ABSTRACT Current attempts to understand unusually high rates of psychiatric illness in complex, chronic illnesses can be guilty of operating within an explanatory framework whereby there are two options. Either (a) that the psychiatric predicaments are secondary to the bodily condition, and (b) that they are primary. In this paper, I draw upon philosophical work on affect, contemporary empirical work, and qualitative first-person patient data to illustrate a much messier reality. I argue that affective experience is generally more complex in (...) such conditions, and that a variety of pre- and post-morbid causal factors dynamically interact such that the resultant psychiatric predicaments do not permit to classification as strictly primary or secondary to the bodily condition. Affective scaffolding, in my view, provides an apt theoretical framework for capturing this nuance. (shrink)

This article defends the counterintuitive conclusion that public assignments of credibility – including statements, by hearers, of ‘that’s right’, ‘she is credible’, or ‘I believe you’ – can actually constitute a pernicious form of epistemic wrong. Sometimes referred to colloquially as ‘lip service’, the wrong occurs when, owing to ethically poisonous epistemic failures, hearers outwardly validate testifiers’ credibility despite not fully or duly believing them. To explain this wrong, I introduce a distinction between performed and internal credibility assignments (PCA and (...) ICA) and describe an epistemic dysfunction in which they misalign. I focus on cases in which misaligned PCA of ‘credible’ falsely – although sometimes non-deliberately – signal to testifiers and bystanders that testifiers have been believed; Republican hearers’ positive reception of Christine Blasey Ford’s 2018 testimony serves as a central case. Although some misaligned PCA are not wrongful, when epistemic and ethical failures including forms of identity prejudice and pernicious ignorance lead PCA of ‘credible’ to misalign, the PCA wrong testifiers in their capacities as knowers. These epistemic wrongs are particularly pernicious because the PCA conceal that testimony has not been efficacious, inflicting and exacerbating distinct harms. (shrink)

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, I (...) will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization. (shrink)

Since its 2007 publication, Miranda Fricker’s Epistemic Injustice has sparked a vigorous conversation in analytic philosophy about how social power corrodes individual’s epistemic capacities and distorts collective meaning-making in unjust ways. Yet for all its normative insights into social silencing, I argue that Fricker’s theorization of epistemic dysfunction remains too individualized, cognitivist, and dematerialized to account for racialized imaginaries. Rather than view racisms as normal and normative in racist cultures, Fricker frames identity-driven prejudice as a troubling aberration from otherwise unblemished (...) epistemic and moral norms. This leads her into adopting an overly voluntarist and idealist theory of social change that centres training better knowers rather than unmaking racialized worlds. Ultimately, I contend that we should return to a materialist theory of ideology, following the work of Stuart Hall. Doing so jettisons the narrow focus on individual epistemic failures and instead problematizes how certain social ideas consolidate and reproduce racial hierarchies. (shrink)

Social epistemology is the study of the social dimensions of knowledge or information. There is little consensus, however, on what the term "knowledge" comprehends, what is the scope of the "social", or what the style or purpose of the study should be. According to some writers, social epistemology should retain the same general mission as classical epistemology, revamped in the recognition that classical epistemology was too individualistic. According to other writers, social epistemology should be a more radical departure from classical (...) epistemology, a successor discipline that would replace epistemology as traditionally conceived. The classical approach could be realized in at least two forms. One would emphasize the traditional epistemic goal of acquiring true beliefs. It would study social practices in terms of their impact on the truth-values of agents' beliefs. A second version of the classical approach would focus on the epistemic goal of having justified or rational beliefs. Applied to the social realm, it might concentrate, for example, on when a cognitive agent is justified or warranted in accepting the statements and opinions of others. Proponents of the anti-classical approach have little or no use for concepts like truth and justification. In addressing the social dimensions of knowledge, they understand "knowledge" as simply what is believed, or what beliefs are "institutionalized" in this or that community, culture, or context. They seek to identify the social forces and influences responsible for knowledge production so conceived. Social epistemology is theoretically significant because of the central role of society in the knowledge-forming process. It also has practical importance because of its possible role in the redesign of information-related social institutions. (shrink)

Social epistemology is the study of the social dimensions of knowledge or information. There is little consensus, however, on what the term "knowledge" comprehends, what is the scope of the "social", or what the style or purpose of the study should be. According to some writers, social epistemology should retain the same general mission as classical epistemology, revamped in the recognition that classical epistemology was too individualistic. According to other writers, social epistemology should be a more radical departure from classical (...) epistemology, a successor discipline that would replace epistemology as traditionally conceived. The classical approach could be realized in at least two forms. One would emphasize the traditional epistemic goal of acquiring true beliefs. It would study social practices in terms of their impact on the truth-values of agents’ beliefs. A second version of the classical approach would focus on the epistemic goal of having justified or rational beliefs. Applied to the social realm, it might concentrate, for example, on when a cognitive agent is justified or warranted in accepting the statements and opinions of others. Proponents of the anti-classical approach have little or no use for concepts like truth and justification. In addressing the social dimensions of knowledge, they understand "knowledge" as simply what is believed, or what beliefs are "institutionalized" in this or that community, culture, or context. They seek to identify the social forces and influences responsible for knowledge production so conceived. Social epistemology is theoretically significant because of the central role of society in the knowledge-forming process. It also has practical importance because of its possible role in the redesign of information-related social institutions. (shrink)

Who is morally permitted to tell jokes about Jews? Poles? Women? Only those in the group? Only those who would be punching up? Anyone, since they are just jokes? All of the standard approaches are too broad or too narrow. In on the Joke provides a more sophisticated approach according to which each person possesses "joke capital" that can serve as "comic insurance" covering certain jokes in certain contexts. When Bob tells a joke about Jews, we can never know exactly (...) what Bob is intending since we cannot see inside Bob’s mind. But we could reasonably infer, if we knew Bob himself was Jewish, if he worked tirelessly for Jewish causes, or was a card-carrying Neo-Nazi. Each would affect his joke capital, and, in certain circumstances, we would have a moral standing to demand to see his ledger to see how much joke capital he had with respect to Jews. The permissibility of that joke depends upon four factors: the joke, the teller of the joke, the audience, and the setting. The view developed in In on the Joke is the only view that clearly explains how each of these components work together in an integrated, effective ethic of humor. (shrink)

Self-ascriptions of one's current mental states often seem authoritative. It is sometimes thought that the authority of such self-ascriptions is, in part, a matter of their indubitability. However, they do not seem to be universally indubitable. How, then, should claims about self-ascriptive indubitability be qualified? Here I consider several such qualifications from the literature. Finding many of them wanting, I nevertheless settle on multiple specifications of the thesis that self-ascriptions are authoritatively indubitable. Some of these specifications concern how other agents (...) ought to treat one's self-ascriptions, while a final specification concerns how one is entitled to respond to others’ doubts about one's self-ascriptions. The result is a pluralistic view of self-ascriptive indubitability: different types of mental state self-ascriptions are indubitable in different ways, and for different people. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead to experiences (...) of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

This chapter considers some epistemic aspects of interactions with those who are believed to be delusional. The chapter makes five main claims: first, for the day-to-day purposes of most individuals, it is helpful to understand delusions as extreme epistemic failures, failures that all are guilty of to some degree. Second, one should be cautious when attributing delusions to others because to call someone delusional can act to discredit them, and this can be especially dangerous when applied to members of oppressed (...) groups. Third, delusional individuals can indeed be wronged by epistemic injustice. Fourth, epistemic responsibility for delusions needs to be extended beyond the individual holding delusional beliefs to the conditions that shape those beliefs. Finally, the virtue of epistemic humility offers several important epistemic benefits in interactions with delusional others. (shrink)

Health research tends to be deficit-based by nature; as researchers we typically quantify or qualify absence of health markers or presence of illness. This can create a narrative with far reaching effects for communities already subject to stigmatization. In the context of Indigenous health research, a deficit-based discourse has the potential to contribute to stereotyping and marginalization of Indigenous Peoples in wider society. This is especially true when researchers fail to explore the roots of health deficits, namely colonization, Westernization, and (...) intergenerational trauma, risking conflation of complex health challenges with inherent Indigenous characteristics. In this paper we explore the incompatibility of deficit-based research with principles from several ethical frameworks including the Tri-Council Policy Statement (TCPS2) Chapter 9, OCAP® (ownership, control, access, possession), Inuit Tapiriit Kanatami National Inuit Strategy on Research, and Canadian Coalition for Global Health Research (CCGHR) Principles for Global Health Research. Additionally we draw upon cases of deficit-based research and stereotyping in healthcare, in order to identify how this relates to epistemic injustice and explore alternative approaches. (shrink)

Children with innate variations of sex characteristics (also termed differences of sex development or intersex traits) are routinely subjected to medical interventions that aim to make their bodies appear or function more typically female or male. Many such interventions lack clear evidence of benefit, they have been challenged for thirty years, and they are now understood to violate children’s rights to bodily autonomy and bodily integrity. In this paper I argue that these persist in part due to epistemic injustices and (...) biomedical authority. Epistemic injustices include limited disclosure of current practices, the systemic marginalisation of community voices and psychosocial professionals, and attempts to discredit or misrepresent testimony. Bioethics has largely failed to change medical practice, and sometimes plays a role in perpetuating epistemic injustices. I find that the development of an intersex movement provides opportunities for epistemic justice and liberation by engaging with other disciplines and promoting oversight of medical decision-making. The paper draws particularly on Australian sources, including internationally influential ethical principles. (shrink)

Las herramientas teóricas destinadas a señalar las injusticias que sufren ciertos grupos socialmente oprimidos pueden acabar siendo utilizadas con propósitos completamente opuestos a los iniciales. Modificar el alcance de una herramienta teórica no es necesariamente problemático: la popularización de un concepto abre las puertas a que se utilice estratégicamente para diferentes fines. La tesis que defendemos en este artículo es que algunos personajes públicos cultivan una imagen particular de sí mismos que parece satisfacer los requisitos de la noción de injusticia (...) testimonial y utilizan esta situación como medio para obtener beneficio político de ella. Más concretamente, estos personajes públicos se benefician de esta condición para generar situaciones de desacuerdos cruzados, que están estrechamente relacionados con el aumento de la polarización. (shrink)

Background Symptom checker apps (SCAs) are mobile or online applications for lay people that usually have two main functions: symptom analysis and recommendations. SCAs ask users questions about their symptoms via a chatbot, give a list with possible causes, and provide a recommendation, such as seeing a physician. However, it is unclear whether the actual performance of a SCA corresponds to the users’ experiences. This qualitative study investigates the subjective perspectives of SCA users to close the empirical gap identified in (...) the literature and answers the following main research question: How do individuals (healthy users and patients) experience the usage of SCA, including their attitudes, expectations, motivations, and concerns regarding their SCA use? Methods A qualitative interview study was chosen to clarify the relatively unknown experience of SCA use. Semi-structured qualitative interviews with SCA users were carried out by two researchers in tandem via video call. Qualitative content analysis was selected as methodology for the data analysis. Results Fifteen interviews with SCA users were conducted and seven main categories identified: (1) Attitudes towards findings and recommendations, (2) Communication, (3) Contact with physicians, (4) Expectations (prior to use), (5) Motivations, (6) Risks, and (7) SCA-use for others. Conclusions The aspects identified in the analysis emphasise the specific perspective of SCA users and, at the same time, the immense scope of different experiences. Moreover, the study reveals ethical issues, such as relational aspects, that are often overlooked in debates on mHealth. Both empirical and ethical research is more needed, as the awareness of the subjective experience of those affected is an essential component in the responsible development and implementation of health apps such as SCA. Trial registration German Clinical Trials Register (DRKS): DRKS00022465. 07/08/2020. (shrink)

This article examines the relationship between epistemic freedom, and epistemic injustice and epistemic oppression. I situate epistemic freedom within the larger project of epistemic decolonisation and argue that epistemic freedom is central to both its positive and negative programme. Through exploring the intersections of the notion of epistemic freedom and the scholarship on epistemic injustice and oppression, I argue that one can think of epistemic injustices and oppression as infringements on epistemic freedom. I identify shared themes between the theorisation of (...) epistemic freedom and the literature on epistemic injustice and epistemic oppression, including silencing, active ignorance, and epistemic exploitation. I briefly explore each of these themes, identifying both intersections and divergences. Lastly, I draw on the literature on epistemic injustice and oppression to sharpen Ndlovu-Gatsheni’s (2018. Epistemic Freedom in Africa: Deprovincialization and Decolonization. London: Routledge) general conception of epistemic freedom and develop a tripartite structure for what substantial epistemic freedom entails. I argue that being epistemically free entails being able to choose one’s epistemic endeavours, having the means to pursue them, as well as being able to meaningfully partake in the shared endeavours of the epistemic communities that one belongs to. (shrink)

My aim in this paper is to identify the wrong that is done in all cases of testimonial injustice, if there is one. Miranda Fricker (2007) proposes one account of this distinctive wrong, and Gaile Pohlhaus Jr. (2014) offers another. I think neither works. Nor does an account based on giving due respect to the testifier's epistemic competence. Nor does an account based on exposing the testifier to substantial risk of harm. Rachel Fraser (2023) describes a further account, and the (...) proposal I favour is a slight amendment of this. (shrink)

Breast Cancer (BC) is a debilitating disease with the global mortality rate of 13.0 per 100,000 of population (Globocan, 2018). BC affects the physical, mental, and emotional well-being and quality...

Literature on testimonial injustice and ways that perpetrators might combat it have flourished since Miranda Fricker’s ground-breaking work on testimonial injustice. Less attention has been given, however, to the role of bystanders. In this paper, I examine the accountability that bystanders may have for their omissions to redress testimonial injustice. I argue that bystander accountability applies in cases where it is opportune for bystanders to intervene, and if they are also sufficiently equipped and able to redress the testimonial injustice. Moreover, (...) I recommend that we move beyond virtue responsibilism for ameliorative thinking about testimonial injustice. (shrink)

Disabled people face obstacles to participation in epistemic communities that would be beneficial for making sense of our experiences and are susceptible to epistemic oppression. Knowledge and skills grounded in disabled people's experiences are treated as unintelligible within an ableist hermeneutic, specifically, the dominant conception of disability as lack. My discussion will focus on a few types of epistemic oppression—willful hermeneutical ignorance, epistemic exploitation, and epistemic imperialism—as they manifest in some bioethicists’ claims about and interactions with disabled people. One of (...) the problems with the epistemic phenomena with which I am concerned is that they direct our skepticism regarding claims and justifications in the wrong direction. When we ought to be asking dominantly situated epistemic agents to justify their knowledge claims, our attention is instead directed toward skepticism regarding the accounts of marginally situated agents who are actually in a better position to know. I conclude by discussing disabled knowers’ responses to epistemic oppression, including articulating the epistemic harm they have undergone as well as ways of creating resistant ways of knowing. (shrink)

A significant proportion of the U.S. population exhibits low health literacy. Evidence suggests that low health literacy is correlated with higher medical costs and poorer health outcomes. Even more concerning, evidence suggests that low health literacy threatens patients’ and families’ autonomy and exacerbates injustices in patients who are already vulnerable to difficulties navigating the health care system. There is also, however, increasing evidence that health literacy interventions—including initiatives such as plain language practices and teach-back—improve comprehension and usefulness of health care (...) information. I show how health literacy best practices can enhance the work of clinical ethicists in their primary roles of policy, consultation, and education. In the final section, I suggest ways health literacy initiatives may be enhanced with insights from clinical ethicists. (shrink)

Domestic violence and abuse (DVA) are at last coming to be recognised as serious global public health problems. Nevertheless, many women with personal histories of DVA decline to disclose them to healthcare practitioners. In the health sciences, recent empirical work has identified many factors that impede DVA disclosure, known as barriers to disclosure. Drawing on recent work in social epistemology on testimonial silencing, we might wonder why so many people withhold their testimony and whether there is some kind of epistemic (...) injustice afoot here. In this paper, I offer some philosophical reflections on DVA disclosure in clinical contexts and the associated barriers to disclosure. I argue that women with personal histories of DVA are vulnerable to a certain form of testimonial injustice in clinical contexts, namely, testimonial smothering, and that this may help to explain why they withhold that testimony. It is my contention that this can help explain the low rates of DVA disclosure by patients to healthcare practitioners. (shrink)

The clinical encounter begins with presentation of an illness experience; but throughout that encounter, something else is constructed from it – a symptom. The symptom is a particular interpretation of that experience, useful for certain purposes in particular contexts. The hermeneutics of medicine – the study of the interpretation of human experience in medical terms – has largely taken the process of symptom-construction to be transparent, focussing instead on how constellations of symptoms are interpreted as representative of particular conditions. This (...) paper examines the hermeneutical activity of symptom-construction more closely. I propose a fourfold account of the clinical function of symptoms: as theoretical entities; as tools for communication; as guides to palliative intervention; and as candidates for medical explanation or intervention. I also highlight roles they might play in illness experience. I use this framework to discuss four potential failures of symptom-interpretation: failure of symptom-type and symptom-token recognition; loss of the complete picture of illness experience through overwhelming emphasis on its symptomatic interpretation; and intersubjective feedback effects of symptom description altering the ill person’s own perceptions of their phenomenal experience. I conclude with some suggestions of potential remedies for failures in the process of symptom-construction. (shrink)

Many critics of medicalization express concern that the process privileges individualised, biologically grounded interpretations of medicalized phenomena, inhibiting understanding and communication of aspects of those phenomena that are less relevant to their biomedical modelling. I suggest that this line of critique views medicalization as a hermeneutical injustice—a form of epistemic injustice that prevents people having the hermeneutical resources available to interpret and communicate significant areas of their experience. Interpreting the critiques in this fashion shows they frequently fail because they: neglect (...) the ways in which medicalization may not obscure, but rather illuminate, individuals’ experiences; and neglect the testimony of those experiencing first-hand medicalized problems, thus may be guilty of perpetrating testimonial injustice. However, I suggest that such arguments are valuable insofar as they highlight the unwarranted epistemic privilege frequently afforded to medical institutions and medicalized models of phenomena, and a consequent need for greater epistemic humility on the part of health workers and researchers. (shrink)

The COVID-19 pandemic crisis has had profound effects on global health, healthcare, and public health policy. It has also impacted education. Within undergraduate healthcare education of doctors, nurses, and allied professions, rapid shifts to distance learning and pedagogic content creation within new realities, demands of healthcare practice settings, shortened curricula, and/or earlier graduation have also challenged ethics teaching in terms of curriculum allotments or content specification. We propose expanding the notion of resilience to the field of ethics education under the (...) conditions of remote learning. Educational resilience starts in the virtual classroom of ethics teaching, initially constituted as an “unpurposed space” of exchange about the pandemic’s challenging impact on students and educators. This continuously transforms into “purposed space” of reflection, discovering ethics as a repertory of orientative knowledge for addressing the pandemic’s challenges on personal, professional, societal, and global levels and for discovering (and then addressing) that the health of individuals and populations also has moral determinants. As such, an educational resilience framework with inherent adaptability rises to the challenge of supporting the moral agency of students acting both as professionals and as global citizens. Educational resilience is key in supporting and sustaining professional identify formation and facilitating the development of students’ moral resilience and leadership amid moral complexity and potential moral transgression—not only but especially in times of pandemic. (shrink)

People experiencing mental distress and illness are frequently on the receiving end of stigma, epistemic injustice, and social isolation. A range of strategies are required to alleviate the subsequent marginalisation. We ran a series ‘philosophy of mind’ workshops, in partnership with a third-sector mental health organisation with the aim of using philosophical techniques to challenge mental health stigma and build resources for self-understanding and advocacy. Participants were those with lived experience of mental distress, or unusual beliefs and experiences; mental health (...) advocates; and mental health service providers. We draw on a shared perspective as a participant and facilitator of the workshop series to assess their impact. We discuss the following benefits: the opportunity for structured discussion of experiences and models; dialogue across different mental health backgrounds; the potential to reduce self-stigma and to increase self-understanding and advocacy; and the potential to alleviate epistemic injustice. We invite researchers and mental health practitioners to consider further opportunities to investigate the potential benefits of philosophy groups in mental health settings to establish whether they generalise. (shrink)

Recent studies have explored the effectiveness of open-label placebos for a variety of conditions, including chronic pain, cancer-related fatigue and irritable bowel syndrome. OLPs are thought to sidestep traditional ethical worries about placebos because they do not involve deception: with an OLP, patients or subjects are told outright that they are not given an active substance. As deception is framed as the primary hurdle to ethical placebo use, the door is ostensibly opened to ethical studies of OLPs. In this article, (...) I suggest that even though OLPs seemingly do not involve deception, there are other ethical considerations in their clinical investigation and subsequent use. Research ethics often focusses on informed consent—of which, deception and honesty are a piece—as a means to justify research practices with human subjects. Yet, it is but one of the ethical considerations that should be taken into account. With research into placebo effects in particular, I argue that the history of clinical placebo use grounds special considerations for OLP research that go beyond respect for the autonomy of individual patients through informed consent and encompass structural concerns about the type of patient for whom a placebo has historically been thought appropriate. (shrink)

In this paper, I argue that Jonathan Glover, a prominent advocate of human genetic engineering, relies on a limited naturalistic account of normal human function in his defense of genetic engineering as a means of decreasing future instances of disability. I show that his concept of disability and the normative argument informed by it in his Choosing Children: Genes, Disability, and Design fails to incorporate the phenomenological dimension of embodiment, and that this dimension should be included in any account of (...) disability and human flourishing. Such inclusion, however, requires us to consider seriously the counterintuitive view that racial minorities are constitutionally disabled in racist societies. (shrink)

Digital phenotyping will potentially enable earlier detection and prediction of mental illness by monitoring human interaction with and through digital devices. Notwithstanding its promises, it is certain that a person’s digital phenotype will at times be at odds with their first-person testimony of their psychological states. In this paper, we argue that there are features of digital phenotyping in the context of psychiatry which have the potential to exacerbate the tendency to dismiss patients’ testimony and treatment preferences, which can be (...) instances of epistemic injustice. We first explain what epistemic injustice is, and why it is argued to be an extensive problem in health and disability settings. We then explain why epistemic injustice is more likely to apply with even greater force in psychiatric contexts, and especially where digital phenotyping may be involved. Finally, we offer some tentative suggestions of how epistemic injustice can be minimised in digital psychiatry. (shrink)

This paper addresses epistemic aspects of the phenomenon of obstetric violence—which has been described as a kind of gender violence—mainly from the perspective of recent theories on epistemic injustice. I argue that what is behind the dismissal of women’s voices in labor is mainly how the birthing subject, in general, is conceived. Thus, I develop a link between the phenomenon of testimonial injustice in labor and the marked irrationality that is seen as a core characteristic of birthing subjects: an irrationality (...) that appears to be always at odds with the kind of knowledge that is, wrongly, privileged within medicalized childbirth. I use Miranda Fricker’s analysis to argue that a central part of obstetric violence involves laboring women being “wrongfully undermined specifically in their capacity as knowers” : they are disbelieved in the labor room because of a double prejudice, one deriving simply from their condition as women, the second involving the kind of knowledge that many women find useful in the process of birthing. Women in labor thus suffer from both systematic and incidental kinds of testimonial injustice. (shrink)

The concepts of disease, illness and sickness capture fundamentally different aspects of phenomena related to human ailments and healthcare. The philosophy and theory of medicine are making manifold efforts to capture the essence and normative implications of these concepts. In parallel, socio-empirical studies on patients’ understanding of their situation have yielded a comprehensive body of knowledge regarding subjective perspectives on health-related statuses. Although both scientific fields provide varied valuable insights, they have not been strongly linked to each other. Therefore, the (...) article aims to scrutinise the normative-ethical implications of patient perspectives in building a bridge to the empirical ethics debates. Three potential fields of tension between the illness and the disease perspective are presented. Consequently, findings from empirical research examining patient perspectives on illness are displayed and the practical implications and associated ethical issues which arise are discussed. This leads to the conclusion that an explicit and elaborate empirical-ethical methodology is needed to deal appropriately with the complex interaction between patients’ views and the medico-professional view of disease. Kon’s four-stage model of normative-empirical collaboration is then applied against the background of empirical data on patient perceptions. Starting from this exemplary approach, the article suggests employing empirical-ethical frameworks for further research on the conceptual and normative issues, as they help to integrate perspectives from the philosophy of medicine with socio-empirical research. The combination of theoretical and empirical perspectives suggested contributes to a more nuanced discussion of the normative impact of patients’ actual understanding of illness. Further empirical research in this area would profit from explicitly considering potential ethical issues to avoid naturalistic fallacies or crypto-normative conclusions that may compromise healthcare practice. Vice versa, medico-theoretical debates could be enriched by integrating subjective views of those people who are immediately affected. (shrink)

Susan has been profoundly deaf since childhood. She is a hearing aid wearer, and likes to use the induction loops built into some public spaces, such as theaters and cinemas, to help cut down the background noise that can make hearing speech very difficult. But this depends on the building having an induction loop fitted and properly maintained. Like many other induction loop users, Susan frequently finds that the advertised loop system is either working poorly or not working at all. (...) Almost as often, she then has the experience of making a complaint about it only to have the problem denied. If she persists, she is often then met... (shrink)

Abstract“Patient-centred care” is the recent response to the malaise produced in the field of health care from the point of view both of a technical mentality and the paternalistic model. The interest in the story-telling approach shown by both the humanities and the social sciences has favoured a “narrative turn” in medicine too, where the new ethics of therapeutic relationship consider the hermeneutic method a means by which to integrate evidence and subjectivity, scientific data and patient experience. The aim of (...) this paper is to show how Ricoeur’s theory of “threefold mimesis” makes a conceptual contribution to the use of narrative interviews in nursing and also be successfully transferred into and applied in the field of healthcare in general. First, the paper examines how this narrative approach might open up new possibilities for the acquisition of in-depth knowledge of patients’ life experiences, a condition indispensable for the improvement of the quality of care. Secondly, it highlights how this Ricoeurian method seems capable of provide an opportunity for healthcare professionals to review their own understanding of the caregiver-patient therapeutic relationship, beginning with their confrontation with the patient’s world as revealed by the narrative they provide. (shrink)

It is common to criticize certain comments as ‘unhelpful’. This criticism is richer than it might first appear. In this paper, I sketch an account of conversational helpfulness and unhelpfulness, the reasons why they matter, and the utility of calling out comments as helpful or unhelpful. First, some unhelpful comments are or easily could be demoralizing for proponents of projects, and criticizing them as such can diminish, deflect, or defend against that demoralization. Second, some unhelpful comments redirect or derail conversations (...) away from their projects and criticizing comments as unhelpful can steer conversations back. Third, some unhelpful comments are made out of a lack of epistemic effort and criticizing them as such can help maintain epistemic standards, standards of respect for other people and their projects, and can ensure that such comments do not receive more attention and consideration than they deserve. (shrink)

We investigate how epistemic injustice can manifest itself in mathematical practices. We do this as both a social epistemological and virtue-theoretic investigation of mathematical practices. We delineate the concept both positively—we show that a certain type of folk theorem can be a source of epistemic injustice in mathematics—and negatively by exploring cases where the obstacles to participation in a mathematical practice do not amount to epistemic injustice. Having explored what epistemic injustice in mathematics can amount to, we use the concept (...) to highlight a potential danger of intellectual enculturation. (shrink)

While there is a steadily growing literature on epistemic injustice in healthcare, there are few discussions of the role that biomedical technologies play in harming patients in their capacity as knowers. Through an analysis of newborn and pediatric genetic and genomic sequencing technologies (GSTs), I argue that biomedical technologies can lead to epistemic injustice through two primary pathways: epistemic capture and value partitioning. I close by discussing the larger ethical and political context of critical analyses of GSTs and their broader (...) implications for just and equitable healthcare delivery. (shrink)

Machine learning (ML) systems play an increasingly relevant role in medicine and healthcare. As their applications move ever closer to patient care and cure in clinical settings, ethical concerns about the responsibility of their use come to the fore. I analyse an aspect of responsible ML use that bears not only an ethical but also a significant epistemic dimension. I focus on ML systems’ role in mediating patient–physician relations. I thereby consider how ML systems may silence patients’ voices and relativise (...) the credibility of their opinions, which undermines their overall credibility status without valid moral and epistemic justification. More specifically, I argue that withholding credibilitydue tohow ML systems operate can be particularly harmful to patients and, apart from adverse outcomes, qualifies as a form of testimonial injustice. I make my case for testimonial injustice in medical ML by considering ML systems currently used in the USA to predict patients’ risk of misusing opioids (automated Prediction Drug Monitoring Programmes, PDMPs for short). I argue that the locus of testimonial injustice in ML-mediated medical encounters is found in the fact that these systems are treated asmarkers of trustworthinesson which patients’ credibility is assessed. I further show how ML-based PDMPs exacerbate and further propagate social inequalities at the expense of vulnerable social groups. (shrink)

Artificial intelligence-based (AI) technologies such as machine learning (ML) systems are playing an increasingly relevant role in medicine and healthcare, bringing about novel ethical and epistemological issues that need to be timely addressed. Even though ethical questions connected to epistemic concerns have been at the center of the debate, it is going unnoticed how epistemic forms of injustice can be ML-induced, specifically in healthcare. I analyze the shortcomings of an ML system currently deployed in the USA to predict patients’ likelihood (...) of opioid addiction and misuse (PDMP algorithmic platforms). Drawing on this analysis, I aim to show that the wrong inflicted on epistemic agents involved in and affected by these systems’ decision-making processes can be captured through the lenses of Miranda Fricker’s account of hermeneutical injustice. I further argue that ML-induced hermeneutical injustice is particularly harmful due to what I define as an automated hermeneutical appropriation from the side of the ML system. The latter occurs if the ML system establishes meanings and shared hermeneutical resources without allowing for human oversight, impairing understanding and communication practices among stakeholders involved in medical decision-making. Furthermore and very much crucially, an automated hermeneutical appropriation can be recognized if physicians are strongly limited in their possibilities to safeguard patients from ML-induced hermeneutical injustice. Overall, my paper should expand the analysis of ethical issues raised by ML systems that are to be considered epistemic in nature, thus contributing to bridging the gap between these two dimensions in the ongoing debate. (shrink)

In this article, I apply the concept of solidarity to collective knowledge practices in healthcare. Generally, solidarity acknowledges that people are dependent on each other in many respects, and it captures those support practices that people engage in out of concern for others in whom they recognise a relevant similarity. Drawing on the rich literature on solidarity in bioethics and beyond, this article specifically discusses the role that epistemic solidarity can play in healthcare. It thus focuses, in particular, on solidarity’s (...) relationship with justice and injustice. In this regard, it is argued (1) that justice and solidarity are two equally important and complementary values that should both be considered in healthcare practices and institutions and (2) that solidarity often arises in unjust situations and can be a means to bring about justice. I transfer these ‘general’ insights about solidarity to knowledge practices in healthcare and link them to the discussion about epistemic injustices in healthcare and how to overcome them. I argue that epistemic solidarity can play an important role in overcoming epistemic injustices as well as—and independently from its contribution to justice—in knowledge production in medicine more generally. To demonstrate how epistemic solidarity can add to our understanding of collective knowledge practices, I discuss two examples: patients sharing their medical data for research purposes and healthcare professionals’ engagement with patients to better understand their afflictions. (shrink)

Contemporary realities of global population movement increasingly bring to the fore the challenge of quality and equitable health provision across language barriers. While this linguistic challenge is not unique to immigration contexts and is likewise shared by health systems responding to the needs of aboriginal peoples and other historical linguistic minorities, the expanding multilingual landscape of receiving societies renders this challenge even more critical, owing to limited or even non‐existing familiarity of modern and often monolingual health systems with the particular (...) needs of new linguistic minorities. The centrality of language to health beliefs, attitudes, practices, cultural scripts, and conceptual frameworks emphasizes its pivotal role in the healthcare process, and consequently in the adverse effects of treatment that is language‐insensitive and unaware. Such an attitude on the part of medical authorities risks considerable epistemic injustice in the form of a (mis)judgement of patients’ intelligence, credibility, and rationality based on the language that they speak and the manner in which they speak it, consequently impacting the quality and equity of care provided. This danger, I argue, may be effectively countered by fostering among the participants in the healthcare process a sense of epistemic humility through greater metalinguistic awareness. Outlining a range of operative steps that can be used to facilitate this. I argue that the reality of language barriers in the healthcare process, while not entirely eliminable, may nevertheless be successfully addressed, in order to mitigate the challenge of quality and equitable healthcare provision in multilingual societies. (shrink)

Background: Patients undergoing invasive neurosurgical procedures offer researchers unique opportunities to study the brain. Deep brain stimulation patients, for example, may participate in research during the surgical implantation of the stimulator device. Although this research raises many ethical concerns, little attention has been paid to basic studies, which offer no therapeutic benefits, and the value of patient-participant perspectives.Methods: Semi-structured interviews were conducted with fourteen individuals across two studies who participated in basic intraoperative research during their deep brain stimulator surgery. Interviews (...) explored interpretations of risks and benefits, enrollment motivations, and experiences of participating in awake brain research. Reflexive thematic analysis was conducted.Results: Seven themes were identified from participant narratives, including robust attitudes of trust, high valuations of basic science research, impacts of the surgical context, and mixed experiences of participation.Conclusion: We argue that these narratives raise the potential for a translational misconception and motivate intraoperative re-consent procedures. (shrink)

Drawing on an analysis of complaint files that we conducted for the Irish Medical Council, this paper offers three possible explanations for the gap between the ubiquity of official commitments to taking patients’ complaints seriously and medical professional regulators’ dismissal—as not warranting an inquiry—of the vast majority of complaints submitted by members of the public. One explanation points to the “regulatory illiteracy” of many complainants, where the remit and threshold of seriousness of regulators is poorly understood by the general public. (...) Another points to possible processes of “institutional epistemic injustice” that unjustly undermine the credibility of certain complainants, such as those with low levels of formal education. A third explanation highlights the marginalization of the general public from “symbolic power” to define what matters in medical professional regulation. The paper is offered in a spirit of ideas in progress and raising questions rather than definitive insights into the regulatory process. (shrink)

The 2007 publication of Miranda Fricker’s celebrated book Epistemic Injustice: Power and the Ethics of Knowing gave way to a burgeoning area of study in philosophy of education. The book’s arguments create a context for expanding the scope of work on epistemic issues in education by moving beyond direct explorations of the distribution of epistemic goods and the role of power in curriculum development. Since that time, the rich scholarship on epistemic injustice in philosophy of education examines a variety of (...) topics, including the impact of epistemic injustice on the experiences of teachers and learners more broadly (focussing mostly on students who are marginalized along lines of race, gender, class, and ability, amongst others) and the implications of epistemic injustice for educational research, policy, and practice. This special issue extends this line of work by compiling a set of articles that address a broad range of topics, some of which are well established in the literature and some of which open new lines of inquiry in the field. In doing so, the issue aims to establish the intersection of epistemic injustice and education as a distinct area of study that holds great significance and potential. In this paper, A. C. Nikolaidis and Winston C. Thompson introduce the issue by discussing these contributions, explaining why education is central to the study of epistemic injustice (and vice versa), and exploring the complex nature of epistemic injustice and education as revealed in the articles that comprise this collection—namely, education’s simultaneous complicity as a perpetrator and promise as a disruptor of epistemic injustice. (shrink)

Mental health legislation that requires patients to accept ‘care’ has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. (...) We also examine how the doctor is legally obligated to compound the epistemic problems by the knowledge they prioritise and the failure to generate new knowledge. Specifically, we describe the problems of testimonial epistemic injustice, epistemic silencing, and epistemic smothering, and address the possible justification provided by epistemic paternalism. We suggest that there is no reasonable epistemic justification for mental health legislation that creates an environment that fundamentally unbalances the doctor–patient relationship. Significant positive reasons to counterbalance this are needed to justify the continuation of such legislation. (shrink)

The rapid development in healthcare technologies in recent years has resulted in the need for health services, whether publicly funded or insurance based, to identify means to maximise the benefits and provide equitable distribution of limited resources. This has resulted in the need for rationing decisions, and there has been considerable debate regarding the substantive and procedural ethical principles that promote distributive justice when making such decisions. In this paper, I argue that while the scientifically rigorous approaches of evidence-based healthcare (...) are claimed as aspects of procedural justice that legitimise such guidance, there are biases and distortions in all aspects of the process that may lead to epistemic injustices. Regardless of adherence to principles of distributive justice in the decision-making process, evidential failings may undermine the fairness and legitimacy of such decisions. In particular, I identify epistemic exclusion that denies certain patient and professional groups the opportunity to contribute to the epistemic endeavour. This occurs at all stages of the process, from the generation, analysis and reporting of the underlying evidence, through the interpretation of such evidence, to the decision-making that determines access to healthcare resources. I further argue that this is compounded by processes which confer unwarranted epistemic privilege on experts in relation to explicit or implicit value judgements, which are not within their remit. I suggest a number of areas in which changes to the processes for developing, regulating, reporting and evaluating evidence may improve the legitimacy of such processes. (shrink)

The 2005 International Consensus Conference on Intersex resulted in a substantive revision of the lexicon and guidelines for treating intersex conditions. The speed with which the new treatment protocol has been adopted by healthcare practitioners and providers is considered unprecedented. However, a number of intersex people and advocacy groups have complained that the recommended revisions are inadequately informed by the testimony of intersex people. In this paper, I argue that such complaints are valid and that, despite the conference conveners stated (...) intention, the revisions perpetuate the epistemic injustice long endured by intersex people. By analyzing the Consensus Conference and its results as a failed attempt to redress the epistemic marginalization of intersex patients and advocacy groups, I am able to identify lingering institutional hurdles to cultivating the virtue of epistemic justice in biomedical practice. (shrink)

There's been a great deal of interest in epistemology regarding what it takes for a hearer to come to know on the basis of a speaker's say-so. That is, there's been much work on the epistemology of testimony. However, what about when hearers don't believe speakers when they should? In other words, what are we to make of when testimony goes wrong? A recent topic of interest in epistemology and feminist philosophy is how we sometimes fail to believe speakers due (...) to inappropriate prejudices – implicit or explicit. This is known as epistemic injustice. In this article, I discuss Miranda Fricker's groundbreaking work on epistemic injustice, as well as more recent developments that both offer critique and expansion on the nature and extent of epistemic injustice. (shrink)

Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine’s understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a potential (...) epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry. (shrink)