. Kious et al. (2023) recently argued that the concept of testimonial epistemic injustice is at best superfluous and at worst detrimental to psychiatric conduct, presenting two key arguments for this. Firstly, that uncritically believing everything a service user says would undermine the critical skepticism necessary for effective psychiatric practice. Secondly, that the careful consideration of information provided by service users is already covered by existing psychiatric guidelines. Unsurprisingly, friends of the epistemic injustice concept responded swiftly and intensely (Aftab, 2023; Kidd et al., 2023).

Kious et al. discuss various psychiatric incidents to support their position, arguing that these cases, often cited as examples of testimonial epistemic injustice, do not involve moral missteps by the attending psychiatrists. Their opponents claim the opposite. Disagreeing with both, we contend that these incidents, regardless of their general moral aspects, are unsuitable for demonstrating testimonial epistemic injustice in psychiatry. To do this, we first clarify that the primary mission of psychiatry is to help service users cope better, i.e., to improve what it is like to be them. We then argue that psychiatrists should not listen to service users indiscriminately or merely for the sake of participation. Instead, they should listen when service users speak about their area of expertise, which regards foremostly what it is like to be them. The cases discussed by Kious et al. and their opponents concern issues outside the natural expertise of service users, who therefore may not be the primary epistemic sources in these contexts.

Generalizing this approach, we propose that the concept of testimonial injustice in psychiatry should be centered on phenomenology, or the study of the lived experience of service users. This conceptualization allows for what Kious et al. call “a degree of healthy skepticism”, which we agree is crucial in psychiatry. Moreover, it highlights an epistemic dimension that is overlooked in psychiatric practice guidelines, thereby clarifying the novelty and the necessity of the epistemic injustice concept for the field. We conclude by examining historical cases in psychiatry, including schizophrenia and autism, to demonstrate that this form of epistemic injustice, which we term phenomenological epistemic injustice, has been prevalent in the profession.

Themistoklis Pantazakos

Sarah Arnaud

Why self-help is not always helpful

 “Self-love is the balance between accepting yourself as you are while knowing you deserve better, and then working towards it.”

― Vex King, Good Vibes, Good Life: How Self-Love Is the Key to Unlocking Your Greatness

‘Self-help’ is a movement and an industry. The rhetoric of self-help includes self-knowledge, self-change, self-improvement, self-understanding, self-mastery, self- motivation and self-love. It all sounds positive, yet there is a darker side to the self-help movement, particularly surrounding illness.  

Self-help literature prioritises self-knowledge and honesty, with self-assessment scales and questionnaires designed to increase knowledge of our own strengths and weaknesses, giving us the ‘truth’ about ourselves (Rimke 2000: 67-68).  The emphasis on self suggests that power is being given to the individual. But the rhetoric of self-help can be used to perpetuate existing power relations under the guise of voluntary ‘self-improvement’. 

Self-love

According to Rimke, we defer to experts in psychology, because we assume that all problems are psychological ones and that psychology can make us happy and ‘normal’. ‘Self-help is the logical extension of a psychologistically oriented culture in which psychology enjoys cultural authority as a form of expert knowledge’ (Rimke 2000: 63). Power operates through self-help with cunning sleight of hand. We are told to love ourselves, to be responsible for our own psychological states but also improve and conform to social psychological benchmarks. 

Self-help rhetoric is full of neoliberal ideals. In brief, neoliberalism is a political and economic ideology favouring capitalism, free market competition and minimal government interference. Neoliberalism can lead to a hyper-individualist, meritocratic outlook where individuals are the authors of their own success and failure (Franssen 2020: 102). The emphasis on self in self-care literature reinforces this. 

However neoliberalism is also accused of exacerbating social inequalities due to excessive individualism and a failure to recognise that individual vulnerabilities are often the result of social and economic disadvantages. There is evidence that for people with mental illness such as bipolar disorder, the internalisation of meritocratic world views, in which individual success or failure is perceived as the result of their own efforts (or lack thereof), results in self-stigmatisation and increased feelings of guilt or shame (Rüsch, Todd et al. 2010). 

If we are being told that ‘individuals possess the ability to choose happiness over unhappiness, success over failure, and even health over illness’ (Rimke 2000: 73) then the implication is that those who fail to recover simply made bad choices or failed to master their own psychology, diverting attention from the forces of power that can actually make structural changes. This is victim-blaming of the most vulnerable.

This dark side of self-help is a type of hermeneutical injustice that is not simply an absence of the appropriate hermeneutical resources needed to make sense of a social experience (Fricker 2007). It is not that we lack the concepts of inequality or neglect in healthcare. Rather, it is a case of what Falbo describes as a species of hermeneutical injustice where there is an ‘overabundance of distorting and oppressive concepts’ which crowd out, defeat or pre-empt the application of a more accurate concept (Falbo 2022: 353). 

In many cases of illness, a failure to recover would be appropriately understood in terms of inequality, disadvantage or neglect. But these concepts are replaced by a hyper-individualised, neoliberal meritocratic ideology, perpetuated by self-help literature. The very movement that is meant to increase self-knowledge becomes hijacked in a way that diverts attention from the structural inequalities that those in power should be addressing, instead blaming the victims of those inequalities. When this happens, self-help rhetoric is not only unhelpful, it is harmful. 

Sally Latham is a PhD student with the Open University and recipient of the Royal Institute of Philosophy Jacobson Studentship. She is soon to submit her thesis arguing for a non-narrative approach to mental health.