Objectivity, Standardization, and Epistemic Injustice in Psychiatry

In “Objectivity, Standardization, and Epistemic Injustice in Psychiatry,” I subscribe to the view that theoretical conceptions of mental health can operate as structural factors that promote epistemically unjust practices in psychiatric clinical settings. I examine how the high value placed on objectivity, conceived in terms of standardized methods and knowledge, may underpin various forms of epistemic injustice toward patients. 

In particular, I argue that it can lead to treating patients as mere informants or, worse, as sources of information, thereby undermining their status as epistemic agents. This state of affairs should be taken seriously because, I argue, the high value placed on objectivity and its standardized conception are theoretical cornerstones of the dominant model of psychiatric practice and research.

Before the development and adoption of the DSM-III in 1980, psychiatry’s disciplinary status was arguably precarious. The likelihood of two psychiatrists agreeing on a diagnosis was little better than chance, and the antipsychiatry movement had raised serious criticisms of its methods and categories. This was unacceptable not only for psychiatry as a discipline but also for patients, who could receive arbitrary diagnoses depending on the individual clinician’s perspective and thus miss out on appropriate treatment.

To establish itself as a branch of medicine, psychiatry needed to rely on objective evidence to support its diagnoses and treatments. Since psychiatric practice relies primarily on patient reports and behaviors, these had to be systematically addressed as its objects of inquiry. 

This required the development of reliable and (at least presumably) valid diagnostic tools — namely, operationalized criteria — and a view of mental symptoms as objects presented by patients and made observable to clinicians through standardized instruments, such as structured interviews and rating scales. 

From this standpoint, being objective in psychiatry means employing these standardized tools. However, by their very nature, such instruments must set aside interpretations — both the patient's and the clinician's — and disregard patients’ idiosyncrasies.

Given such a high value and standardized conception of objectivity, some clinicians may lack either the skills or the will to engage with information that falls outside the standard (and is thus deemed “subjective”), to take up or engage with patients’ conceptual resources and interpretations, and more broadly, to treat patients as epistemic agents seeking self-understanding. 

Others, of course, do have both the skills and the will. But what must be emphasized is the structural dimension of the issue: beyond individual clinicians’ attitudes lies a fundamental conception — that of objectivity — which underpins psychiatric theory and practice, and which systematically hinders engagement with patients as epistemic agents, instead promoting their treatment as mere informants or sources of information.

"[I]f psychiatry is to be an epistemically just discipline,
it must also find ways to engage with patients as epistemic agents."

I am not arguing that psychiatry should abandon the pursuit of objectivity or that generalized knowledge is without value. On the contrary, such knowledge is essential for making predictions about the course of mental conditions and identifying effective treatments. 

My point is that, if psychiatry is to be an epistemically just discipline, it must also find ways to engage with patients as epistemic agents. This would bring not only epistemic benefits but therapeutic ones as well. What is needed, in my view, is a collective theoretical effort comparable to the one that reoriented psychiatry toward standardization. We must now articulate the conditions under which attention to patients’ particularities and perspectives can also be regarded as objective.

Finally, if this analysis is correct, it has implications for the inclusion of patient perspectives in DSM revisions. While their inclusion will be bound to bring epistemic and therapeutic benefits, it falls short of addressing the complex realities of clinical practice. 

Standardized instruments may vary in how well they achieve their theoretical and practical aims — and in the extent to which they promote epistemic and social practices that are just— but they will always be insufficient to fully address patients as unique subjects and as epistemic agents.

Virginia Ballesteros is Assistant Professor in the Department of Philosophy at the University of Valencia. Her research focuses on the philosophy of psychiatry and altered states of consciousness. 

She is particularly interested in how mental disorders and psychiatric treatments are theoretically conceived, and the implications this has — for instance, in matters of epistemic justice, in phenomena such as self-illness ambiguity, or in the adequacy of pharmacological interventions. She has also worked on the philosophy of birth, exploring the epistemic aspects of medical birth care and the metaphysics of the birthing experience.

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.

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.

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).

Structural Injustice: Reflections on Social Groups, Identity and Intersectionality

The Special Issue "Structural Injustice: Reflections on Social Groups, Identity and Intersectionality", co-authored by Ingrid Salvatore and me, was published in the journal Phenomenology and Mind at the end of 2024. The volume investigates the ways in which oppression, marginalization, and misrecognition are determined and/or fostered by practices, social standards, and attitudes concerning intersectional identities and how we should conceptualize social groups against these circumstances. 

The various contributions, from different perspectives, tackle how forms of oppression can be directed toward individuals qua members of a specific group and can involve systemic forms of misrecognition often coupled with unwarranted biases regarding the epistemic credibility of these individuals (Dotson 2011; Fricker 2007). Many contributions reason upon how social discrimination against members of racialized, sexualized, or otherwise stigmatized and oppressed groups must be understood as institutional, structural, or systemic phenomena deeply embedded in the social system of our political societies. 

From this normative framework it follows that addressing injustices related to identity groups requires clarifying the self-reinforcing dynamics between structural disadvantages and identity-based prejudices. These forms of injustice take stock of the constrained position in which members of disadvantaged groups find themselves given the “unintended consequences of the combination of the actions of many people” (Young 2011, p. 53).

Not just bad luck;
disadvantaged groups often face the consequences
 of actions within unjust social structures.

The special issue illustrates the social dynamics impacting agents in making fundamental life decisions within the constraints of unjust social structures that restrict their options and capacity for critical reflection. The attempt by some of the contributions, then, is to outline a paradigm of social justice that aims to provide normative guidance for actual people, situated within their complex lives and interacting with societal structures and imperfect political institutions. From the perspective of disadvantaged social groups, multiple belonging invites intersectional philosophical and sociological investigation into how individuals can be victims of multiple injustices (Crenshaw 1989). But it also requires deeper philosophical research on personal identity and group belonging (Appiah 2006).

Specifically on the topic of epistemic injustice in healthcare, I think that the last section of the volume, Power, Social Oppression and Recognition, is of most interest. The section has a double goal: on the one hand, it is interested in laying out concrete instances of group discrimination related to specific ascriptive characteristics possessed by groups’ members and in proposing some justice-oriented remedies; on the other hand, this section delves into the notion of recognition, illustrating how helpful the recognition framework (Honneth 1996) is in identify instances of social injustice in contemporary societies.

In the context of mental illness and disabilities that impact the collective perception of agents’ epistemic capacities, it is essential to promote epistemic justice that improves relationships between speakers with mental disorders and people who care for them in society. On this specific topic, the volume presents two relevant contributions. 

First, the article by Christian Tewes, “Reconsidering the Double Empathy Problem”, addresses the exclusionary mechanisms directed towards autistic individuals, showing the deeply discriminating side-effects of neurotypical individuals and institutions projecting their implicit normative rules of behavior and assumptions onto autistic individuals. In so doing, Tewes argues that neurotypical individuals and institutions inaccurately ascribe a lack of empathetic understanding to autistic individuals, resulting in their exclusion, stigmatisation, and even traumatisation (Milton 2012). This analysis, employing a range of embodied-phenomenological perspectives, is illuminating in showing the often-overlooked exclusionary mechanisms activated, sometimes even involuntarily, by social norms and social conventions that are established mirroring the preferences, costumes, and ascriptive characteristics of members of the cultural majority (Galeotti 2017). 

On similar lines, a second contribution, by Donata Chiricò and Maria Tagarelli De Monte, “Hearing perspectives on deafness: a century-long form of power” illustrates the kind of structural exclusion and discrimination historically suffered by deaf and hear-impaired individuals. Through the powerful example of Charles-Michel L’Épée (1776), who founded a school where deaf individuals were treated equally to hearing individuals, the authors problematize the exclusionary dimension of spoken language for subjects precluded from it and the enduring implicit stigmatization that characterizes the historically established notion of “physical and cognitive normality”.

Federica Liveriero is associate professor of political philosophy at the Department of Political and Social Sciences of the University of Pavia. Liveriero's main areas of interest are normative theories of justice and legitimacy; democratic theory; social epistemology and oppression studies. She is interested in understanding what we owe to each other as fellow citizens in democratic settings, both practically and epistemically. You can see more about her publications and published monographs here.

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. 

Psychiatry as mind-shaping

 In this post, project EPIC postdoc Jodie Russell summarises her recent paper “Psychiatry as Mind-shaping”, published in Erkenntnis:

I make the case that researchers in mental health, clinicians and the wider public participate in a process called mind-shaping. By highlighting the involvement of these individuals in shaping the minds of people with disordered experiences, we can better understand phenomena like looping effects (when the behaviour of the person being labelled changes in response to that label, which in turn changes the meaning of the label). Moreover, characterising psychiatry as mind-shaping also helps us understand harms like epistemic injustice in a new light. But, first, let me unpack what I mean by psychiatry as mind-shaping.

Mind-shaping is a particular theory of social cognition – the study of how we understand each other. In contrast to traditional theories of social cognition, where we try to ‘read’ the minds of other people, the mind-shaping thesis proposes that understanding occurs through trying to get another person to conform to some set of shared rules. For example, I understand that my partner is hungry because their behaviour conforms to certain norms of being a ‘hungry person’, i.e., they rub their stomach, look wistfully at the kitchen, or graze on near-by biscuits. In this example, I try to understand what ‘type’ of person my partner is trying to be, assuming their behaviour conforms to some norms of that ‘type’ that I also adhere to.

In this way, I argue that researchers and clinicians are trying to understand what kinds of people individuals with disordered experiences are. In other words, clinicians and researchers might try and understand whether someone is a ‘well’ or ‘unwell’ person, a person with schizophrenia, or a person with a brain disease etc.

However, under the mind-shaping view, this process of categorizing people comes with certain expectations; in order for social understanding to be successful, it may be necessary to conform to certain norms. For example, for my partner and I to successfully coordinate over our shared task of making food for dinner, I really need to know that my partner is hungry. If they act hungry when they aren’t, we’ll make food for no reason. If they don’t act hungry when they are, my partner starves (if they are feeling melodramatic). Either way, if my partner is unreliable in conforming to norms, it makes working together to make dinner more difficult, and communication in general might struggle if they are not in some way reliable. There are therefore certain expectations at play in social understanding; if you are a hungry person, you should act like it. This is what it means to be mind-shaped.

This has, however, some unintended consequences when it comes to mental health research, namely, that individuals with mental disorder who are labelled may be prone to particular “expectancy effects”. In other words, by being labelled or studied in a particular way, as a particular kind of person, people with mental disorder may be obligated to act in certain ways. One such case study of this can be seen in a study conducted by Örmonet al. (2014). They noticed that the women in their study who had experienced abuse did not often have their experiences validated by clinicians, with their history of abuse considered irrelevant to diagnosis, and thus the women did not receive what they felt was the appropriate care. As such, the women responded to this treatment by changing their behaviour to conform to particular disorder categories that were seen as worthy of care (such as bipolar disorder). In this case, I argue that the women conformed to norms of being mentally unwell that clinicians typically expected to find; by understanding their patients as unwell, the clinicians were then able to provide some kind of care for these women. In this way, both the patients and clinicians were mind-shaped in order to coordinate on some goal (getting care for the women).

The consequences of this particular case study, however, was that the struggle of the women to have their abuse acknowledged was then interpreted by clinical staff through the lens of mental illness. This struggle was then either a mental health problem or secondary to the mental health problem. It is in this way that I think we should pay closer attention to the effects of mind-shaping, and how it may perpetuate epistemic injustices. Given that a core part of social understanding is the expectation we conform to shared norms, we may not only present very narrow options to individuals with mental disorder if they want to be understood by others (e.g. through the lens of specific disorder categories that may or may not fit their experiences), we may also exclude as irrelevant, or un-understandable, those behaviours, thoughts and feelings, which don’t fit our expectations but that are nevertheless important to the individual in question. The solution, I would want to propose, is giving people with mental disorder more agency to determine what norms are in play so that they might be better understood on their own terms.