Philosophy of Medicine Roundtable 2025 (part two)

This is a brief report of some of the talks delivered on the second day of the Philosophy of Medicine Roundtable hosted by King's College London in June 2025. For a report of day one, please go here.

From the poster of the Roundtable

The second day of the event started with a presentation by Devora Shapiro on the role of EBM (evidence-based medicine) in enabling phenomena such as medical gaslighting and illness invalidation. Shapiro discussed cases where patients are told that there are no medical issues for them, because the test results come back with no indication of pathology, and yet the patient has a complaint that matters to them and is not given sufficient uptake.

A slide of Shapiro's presentation

The discussion following the presentation centred on what causes the problems of power-imbalanced relationships between doctors and patients, whether it is EBM or something else, for instance a failure to provide care or a lack of recognition that, although successful, medicine cannot tackle all human problems.

In one of the several talks by project EPIC members at the Roundtable, Elisabetta Lalumera asked why definitions matter in medicine and how linguistic labels function as operational tools. Conceptual engineering and conceptual choice may serve various goals such as diagnostic utility and inclusivity. One example of the importance of definitions is the change in the definition of pain, which has been revised in 2020 to include the sensations of those who cannot describe pain such as infants, nonverbal patients and animals.

Elisabetta Lalumera on definitions of pain

Such revision was motivated by inclusivity and ethical concerns so it was a deliberate value-laden choice. The new definition has the merit of avoiding the risk of epistemic injustice (e.g. when a patient claims to be in pain but no lesion is found) but has risks as well, being more vague, more difficult to operationalise, and likely leading to overmedicalisation of human experience.

In the next talk, Kathleen Murphy-Hollies, postdoc on project EPIC, presented a talk about what it means to give uptake to the metaphorical meaning of delusions. Murphy-Hollies started talking about the experience of entomologists being contacted by people with delusions of parasitosis claiming that they are suffering from an infestation. How should entomologists deal with these cases? To what extent should they believe the people claiming an infestation?

Each testimony has two aspects: the propositional content conveyed and the perspective conveyed in the statement. We can fail to believe what the person says and yet take their perspective seriously. Maybe delusions express metaphorical meaning that is worth trying to understand. Murphy-Hollies builds on account by Federico Bongiorno and Rosa Ritunnano to explore the metaphorical interpretation of delusional utterances.

Kathleen Murphy-Hollies on delusions

In the rest of the talk, Murphy-Hollies observed how metaphorical meaning is not just relevant to people reporting delusional beliefs, but is often conveyed in cases of reports by people who experienced trauma or have implicit knowledge. This observations lead to a new understanding of uptake which is not just believing what the person is saying but is about mutual engagement.

Dan Degerman talked about the medicalisation of silence. Silence has been seen as a cause of depression (not talking about something might lead someone to become depressed), as a symptom of depression (it appears in the criteria for depression), as a problem in the workplace (underperforming) and as a cause and symptom of depression in that context.

Dan Degerman on silence

Degerman asks why the medicalisation of silence is a worry. Silence is a diagnostic marker for depression and can be associated with distress. But by medicalising silence we represent it as a threat, we end up avoiding it, and we obscure its benefits:

• social benefits
• epistemic benefits
• medical benefits.

More important, we may override the benefits of silence for medical or health-related reasons.

As hopefully shown by these remarks on some of the talks, the second day of the Philosophy of Medicine Roundtable was very rich and addressed a variety of issues in the metaphysics, epistemology, and ethics of 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.

Project EPIC on World Mental Health Day 2024

On the occasion of World Mental Health Day (#WMHD2024), we asked project EPIC team members to share a quote and a resource relevant to their work on epistemic injustice in healthcare.

Jodie Russell

Jodie is a researcher working at the University of Birmingham on one of EPIC case studies. Jodie is the author of "Problems for Enactive Psychiatry as a Practical Framework", published open access in Philosophical Psychology, highlighting the limitations of enactivism in reducing the harm and suffering experienced by individuals diagnosed with mental disorders.

 

Lisa Bortolotti

Lisa is an investigator in project EPIC, based at the University of Birmingham. Lisa has co-authored with Kathleen Murphy-Hollies a paper entitled "Why We Should Be Curious about Each Other", published open access in Philosophies, arguing that curiosity a good antidote to epistemic injustice. Lisa also edited and contributed a chapter to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Dan Degerman

Dan is a researcher on project EPIC, based at the University of Bristol. Dan's research explores the idea that it might not always be good to talk about one's mental health. If you want to know more, you can read Dan's article written for the Conversation.

Havi Carel

Havi is project EPIC principal investigator, based at the University of Bristol. Havi's work focuses on the experience of illness and she pioneered the application of the notion of epistemic injustice to healthcare. Watch this video where she introduces project EPIC.

Rabih Chattat

Rabih is a project EPIC partner, based at the University of Bologna. Rabih's work focuses on psychosocial interventions in dementia and the clinical psychology of ageing. He recently wrote a post for the EPIC blog on good living and social health as applied to dementia. Rabih also contributed a chapter on these themes to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Jude Williams

Jude is the project manager for EPIC at the University of Birmingham. Jodie volunteers for the Choir with No Name, the choir that gives homeless people a voice. If you want to know more about what the Choir is about and what impact it has, please read this.

Matthew Broome

Matthew is an investigator on EPIC and directs the Institute of Mental Health at the University of Birmingham. He recently co-authored a paper with Lucienne Spencer on epistemic injustice and claims of suicidality that can be found here. Together with Michael Larkin, Lisa Bortolotti, and Rose McCabe, Matthew contributed a chapter on youth mental health to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Eleanor Byrne

Eleanor is a researcher on project EPIC, based at the University of Birmingham. Eleanor works in the philosophy of medicine, on conditions that impact on the mental and physical capacities of those affected. In this podcast, she discusses an area at the intersection of philosophy and psychotherapy, focusing on experiences of fatigue.

Elisabetta Lalumera

Elisabetta is an EPIC project partner based at the University of Bologna. Elisabetta works in the philosophy of medicine. You can read this blog post where she talks about how to achieve epistemic justice in the biomedical paradigm. Elisabetta also contributed a chapter on digital health technologies to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Rose McCabe

Rose is an EPIC project partner based at City University, London. Rose specialises in research on clinical communication and contributes to the design of interventions to improve the capacity of professionals to listen to people who seek support for their mental health. See an example here. Together with Michael Larkin, Lisa Bortolotti, and Matthew Broome, Rose contributed a chapter on youth mental health to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Lara Calabrese

Lara is interested in ways of explaining and ameliorating the stigmatisation of people with dementia. She is a researcher at the University of Bologna, and is going to collect the data for one of EPIC case studies. 

Luigi Grassi

Luigi is an EPIC project partner, working at the University of Ferrara. Luigi recently shared some of this research interests in dignity and stigma in end of life care on the EPIC blog. Luigi also contributed a chapter on these themes to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot)

Kathleen Murphy-Hollies

Kathleen is a researcher at the University of Birmingham. Kathleen has worked with some entomologists to better understand delusions of parasitosis, when people come to believe that their bodies have been infested by insects. To know more about this fascinating condition and the challenges it poses, go here.

Martino Belvederi Murri

Martino is an EPIC project partner, working at the University of Ferrara. Martino recently shared of his research interests in demoralisation and testimonial injustice in an acute psychiatric ward on the EPIC blog. Martino also contributed a chapter on these themes to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Epistemic Injustice and Genocide

For the next two weeks, Melanie Altanian presents her new book, The Epistemic Injustice of Genocide Denialism (Routledge 2024), which is open access. In today’s and next week’s post, Altanian discusses particularly the psychological harms resulting from conditions of epistemic oppression created and sustained by genocide denialism.

Cover of the book by Melanie Altanian

In my recently published book, I argue for two intertwined theses: 

1. genocide denialism should be understood and explained as a substantive epistemic practice, one that creates and sustains ignorance and ignorant agency; 
2. this kind of ignorance is pernicious, because it perpetuates and sustains epistemic oppression. 

I elaborate on this in relation to two interrelated forms of epistemic oppression: 

• testimonial oppression, which concerns institutionalized disabling constraints on epistemic agency qua genocide testimony, and 
• hermeneutical oppression, which concerns institutionalized disabling constraints on epistemic agency qua genocide remembrance.

Silences in the aftermath of genocide

In the book, I stress the need for distinguishing two types of silence that may occur in the immediate and long-term aftermath of genocide – deliberate or resistant silence, and (coerced) silencing – and that it is by focusing on the latter that we get a clearer picture of the epistemic injustices that genocide survivors may encounter.

As opposed to deliberate or resistant silence, where survivors temporarily and strategically remain silent about their painful memories because it helps them rebuild their lives, (coerced) silencing usually occurs under conditions of genocide denialism, where the social uptake conditions for genocide testimony are rendered systematically dysfunctional.

Such epistemic oppression is intrinsically wrong and comes with a range of follow-on harms. In this post (published in two parts), I would like to draw attention to the psychological harms resulting from conditions of epistemic oppression created and sustained by genocide denialism.

Genocide, trauma, and recovery

Particularly as a long-term strategy to consolidate relations of domination, genocide denialism impacts the psychological well-being of both genocide survivors and their descendants. Besides being re-traumatizing, it obstructs the possibility of processing, thus prolonging, cross-generational personal and collective trauma. These trauma-effects have been studied to a great extent in relation to both the Holocaust and the Armenian genocide (Alayarian 2008, Azarian-Ceccato 2010, Karenian et al. 2010, Kupelian et al. 1998, Lehrner and Yehuda 2018).

For example, a study by Kalayjian et al. (1996) identified feelings of humiliation associated with loss of status, autonomy, property, and dignity among the stressors experienced and reported by survivors of the Armenian genocide, while they experienced recalling the deaths of their family members as most painful. Their responses “reflected feelings of helplessness, loss of control, resignation, uncontrollable re-experiencing of the traumatic events, and sadness”, while “the value and emphasis the Armenian culture places on togetherness served respondents as a coping style – sharing the pain and suffering by ‘sticking together’” (92). 

This already indicates the importance of a supportive environment to turn to for coping with trauma, and the above findings are congruent with trauma research more generally. In Trauma and Recovery, Herman (2015 [1992]) argues that traumatic events are characterized by an experience of helplessness in the face of overwhelming force. Such events “overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning” (44). To recover from trauma thus requires the restoration of a sense of agency and control.

While trauma recovery always depends on social support, in cases of collective violence such as genocide, it must include a political response in the form of public recognition and repair. Rebuilding the survivor’s sense of order and justice requires community action, including assignment of responsibility for and reparation of the harms. We can thus begin to assess the perniciousness of genocide denialism, as it upholds the breach between traumatized persons and the community.

Melanie Altanian is assistant professor for epistemology and theory of science at the University of Freiburg. Her research focuses on issues in social and political epistemology, moral philosophy, and social philosophy.

Is there a right to silence?

Silence is often perceived as politically harmful and something that has to be broken. But what if silence can also be politically beneficial in democracies and we have good reasons to protect our right to stay silent?

Specifically, is speech always better than staying silent in situations of compelled speech and possibly compelled lies due to social pressure? Is speech better than silence when the audience might misinterpret or deconstruct what we way?

In our article (open access in Philosophical Quarterly, 2024), Dan Degerman and I address the political importance of being able to hold to one’s silence and we argue that a democratic right to silence can be motivated by politically relevant epistemic reasons.

Generally, the right to stay silent is seen within the legal context as the right one has to protect oneself against self-incrimination. However, we can broaden this and argue in favour of the right to silence as the entitlement one has to stay silent, either by not speaking or by not speaking about something in particular.

The right to silence so formulated can have many benefits, but specifically we can focus on some epistemic benefits silence can bring. The first is that silence can prevent the risk of jeopardising the individual’s credibility and spreading falsehood while undermining the notion of truth. This is the case when someone might be compelled to lie in public. These situations can be present due to political, legal, and social pressure. Cases of this kind are show trials, but we can also imagine contexts related to free speech on the internet or in public spaces. A robust right to silence can allow individuals to adhere to it while avoiding the epistemic harms that can be generated by publicly admitting what is known to be false

The second benefit is the one of preventing the misconstruction of what someone might say when they are faced with an audience that pressures them to speak. This case can be seen in cases of compulsory representation when someone is asked to speak in quality of representing a given minority and whatever is said risks being misinterpreted. The epistemic damage in these cases is not limited to the epistemic agency of the speaker but also that of the group they are taken to represent. Again, in the context of internet and speed news, it is not difficult to imagine a case in which someone’s option might be misconstructed or re-interpreted for given purposes. As we argue, in both these cases silence is a better option.

How can we implement the right to silence? The answer is not simple and many steps have to be taken politically and legally. However, we believe that a first step can be seen in making people comfortable with their right to be silent in situations of pressure or in which their status as epistemic agents might be compromised. And our paper aims to guide them to do so.

Francesca Bellazzi is Teaching Fellow in Philosophy in the Department of Philosophy, Theology and Religion at the University of Birmingham and Honorary Visiting Fellow in Philosophy at the University of Bristol.

Francesca works in the metaphysics and philosophy of science and in applied philosophy and ethics.

Silence

This post is by Dan Degerman, Leverhulme Early Career Research Fellow at the University of Bristol. Dan is soon to join project EPIC. 

Some members of team EPIC: Matthew Broome, Ian Kidd, 
Dan Degerman, Havi Carel, Kathleen Murphy-Hollies, and Fred Cooper.

Silence is an important phenomenon in mental health. But while philosophers have had much to say about the social silencing of people with psychiatric diagnoses, other ways in which silence can feature in psychopathology have been underexplored. In a recent workshop at the University of Bristol, generously funded by the Leverhulme Trust, we sought to begin to address this neglect by exploring the different faces of silence in psychopathology.

Ian Kidd opened the workshop with a talk that explored painful silences common in bereavement grief. In particular, he focused on four silences, each characterised by a loss of communicative possibilities that follows the death of a loved one. This included, for example, silence as the loss of the distinctive communicative style of the deceased and silence as the permanent absence of narrative closure. For the person subject to these silences, they are painful for three reasons, Ian explained. Firstly, these silences cannot be filled. Secondly, they involve the awareness that the ways of being in the world the relationship with the deceased made possible are now impossible. Thirdly, they involve the awareness that one can no longer be the same person that one was with the deceased.

Ian Kidd

The second speaker, Richard Stupart, drew on accounts of investigative journalists working in South Sudan to shed light on some of the mental dangers of being silent. He argued that journalists are at a heightened risk of moral injury, referring to the negative psychological impact a person experiences when they are unable to respond to a situation in what they consider a morally appropriate way. Journalists in conflict and crisis situations are particularly vulnerable to such injury because they often find themselves subject to structural pressures that may prevent them from communicating their knowledge about morally charged stories.

Richard Stupart

Inner speech in mental disorders was the subject of the next talk by Sam Wilkinson. He defended what he called a strong dialogical account of inner speech, which entails that all inner speech is directed at a recipient, namely, ourselves. This account also suggests, among other things, that inner speech plays a central role in shaping our identity. Sam then outlined some ways this account can help clarify the implications of inner speech and its absence in different mental disorders. For example, the strong dialogical account indicates that negative inner speech in anxiety and depression is not just an epiphenomenon of pre-existing a person’s feelings but that it can create a downward spiral of those feelings.

 

Sam Wilkinson

The fourth talk by Anna Bortolan examined experiences of silence in social anxiety. Drawing on some distinctions proposed in a recent paper on silence in mood disorders, Anna showed that these capture experiences described by people with social anxiety as well. She then went beyond that account to argue that a further two experiences of silence can be discerned in accounts of social anxiety. The first is characterised by a perceived inability to fill certain silences when one wants to do so, and the second is accompanied by a diminished sense of agency over how silences are filled.

Anna Bortolan

Finally, in my talk, I argued for the importance of attending to first-person experiences of silence in psychopathology through a case study drawn from accounts of depression. Using a phenomenological framework inspired by the work of Merleau-Ponty, I described an experience common in first-person accounts of depression that I termed empty silence. This is an unpleasant experience that involves a solicitation to speak and a breakdown in a person’s habitual relationship with words, which confronts them with their own outward and inner silence. I proceeded to argue that if lived repeatedly, it may give rise to bodily doubt in one’s ability to speak.

Dan Degerman

If you are interested in learning more about the talks, presentation materials from most of them can be found here. The talks were followed by wonderful discussions with the interdisciplinary audience that was in attendance in the room and online, and I want to extend heartfelt thanks to all those who participated.

The workshop was the capstone event for my Leverhulme Early Career Fellowship. However, it also served as an informal launch event for the EPIC project, with many of its team members in attendance, including Ian Kidd, Havi Carel, Matthew Broome, Fred Cooper, Kathleen Murphy-Hollies, and myself. The conversations and explorations that began during this workshop on silence and psychopathology will continue as part of the project, and if you are interested in contributing or participating in some way, please do get in touch.

Dan Degerman joins EPIC

Excellent news for project EPIC! Dan Degerman, currently a Leverhulme Early Career Fellow, will join EPIC as a Senior Research Fellow based in the Philosophy Department at the University of Bristol. We asked Dan a few questions about current interests and future plans.

Dan Degerman

Hi Dan! What are your main research interests?

Hello! I am interested in issues at the intersection of mental health, emotions, and politics. 

For example, my first monograph, Political Agency and the Medicalisation of Negative Emotions, examined how the growing tendency to talk and think about emotions like anger and fear in terms of mental health problems affects our ability to act politically. It did so through a series of case studies of political movements and events – ranging from the Brexit referendum to the psychiatric service user/survivor movement – in which people’s capacity to participate in public life was called into question.

Since completing the book, I have been focusing on experiences of powerlessness among individuals with mental illness, particularly in terms of how symptoms, diagnoses, and stigma may lead such individuals to speak or be silent. These are, of course, issues that are closely related to epistemic injustice in healthcare as well as my case study on the EPIC project.

Why do you think it is important to study epistemic injustice in healthcare?

Being ill tends to increase our dependence on others, not only family members and healthcare practitioners, but also on, for example, friends, colleagues, and teachers. Over a remarkably short and fruitful period, scholars working on epistemic injustice in healthcare have provided rich insights into how people with ill health can be silenced in the relationships that arise and change through illness. This work has been and continues to be vital to empowering patients and improving healthcare.

However, a worry I have with the growing scholarship on epistemic injustice, in general, is that silence tends to feature in it only as a socially imposed harm and, accordingly, something that should be broken. Such a narrow understanding of silence overlooks the range of meanings and functions of silence for people with ill health, some of which may be restorative or empowering. And, by acting on it carelessly, we risk compounding the epistemic and other harms that such people face.

To realise the practical potential of epistemic injustice as a concept for patients and healthcare practitioners and to ameliorate the harms that this concept highlights, we need a better understanding of silence in ill health and its relationship to epistemic injustice. This is what I will aim to provide in my case study by examining how people with bipolar disorder – who may have a unique and conflicted relationship to silence and speech – experience and use silence in their lives.

What are you working on right now?

I’m working on a series of papers that will inform the conceptual framework of my case study. The first sets out an epistemic case for recognising a substantive political right to silence.

American crime shows might mislead us into thinking that this right is already legally protected. The phrase ‘You have the right to remain silent’ is probably among the most famous in the English language. In the UK – where what we do not say can be used against us in court – we do not have that right. However, even if we did, a right to remain silent in criminal contexts is too circumscribed to provide the protection that we need for our silence in a democracy.

A political right to silence must be able to protect our ability to be silent across various contexts because there are often good epistemic reasons for us not to speak. For example, we might feel pressured to lie if we speak, or we might know that what we say will be misunderstood or misused by others. In such circumstances, silence might be the best option. But, in a society like ours where silence is frequently denigrated, it may seem an untenable one.

I think this right could have important implications for people with ill health, who can, for example, be subject to pressure to disclose their illness at their place of work or education.

I’m looking forward to developing this and other ideas over the next few years in the context of the EPIC project.