Navigating dislike in healthcare: October takeover

In today's post, EPIC's Fred Cooper introduces a series of blogs on like and dislike in health care, and their epistemic consequences.

Image credit: Wellcome Collection

In his famous meditation on general practice in the 1960s, A Fortunate Man, John Berger asked how his subject, Dr John Sassall, can have his measure taken. ‘We find ourselves without a scale of standards for judging or assessing one another’, Berger argues; ‘the only standard which remains is that of personal liking – or its commercial variant, which is Personality.’ Berger liked Sassall – a pseudonym for his own GP, John Eskell – immensely, but he recognised something impoverished and flat in the tyranny of that metric.

Berger’s subject, Eskell, was the kind of GP who thought deeply about his relationship with his patients, and understood the complexities of his role as witness and consoler, meeting the ‘patient’s deep, unformulated expectation of fraternity’ in illness and injury. His apartness, Berger observed, barred him from the benefits of that cultivated – but no less authentic – fraternity, while allowing him to confer them on all of his patients, regardless of his personal impression of them.  

Contrary to Berger’s romanticised view of Eskell, and of general practice more broadly, his contemporaries seemed to have more trouble. In their 1976 study, Doctors talking to Patients, Patrick Byrne and Barrie Long conducted a close linguistic analysis of dozens of tape-recorded medical consultations, paying particular attention to how doctors’ individual questioning styles opened up or shut down lines of enquiry vital to correct diagnosis. While different doctors frequently had entrenched and observable styles, whether paternalist and taciturn, open and curious, or somewhere in between, the researchers also found a significant degree of variation by practitioner. Some interactions were easy, marked by mutual respect; others more abrupt, resigned, frustrated, and these were far less likely to allow the patient to really speak.

Inscrutable in these interviews, there is distinct politics to who gets to be liked by who, or who can and can’t access the kinds of easy geniality increasingly expected to smooth interactions along; what Teow Lim Goh describes as ‘the dehumanising politics of likability’. One curt greeting in Byrne and Long’s study, ‘you again’, gives us one clue to a set of relations probably more likely to fray than most: those between the doctor and the ‘repeat attender’, the frequent patient with no clear physical cause for their troubles. T.F. Main’s 1957 essay, The Ailment, argued that protracted, mysterious, and refractory complaints introduced novel psychodynamic problems into medical care: in his words, ‘the patient’s attendants are pleased neither with him nor themselves and the quality of their concern for him alters accordingly.’ Main discerned a pattern, again in his words, of ‘old unsettled interpersonal scores hitherto unrecognized’, including ‘guilts, angers, envies, resentments, unspoken blamings, alliances and revenges’, ‘shown now to have both animated some of the nursing procedures offered these patients, and to have been concealed behind them.’

We can see some of these concerns surfacing again in the early 1990s, in Darryl Watts and Gethin Morgan’s formulation of the concept of ‘malignant alienation’. Detailing a rapid epistemic and relational breakdown between doctor and patient, which the authors recognised as a common factor in a number of potentially preventable suicides, the article carried the subheading ‘dangers for patients who are hard to like.’ This marked a subtle – but vital – shift in emphasis on who, precisely, is bringing their baggage into the consultation room.

The next three entries in the EPIC blog unpick questions of dislike – and their epistemic consequences – across three significant pressure points in healthcare. Cristina Ganz, in her work on midwives and obstetric violence; Davy Tennison, in their research on the medical dislike of fibromyalgia patients as epistemic injustice and epistemic dysfunction; and Hugh Robertson-Ritchie, in his reflection on ME/CFS and the frictions generated by incompatible aetiological interpretations. The essays address an area of experience which has so far been black-boxed by epistemic injustice researchers, being supposedly too unknowable or idiosyncratic to make any kind of systematic sense from. Attending critically to like and dislike can take us further than simple bad luck, revealing significant – and unjust – disparities in experiences or outcomes that might otherwise elude analysis.

John Berger and Jean Mohr. 1967. A fortunate man. The story of a country doctor. London: Allen Lane.  

P. Byrne and B. Long. 1976. Doctors Talking to Patients. London: HMSO.

Teow Lim Goh. 2019. The Dehumanizing Politics of Likability. Los Angeles Review of Books. August 21. https://lareviewofbooks.org/article/dehumanizing-politics-likability/.

T. F. Main. 1957. The Ailment. British Journal of Medical Psychology, 30: 129-145. https://doi.org/10.1111/j.2044-8341.1957.tb01193.x

D. Watts and G. Morgan. 1994. Malignant alienation. Dangers for patients who are hard to like. The British journal of psychiatry: the journal of mental science, 164(1): 11–15. https://doi.org/10.1192/bjp.164.1.11. 

Fred Cooper is a historian of medicine, and a senior research associate at EPIC. He leads an EPIC case study on loneliness and epistemic injustice. 

Workshop Report: Trust and the Affective Dimensions of Health and Healthcare

 In this post, Sofia Martellini reports back from a workshop on Trust and Affective Justice at the University of Bristol.

Source: Wellcome Collection

On June 9^th, Project EPIC and the Centre for Health, Humanities and Science co-sponsored an afternoon of guest lectures and group discussions, on the theme of Trust and the Affective Dimensions of Health and Healthcare.

While my talk highlighted one aspect of epistemic injustice in healthcare, the wide range of expertise exhibited by the other speakers brought diverse and interesting perspectives on the meaning of Trust and Affectivity.

Professor Havi Carel opened with a provocation: we walk through the world with a deep, unspoken faith in our bodies. We quietly, blindly believe that we're going to be ok and we are capable of doing what we want with our bodies. Illness has the capacity to shatter this tacit certainty, even more so in critical or end-of-life conditions, where our body becomes uncapable of the most basics of actions. She distinguished bodily doubt in everyday illness  from radical bodily doubt; the kind that sets in at the extremes of experience. Here, continuity collapses entirely, the body becomes entirely medicalized, subjectivity dropping away as the body is treated as an object from those around it. Her discussion of ICU experiences, also sourcing from her own personal experience, where passivity is total and people simply have things done to them, was particularly striking.

Dr Ross Pain then turned our attention to Indigenous healthcare in Australia, where outcomes between white and indigenous people remain deeply inequitable. Different contexts have different ways of understanding and processing pain, and Dr Pain highlighted philosophy’s tendency of overgeneralizing in order to arrive to a theoretical explanation. When philosophical concepts like epistemic injustice travel across different cultural contexts, do they actually fit? His notion of the "fittingness condition" asks us to reckon honestly with the limits of our conceptual tools.

Drawing on my time in the LeTs-Care research project, I argued that informal caregivers are victims of hermeneutical injustice, since they lack the shared concepts to make sense of, and communicate, their own experience. In Mediterranean contexts especially, there is often no culturally resonant word for "caregiver" at all; caring is only a part of family duty, invisible and unnamed. My proposed PhD aims to address this through phenomenological interviews and a broader look at how care appears across different cultures, asking whether these radically different ways of understanding care are given any epistemic recognition in the policies that are supposed to help caregivers today.

Doctoral fellow Anna Pathmanathan then brought the discussion to the clinic and the prescription pad, presenting research on antibiotic prescribing disparities across minoritized ethnic populations in primary care. Combining large-scale data with patient and prescriber interviews, her work surfaces how systemic inequity can hide in plain sight, encoded in everyday clinical decisions. The doctor-patient trust relationship varies across social status, culture and other variables, filled with prejudices and epistemic inequalities: understanding how this complex dynamic works can bring light to the issue of overmedicalization, still much present in the UK.

Finally, Cristina Ganz examined communication-based epistemic injustices in doctor-patient relations, mapping how discursive, epistemic, and affective injustices layer on top of each other in clinical interactions. Her clear framework showed how different ways of addressing patients corresponded to different kinds of epistemic injustice and separating them allows us to understand how to better direct the dialogue between doctor and patient.

The variety and depth of  different interventions showed how an apparently simple concept like trust can be conjugated in meaningful but diverse ways, tied to the notion of epistemic injustice. From the creation of a theoretical concept such as radical bodily doubt, to empirical research projects meant to show trust relationships and the issues of philosophy when applied to real cases of trust loss, epistemic injustice and trust intertwine throughout different disciplines and cases. This event made me realize even more intensely how fundamental interdisciplinarity is for better research and progress, especially in fields where theory and practice come into contact. 

Without culturally specific, in-depth empirical research, philosophers can risk falling into overgeneralization, as Dr Ross Pain showed; on the other hand, through philosophically developed concepts such as epistemic injustice, negative clinical experiences can be better understood. By sharing our experiences and projects, our collective understanding of epistemic injustice, trust and affective dimensions can grow throughout different disciplines, bringing progress and new solutions to epistemic injustice issues all over the world.

Sofia Martellini is a Philosophy PhD candidate at the University of Bristol, supervised by Professor Havi Carel and Wilhelm Dagmar. Her research sits at the intersection of epistemic injustice, phenomenology and ethics of care, with a particular focus on informal caregiving and the hermeneutical gaps that leave carers without adequate concepts to make sense of their own experience. She holds degrees in Philosophy from KU Leuven and Applied Ethics from Utrecht University and has been involved in the LeTs-Care European research project. She spoke at the CHHS & EPIC workshop in June 2026.

Evidential Pluralism Mitigates Epistemic Injustice in Evidence-Based Evaluation

Today's post comes from Dr Alexandra Trofimov and summarises her talk at part of the Manchester Online Seminars on Evidential Pluralism titled "How Evidential Pluralism mitigates epistemic injustice in evidence-based evaluation", which will take place on the 14th of April, 2025, at 3pm BST. You can register and see the rest of the talks in the series here. 

Evidence-based evaluation aims to ensure that interventions, such as medical treatments or public policies, effectively achieve the ends at which they aim. But what kind of evidence should be considered? Orthodox evidence-based evaluation advocates an exclusive focus on comparative studies. In contrast, Evidential Pluralism advocates an inclusive approach to evidence and has been defended on the grounds that it enables more robust evaluations. In an upcoming talk, I offer a new line of argument: that Evidential Pluralism helps to mitigate epistemic injustices that result from orthodox evidence-based evaluation.

Orthodox evidence-based evaluation

Orthodox evidence-based evaluation has created an influential stereotype of ‘good evidence’ that, I argue, results in epistemic injustice.

Orthodox evidence-based evaluation is characterised by evaluation methods and evidence hierarchies that focus almost exclusively on comparative studies, especially randomized controlled trails (RCTs). This is most explicitly captured in the evidence hierarchies of evidence-based medicine, which place systematic reviews and meta-analyses of RCTs are at the top of the hierarchy, followed by individual RCTs and then observational studies. All other kinds of studies are relegated to a lower position on the hierarchy and, in practice, typically excluded from consideration. Similarly, the UK Government’s Magenta Book, which provides evaluation guidance for all Government policy and regulatory interventions, prioritises the use of experimental or quasi-experimental studies and advocates the use of other kinds of study only when these are unavailable.

Consider, for example, the controversy surrounding the effectiveness of face mask mandates during the Covid-19 pandemic. A highly influential Cochrane Collaboration systematic review that included only RCTs found no clear reduction in infections from face masks. The authors of the review concluded that, due to the various limitations of the included RCTs, firm conclusions could not be drawn. They called for further, well-designed RCTs to address the uncertainty. Many, however, mistakenly interpreted the review to mean ‘masks did nothing’. There were also dismissals of non-RCT evidence. A review that included a wide range of evidence found face masks can effectively reduce transmission. The review was criticised for being non-systematic and recommending public policies in the absence of RCT evidence.

The extent to which RCT evidence was prioritised and other kinds of evidence were devalued or dismissed is, I argue, indicative of prejudice and results in both testimonial injustice and hermeneutical injustice.

Evidential Pluralism

Addressing the epistemic injustice that results from orthodox evidence-based evaluation is crucial; it is a significant wrong that can have disastrous practical consequences. In the case of Covid-19 face masks, it led to policy delays that likely cost ‘thousands of lives’. 

Evidential Pluralism offers a solution. According to Evidential, establishing a causal claim requires establishing that the putative cause and effect are both correlated and connected by an appropriate mechanism. This, in turn, will typically require consideration of a broad range of evidence types. Evidential Pluralism takes each item of evidence on its own merits. It does not commit to pre-determined rankings of evidence or preclude certain types of studies from providing high quality evidence simply in virtue of their methodology. 

The benefits of Evidential Pluralism are illustrated in a proof-of concept evaluation of Covid-19 face mask mandates. The evaluation included a broad range of evidence types and concluded that Covid-19 face mask mandates were effective at reducing infections, hospitalisations and deaths.

By advocating a more inclusive approach to evidence, Evidential Pluralism enables more robust evaluations. It also avoids evidence being prejudicially devalued or dismissed and therefore avoids the epistemic injustice that results from orthodox evidence-based evaluation’s stereotype of ‘good evidence’.

The fact that Evidential Pluralism is able to mitigate epistemic injustice supports its adoption as a new methodology for evidence-based evaluation.

Alexandra Trofimov is a research associate in philosophy at the University of Manchester. Her research interests are in moral philosophy, legal philosophy and normative epistemology. She is currently working with Professor Jon Williamson on a Leverhulme Trust funded project ‘EBL+: New Philosophical Foundations for Evidence-Based Law’. Through an application of Evidential Pluralism to evidence-based law, the project aims to provide a new methodology for evidence evaluation to improve the effectiveness of legislative and regulatory interventions. Alexandra is also interested in improving evidence evaluation more broadly, including in public policy and public health.

The Role of Curiosity in Healthcare

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

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

Girls being curious about botany

Curiosity in Healthcare

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

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

Barriers to Curiosity and Ways Forward

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

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

People looking quizzical

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

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

Katherine Cheung

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