Mainstream epistemology is a highly theoretical and abstract enterprise. Traditional epistemologists rarely present their deliberations as critical to the practical problems of life, unless one supposes—as Hume, for example, did not—that skeptical worries should trouble us in our everyday affairs. But some issues in epistemology are both theoretically interesting and practically quite pressing. That holds of the problem to be discussed here: how laypersons should evaluate the testimony of experts and decide which of two or more rival experts is most (...) credible. It is of practical importance because in a complex, highly specialized world people are constantly confronted with situations in which, as comparative novices, they must turn to putative experts for intellectual guidance or assistance. It is of theoretical interest because the appropriate epistemic considerations are far from transparent; and it is not clear how far the problems lead to insurmountable skeptical quandaries. This paper does not argue for flat-out skepticism in this domain; nor, on the other hand, does it purport to resolve all pressures in the direction of skepticism. It is an exploratory paper, which tries to identify problems and examine some possible solutions, not to establish those solutions definitively. (shrink)

find myself believing all sorts 0f things for which I d0 not possess evidence: that smoking cigarettes causes lung cancer, that my car keeps stalling because the carburetor needs LO be rebuilt, that mass media threaten democracy, that slums cause emotional disorders, that my irregular heart beat is premature ventricular contraction, that students} grades are not correlated with success in the ncmacadcmic world, that nuclear power plants are not safe (enough) . . . The list 0f things I believe, though (...) I have no evidence for the truth of them, is, if not infinite, virtually endless. And.. (shrink)

In this paper we argue that ill persons are particularly vulnerable to epistemic injustice in the sense articulated by Fricker. Ill persons are vulnerable to testimonial injustice through the presumptive attribution of characteristics like cognitive unreliability and emotional instability that downgrade the credibility of their testimonies. Ill persons are also vulnerable to hermeneutical injustice because many aspects of the experience of illness are difficult to understand and communicate and this often owes to gaps in collective hermeneutical resources. We then argue (...) that epistemic injustice arises in part owing to the epistemic privilege enjoyed by the practitioners and institutions of contemporary healthcare services—the former owing to their training, expertise, and third-person psychology, and the latter owing to their implicit privileging of certain styles of articulating and evidencing testimonies in ways that marginalise ill persons. We suggest that a phenomenological toolkit may be part of an effort to ameliorate epistemic injustice. (shrink)

I shall first briefly revisit the broad idea of ‘epistemic injustice’, explaining how it can take either distributive or discriminatory form, in order to put the concepts of ‘testimonial injustice’ and ‘hermeneutical injustice’ in place. In previous work I have explored how the wrong of both kinds of epistemic injustice has both an ethical and an epistemic significance—someone is wronged in their capacity as a knower. But my present aim is to show that this wrong can also have a political (...) significance in relation to non-domination, and so to freedom. While it is only the republican conception of political freedom that presents nondomination as constitutive of freedom, I shall argue that non-domination is best understood as a thoroughly generic liberal ideal of freedom to which even negative libertarians are implicitly committed, for non-domination is negative liberty as of right—secured non-interference. Crucially on this conception, non-domination requires that the citizen can contest interferences. Pettit specifies three conditions of contestation, each of which protects against a salient risk of the would-be contester not getting a ‘proper hearing’. But I shall argue that missing from this list is anything to protect against a fourth salient threat: the threat that either kind of epistemic injustice might disable contestation by way of an unjust deflation of either credibility or intelligibility. Thus we see that both testimonial and hermeneutical injustice can render a would-be contester dominated. Epistemic justice is thereby revealed as a constitutive condition of non-domination, and thus of a central liberal political ideal of freedom. (shrink)

It is generally accepted that the therapeutic relationship between professionals and patients is one of trust. Nonetheless, some patient groups carry certain social vulnerabilities that can be exacerbated when they extend trust to health-care professionals. In exploring the epistemic and ethical implications of expert status, this paper examines how calls to trust may increase epistemic oppression and perpetuate the vulnerability of people with impairments. It critically evaluates the processes through which epistemic communities are formed or determined, and examines the institutional (...) structure and power relations that contribute to or sustain such self-affirming ideological communities. It also argues for a two-way collaborative approach between professionals and people with impairments that recognizes the role of local knowledge in enhancing professionals’ own understanding of their theoretical framework and promoting responsive practices and policies. (shrink)

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (...) (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

This essay explores the role of informal logicand its application in the context of currentdebates regarding evidence-based medicine. This aim is achieved through a discussion ofthe goals and objectives of evidence-basedmedicine and a review of the criticisms raisedagainst evidence-based medicine. Thecontributions to informal logic by StephenToulmin and Douglas Walton are explicated andtheir relevance for evidence-based medicine isdiscussed in relation to a common clinicalscenario: hypertension management. This essayconcludes with a discussion on the relationshipbetween clinical reasoning, rationality, andevidence. It is argued that (...) informal logic hasthe virtue of bringing explicitness to the roleof evidence in clinical reasoning, and bringssensitivity to understanding the role ofdialogical context in the need for evidence inclinical decision making. (shrink)

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are ‘drug seeking’, ‘abusing’ and ‘diverting’ prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, (...) with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient–physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient–physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient–physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients’ subjective knowledge in enhancing physicians’ self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain. (shrink)

Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions - not all - are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and (...) knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time. (shrink)

In this paper I argue that it is morally important for doctors to trust patients. Doctors' trust of patients lays the foundation for medical relationships which support the exercise of patient autonomy, and which lead to an enriched understanding of patients' interests. Despite the moral and practical desirability of trust, distrust may occur for reasons relating to the nature of medicine, and the social and cultural context within which medical care is provided. Whilst it may not be possible to trust (...) at will, the conscious adoption of a trusting stance is both possible and warranted as the burdens of misplaced trust fall more heavily upon patients than doctors. (shrink)

The notions of “expert” and “expertise” imply that some people have more credibility than others on certain matters. While expert authority is often taken for granted, there are questions as to whether expert power in some cases can be a form of epistemic oppression. Informed by bedside disagreements between family and clinicians as well as feminist discussions of epistemic oppression, this paper argues for a commitment to epistemic humility and the adoption of a two-way collaborative approach between clinicians and families (...) that can help to enhance professionals’ own understanding of their theoretical framework and also promote responsive patient care. (shrink)

The point of departure for this essay is the question of why pain is seriously undertreated in the United States. Some kinds of pain (for example, chronic nonmalignant pain) are treated worse than others (acute pain secondary to cancer), but there is excellent evidence that no matter what kind of pain, astonishingly large percentages of pain sufferers are undertreated (Furrow 2001; Hill 1995; Kirou-Mauro et al. 2009; Martino 1998; Morris 1991; NCHS 2006; Resnik, Rehm, and Minard 2001). Although some kinds (...) of pain are difficult to treat, we generally possess the technical armamentarium to significantly ameliorate the vast majority of pain experiences. Yet we do not. And, for as long as anyone in the United States .. (shrink)

It is frequently said that pain is incommunicable and even that it destroys language . This paper offers a phenomenological account of pain and then explores and critiques this view. It suggests not only that pain is communicable to an adequate degree for clinical purposes, but also that it is itself a form of communication through which the person in pain appeals to the empathy and ethical goodness of the clinician. To explain this latter idea and its ethical implications, reference (...) is made to the writings of Emmanuel Levinas. (shrink)

ABSTRACT Defining a nonpaternalistic yet achievable form of trust in medicine in an era of simultaneous patient empowerment and institutional control has been and remains an important task of bioethics. The ‘crisis of trust’ in medicine has been viewed mainly as the problem of getting patients to trust their health care providers, especially physicians. However, since paradigmatic cases of trust are mutual, bioethicists must pay more attention to physician trust in patients. A physician’s view of the reasonableness of trust in (...) a particular patient is affected not just by his or her relationship with that patient, but also by what is going on institutionally, professionally, legally, and politically with regard to a given treatment or intervention. Since general moral principles are insufficient in determining the moral value and reasonableness of trust in particular instances, I discuss in detail the role of trust and distrust in the specific case of treating patients with medications implicated in drug abuse. I conclude that it is important to become aware, first, of the clinical significance of physician trust and distrust in patients, and second, of the many factors which inform both of these moral attitudes. These two claims together suggest that a central, but overlooked, virtue of medical practice is reflective, context‐responsive trust in patients. (shrink)

For over 20 years the medical literature has carefully documented the undertreatment of all types of pain by physicians. During this same period, as the field of bioethics came of age, the phenomenon of undertreated pain received almost no attention from the bioethics literature. This article takes bioethicists to task for failing to recognize the undertreatment of pain as a major ethical, and not merely a clinical, failing of the medical profession. The nature and extent of the problem of undertreated (...) pain is examined, as well as possible reasons for its disregard by bioethicists. The factors contributing to undertreated pain in the clinical setting are considered, as well as the hazards posed by recent failures to address ethically questionable clinical practices. Finally, suggestions are offered for refocusing the attention of bioethicists to this significant problem. (shrink)