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 agency is not compromised by delusional or conspiracy beliefs

This post is by EPIC investigator Lisa Bortolotti.

It may be surprising to realise how many researchers from various disciplines are interested in the relationship between clinical delusions and beliefs in conspiracy theories: on the surface, the former often have bizarre contents and signal a psychological disruption to the person's life that is often explained by a psychiatric diagnosis, whilst the latter seem to be deeply embedded in societal debates, are shared by groups (even by entire sub-cultures), and are not usually accompanied by distress.

In a recent paper, I argue that one thing they do have in common is how delusions and beliefs in a conspiracy theory are received. People who report delusional and conspiracy beliefs tend to be excluded from common epistemic projects. What do I mean by that?

Although there is a recognition that all speakers have a unique perspective and interests, and the capacity to pursue goals and make decisions, exploring delusional or conspiracy beliefs is not considered worthwhile. And it is considered a waste of time and resources to engage with people's goals and decisions of people when these are informed by delusional or conspiracy beliefs. That is because, in the eyes of the interpreters, those beliefs do not just happen to be false but undermine the confidence in the speakers' capacity to exercise their epistemic agency. 

But is this stance justified? I argue that it is not. It is a mistake to think that the presence of a belief that has some characteristics (e.g., a belief that we find implausible but that the speaker holds onto strenuously and identifies with) is sufficient reason to doubt the capacity of the speaker to exercise their agency. Rather, the endorsement of a delusional or conspiracy belief is usually a direct manifestation of the speaker's epistemic agency.

When do we endorse beliefs that are deemed delusional? When we have an unusual experience that demands an explanation. When we attempt to impose meaning on a confusing and distressing reality. When we need to manage overwhelming emotions to avoid an entire paralysis of agency. When we make sense of unexpected and distressing events. When we intend to show loyalty or affiliation to groups characterised by a certain ideology. When alternative explanations seem somehow unavailable or disempowering to us.

There are many reasons why people may endorse a belief that appears implausible to others and yet becomes important to how they see themselves and the world around them, to the point that it becomes difficult to give up the belief or recognise the strength of the evidence against it. But there is no good reason to think that the belief formation process or its outcome are themselves signs of irremediable irrationality or even of a pathology.

As I show in the paper, many of the cognitive biases and psychological needs that have been identified as antecedents of delusions and conspiracy theories characterise human belief formation more generally, though their influence can be heightened in some people due to background knowledge and reasoning style, or to their experience of adverse and stressful circumstances.

What does this have to do with epistemic injustice, you may ask. I think it is at the core of it. Epistemic justice is not achieved when people believe each other's testimonies uncritically or accept that all hermeneutical resources are equally good. Rather, epistemic justice is achieved when all epistemic agents are treated as such, and not as broken records, puppets or sheep: their views are not dismissed before being explored, but they are listened to with interest and curiosity. Agreement is not the goal, engagement is. 

McPin Young People's Network

In this post, Lisa Bortolotti interviews Rachel Kimberley Temple, Public Involvement in Research Manager (Youth Involvement Lead) at the McPin foundation.

Logo of McPin's Young People's Network

LB: Hello Rachel! What is the McPin Young People's Network and what is your role in it?

RKT: Hi Lisa! The young people’s network consists of over 400 young people from across the UK, aged 13-28, who identify as having lived experience of a range of mental health issues. Everyone in the network has signed up because they wish to get actively involved in mental health research. Researchers can contact us and share their youth involvement opportunities with the network. The network is essentially intended as a resource for both young people and researchers who are seeking to work together. 

My role is to manage a small team who oversee the network; raising awareness about it, building membership, and sharing key findings from projects connected to the network. We also collaborate directly with researchers who wish to engage with the network, advising and facilitating youth involvement in their projects.

LB: Why do you think is important that young people are actively involved in mental health research?

RKT: I think it’s vital that young people have a role in research that will directly impact them. By applying their expert knowledge, the research becomes more relevant, accessible and appropriate. This not only improves the quality of the research but also makes it more likely to achieve the desired impact. Research therefore benefits hugely for involving young people.

LB: How do young people benefit from involvement in mental health research?

RKT: Young people we have worked have told us that they value learning new skills and find it empowering to apply their expertise to something that will positively benefit others. I think this is so important, because having mental health issues can make you feel powerless. Therefore, being actively involved in research can offer a sense of control - a feeling like you can make a difference. 

We’ve also been able to see young people grow in the role; becoming more confident, making valuable connections with external partners and building their own careers.

LB: Can you give us an example of a research project you have been involved with, and of what the young people helped achieve?

RKT: One example that comes to mind is the agency project. On this project, we worked with young people and academics to co-analyse video data of young people’s mental health interactions within emergency departments. We drew on our unique perspectives and expertise, and combined this to make some important discoveries: how to maximise young people’s agency in interactions about their mental health. We translated those findings into various resources targeted at professionals, young people and other researchers.

To learn more about the Young People's Network visit their website or follow them on X and Instagram. 

If you are a researcher seeking to involve young people in your project or collaborate with McPin, visit this page. 

McPin Young People's Network has contributed to several outputs for the Agency Project including a podcast called "How to give young people agency in mental health" and a poster entitled "What I wish my younger self knew about mental health" aimed at secondary school students. Check them out!

Logo of the Agency Project