What is Epistemic Loneliness?

In today's post  Ramón Alvarado discusses the notion of epistemic loneliness.

representation of loneliness

Often, we think of loneliness as a matter of social isolation. If we had someone— anyone— by our side, we would feel less lonely. Sometimes, we acknowledge that there is an extra component to this companionship. If we, or other lonely person, had not just any other person but a significant other, then we would be less lonely. And yet, we often feel lonely in crowds, in loving relationships, and even amongst friends and family. If this is the case, then there must be something else to certain instances of loneliness that is not addressed merely by the presence of others or even significant others.

In recent work, some philosophers of loneliness have suggested that what it is missing in such instances is a kind of recognition. For some, this comes from a mutual, evolutionarily convenient recognition of kinship. For others, it is a recognition of intellectual and character complexities that constitute your uniqueness. However, just as we saw above and as many highly recognized individuals can attest, being recognized is sometimes the reason why one may feel intellectually lonely. So there must be something else in some instances of loneliness where being in company of others, significant others, or being recognized does not suffice.

For example, many times we feel lonely because we are not “understood”. But this isn’t just us lacking someone we can impart knowledge to or someone that recognizes how smart and unique we are. Rather, we yearn for a conversation partner that can hold their own, someone that will not just challenge our beliefs but that can also help us build new ones. In short, sometimes what we yearn for and do not or cannot have is an epistemic partner—a willing and able interlocutor with whom we can share, exchange, and construct new knowledge. These are instances of epistemic loneliness.

Sometimes we feel lonely because we do not something others do.

While it is easy to think of extreme cases in which this happens— say the lonely genius or the trauma survivor— notice that epistemic loneliness is far more common in our everyday life. Most of us have felt it at least temporarily— teenagers, parents, romantic partners, introverts, academics, uneducated people, etc. In these instances, the loneliness arises because we know something that others didn’t but also because we do not know something others do. This is a very particular yet common instance of loneliness.

Understanding different kinds of loneliness allows us to better understand the different dimensions of this growing and worrying global phenomena. It can also elucidate the kinds of resources most apt to address or assuage it. Understanding epistemic loneliness in particular can help us make sense of the instances in which our loved ones and those we care for seem to lack something other than mere companionship. 

We are epistemic creatures. The acquisition, exchange, and creation of knowledge is at the center of our understanding of ourselves and our place in the world and amongst others. We should know and acknowledge this.

Ramón Alvarado is an Assistant Professor of  Philosophy at the University of Oregon. 

Ramón is interested in the philosophical implications of the design, development and deployment of computational methods and technologies in science and society. 

Ramón recently published a paper in Synthese on epistemic loneliness.

Epistemic Trust Injustice and Distrust in Public Health: Amelioration Strategies

In today's post, Elena Popa summarises a talk she gave as part of the pre-conference workshop “Epistemic Injustice in Healthcare” at the Nova University Lisbon. You can see the list of speakers here.

Trust plays a key role in public health. The success of guidelines and recommendations requires a trusting relation between the scientists making claims about the efficiency of interventions, policymakers and members of the public. Even on the best available evidence and policy design, public health interventions can fail if the levels of trust are insufficient. 

The example of vaccine uptake is particularly illustrative: distrust is an important driver of vaccine hesitancy and if such attitudes are present among a significant part of the population, this can undermine the aim of achieving sufficient levels of immunity within a population to prevent further infection. Similarly, guidelines regarding lifestyle, diet or other kinds of medical advice are less likely to be heeded in a context of distrust.

While there are several sources of distrust, my interest will be on the connection between distrust and epistemic injustice and the challenges it brings to public health and health sciences more broadly. The link between distrust and injustice has been pointed out in political context. As the scientific establishment also functions within a socio-political context such patterns of injustice and oppression can also spill over in scientific practice. 

This, in turn, yields warranted distrust in members of groups that have suffered oppression. Examples include unethical practices in medical research that have affected members discriminated on ethno-racial grounds or the neglect of women when investigating particular health conditions, such as heart disease or illnesses that do not have a clear link to fertility.

While the connection between injustice and distrust embodies a multitude of factors, including material and social ones, there is an important epistemic dimension to highlight. Particularly, if oppressed groups have good reasons to distrust scientific institutions or healthcare providers, these groups are also harmed in their capacity as knowers. 

The term ‘epistemic trust injustice’ thus refers to cases where the conditions that ground public trust in experts, or enable public access to scientific knowledge, are not met for members of oppressed groups. This kind of epistemic injustice is particularly harmful for the members of oppressed groups because it further limits access to needed health services or relevant medical knowledge. Furthermore, from a population-level perspective, the resulting distrust can exacerbate existing health disparities, making it more difficult to act so as to improve overall health.

How can this type of epistemic injustice be ameliorated? One thing to clarify is that solutions looking particularly at health research and healthcare also require improvements in social justice in the background. That is to say, scientific and healthcare institutions are moving away from or, ideally, completely eliminating, historically oppressive practices that have given rise to distrust. 

Assuming this background, more specific solutions involve acknowledging and highlighting structural factors leading up to health disparities, providing health professionals with skills to spot them when working with patients and engage in advocacy, and incorporating input from patients with relevant backgrounds.

First, taking a more population-focused approach in public health, particularly around social determinants of health and upstream causes of illness, would emphasize issues such as poverty, experiences of discrimination or oppression, lack of access to education or decent living conditions. Not only are all of these relevant for health outcomes, but they are more likely to affect vulnerable segments of the population, thus drawing attention to issues experienced by discriminated groups rather than focusing on the needs of better off groups that can access healthcare or expensive treatments with more ease. 

Furthermore, as these problems are more effectively approached through population-based interventions, this perspective is also likely to address health disparities as they do not require conditions that are unlikely to be met among oppressed groups. Through its explicit incorporation of problems likely to affect previously oppressed or excluded groups, this approach may also increase trust with time.

Second, medical and public health practitioners can play an important role in this perspective, as they can recognize patterns of epistemic trust injustice when interacting with patients. As opposed to placing the responsibility on the patients to acquire more knowledge about, e.g., vaccination or asking for blind trust from patients, which is common, health practitioners could acknowledge the problems faced by their patients and advocate for addressing them at the level of society or the health system. The skill of structural competence can enable this shift in practice.

Nevertheless, leaving the solutions to scientists and healthcare professionals is insufficient. Input is further needed by those most likely to be affected by how public health science and health policy are conducted. This can be done, for instance, though patient activism or activism from groups whose health problems have been neglected. Input from such groups can generate epistemic resistance, challenging existing frameworks and producing epistemic resources better suited for spelling out the health needs of oppressed groups.

A final point to stress is that these proposals for ameliorating epistemic trust injustice are not without pitfalls. They are all entangled with further political dynamics; it is possible that some solutions can be hijacked to tip the balance in favor of more influential groups. In order to counter that, a further condition, together with the move towards a more just society, is the closer integration of the goals and activity of experts with those of the patients and the public at large. Thus, ameliorating epistemic trust injustice in healthcare contexts can be done by orienting practices in healthcare towards the needs of oppressed groups within a background where wider steps are taken towards more social justice and integrated health goals.

Elena Popa is Ramón y Cajal fellow at the University of Seville working on a project conceptualizing causality in connection to social determinants of health funded by the Spanish Ministry of Science, Innovation, and Universities and the State Research Agency. Her research focuses on causality and causal reasoning and values in science, with special emphasis on cultural and social issues in medicine, particularly psychiatry and public health. Her published work includes articles in journals such as Synthese, Studies in History and Philosophy of Science: Part C, and Topoi and book chapters with publishers such as Oxford University Press and Cambridge University Press.

Choosing Health Concepts: A Matter of Epistemic Justice

In healthcare, definitions matter. The way we define "health" is not just a technical issue — it shapes research priorities, clinical decisions, healthcare policies, and even citizens' rights. In my recent article, Health Concepts in Medicine and the Role of Philosophy, I argue that philosophers of medicine have an important role to play in this process. Choosing between competing concepts of health means not just offering better definitions, but also asking critical questions about the goals behind them and whose interests they serve.

Health and wellbeing

Although the article does not explicitly discuss epistemic injustice, the connection is clear. Epistemic injustice occurs when individuals or groups are wronged specifically in their capacity as knowers — when their experiences, knowledge, or perspectives are dismissed or undervalued. Conceptual choices in healthcare can either help correct these injustices or reinforce them. 

A narrow definition of health as simply the absence of disease, for example, can be useful if we want to defend healthcare as a universal right, but can marginalize people living with chronic conditions who still consider themselves healthy. On the other hand, concepts that emphasize adaptation and self-management may place unfair burdens on individuals in disadvantaged circumstances, turning social inequalities into personal "failures" of health.

In this sense, choosing a concept of health is not epistemically neutral. Different definitions elevate different voices — whether those of patients, clinicians, policymakers, or researchers. Some concepts recognize and validate the experiences of marginalized groups, while others risk silencing them. A focus on self-management, for instance, might overlook the structural barriers that make adaptation difficult for many.

Cover of Lalumera's new book

Importantly, the same concerns apply to other concepts in healthcare, such as well-being and quality of life. These are not purely descriptive terms; they are value-laden, and how we define them has real consequences for research, clinical care, and policy. I explore these broader issues in my forthcoming book, Health, Well-Being, and Quality of Life: A Philosophical Analysis, where I extend the framework of conceptual choice to these crucial notions. 

Ultimately, conceptual choice in healthcare is not just a theoretical exercise. It is a site where epistemic justice is at stake. Being attentive to whose experiences are recognized — and whose are left out — is essential if we want health concepts to serve everyone, not just a privileged few.

Elisabetta Lalumera is Associate Professor in the Department for Life Quality Studies at the University of Bologna and she is also one of the partners of project EPIC. Her research applies philosophical analysis to conceptual and methodological issues in medicine.

Digital Age: Mental Health, Cognitive Robotics, and AI

On the 9th of April 2025, Seiara Imanova organised an event, along with Andrew Hicklin, called "The Digital Age: Mental Health, Cognitive Robotics & AI", held at the Edgbaston campus, University of Birmingham as well as online. This post is a report of the event.

Speakers of The Digital Age event

The goal of the event was to highlight just how important the digital world has become, and the ways it’s shaping so many areas of our lives. As technology continues to shape how we communicate, understand who we are, and engage with systems of care, it’s crucial that we pause and critically examine what this means for fields like mental health, psychiatry, and beyond.

Seiara Imanova introduced Lucienne Spencer

The event began with an insightful presentation by Lucienne Spencer (University of Oxford), titled “Social Media & Shifts of Ontic Power in Mental Health”, which explored how digital spaces, such as social media platforms, can act as catalysts for shifts in psychiatric authority. In other words, online platforms like TikTok, Instagram as well as AI powered chatbots, are changing who gets to define, talk about, and influence mental health and psychiatry. Dr. Spencer highlights that although this shift could be considered a kind of ontic empowerment for people with mental ill health, re-shaping diagnostic categories in digital spaces carries the risk of distorting and diluting their original meaning.

Spencer’s presentation was followed by another incredible talk by Alan Winfield (University of Bristol), titled: “The Ethical Roboticist - From robot ethics to ethical robots”. Winfield looked at questions such as what do robot ethicists actually do, what kinds of harm can robots and AI cause, as well as ways for setting an ethical standard and regulations. Perhaps most striking was his demonstration of The AI Incidents Database, which highlighted why ethics was important in robotics, and how AI is already causing harm in the real world.

Alan Winfield's presentation

Last but most definitely not least, the third presentation was given by Paris Lalousis (King’s College London) titled: “Artificial Intelligence in Mental Health: Challenges, Pitfalls, and Opportunities” which is based on the excellent work he does at his AIM Lab at King’s. In contrast, Lalousis discussed the growing need for AI in healthcare, particularly in psychiatry, by highlighting the limitations of current neuroscientific approaches, such as the constraints of neuroimaging, the challenges posed by diagnostic ambiguity and high comorbidity rates between psychiatric conditions. 

Presentation by Paris Lalousis

Lalousis argued that intelligent systems hold significant potential to address these gaps. He presented his study on how the use of machine learning can better predict remission for patients with mental disorders such as schizophrenia or bipolar, and a glimpse into precision medicine.

The event hoped to achieve its goal which was to foster meaningful reflection on both the possibilities and ethical tensions that arise as human experience becomes more entangled with algorithmic and artificially intelligent systems. You can watch the live recording of the event below.

Metaphor and Epistemic Injustice in Schizophrenia

Today we interview Francesca Ervas and Lina Lissia on their project entitled: “Metaphor and Epistemic Injustice in Mental Illness: The Case of Schizophrenia” funded by PRIN, an Italian funding scheme to support research project of national interest. The project investigates epistemic injustice in metaphorical communication in the case of mental illness. A series of seminars has been planned as part of the project and the final meeting will be a conference held in Cagliari on 22-24 October 2025.

Metaphorical communication

Lisa: What are the research interests that gave rise to this project? 

Francesca and Lina: The project was born due to a common interest in metaphor as a way to express the self/mental illness relationship. The link with epistemic injustice, defined as the injustice towards a person as a knower, came later, and was based on the idea that metaphor can precisely be seen as an epistemic device. We were interested in both forms of epistemic injustice, as Miranda Fricker defined them in 2007: 1) as a failure to attribute credibility to people with mental illness (testimonial injustice), and 2) as an attempt to marginalize their epistemic resources thus not recognizing their ability to interpret their own experience of illness (hermeneutical injustice). 

The project builds on understanding and empirically investigating both the cognitive and social mechanisms behind testimonial and hermeneutical injustice, where people with mental illness often face epistemic challenges in credibility and interpretation. We hypothesized that metaphor can have a role as a communicative tool to overcome the ineffable and inarticulate nature of the mental illness experience and, notwithstanding social stigmas and interpretive difficulties, to reach an affective attunement with the relevant others (families, friends, doctors, healthcare professionals, other people in their social lives, etc.). 

Lisa: What are the main objectives of your project?

Francesca and Lina: Focusing on schizophrenia, the project analyzes the cognitive and bodily mechanisms at the root of the failure to attribute credibility (testimonial injustice) and interpretive capacities (hermeneutical injustice) to people with mental illness, when they communicate their illness to other people via metaphors vs. their literal counterparts.

We hypothesized that affective attunement in communication is a cooperative enterprise that needs to overcome both patients’ difficulties in embodying metaphors in illness communication and interpreters’ negative social and moral stereotypes, which concur to create the case for epistemic injustice.

The project involves three research units: the University of Cagliari (UniCa), the University of Messina (UniMe), and the University of Chieti (UniCh), respectively exploring:

1. the interpreter’s perspective (UniCa, Prof. Francesca Ervas, PI of the project)
2. the mental-ill speaker’s perspective (UniMe, Prof. Valentina Cuccio)
3. the mental-ill speaker/interpreter interaction (UniCh, Prof. Francesca Ferri)

Such factors help us understand the cognitive mechanisms responsible for the missing attunement between people with mental illness and interpreters. 

Metaphor is proposed as a valuable resource to foster a better attunement between the speakers with schizophrenia and the interpreters and to possibly prevent or overcome epistemic injustice in illness communication. Metaphor is indeed a necessary tool for people with schizophrenia to express their illness and themselves in relationship with the illness, but also for relevant others to access what the speaker feels as meaningful to articulate of their experience of illness.

Working together

Lisa: Does your project involve different disciplines and perspectives? 

Francesca and Lina: The three research units have different disciplinary backgrounds and methodologies: philosophy of language and experimental pragmatics (UniCa); philosophy of mind and psycholinguistics (UniMe); cognitive neuroscience and psychiatry (UniCh). UniCa and UniMe embrace a theoretical-philosophical approach to the problem of epistemic injustice in the case of metaphor. 

All the units adopt an experimental approach to empirically investigate the cognitive mechanisms at the basis of the problem, focusing on schizophrenia. However, each unit tackles the very same problem from different angles and via different empirical methodologies. Check the members and the disciplinary background of all our teams.

Lisa: What do you expect the impact of this project to be?

Francesca and Lina: Results will significantly advance the understanding of the theoretical, linguistic and cognitive aspects of metaphor use in mental illness communication, with interdisciplinary scientific and academic impact and social impact on public policies and health institutions. A social campaign, based on the experimental data on metaphors production/understanding and the active engagement of stakeholders, will also be designed and produced, with an impact on the general public. 

Finally, the outcomes have the potential to lead to the development of novel rehabilitative interventions and novel social behaviors to prevent epistemic injustice.

The Metaphor and Epistemic Injustice in Schizophrenia project team:

Francesca Ervas, Martina Montalti, Valentina Cuccio, Alice Guerrieri, Francesca Ferri, Lucienne Huby, Lina Lissia.

Rethinking silence and epistemic agency in mental illness

In the scholarship on epistemic injustice and mental illness, silence figures almost exclusively as an epistemic harm. More specifically, we usually understand silence as a deficit in epistemic agency resulting from social prejudice or an unfair lack of adequate conceptual resources. Often that is indeed the case, and breaking such imposed and harmful silences is crucial for achieving epistemic justice.

However, this picture of silence is incomplete and potentially harmful. It ignores the possibility that silence can play an epistemically constructive role in the lives of people with mental illness, and that discouraging or breaking silence in such cases could be destructive. This is a possibility I explore in a recent article. Focusing on experiences of silence among people experiencing mania, I argue that silence can be a powerful act of epistemic agency – the capacity to acquire, maintain, and share knowledge competently and freely.

Epistemically agential silence

I articulate three kinds of epistemically agential silence: communicative silence, listening silence, and withholding silence. Each refers to a literal silence – an absence of speech or noise – through which a person is attempting to perform an epistemic action:

1. Communicative silence is a silence through which a person intends to share knowledge with others. An example would be when you use your silence to express disapproval of something inappropriate someone has said.
2. Listening silence is a silence through which a person intends to acquire knowledge from a speaker. An example would be when you fall silent in a conversation so your interlocutor can speak and you can hear what they have to say.
3. Withholding silence is a silence through which a person intends to withhold knowledge from others. The function of such a silence might be to maintain knowledge, as when you decide not to share something with a person who might manipulate you into thinking you are mistaken. Its function can also be to avoid sharing knowledge, as you might do when you know an audience isn’t equipped to understand what you have to say.

These silences are plausibly important for everyone, but they seem particularly important for those who experience mania.

Losing silence in mania

Two common symptoms of mania are increased talkativeness and an uncontrollable urge to speak. First-person accounts suggest that people with these symptoms often find that their capacity to perform epistemically agential silence has been impaired.

Some describe losing the ability to perform listening silence. For example, in her memoir of living with bipolar disorder, Terri Cheney describes how, when she was severely manic, she’d become unable to ‘shut up and listen’. Another writer with bipolar, Bassey Ikpi, says that in mania she sometimes 'couldn’t remember how to quiet her brain enough to listen’.

Others report becoming unable to perform withholding silence. For instance, one contributor to a bipolar forum says that when she is manic, she does not ‘know how to stop talking’ and ends up telling everyone that she has bipolar, even if they have no need to know or are prejudiced or ignorant about mental illness.

This can have a profoundly negative impact on individuals with mania. Losing the capacity for silence can deprive them of vital information and undermine their support networks. Meanwhile, losing the capacity for withholding silence may lead individuals to reveal information about themselves and their illness in circumstances where disclosure might expose them to misunderstanding or discrimination.

People who experience mania are often well aware of these risks. Therefore, when they feel their capacity for silence is deteriorating, they may look for new ways to stay silent when they need to—for example, by clenching their jaw, jiggling their leg, or digging their nails into their palms. For them, silence is not an epistemic harm but a hard-won epistemic achievement.

The costs of misunderstanding silence

So silence can clearly have significant epistemic value for people with mania. This is why the assumption that silence is a sign of epistemic injustice may inadvertently perpetuate or even exacerbate harm. For example, it may prompt a well-intentioned individual to misunderstand a manic person’s epistemically agential silence as evidence of epistemic oppression and, therefore, seek to break their silence, perhaps by urging them to speak. That may end up undermining the epistemic agency of the manic person and expose them to epistemic and hazards they were trying avoid through silence.

To avoid contributing to this, those of us researching epistemic injustice must begin to explicitly acknowledge in our work that silence is a diverse phenomenon. Sometimes it does represent epistemic oppression. But it can also be empowering, constituting a vital epistemic tactic that ill persons and other vulnerable individuals use to navigate complex interpersonal, institutional, and social landscapes. If analyses of epistemic injustice in healthcare and beyond are to be relevant and helpful, this is not something we can ignore.

Dan Degerman is a Research Fellow on the EPIC project and a AHRC Research, Development, and Engagement Fellow on the 'Beyond Voice' project. His current research explores the relationship between silence and epistemic injustice in bipolar disorder.

Tackling Hermeneutical Injustices in Gender-Affirming Healthcare

As any trans person will tell you, it is a scary time to be living in the UK. One reason is that gender-affirming healthcare is becoming increasingly hard to access. In December 2024 the Health Secretary made a ban on prescribing puberty blockers to trans adolescents permanent, following the recommendation of the deeply flawed Cass Review. This ban has been criticised by several relevant professional bodies, diverges significantly from the consensus on best practice in peer countries, and flies in the face of decades-long histories of these drugs’ safe and effective use.

                                               
           

As a result, trans adolescents are being forced against their wills to undergo puberties distressingly at odds with their gender identities. Simultaneously, trans adults hoping to access gender-affirming healthcare from the NHS are being made to wait several years for their first appointment at a Gender Identity Clinic (GIC). These long wait times are taking a considerable toll on their mental and physical health. Moreover, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is no longer always sufficient since some GPs are unilaterally refusing or reversing GICs’ recommendations to prescribe hormones to their trans patients.

  

Trans identity and hermeneutical injustice

In addition, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is not always easy. Doing so is a matter of a patient rendering it intelligible to these (usually cis) doctors that they are indeed trans. This can prove difficult when the relevant doctors employ overly-narrow conceptions of transness. For instance, gay patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to be straight. 

Similarly, non-binary patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to identify as either a trans man or a trans woman. Moreover, that doctors sometimes work with such overly-narrow conceptions is a result at least in part of trans people having been deprived of opportunities to shape how people think about transness. In sum, trans adults sometimes suffer hermeneutical injustices when attempting to access gender-affirming healthcare from the NHS.

What can be done?

What should be done to prevent such hermeneutical injustices? In a recent paper, I distinguish between two sorts of strategy that might be pursued to this end. Interests-as-given strategies would take for granted trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and aim only to enable them to satisfy these interests. For instance, we might look to educate the relevant doctors or to engage in political activism aimed at propagating better-fitting conceptions of transness. 

All previously proposed strategies for preventing hermeneutical injustices are of this sort, yet it is sometimes possible to go about preventing hermeneutical injustices very differently. An interests-in-question strategy would instead look to do away with trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and thus with the possibility of these interests’ unfair nonsatisfaction. 

Consider that trans patients only have these interests in the first place because the prevailing gatekeeping model makes it a requirement on the provision of gender-affirming healthcare that trans patients first convince the relevant doctors at a GIC of their need for it. I argue on grounds of trust, privacy, and respect that the NHS ought to cease making this a requirement. One way to do so would be by switching to an informed consent model, under which pretty much all that a well-informed adult capable of consent would have to do to access gender-affirming healthcare would be to ask for it – an example of a more materialist strategy for preventing hermeneutical injustices. 

Unfortunately, in a time of intense anti-trans backlash it seems unlikely that the NHS will make such a progressive move anytime soon. We thus may need to think about what else can be done to prevent such hermeneutical injustices in the unjust meantime.

Nick Clanchy is a Postdoctoral Research Fellow with a joint appointment at the Canada Research Chair on Epistemic Injustice and Agency (UQAM) and Le Centre de Recherche en Éthique (UdeM) in Montréal, where they are also a member of the philosophy department at McGill.

Most of Nick's work is dedicated to thinking about hermeneutical injustices. They also have research interests in trans philosophy, the philosophy of love, and the work of a number of figures on the margins of philosophy - especially Roland Barthes. 

More about Nick and their work can be found here.

Epistemic injustice in global antimicrobial resistance research

Today's post comes from Phaik Yeong Cheah at the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Bangkok, Thailand, and Nuffield Department of Medicine, University of Oxford, Oxford, UK. This post summarises her recent co-authored paper "Tracing epistemic injustice in global antimicrobial resistance research".

Introduction

Antimicrobial Resistance (AMR) arises when microorganisms such as bacteria, viruses, fungi, and parasites become resistant to the medicines used to treat them. This makes infections harder or impossible to treat and increases the risk of disease spread, severe illness, and death. AMR affects everyone but disproportionately harms disadvantaged and marginalized populations. Despite this, the experiences, data, and voices of these communities are often excluded or overlooked in AMR research.

Epistemic Injustice and AMR Research 

This paper focuses on epistemic injustice in AMR research—questions such as what causes AMR, who is most affected, what drives AMR, and what can be done to mitigate it. This form of injustice contributes to a lack of representation, skewed priorities, and blind spots in global AMR efforts. We identify three overlapping domains where epistemic injustice occurs and emphasize the need to include diverse perspectives and community voices to make AMR research more inclusive, equitable, and effective. This work is part of a broader project exploring justice in the context of AMR.

Firstly, who sets global AMR research priorities? One key area where epistemic injustice arises in AMR research relates to how global AMR research priorities are set. These priorities are largely determined by the WHO and international funding bodies that support AMR research globally. However, priority-setting exercises rarely include substantive representation from people in low- and middle-income countries (LMICs)—whether they be researchers, clinicians, policymakers, or affected communities.

Secondly, who produces, interprets, and uses AMR knowledge? While AMR disproportionately affects people in LMICs, research in this field is largely dominated by academics from high-income countries and a small number of disciplines. Additionally, researchers from low-resource settings face significant barriers to publishing in high-impact journals. Language challenges hinder their ability to produce competitive manuscripts, and limited access to protected, paid research time constrains their capacity to write. This imbalance perpetuates epistemic injustice in two ways: it limits opportunities for LMIC researchers to shape global AMR knowledge, and it sidelines valuable experiences, knowledge, and potential interventions that could emerge from these settings.

Finally, what knowledge is currently available and valued? A major gap in AMR research is the lack of data from LMICs, particularly in medically underserved areas and communities. This can lead to surveillance strategies that are unrepresentative of the populations they aim to serve. Significant data gaps or biases in AMR prevalence hinder reliable estimates, especially in regions with limited laboratory capacity and data collection systems, potentially resulting in inappropriate responses. There is also a lack of data on health-seeking behaviors, health practices, and medication use in many marginalized or vulnerable communities worldwide.

Consequences of Epistemic Injustice in Global AMR Research 

Epistemic injustices in AMR research create "blind spots". These include a dominant focus on high-income countries, hospital-based interventions, and drug development, while critical LMIC issues—such as infection burden, antibiotic use in livestock, prescribing practices in primary care, and access to affordable diagnostics—are overlooked. These imbalances can also lead to unintended consequences. For example, malaria rapid diagnostic tests have increased antibiotic use in some countries, and AMR awareness campaigns have sometimes instilled fear or unfairly stigmatized small-scale farmers.

Suggestions for the Way Forward 

To address epistemic injustice in global AMR research, we recommend inclusive agenda setting with diverse representation across geography, disciplines, and gender. Research should include under-served populations, removing barriers to participation and recognising their agency. Community engagement around AMR should be encouraged to ensure the voices of affected communities are heard.

Phaik Yeong Cheah is a Professor of Global Health at the University of Oxford. She co-leads a project funded by the British Academy (GCPS2\100009), ‘A Just Transitions Framework for The Equitable and Sustainable Mitigation of Antimicrobial Resistance’ project.

Agential epistemic injustice is bad for medicine

On occasion of Mental Health Awareness Week 2025 (in the UK 12-18th May and in other European countries 19-25th May), I suggest that some forms of epistemic injustice may prevent mental health interactions from fulfilling their clinical goals, and thus need to be identified and avoided not just for moral reasons but to enhance clinical practice. I offer this argument in a paper recently published open access in Philosophy of Medicine. 

Youth mental health

What is agential epistemic injustice?

Medina has identified a phenomenon called "agential epistemic injustice" which occurs when the exercise of epistemic agency in people from marginalised groups is  constrained,  manipulated,  or  distorted. A speaker does not need to be silenced for epistemic injustice to occur. The speaker's contribution to a conversation or to an epistemic project can be actively solicited. However, if their contribution is then challenged or reconstrued by the listener, without being first explored in its own right, there is still a problem. This "failed uptake" is often due to the speaker's agency being called into question. 

I believe that the notion of agential epistemic injustice is especially apt to capture problems with interactions involving people who are experiencing a mental health crisis because the stigma associated with poor mental health tends to target people’s epistemic agency. When people struggle with their mental health, it is assumed that their agency is compromised, and their capacities for rational thought, appropriate affect and mood, competent decision-making, and autonomous action are negatively affected by their health condition.

Failed uptake

What are the effects of agential epistemic injustice?

Recent qualitative studies of communication between practitioners and young people accessing mental health emergency services (Bergen et al. 2023) suggests that the young people's reports are not always validated  and  explored. Instead, practitioners sometimes fail to legitimise the young person's concerns and imply that their descriptions of the way they feel is inaccurate or inconsistent with previous medical notes or observable data. Statements  that support the practitioner’s view are accepted and integrated in a narrative explanation of the situation that goes on to inform the decision-making  process. But statements that are in tension with the practitioner’s view are undermined. 

These challenges often compromise the quality of the exchange, with young people gradually withdrawing and reducing their engagement. Everyone may agree that validating and exploring patient reports may have a positive psychological impact on patients. But some have argued that such benefits come at a cost, and that epistemic justice in clinical interactions may be an obstacle to improving health outcomes for patients. This surprises me, because I have come to think of the avoidance of agential epistemic injustice not just as "a nice to thing to do" or as what morality demands, but as a way to increase the chance that the medical goals of the clinical interactions are met.

A clinical interaction is successful when it leads to

1. understanding the nature of the problem the person is seeking support for;
2. identifying the best means of support for the person experiencing the problem; and
3. promoting favourable conditions for the person to address the problem via those means.

Clinical interactions characterised by agential epistemic injustice are less likely to achieve (1)-(3). I offer two arguments for this conclusion. 

Knowledge argument: 

• A genuine exchange of information enables knowledge about the person’s experiences to be shared, including knowledge about how a mental health issue is affecting the person's life. 
• Agential epistemic injustice may prevent a genuine exchange of information from happening, leading to practitioners offering a premature diagnostic label or suggesting treatment options that are based on partial information and thus turn out to be misguided or ineffective.

Trust argument:

• When patients’ experiences and concerns are not considered as valuable contributions to the exchange, this may contribute to their feeling incompetent and losing trust in themselves. 
• If the practitioner treats patients just as a diagnostic puzzle to solve, this may suggest that the practitioner is not interested in what they are experiencing or is unwilling to explore their concerns further. 
• Agential epistemic injustice negatively affects the capacity patients have to address the problems they have via the means identified in the interaction: the patient may feel disempowered and helpless and medical advice is less likely to be perceived as something worth following and, if another crisis is experienced, people may be reluctant to seeking support again. 

Good communication in a clinical interaction

Agential epistemic injustice as an obstacle to good medicine

To sum up, lack of information due to reduced engagement may compromise diagnosis and render suggestions for further support irrelevant or unlikely to be taken up. Moreover, making people feel inadequate, unable to report their own feelings in a coherent or persuasive way, may cause them to doubt their own capacity to help themselves and get better. The impression that practitioners are not interested in what happened to them may also interfere with people's willingness to access services again, and their trust in medical advice, potentially compromising adherence.

In an interaction whose goals can be met when all participants make a genuine epistemic contribution, practices characterized by agential epistemic injustice are not just morally problematic but they constitute an obstacle to the interaction achieving its goals. Clinical interactions are no different.

Why Disabled Voices Must Be Central to Health Research

Disabled people can experience profound health disparities. Yet, while these inequities are well-documented, one key question remains under-asked: who is conducting the research meant to address them?

In our paper, published in the Journal of Medical Ethics, we argue that the health research community must urgently confront a gaping omission - the absence of disabled researchers from within its own ranks. This exclusion, we contend, constitutes a form of epistemic injustice. Without the voices of disabled scholars at the table, how can we claim to fully understand, let alone solve, the very issues that affect them?

Epistemic injustice, a term first introduced by Miranda Fricker (2007), refers to a wrong done to someone in their capacity as a knower - denial of credibility or the opportunity to contribute knowledge. When disabled people are systemically excluded from academic research, their perspectives, insights, and lived experiences are undervalued or erased entirely. This leads to skewed understandings of disability and results in research, policy, and clinical practice that fail to capture the complexity of disabled lives.

The lack of representation is not accidental. Across the UK academy, structural and attitudinal barriers persist: inaccessible environments, discriminatory hiring practices, and a pervasive lack of institutional support. The “pipeline” for aspiring disabled health researchers is fractured at every level, from education through to recruitment, career progression, and funding. Often, disabled individuals must fight battles on multiple fronts just to gain access to a field that should be enriched by their insight.

                                    

We believe this silence has serious consequences. Disabled people are routinely positioned as objects of study, but rarely as agents of research. Their lived expertise is essential, not optional. Research that is truly inclusive and ethically grounded must involve those with direct experience of the issues at hand. Anything less reinforces the very inequalities we purport to address.

What needs to be done?

The good news is that change is possible. Academic institutions must take deliberate steps to dismantle these barriers - not through tokenism, but through genuine structural reform. Accessibility must be embedded into the fabric of research environments. Recruitment strategies must be inclusive by design. Mentorship and funding opportunities must actively support disabled scholars.

We also call on funders and policymakers to recognise the urgency of this issue. Resources should be directed towards diversifying the research community including supporting disabled-led research and scholarship that challenges dominant, often medicalised, narratives of disability.

Ultimately, we wrote this paper not just to critique the status quo but to imagine a better future: one in which disabled scholars are central to health research, shaping agendas, asking the right questions, and leading the work that affects their own communities. When research includes disabled voices, it becomes more accurate, more ethical, and more impactful.

We must fix the pipeline - not only to advance equity, but because the future of health research, and the well-being of the most overlooked population in society, depends on it.

Charlotte Blease (PhD) is an Associate Professor at Uppsala University. She is a health informaticist whose research spans philosophy, psychology, cognitive science and medical humanities. She is co-author of The Nocebo Effect: When Words Make You Sick. More about her research can be found here.

Joanne Hunt (MSc, MBACP, GMBPsS) is a disabled researcher with a background in psychological therapies. Her interdisciplinary research is sited at the intersection of disability studies, psychology, feminist studies and ethics, and includes the biopolitics of medically and societally ‘contested’ chronic illness and related disability. More about her research can be found here.

For more on ableism in academia see Brown, N (2021) and Brown, N & Leigh, J (2020).

The Added Value of Epistemic Injustice

During #PhiloFortnight2025 the British Philosophical Association launched a campaign to raise awareness of the role of philosophy in our lives. As part of this initiative, EPIC at Birmingham organised a webinar to launch the recently published open-access book, Epistemic Justice in Mental Healthcare (Palgrave 2025). 

Poster of the event

The panelists (all partners of project EPIC) presented their research and then engaged in discussion about the importance of the notion of epistemic injustice and the strategies we should adopt to reduce the harms that come from it. 

In this post, I want to share our conversation about what we might call "the added value of epistemic injustice": when we analyse patient-doctor relationships and clinical interactions more broadly, we tend to use a variety of concepts, including person-centred care, feeling understood, dignity, trust, social health, good living, and agency. 

What does the appeal to epistemic injustice add to these analyses? Aren't the concepts we have used so far, those that preceded the application of the notion of epistemic injustice to the heathcare context, sufficient? Each of the panelists gave an insightful reply to this question.

A slide from Michael's presentation on feeling understood

Michael Larkin described a case he encountered in a paper on consent where a young man hit one of the doctors. When he was asked why, he said that he did so because he was angry. But then in interactions with other doctors, this idea that anger was what caused the young man to act was challenged and reinterpreted: one doctor said that the young man acted that way because he was delusional. 

Another doctor said that the young man acted that way because he had schizophrenia. And the young person did not recognise these as reasons why he hit the doctor, repeating that yes, maybe he was delusional and he had schizophrenia, but he acted that way because he was angry. Michael remarked that the notion of epistemic injustice would have been very useful in that context, due to its precision, because it precisely identifies a failure to recognise knowledge. 

A slide from Rose's presentation about clinical communication

Rose McCabe remarked that the idea of "injustice" is also very important in the notion of epistemic injustice and goes beyond what we may convey when we talk about trust. Although people who use services know when this happens, when healthcare professionals dismiss or reinterpret what they have to say in a way that misrepresents them, they don't always have the right language to report it or to refer to it. 

Having a way to reflect on communication and the respective epistemic stances in clinical interactions is valuable. Also, research on epistemic injustice is welcome because relationships and communication are crucial to the experience of services by people who seek help, but have not always been the focus of research. The epistemic injustice literature has zoomed in on those issues.

A slide from Luigi's presentation on dignity

Luigi Grassi observed how rejecting a person's explanation for their own behaviour because they are delusional is not the only situation in which epistemic injustice happens: when people talk about their symptoms, even when they are not diagnosed with a serious mental illness, doctors often tell them that it is all in their head, do not believe them, and even suggest that what they are reporting is not possible. 

Epistemic injustice is an important new perspective that is central to research and training and should be made into a tool -- just like there is a dignity inventory there could be an epistemic injustice inventory.

A slide from Rabih's presentation on stigma and its consequences

Rabih Chattat argued that talking about epistemic injustice is not the same as talking about stigma because the notion of justice brings to the fore that there are rights that are being violated, such as the right to self-determination, and this is evident in the treatment of older people with dementia. 

To this, Rose added that epistemic injustice also enable us to see important connections between what happens in healthcare (where a doctor may dismiss the subjective experience of a patient) and what happens in other contexts where there is a power imbalance (for instance, where a teacher dismisses the perspective of a student). 

A slide from Elisabetta's presentation on bias in diagnosis

Elisabetta Lalumera highlighted another aspect of epistemic injustice that is very distinctive. When we treat an expert as a non-expert, we act unwisely. When we are committing epistemic injustice, it is not just that we are not being nice to the person who is sharing their knowledge, but we are also throwing out valuable information because of a prejudice. It is a mistake of judgement that harms us as well as the person whose knowledge we dismiss.

If you are intrigued by this discussion and want to watch the whole webinar, it is available here: