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.

Epistemic injustice in global antimicrobial resistance research

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

Introduction

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

Epistemic Injustice and AMR Research 

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

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

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

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

Consequences of Epistemic Injustice in Global AMR Research 

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

Suggestions for the Way Forward 

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

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

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.

EPIC Women in Philosophy Workshop

At Birmingham, we are lucky to receive funds from the school for Women in Philosophy events, workshops, meetings and other activities. Last Thursday, we held a workshop for Early Career Women in Philosophy who work on epistemic injustice.

We were kicked off by Sally Latham who defended the value of non-narrativity about one's illness experiences. Sally argued that people who do not, or cannot, narrate their illness experiences in a particular way are vulnerable to a variety of epistemic injustices. 

We then heard from Eleanor Byrne who spoke about the relationship between epistemic injustices and affective injustices. She discussed the complex intentional structure of our affective lives to shed light on the variety of ways that we can give or deny "uptake" to people's emotions, moods and feelings. 

After lunch, Ellie Palafox-Harris then told us about hypervigilance and the psychiatrist. She presented on the absence of trust in patients in psychiatric encounters, and argued that psychiatrists exhibit epistemic hypervigilance which she takes to be persistent unwarranted distrust.

Kathleen Murphy-Hollies then dissolved the so-called trade-off in our interpersonal interactions with others between the desire to receive accurate information and the desire to be kind. Kathleen argued that the way our description of our experience is received by others shapes that very experience, and that we need to feel that others see us as having agency in order for us to have that agency. 

Jodie Russell then warned us that pluralism about models is not sufficient to bring about a more feminist psychiatry. In the spirit of Sara Ahmed's Queer Phenomenology, Jodie argued that science should also be 'queered', seeking a more radical 'table-flipping' approach to a plurality of perspectives and epistemic practices in science. 

Alice Moneypenny, whose blog will feature next week, spoke to us about testimonial smothering that patients with conditions like chronic pain can be victim to. She argued that being able to navigate and resist being dismissed through tactical adjustment of one's tesitmony illustrates a special form of agency in patients. 

Last but certainly not least, Francesca Bellazzi motivated how we make sense of the so-called human right to science. She argued that truth-seeking is related to epistemic justice, and that active engagement with science allows people to resist a variety of epistemic injustices.