Epistemic Isolation in Psychiatric Healthcare

This blog is based on an article by Dr Lucienne Spencer which was published last month in the journal Social Epistemology.

Kidd and Carel’s concept of ‘epistemic isolation’ occurs in ‘situations where a person or group lacks the knowledge of, or means of access to, particular information’ (Kidd and Carel 2017, 183–184). Such epistemic isolation can be found in psychiatric healthcare, where treatment plans and even diagnoses can be withheld from the patient (Spencer, 2024).

Goldstein distinguishes between epistemic isolation as an epistemic injustice or as an epistemic disadvantage (Goldstein 2022). Not all epistemic harms are necessarily epistemic injustices, but rather ‘circumstantial epistemic bad luck’ (Fricker 2007, 152). While Fricker limits ‘epistemic bad luck’ to the product of ‘hermeneutical disadvantage’, Goldstein broadens this notion to ‘Epistemic Disadvantage’, which occurs when a person or group is excluded from knowledge in a warranted way, even if it results in intellectual or moral harm.

A thinking head

Goldstein argues epistemic isolation is an epistemic disadvantage when it meets the following criteria:

1. ‘Harms are non-deliberate, arising in circumstances of bad luck’.
2. ‘Speakers lack precision or mastery of concepts to effectively communicate their experience’.
3. ‘Affected participants are justifiably excluded or subordinated from the practice that could make the concept known’. (Goldstein 2022, 1870–1871)

Here, I examine Goldstein’s criteria in relation to epistemic isolation in psychiatric healthcare.  

Criteria 1

For Fricker, epistemic injustice is necessarily non-deliberative. The epistemic injustices she conceives of are ‘discriminatory but ingenuous misjudgement’ rather than ‘deliberate manipulation’ (Fricker 2017, 54). Therefore, unintentional epistemic harm is not unique to epistemic disadvantage.

As Goldstein observes, epistemic injustice must be motivated by an identity prejudice. To refer to epistemic isolation in psychiatric healthcare as an instance of ‘bad luck’ would be to assume that it is merely circumstantial that the clinician does not have time to meet the patient’s epistemic needs: to ensure they understand their treatment and diagnosis. However, this so-called ‘bad luck’ is driven by what Fricker calls an ‘institutional epistemic vice’ in the healthcare system (Fricker 2021).

Institutional epistemic vice is a culpable lapse in the institution’s epistemic ethos (Fricker 2021, 101). Fricker imagines a school with good epistemic commitments but has developed ‘sloppy information sharing’ (Fricker 2021, 100). Similarly, the psychiatric healthcare system has a good ethos, yet flawed information-sharing practices and an institutional attitude that deprioritises the epistemic needs of the patient. This epistemic isolation emerges from a structural identity prejudice that is not located in the clinician but, rather, in the bones of the institution.

Criteria 2

Here, we need to determine if an inability to effectively communicate emerges from a ‘lack of mastery’ or from hermeneutical injustice. A ‘lack of precision or mastery of concepts’ may simply be a lack of mastery in the imposed interpretive framework. One may have a good capacity for communicating one’s experience in one’s own words, beyond a clinical framework; however, such communication is not understood or taken seriously.

Instead, we can ask whether there is a just division in epistemic labour between experts and non-experts. Goldstein follows Goldman in defining an expert as those with a ‘superior quantity or level of knowledge in some domain and an ability to generate new knowledge in that domain’ (Goldman 2001, 91). Clinicians, indeed, have developed skills in their field and act as generators of knowledge. However, those with psychiatric illness hold a unique form of experiential knowledge and expertise.

Illness ‘gives us experiences that we would not otherwise have had and that we cannot know what it is like to have until we undergo them’ (Carel et al. 2016, 1152). Therefore, if we take the ‘domain’ to be the psychiatric illness under evaluation, psychiatric patients cannot be said to lack a ‘superior quantity or level of knowledge’ or ‘an ability to generate new knowledge’. If the patient is treated as a non-expert from the outset, and knowledge is withheld, they are deprived of the opportunity to ‘master the concepts to effectively communicate their experience’. Instead, ignorance is imposed upon the patient from the offset.

Criteria 3

Clinical institutions could attempt to justify withholding information through the ‘non-maleficence principle’, the idea that revealing a diagnosis or treatment plan will cause harm to the patient. Alternatively, it could be argued that the deprioritisation of the patient’s epistemic needs is justified due to limits on time and resources. However, withholding information from a patient often causes the patient more harm than good (Spencer, 2024).

Most significantly, institutionalised epistemic isolation places the patient at a ‘cognitive disadvantage’. As such, they are inhibited not only from contributing to the pool of knowledge regarding their illness but also from making sense of their illness themselves. Although the diagnosis may be withheld due to the fear of stigmatisation, it is the stigmatisation that causes harm, not the diagnosis itself. This stigmatisation is only exacerbated by a culture of silence around the diagnosis.

Goldstein provides a valuable development of epistemic isolation, and I share her concern for overstretching the term epistemic injustice beyond the unjust. I show that epistemic isolation in psychiatric healthcare is not such a case of epistemic disadvantage.

Lucienne Spencer

Lucienne is a a Postdoctoral Researcher in Mental Health Ethics located within the Neuroscience, Ethics and Society (NEUROSEC) Team in the Department of Psychiatry, University of Oxford. Her research primarily focuses on phenomenology, epistemic injustice and the philosophy of psychiatry.