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.

McPin Young People's Network

In this post, Lisa Bortolotti interviews Rachel Kimberley Temple, Public Involvement in Research Manager (Youth Involvement Lead) at the McPin foundation.

Logo of McPin's Young People's Network

LB: Hello Rachel! What is the McPin Young People's Network and what is your role in it?

RKT: Hi Lisa! The young people’s network consists of over 400 young people from across the UK, aged 13-28, who identify as having lived experience of a range of mental health issues. Everyone in the network has signed up because they wish to get actively involved in mental health research. Researchers can contact us and share their youth involvement opportunities with the network. The network is essentially intended as a resource for both young people and researchers who are seeking to work together. 

My role is to manage a small team who oversee the network; raising awareness about it, building membership, and sharing key findings from projects connected to the network. We also collaborate directly with researchers who wish to engage with the network, advising and facilitating youth involvement in their projects.

LB: Why do you think is important that young people are actively involved in mental health research?

RKT: I think it’s vital that young people have a role in research that will directly impact them. By applying their expert knowledge, the research becomes more relevant, accessible and appropriate. This not only improves the quality of the research but also makes it more likely to achieve the desired impact. Research therefore benefits hugely for involving young people.

LB: How do young people benefit from involvement in mental health research?

RKT: Young people we have worked have told us that they value learning new skills and find it empowering to apply their expertise to something that will positively benefit others. I think this is so important, because having mental health issues can make you feel powerless. Therefore, being actively involved in research can offer a sense of control - a feeling like you can make a difference. 

We’ve also been able to see young people grow in the role; becoming more confident, making valuable connections with external partners and building their own careers.

LB: Can you give us an example of a research project you have been involved with, and of what the young people helped achieve?

RKT: One example that comes to mind is the agency project. On this project, we worked with young people and academics to co-analyse video data of young people’s mental health interactions within emergency departments. We drew on our unique perspectives and expertise, and combined this to make some important discoveries: how to maximise young people’s agency in interactions about their mental health. We translated those findings into various resources targeted at professionals, young people and other researchers.

To learn more about the Young People's Network visit their website or follow them on X and Instagram. 

If you are a researcher seeking to involve young people in your project or collaborate with McPin, visit this page. 

McPin Young People's Network has contributed to several outputs for the Agency Project including a podcast called "How to give young people agency in mental health" and a poster entitled "What I wish my younger self knew about mental health" aimed at secondary school students. Check them out!

Logo of the Agency Project

Stereotypes about young people who hear voices

Negative stereotypes associated with people who report unusual experiences and beliefs cause lasting harm and often undermine agency. In a series of workshops with the young people of the Voice Collective, facilitated by Fiona Malpass (Mind in Camden) and designed by Lisa Bortolotti and Kathleen Murphy-Hollis, we discussed the challenges that hearing voices poses for young people, at home, at school, and in healthcare settings.

The result of our conversations was a script created by the young people who participated in the workshops, where they described three forms of negative stereotyping that cause harm: 

• perceived dangerousness, leading to the thought that the young person poses a threat; 
• perceived lack of capacity or incompetence, leading to the thought that the young people cannot achieve anything valuable or challenging; 
• perceived difference or weakness, leading to social exclusion.

The script was turned into an animated video, produced by Squideo (click below to watch).

Snake or dangerousness

Snake

Perceived dangerousness is represented by Snake, who does not really pose a threat to humans but is feared and kept at a distance. Contrary to popular belief, most snakes are neither venomous nor dangerous. Snakes defend themselves if someone disturbs or attacks them but are not aggressive towards humans. Yet, many people make assumptions about their being dangerous. So, Snake in the video is right that his bad reputation is undeserved.

Butterfly or incompetence

Butterfly

Perceived lack of capacity is represented by Butterfly. Although she is an active pollinator contributing to the life of the garden, Bee teases her and suggests that she is lazy and useless, based on her past as a caterpillar, when she was seen eating all day long. Seeing a chewed leaf might make us think that caterpillars are good for nothing but destroying plants. However, caterpillars are actually very important to their environment even before they become pollinators. They prevent vegetation from growing too quickly and depleting nutrients in the soil. So Bee's attitude towards caterpillars and butterflies in our video is unjustified.

Wolf or exclusion

Wolf

Perceived difference or weakness is represented by Wolf. Wolf got an injury and because of that he was left behind by his pack. The other wolves assumed he would be a burden, unable to keep up and hunt for himself. But there is no reason that his small, temporary injury would have made his contributions to the pack less valuable in the long term. He would have probably needed some support until the injury was healed, and then he would have been in a position to run and hunt as fast as the other members of the pack.

A safe space

Snake, Wolf and Butterfly in the clearing

Being treated as dangerous for no good reason, being considered as a burden and nothing else, and being excluded by shared decision-making, are all harmful (and sadly common) experiences for young people who hear voices. Young people struggling with their mental health have a lot to contribute and with some support they can continue to pursue the projects that are important to them.

In the video, Snake, Wolf and Butterfly meet in the clearing to share their experiences and support each other. What happens in the clearing, sharing experiences in an environment that is safe and non-judgemental, is what happens in the Voice Collective. Young people who hear voices and have other unusual experiences or beliefs come together and connect with people who are in a similar situation. 

The video is an invitation to go beyond the stereotypes and see the person, not the label. To learn more about myths and truths about hearing voices, visit The Voice Collective website.

You find The Wolf, the Snake and the Butterfly and other animated videos introducing philosophical issues in The Philosophy Garden, a virtual philosophy museum gathering and producing resources for young people, educators, and the general public. 

The Philosophy Garden is a project run by EPIC co-investigator Lisa Bortolotti, with the collaboration of Kathleen Murphy-Hollies, Anna Ichino, and Fer Zambra.

When is dismissing a report an act of injustice?

There is a fable by Aesop called The Stag and the Fawn. The stag scares the rest of the herd with his stamping and bellowing but is terrified by the hound. Aesop tells us that this is a story about courage and cowardice but it can also be seen as a story about power relations in a group. The stag can afford to terrorise the other deer because he is more powerful and more highly respected than they are.

 

The Stag and the Fawn by Aesop  

A STAG, grown old and mischievous, was, according to custom, stamping with his foot, making offers with his head, and bellowing so terribly that the whole herd quaked with fear of him; when one of the little fawns, coming up to him, addressed him thus: Pray, what is the reason that you, who are so formidable at all other times, if you do but hear the cry of the hounds, are ready to fly out of your skin for fear?

What you observe is true, replied the stag, though I know not how to account for it. I am indeed vigorous and able, and often resolve that nothing shall ever dismay my courage; but alas! I no sooner hear the voice of a hound but my spirits fail me, and I cannot help making off as fast as my legs can carry me.

Moral: The greatest braggarts are the greatest cowards.

(Aesop's Fables, 1881, WM.L. Allison, New York)

Consider another story featuring a fawn, mother and father deer, and a mountain lion. Watch the video below, which was produced by Squideo from a script I wrote in order to illustrate what epistemic injustice is.

The Fawn and the Mountain Lion 

When is dismissing another's report an act of injustice? 

Father deer (to Mother Deer and Fawn): It’s late let's go to the lake to get some water before it gets dark.

Fawn (eyeing an acorn in the bushes): Wow I would love to gobble that up! (spotting a mountain lion): Oh no, never mind the acorn! 

Fawn (running to catch up with Mother and Father Deer down the lake): Mommy Daddy I just saw a huge mountain lion behind the bushes! We have to go, it is not safe here!

Father Deer (sceptical): If there was a mountain lion behind the bushes I would have heard the steps… you must have imagined it.

Mother Deer (concerned): I am not sure we should stay. Shouldn't we listen to Little Fawn and get back to the herd? Fawn has never lied to us before! 

Father Deer (in a patronising tone): Calm down, young ones don't distinguish reality from imagination and they always try to draw attention to themselves. (then smiling to Fawn) Why don't you get some water little Fawn, you will be thirsty otherwise! This water is delicious, so fresh!

(Mountain Lion attacks Father Deer and bites his the leg but is chased away by Owl descending on the scene with loud screchees)

Mother Deer (to Father Deer): Are you okay?

Owl (to the viewers): We sometimes dismiss a report when we don't trust the speaker due to some negative stereotype but in dismissing what the speaker has to say we pay a high price. We reject information that can be valuable to us.

Mother Deer: You are right wise owl.  In our herd, females and fawns are never listened to but little Fawn recognizes a mountain lion when he sees one! To dismiss him is not just risky, it is an injustice! He should not be silenced when he has something to say.

In this story, the fawn sees a mountain lion and warns his father that there is danger but is not believed. The reason why the fawn is not believed is important: the fawn is not known for lying, being unreliable, or seeking attention, as his mother points out. However, his father assumes that the fawn's report is not something worth acting upon, based on the assumption that fawns are likely to confuse reality with imagination and to draw attention to themselves. 

As the dismissal of the fawn's warning is motivated by stereotypes usually associated with the young, it is a case of epistemic injustice. Not an isolated case either: mother deer reflects bitterly on the fact that in a very hierarchical society like theirs, the views of fawns and females are often openly disregarded, whereas the views by the dominant males are taken seriously. What are the effects of this?

In the story we see two types of effects. First, the fawn and his mother are saddened and disappointed by the deer's lack of consideration for what they have to say. We can imagine the fawn deciding not to warn his herd in the future for fear of being ignored and ridiculed. We can also imagine the fawn internalising his father's criticism and coming to consider himself as unreliable.

Second, father deer, who ignores the warning, is attacked and wounded by the mountain lion, who runs away only when the owl screeches loudly causing a commotion. Ignoring the warning caused him harm as he could not avail himself of important information that would have prevented the mountain lion's attack.

The story is so short that there is no time to explore the further consequences of the event and the development of its characters. However, it shows some interesting features of epistemic injustice, including the pervasive and harmful nature of unquestioned stereotypes and the fact that it harms the vulnerable person whose report is dismissed but also, more subtly, the powerful person who dismisses it.

Young people are often thought to be lazy, immature, lacking resilience, and seeking attention. They are often called "snowflakes" and "drama queens" in the press. These are not harmless stereotypes as they may affect the likelihood that we listen to what they have to say and take their testimony seriously. Their capacity to acquire and share knowledge is even more severely challenged when they experience mental health problems, as their reports may be taken to be a product of their illness as opposed to a reflection of their experiences.

This is what interests me about EPIC, our project on epistemic injustice in the healthcare context: how we can make sense of the dismissal of young people who experience mental health difficulties, and how we can stop it.

This post is by Lisa Bortolotti, who is a Professor of Philosophy at the University of Birmingham and an investigator in EPIC. Among other things, Lisa creates and gathers resources to bring philosophy to everyone at The Philosophy Garden, where you find the video of The Fawn and the Mountain Lion and other videos on a number of timely issues that deserve attention.

Undermining versus Accepting Young People's Experiences

Laura was brought to the emergency department (ED) by ambulance after a pharmaceutical overdose. Earlier in the assessment, she said she visited her General Practitioner earlier in the day seeking mental health support but she didn't feel she got the support she needed. She reported that she later took a pharmaceutical overdose because she felt very suicidal. The practitioner Laura talks to in the ED  recharacterizes Laura’s experience of suicidal ideation as brief and her act as impulsive. 

What happens in such cases?

In a new open access paper (Bergen et al. 2023), a team of academics and young people with lived experience of mental health services analyse conversations in clinical encounters and observe that people's description of their own experiences is often challenged. These episodes where the practitioner either implies that the patient's report is implausible or undermines it with alleged counter-evidence can be understood within the framework of epistemic injustice. The authors write:

"From a philosophical perspective, applying the concept of epistemic injustice to the clinical encounter enables us to conceptualize the attitude of an epistemically privileged party not as a lack of respect or a failure of empathy (which would not be specific enough) but as an act of injustice toward the party who is epistemically subordinate. The injustice amounts to assigning reduced credibility to a patient’s reports, effectively preventing the perspective of the patient from contributing to shared knowledge and decision making. As epistemic injustice concerns knowledge first and foremost, this does not simply tell us that dismissing a person’s perspective due to prejudice is morally objectionable. Rather, it is problematic from an epistemic point of view because the opportunity to gather knowledge that would benefit both parties and society at large is missed."

 

Clara Bergen

In this table from the paper, we can see that several studies have already gathered evidence of this practice of implying implausibility or undermining the patient's report of their experiences, and that the practice can take several forms:

In the case I started with, one of the five cases examined in the paper, young person Laura's reported intention to kill herself is challenged on numerous occasions, via different strategies: 

1. asking questions that anticipate a compromising response ("And I hear you called the ambulance straight away?"); 
2. asking questions that imply implausibility or inconsistency ("So when you called 111 what did you expect them to do?"); 
3. juxtaposing contrasting information ("You called them so that they could get you help"); 
4. implying information that provides evidence of an alternative characterisation ("So would you say that you took the tablets at the spur of the moment?").

As a result of the encounter, the practitioner concludes that Laura took the tables impulsively and suggests that, if Laura feels suicidal again, she should get support from people she knows or call the Samaritans. The involvement of the rapid response team is deemed unnecessary, and Laura is not referred to mental health services.

Rose McCabe

Future research should explore to what extent recharacterization could be minimized through further communication training or unconscious bias training, and to what extent a long-term solution may lie in increasing accessibility of mental health services for people who self-harm and experience suicidal ideation.