Ageing, Life, and Philosophy

This post by Anna Videbaek Smith reports on the proceedings of a workshop on ageing and philosophy at the University of Nottingham.

  

On the 8th of June, the University of Nottingham hosted the EPIC Project workshop, “Ageing, Life, and Philosophy.” The event featured presentations by Saloni de Souza (Bath Spa University), Nga Chun Josh Law (University of Bristol), and Victoria Cluley (University of Nottingham).

The workshop opened with Saloni de Souza’s exploration of immortality in a talk entitled “I Want to Be Forever Old?” Souza introduced Bernard Williams’ conditions for a choiceworthy life, noting that Williams does not consider immortality a choiceworthy life for anyone. Souza then distinguished between two forms of immortality: the Babylon 5 model, where death is eliminated and physical ageing stalls at one’s physiological prime, and the Struldburg model, which similarly removes death but involves continuous physiological ageing. 

With this groundwork in place, Souza challenged two assumptions: (i) that Struldburg immortality cannot offer a choiceworthy life, and (ii) that Babylon 5 immortality is clearly preferable to the Struldburg model. To address (i), Souza disputed the claim that progressive physiological ageing necessarily entails a loss of pleasures and memory, suggesting that other benefits may offset any such losses. Regarding (ii), Souza questioned whether immortality necessarily involves a loss of categorical desires. While it may be possible to develop new categorical desires or find different ways to fulfil existing ones under a Babylon 5 model, ongoing physiological ageing may complicate this process. 

To mitigate this concern, Souza noted that physiological decline need not correlate with cognitive or moral decline, and that adapting to physiological ageing may prompt shifts in our categorical desires or the way we pursue them. Finally, the talk provoked discussion about how life cycles and the concept of ‘biographical disruption’ apply to ageing more broadly.

After lunch and a walk around Nottingham’s scenic campus, Josh Law presented a chapter from his PhD thesis, “Habit in Later Life: Repetition Without Stagnation in Beauvoir’s Old Age.” Law aimed to identify the optimism in Beauvoir’s otherwise pessimistic Old Age by exploring the role of habits in later life.  As Beauvoir takes old age to involve a reduction of future possibilities, we may wonder whether authentic transcendence is even possible at this stage of life. To examine this, Law drew on Beauvoir’s notion of old age as a ‘normal abnormality’: a paradoxical mode of existence where the ‘abnormal’ becomes the governing norm of daily life. 

Using the example of the paralysed painter, August-Pierre Renoir, Law argued that habits can enable older individuals to find a new, if fragile, sense of normalcy. Importantly, this does not hold for all habits, prompting Law to distinguish between two types. Invertebrate habits can be understood as “the habit of having a habit,” reflecting withdrawal, rigidity, and stagnation. This is contrasted with what Beauvoir calls ‘the poetry of habit,’ denoting habits that are integrated into our lives, providing us with a sense of “ontological security.” Law maintained that this latter type of habit can anchor older individuals in our shared social world and enable them to engage in repetition without stagnation.

The final talk, “The Relationship between Older Age, Health Inequality, and Race: Philosophical Interpretations”, was delivered by Victoria Cluley. Building on her work with the ‘Understanding Frailty’ Project, Cluley and her co-authors explored the interaction between ethnicity and the experience of frailty in old age using an anti-racist, photovoice approach. They provided 69 participants from six ethnic groups with digital cameras, instructing them to photograph their day-to-day activities to capture their experience of growing older. This culminated in 1,126 pictures depicting everything from pets to religious practices and bouncy houses at family functions. 

Several key themes emerged, including experiences of racism, the role of purpose, and the inherent diversity of older individuals as a social group. Particularly relevant to the EPIC Project were several photos depicting healthcare settings. This prompted participants to recall experiences of testimonial injustice in healthcare contexts, which they largely attributed to their race and old age. Cluley observed that some of the more privileged Black British participants referenced structural racism to make sense of these experiences. Interestingly, the participants of Indian or Caribbean descent, who tended to come from more disadvantaged backgrounds, did not invoke this concept. Perhaps the lack of access to a concept like structural racism can itself be considered an epistemic injustice. 

More information on this project can be found here.

Author bio

Anna Videbaek Smith is a DPhil candidate in philosophy at the University of Oxford. Her research explores ageism as an intersectional form of oppression, focusing on its moral, epistemic, and aesthetic dimensions. Prior to joining Oxford, she completed an MA (Hons) and an MLitt, both in Philosophy, at the University of St Andrews.

Self-diagnosis and its implications in child and adolescent psychiatry

This week's post by Christophe Gauld, Laelia Benoit, and Floriane Brunet considers how the increasing prevalence of self-diagnosis influences the relationship between clinicians and young patients.

In recent years, many adolescents have begun arriving at psychiatric consultations not to seek a diagnosis but to confirm one they already believe they have. They describe themselves as, for instance, autistic or having ADHD, after reading descriptions (online) that resonate with their experience. This phenomenon of self-diagnosis happily challenges established hierarchies of knowledge in psychiatry, especially in child and adolescent care.  

But it also raises an important question, which we explored in depth in a recent article: how should clinicians and young patients (re)position themselves in relation to one another, especially when differences in age and status necessarily influence the clinical relationship?

Let us recall that in most clinical contexts, diagnostic authority is concentrated in professional hands. And since psychiatric categories do not rely on biomarkers, the formulation of a diagnosis remain closely connected with social and moral judgments of harm. This interpretive dependence of diagnosis on clinicians creates an asymmetric epistemic space, in which the clinician’s account can prevail over the patient’s own lived experience and interpretation.

In children and adolescents, this imbalance could combine with childism, a form of discrimination that assumes the child’s voice is unreliable, immature or irrelevant. Like ageism, which marginalizes people because of age, childism operates on the same generational axis by devaluing children through assumptions of dependency and immaturity. It refers to a system of attitudes and practices that naturalise adult superiority, treating children as incomplete or incapable of rational understanding. Its specificity is in the transformation of developmental difference into a moral and social justification for inequality.

Childism operates structurally, embedded in institutional norms and clinical routines that reinforce adult authority and marginalise children’s voices. It frames adult perspectives as normative, establishing “standards of reason,” credibility and emotional coherence that children are expected to follow. In clinical practice, it appears to arise “naturally” from age differences. This naturalistic assumption biases how clinicians listen to patients whose discourse differs from their own. And this is compounded by the fact that childism intersects with other forms of discrimination (e.g., gender, disability, class, etc.), producing cumulative disadvantages that shape how young people are heard and understood.

To see how this might play out in clinical practice, consider an example. When, for instance, an adolescent comes to a clinician declaring “I think I’m autistic”, they do not simply misuse medical language. They reclaim interpretative power over their own experience. They demand recognition as knowers. These acts are epistemically and politically significant. They reveal how power and knowledge are interdependent in psychiatry: thus, although some self-diagnoses may rely on incomplete or misleading information, they also open a space for rethinking how clinical knowledge is shared and validated.

Due to their distinct conceptual histories and to the primary object of application of childism – i.e., childhood – epistemic injustice and childism are conceptually related and mutually reinforcing, operating across interconnected levels. Epistemic injustice designates a harm to someone’s capacity as a knower, which becomes visible within communicative and epistemic exchanges where authority and credibility are unequally allocated, and which contributes to broader structural patterns. 

Childism, in parallel, refers to the institutional norms, laws and professional practices that naturalise adult superiority, and which are enacted and reproduced within everyday clinical interactions. In this sense, childism both shapes and is shaped by interpersonal clinical practices, and epistemic injustice reflects how these normative assumptions are lived and negotiated in concrete encounters in child and adolescent psychiatry. Together, these overlapping dynamics help explain how self-diagnosis makes visible the ways credibility, authority and recognition are distributed in clinical care.

Bios

Christophe Gauld is a French adolescent psychiatrist with a PhD in philosophy of psychiatry (Université Paris 1 Sorbonne).

Laelia Benoit, MD, PhD, is a child and adolescent psychiatrist and researcher affiliated with Yale University and Inserm. Her work focuses on qualitative and mixed-methods research, child mental health, and the social and systemic determinants of psychiatric care..

Floriane Brunet is a French child psychiatrist and holds a university diploma in philosophy of psychiatry.

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 across disciplinary lines

This week, post-doc Fred Cooper reports from a GW4 residential on health inequalities and social justice.

For the last eight years, the GW4 Alliance – a consortium of universities in the south west of England and South Wales, consisting of Bath, Bristol, Cardiff, and Exeter – has run GW4 Crucible, a leadership development programme, which brings together future research leaders from across disciplines and institutions to explore how they can enhance their career through interdisciplinary collaboration. The programme has been running since 2017; with over 200 alumni, it runs over the course of four months, providing two in-person residential ‘labs’ and a series of online masterclasses.

Each cohort addresses a particular problem, an urgent challenge too complicated and embedded to be tackled by any singular form of expertise. For 2024, the focus of GW4 Crucible is ‘health inequalities and social justice’, and the methodologies of ‘radical interdisciplinarity’ necessary to approach them. My application to the programme emphasised my (at that point, barely started) research on epistemic injustice, and my interest in having conversations with people that historians don’t always get to meet; such as architects, engineers, scientists, and mathematicians. 

As a historian of medicine, and having worked for six years in an interdisciplinary health research centre, I began my post at EPIC with a sense that considerable numbers of researchers across disciplines are actively engaged with many of the themes and questions that animate the project, but without necessarily deploying the same kinds of language. 

Reading the profiles of my fellow ‘Cruciblees’, in anticipation of meeting them for a two-day residential in a hotel in the misty, rainy hills above Cardiff, nobody presented themselves as a philosopher; I was a rare representative, with a literary scholar, of the humanities in general. At a stage in my own work of trying to gauge the reach and purchase of literatures on epistemic injustice in the kinds of spaces that might usefully benefit from them, the structured and unstructured exchanges that Crucible offered felt like an opportunity to take a (wholly unrepresentative and unscientific) temperature. 

Over the course of the two days, discussions crystallised around six themes, developed in small groups with fluid memberships. While I couldn’t be part of every conversation, I stayed with the two subjects which seemed to show most promise for thinking on epistemic injustice across disciplines, occupied as they were with researcher positionality and lived experience, and the ethics and practice of meaningful inclusion in ‘PPI’ (patient and public involvement), here a cipher for participatory research more broadly. 

Although each of these concerns have their own distinct histories, they begin from a shared proposition immediately familiar to work on epistemic injustice in healthcare contexts; that the experience of being ill, and of becoming a patient, imparts knowledge which is 

• highly pertinent to collective and professional understandings of health, illness, disease, and medical systems; 
• impossible to otherwise come by; and 
• not easily formed, articulated, communicated, or formalised. 

Acknowledging the need for researchers to address, incorporate, and interpret lived experience, and to move towards programmes of work which are (genuinely) co-created or user-led, carries another tacit, latent acknowledgement; that the contexts and processes of health care and research as currently constituted reproduce a raft of epistemic harms, exclusions, injustices, and lacunae. Although different researchers work in different registers and are comfortable with (and able to advance) varying degrees of critique, even the most constructive, positive, ‘inclusive’ argument for greater attentiveness to experience implicitly and necessarily identifies a problem, which can only be fully understood in terms of respective epistemic power. 

Overwhelmingly, the interdisciplinary exchanges taking place in the Crucible spoke to the extensive common ground between researchers interested in problems of speaking and silence, shamed and ‘hidden’ illnesses and experiences, and how lived knowledge can be encouraged, supported, valued, and operationalised. 

The literature on epistemic injustice is, undeniably, extensive, prompting some researchers – including in past entries of this blog – to question its over-zealous application and its dilution or bland reproduction as an idea. These concerns come from very different perspectives and summations of worth, but they both chart pathologies of saturation and abundance. While this may be the case from a particular disciplinary view, discussing epistemic injustice with a broad spectrum of health researchers conferred the opposite impression: that of a highly pertinent and useful set of ideas not (yet) widely taken up, even in research that worked in almost identical spaces, on almost identical problems. 

This is not, of course, an argument that anyone’s work was (or is) ‘in need’ of a closer engagement with epistemic injustice; every Cruciblee had their own robust intellectual and practical tools, making for a compelling – and sometimes challenging – set of conversations. In broader literatures on health and healthcare, however, you can frequently find accounts of many of the phenomena discussed and taxonomized in work on epistemic injustice, but without any particular theoretical framework to interpret and organise them. 

Nobody is obliged to apply the insights of any particular literature to their work, unless, perhaps, the omission is especially glaring (or revealing of patterns of power and exploitation in the academy); but too often, in complicated work addressing multiple themes, meanings only half solidified can sometimes slip away. 

As the study of epistemic injustice moves across and beyond disciplinary lines, one of the biggest challenges will necessarily be around keeping these exchanges rich, complex, and mutually responsive. At the basic level of definition, epistemic injustice is a useful idea; where it can be genuinely transformative, though, is in the pluralism and depth of its conceptualisations, allowing us to think critically and rigorously about a number of significant barriers to health, justice, and care. 

Every discipline has something particular to offer here. For example, my work on the history of loneliness – and Michael Bresalier’s work on the history of tuberculosis vaccination – attends to how systems of knowledge and practice are built over time, in ways that fold in and perpetuate unjust epistemic phenomena. At the GW4 Crucible, I met researchers who, if they had the inclination, could use their expertise and training to take research on epistemic injustice in innovative and exciting directions. Even for a literature already experiencing some of the problems of success, that is an encouraging thought. 

Fred Cooper is a post-doctoral researcher and medical historian on project EPIC based at the University of Bristol.

"The Unequal Pandemic" Film Premiere with #ProjectEPIC

On Thursday 30th May, the short film "The Unequal Pandemic" (produced by Lorne Guy and Phil Webb) premiered in Bristol. The event was co-convened by University of Bristol's Centre for Black Humanities and the Epistemic Injustice in Healthcare (EPIC) Project with support from Good Guys Productions. Below you can read a discussion about the film and the premiere with one of the film's producers, Lorne Guy.

What is the film about?

The Unequal Pandemic delves below the sensational headlines around the Covid-19 pandemic to reveal the tragic family stories of how we were not all in it together.

The film charts how the pandemic swept across the UK and why exactly it was far more deadly for people in lower socio-economic areas, for ethnic minorities and for the disabled. It examines how the North-South divide was clearly highlighted and how front-line NHS doctors, deeply affected by what they witnessed, experienced ‘war like’ trauma which is still not spoken about.

Startling evidence from Prof Sir Michael Marmot and other world leading public health figures gives a clear picture of how wider societal and historical political choices led to the outcome of the UK having one of the worst pandemic death rates among European countries.

Our goal was to get the film's message directly out to those around the country who feel their voice is not being heard. We also wanted to initiate a live dialogue about deep-seated inequalities in the UK today which preceded the pandemic. For instance, from 2011-2018, the UK's life expectancy improvement was the lowest among all other rich or OECD countries apart from Iceland and the USA. Life expectancy was beginning to fall in deprived areas, which hadn’t happened since the second world war.

If you were from an ethnic minority like Black African, Black Caribbean, Indian, Bangladeshi, Pakistani you were far more likely (2, 3 sometimes 4 times) to die than your white counterpart. This is not the reason, it’s a whole raft of reasons that we explore in the film. For instance, in the film, Francesca's mum was poor and disabled and it seems clear that she died as a result of years of inequality. Similarly, Lobby Akkinola lost his Dad Femi, who was a key worker. He died at home before any help could get to him.

How did the film come about?

We were approached by MP Debbie Abrahams, who has a background in public health. She wanted to collaborate on a film around inequality and the pandemic. There was a concern that the Covid-19 Public Inquiry would not sufficiently account for how inequalities before the pandemic impacted people. For instance, how people on low incomes, ethnic minority communities, people with disabilities, and people in the North of England were disproportionately affected.

How was the premiere?

We saw a diverse audience made up of local Bristol groups organisations, activists, academics, journalists as well as affected individuals from as far away as Abergavenny, Wales. The film was introduced by the filmmakers and Dr Josie Gill (University of Bristol).

Following the screening of the 25-minute long film, a panel and audience Q&A took place. The panel was chaired by Dr Connor Ryan (University of Bristol), and the panel participants were Prof Havi Carel (ProjectEPIC Principal Investigator), Huda Hajinur (Caafi Health), and Dr Habib Naqvi MBE (Director, NHS Race and Health Observatory).

An engaging one-hour discussion and audience Q&A followed the screening. Some salient themes in the discussion were how, despite the fact that successful local action was often taken, it was often ignored or interrupted by government and how historical system failures led to community mistrust and exacerbated inequality. Dr Habib Naqvi highlighted and expanded on a quote within the film around the ‘causes of the causes’ of race inequality and disproportionate death toll for certain communities as a result.

The film has also been screened in Parliament. How was that?

The first screening of the film was at Parliament at the end of 2023 followed by an amazing panel discussion including Prof Sir Micheal Marmot, Prof Clare Bambra and Lobby Akinnola.

The reaction was incredible. It was an emotional event but also uplifting.

As a result, there was a demand to show the film wider so we then set out on a UK free screening tour in Preston, York, Newcastle, Liverpool and Manchester. These last two were supported and introduced by Mayor Steve Rotherham and Mayor Andy Burnham. We have just screened in Bristol, and will end with a London screening on June 25th, organised by UCL and the Covid 19 Bereaved Families for Justice.

Some reactions to the first parliament screening:

“A powerful film highlighting the deeply entrenched inequalities in society and how much needs to change to improve the health and resilience of our nation.” Kim Leadbeater, MP

“A heart-rending and sobering gem of a film… The powerful commentary by families and public health experts will live long in the memory.” Ian Byrne, MP

“It was an honour to be at this screening last night and hear from Lobby Akinnola and others share their experiences. Hopefully this gets picked up.” Prof Aaron Reeves

“The film left me as it did others very emotional” Alex Cunningham, MP