The effects of mental disorder are apparent and pervasive, in suffering, loss of freedom and life opportunities, negative impacts on education, work satisfaction and productivity, complications in law, institutions of healthcare, and more. With a new edition of the 'bible' of psychiatric diagnosis - the DSM - under developmental, it is timely to take a step back and re-evalutate exactly how we diagnose and define mental disorder. This new book by Derek Bolton tackles the problems involved in the definition and (...) boundaries of mental disorder. It addresses two main questions regarding mental illness. Firstly, what is the basis of the standards or norms by which we judge that a person has a mental disorder - that the person's mind is not working as it should, that their mental functioning is abnormal? Controversies about these questions have been dominated by the contrast between norms that are medical, scientific or natural, on the one hand, and social norms on the other. The norms that define mental disorder seem to belong to psychiatry, to be medical and scientific, but are they really social norms, hijacked and disguised by the medical profession? Secondly, what is the validity of the distinction between mental disorder and order, between abnormal and normal mental functioning? To what extent, notwithstanding appearances, does mental disorder involve meaningful reactions and problem-solving? These responses may be to normal problems of living, or to not so normal problems - to severe psycho-social challenges. Is there after all order in mental disorder? With the closing of asylums and the appearance of care in the community, mental disorder is now in our midst. While attempts have been made to define clearly a concept of mental disorder that is truly medical as opposed to social, there is increasing evidence that such a distinction is unviable - there is no clear line between what is normal in the population and what is abnormal. 'What is Mental Disorder?' reviews these various crucial developments and their profound impact for the concept and its boundaries in a provocative and timely book. (shrink)

Encouraged by the success of smoking denormalization strategies as a tobacco-control measure, public health institutions are adopting a similar approach to other health behaviors. For example, a recent controversial ad campaign in New York explicitly aimed to denormalize HIV/AIDS amongst gay men. Authors such as Scott Burris have argued that efforts like this are tantamount to stigmatization and that such stigmatization is unethical because it is dehumanizing. Others have offered a limited endorsement of denormalization/stigmatization campaigns as being justified on consequentialist (...) grounds; namely, that the potential public health benefits outweigh any stigmatizing side effects. In this paper, I examine and reject the blanket condemnation of stigmatization efforts in public health. I argue that the moral status of such efforts are best evaluated within a contractualist, as opposed to a consequentialist, framework. Contractualism in public health ethics asks whether a particular stigmatizing policy could be justified to reasonable individuals who do not know whether they will be affected by that policy. Using this approach, I argue that it is sometimes permissible for public health institutions to engage in health-related stigmatization. (shrink)

Implicit intergroup biases have been shown to impact social behavior in many unsettling ways, from disparities in decisions to “shoot” black and white men in a computer simulation to unequal gender-based evaluations of résumés and CVs. It is a difficult question whether, and in what way, agents are responsible for behaviors affected by implicit biases. I argue that in paradigmatic cases agents are responsible for these behaviors in the sense that the behavior is “attributable” to them. That is, behaviors affected (...) by implicit biases reflect upon who one is as a moral agent. (shrink)

Human rights may be the most globalized political value of our times. The rights paradigm has been criticized, however, for being theoretically unsound, legalistic, individualistic and based on the assumption that there is a given and universal humanness. Its use in the area of health is relatively new. Proponents point to its power to frame health as an entitlement rather than a commodity. The problems and the possibilities of a rights approach in addressing health ethics issues are explored in this (...) article. (shrink)

In Epistemic injustice, Miranda Fricker makes a tremendous contribution to theorizing the intersection of social epistemology with theories of justice. Theories of justice often take as their object of assessment either interpersonal transactions (specific exchanges between persons) or particular institutions. They may also take a more comprehensive perspective in assessing systems of institutions. This systemic perspective may enable control of the cumulative effects of millions of individual transactions that cannot be controlled at the individual or institutional levels. This is true (...) not only with respect to the overall distribution of such goods as income and wealth, but also with respect to the goods of testimonial and hermeneutical justice. Cognitive biases that may be difficult for even epistemically virtuous individuals to correct on their own may be more susceptible to correction if we focus on the principles that should govern our systems of testimonial gathering and assessment. Hence, while Fricker’s focus on individual epistemic virtue is important, we also need to consider what epistemic justice as a virtue of social systems would require. My paper will indicate some directions forward on this front, focusing on the need for integration of diverse institutions and persons engaged in inquiry. (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)

This article provides a conceptual map of the debate on ideal and non‐ideal theory. It argues that this debate encompasses a number of different questions, which have not been kept sufficiently separate in the literature. In particular, the article distinguishes between the following three interpretations of the ‘ideal vs. non‐ideal theory’ contrast: (i) full compliance vs. partial compliance theory; (ii) utopian vs. realistic theory; (iii) end‐state vs. transitional theory. The article advances critical reflections on each of these sub‐debates, and highlights (...) areas for future research in the field. (shrink)

The companion piece to this article, “Situating Moral Justification,” challenges the idea that moral epistemology's mission is to establish a single, all-purpose reasoning strategy for moral justification because no reasoning practice can be expected to deliver authoritative moral conclusions in all social contexts. The present article argues that rethinking the mission of moral epistemology requires rethinking its method as well. Philosophers cannot learn which reasoning practices are suitable to use in particular contexts exclusively by exploring logical relations among concepts. Instead, (...) in order to understand which reasoning practices are capable of justifying moral claims in different types of contexts, we need to study empirically the relationships between reasoning practices and the contexts in which they are used. The article proposes that philosophers investigate case studies of real-world moral disputes in which people lack shared cultural assumptions and/or are unequal in social power. It motivates and explains the proposed case study method and illustrates the philosophical value of this method through a case study. (shrink)

abstract Emerging from the political activism of disabled people's movements and mainly theorised by the scholar Michael Oliver, the social model of disability is central to current debates in Disability Studies as well as to related perspectives on inclusive education. This article presents a philosophical critique of the social model of disability and outlines some of its theoretical problems. It argues that in conceptualising disability as unilaterally socially caused, the social model presents a partial and, to a certain extent, flawed (...) understanding of the relation between impairment, disability and society, thus setting a framework that needs clarifications and extensions and presents limits to the achievement of its own aim of inclusion. This article concludes by suggesting that, despite its theoretical limits, the social model acts as a powerful and important reminder to face issues of inclusion as fundamental, moral issues. (shrink)

IntroductionThose in mental health-related consumer movements have made clear their demands for humane treatment and basic civil rights, an end to stigma and discrimination, and a chance to participate in their own recovery. But theorizing about the politics of recognition, 'recognition rights' and epistemic justice, suggests that they also have a stake in the broad cultural meanings associated with conceptions of mental health and illness.ResultsFirst person accounts of psychiatric diagnosis and mental health care (shown here to represent 'counter stories' to (...) the powerful 'master narrative' of biomedical psychiatry), offer indications about how experiences of mental disorder might be reframed and redefined as part of efforts to acknowledge and honor recognition rights and epistemic justice. However, the task of cultural semantics is one for the entire culture, not merely consumers. These new meanings must be negotiated. When they are not the result of negotiation, group-wrought definitions risk imposing a revision no less constraining than the mis-recognizing one it aims to replace. Contested realities make this a challenging task when it comes to cultural meanings about mental disorder. Examples from mental illness memoirs about two contested realities related to psychosis are examined here: the meaninglessness of symptoms, and the role of insight into illness. They show the magnitude of the challenge involved - for consumers, practitioners, and the general public - in the reconstruction of these new meanings and realities.ConclusionTo honor recognition rights and epistemic justice acknowledgement must be made of the heterogeneity of the effects of, and of responses to, psychiatric diagnosis and care, and the extent of the challenge of the reconstructive cultural semantics involved. (shrink)

The process of medicalization has been analyzed in the medical humanities with disapprobation, with much emphasis placed on its ability to reinforce existing social power structures to ill effect. While true, this is an incomplete picture of medicalization. I argue that medicalization can both reinforce and disrupt existing social hierarchies within the clinic and outside of it, to ill or good effect. We must attend to how this takes place locally and globally lest we misunderstand how medicalization mediates power and (...) justice. I provide concrete examples of how this occurs by considering dysesthesia ethiopsis, autism, chronic fatigue syndrome, depression, and HIV/AIDS. (shrink)

New and proposed medical technologies continually challenge our vision of what constitutes appropriate medical treatment. As scholars and consumers grapple with the meaning of innovation, one common critical theme to surface is that it constitutes undesirable medicalization. But we are embodied creatures who can often benefit from medical knowledge; in addition, rejection of medicalization may be in some cases based on an untenable appeal to nature. Harnessing the power of medicine for women’s welfare requires us to rethink the goals of (...) medicine as well as implement fundamental reforms. (shrink)

Although Burke, Bentham, Hegel and Marx do not often agree, all criticized certain ethical theories, in particular theories of rights, for being too abstract. The complaint is still popular. It was common in Existentialist and in Wittgensteinian writing that stressed the importance of cases and examples rather than principles for the moral life; it has been prominent in recent Hegelian and Aristotelian flavoured writing, which stresses the importance of the virtues; it is reiterated in discussions that stress the distinctiveness and (...) particularity of moral vicissitudes and query the importance of ethical theory. Recent critics of abstraction are opposed not only to theories of rights, and the Kantian notions with which these are linked, but also to consequentialist ethical theories. The two ethical theories that are most influential in the English-speaking world now both stand accused of being too abstract. (shrink)

The social model of disability gives us the tools not only to challenge the discrimination and prejudice we face, but also to articulate the personal experience of impairment. Recognition of difference is therefore a key part of the assertion of our common humanity and of an ethics of care that promotes our human rights.

This article analyses the phenomenon of epistemic injustice within contemporary healthcare. We begin by detailing the persistent complaints patients make about their testimonial frustration and hermeneutical marginalization, and the negative impact this has on their care. We offer an epistemic analysis of this problem using Miranda Fricker's account of epistemic injustice. We detail two types of epistemic injustice, testimonial and hermeneutical, and identify the negative stereotypes and structural features of modern healthcare practices that generate them. We claim that these stereotypes (...) and structural features render ill persons especially vulnerable to these two types of epistemic injustice. We end by proposing five avenues for further work on epistemic injustice in healthcare. (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)

This is the first of two companion articles drawn from a larger project, provisionally entitled Undisciplining Moral Epistemology. The overall goal is to understand how moral claims may be rationally justified in a world characterized by cultural diversity and social inequality. To show why a new approach to moral justification is needed, it is argued that several currently influential philosophical accounts of moral justification lend themselves to rationalizing the moral claims of those with more social power. The present article explains (...) how discourse ethics is flawed just in this way. The article begins by identifying several conditions of adequacy for assessing reasoning practices designed to achieve moral justification and shows that, when used in contexts of cultural diversity and social inequality, discourse ethics fails these conditions. It goes on to argue that the failure of discourse ethics is rooted in its reliance on a broader conception of moral epistemology that is invidiously idealized. It concludes by pointing to the need to rethink both the mission and the method of moral epistemology. (shrink)

Philosophers who have written about implicit bias have claimed or implied that individuals are not responsible, and therefore not blameworthy, for their implicit biases, and that this is a function of the nature of implicit bias as implicit: below the radar of conscious reflection, out of the control of the deliberating agent, and not rationally revisable in the way many of our reflective beliefs are. I argue that close attention to the findings of empirical psychology, and to the conditions for (...) blameworthiness, does not support these claims. I suggest that the arguments for the claim that individuals are not liable for blame are invalid, and that there is some reason to suppose that individuals are, at least sometimes, liable to blame for the extent to which they are influenced in behaviour and judgment by implicit biases. I also argue against the claim that it is counter-productive to see bias as something for which individuals are blameworthy; rather, understanding implicit bias as something for which we are liable to blame could be constructive. (shrink)

Research programs in empirical psychology from the past two decades have revealed implicit biases. Although implicit processes are pervasive, unavoidable, and often useful aspects of our cognitions, they may also lead us into error. The most problematic forms of implicit cognition are those which target social groups, encoding stereotypes or reflecting prejudicial evaluative hierarchies. Despite intentions to the contrary, implicit biases can influence our behaviours and judgements, contributing to patterns of discriminatory behaviour. These patterns of discrimination are obviously wrong and (...) unjust. But in remedying such wrongs, one question to be addressed concerns responsibility for implicit bias. Unlike some paradigmatic forms of wrongdoing, such discrimination is often unintentional, unendorsed, and perpetrated without awareness; and the harms are particularly damaging because they are cumulative and collectively perpetrated. So, what are we to make of questions of responsibility? In this article, we outline some of the main lines of recent philosophical thought, which address questions of responsibility for implicit bias. We focus on (a) the kind of responsibility at issue; (b) revisionist versus nonrevisionist conceptions of responsibility as applied to implicit bias; and (c) individual, institutional, and collective responsibility for implicit bias. (shrink)

In this paper I explore the way that mental illness stigma impacts epistemic credibility in people who have mental illness. While any kind of stigma has the potential to discredit a person’s epistemic agency, in the case of mental illness the basis for discrediting is in some cases and to some extent justifiable, for impairments in rationality, control, and reality perception can indeed be obstacles to participating appropriately in epistemic activities such as normal conversation and public discourse. People with mental (...) illness are still potentially subject to epistemic injustices, however, especially when we rely on stereotypes and fail to make complicated and nuanced judgments which are more accurate. In this paper, I explain some of the ways that people with mental illness may be subject to epistemic injustices, and I propose some suggestions for how epistemic injustice can be avoided. (shrink)

Many feminists are critical of the practices and institutions that medicalize people’s lives, especially the lives of women and other members of marginalized groups. I argue that this critique does not necessarily imply a rejection of medicine. I give a brief analysis of the concept of medicalization that supports the view that one can desire medicine without desiring medicalization. I then discuss the relations among what is considered natural, socially constructed, and medicalized.

Fricker shows that virtue epistemology provides a general epistemological idiom in which these issues can be forcefully discussed.

I offer an account of what trust is, and of what epistemic self-trust consists in. I identify five distinct arguments extracted from Chapter 2 of Zagzebski's Epistemic Authority for the rationality and epistemic legitimacy of epistemic self-trust. I take issue with the general account of human rational self-regulation on which one of her arguments rests. Zagzebski maintains that this consists in restoring harmony in the psyche by eliminating conflict and so ending. I argue that epistemic rationality is distinct from psychic (...) mechanisms aimed at eliminating dissonance, and these two sometimes pull in opposed directions. (shrink)

Over the course of her career, Jean Harvey contributed many invaluable insights that help to make sense of both injustice and resistance. Specifically, she developed an account of what she called “civilized oppression,” which is pernicious in part because it can be difficult to perceive. One way that we ought to pursue what she calls a “life of moral endeavor” is by increasing our perceptual awareness of civilized oppression and ourselves as its agents. In this article I argue that one (...) noxious form of civilized oppression is what Miranda Fricker calls “testimonial injustice.” I then follow Harvey in arguing that one of the methods by which we should work to avoid perpetrating testimonial injustice is by empathizing with others. This is true for two reasons. The first is that in order to manifest what Fricker calls the virtue of testimonial justice, we must have a method by which we “correct” our prejudices or implicit biases, and empathy serves as such a corrective. The second is that there are cases where the virtue of testimonial justice wouldn't in fact correct for testimonial injustice in the way that Fricker suggests, but that actively working to empathize would. (shrink)

Too often, identifying practices of silencing is a seemingly impossible exercise. Here I claim that attempting to give a conceptual reading of the epistemic violence present when silencing occurs can help distinguish the different ways members of oppressed groups are silenced with respect to testimony. I offer an account of epistemic violence as the failure, owing to pernicious ignorance, of hearers to meet the vulnerabilities of speakers in linguistic exchanges. Ultimately, I illustrate that by focusing on the ways in which (...) hearers fail to meet speaker dependency in a linguistic exchange, efforts can be made to demarcate the different types of silencing people face when attempting to testify from oppressed positions in society. (shrink)

This book explores the epistemic side of racial and sexual oppression. It elucidates how social insensitivities and imposed silences prevent members of different groups from listening to each other.

"The subject of this book is the gradual social transformation of deviance designations in American society from "badness" to "sickness." This has been the most profound change in the definition of deviance in the past two centuries. By examining the medicalization (and demedicalization) of deviance in American society, we may also investigate the general sociohistorical process of defining deviance. Thus this book has a dual focus: it is a historical and sociological inquiry into the changing definitions of deviance and an (...) analysis of the transformation from religious and criminal to medical designations and control of deviance." -- preface. (shrink)

In At the Will of the Body , Arthur Frank told the story of his own illnesses, heart attack and cancer. That book ended by describing the existence of a "remission society," whose members all live with some form of illness or disability. The Wounded Storyteller is their collective portrait. Ill people are more than victims of disease or patients of medicine they are wounded storytellers. People tell stories to make sense of their suffering when they turn their diseases into (...) stories, they find healing. Drawing on the work of authors such as Oliver Sacks, Anatole Broyard, Norman Cousins, and Audre Lorde, as well as from people he met during the years he spent among different illness groups, Frank recounts a stirring collection of illness stories, ranging from the well-known--Gilda Radner's battle with ovarian cancer--to the private testimonials of people with cancer, chronic fatigue syndrome, and disabilties. Their stories are more than accounts of personal suffering: they abound with moral choices and point to a social ethic. Frank identifies three basic narratives of illness in restitution, chaos, and quest. Restitution narratives anticipate getting well again and give prominence to the technology of cure. In chaos narratives, illness seems to stretch on forever, with no respite or redeeming insights. Quest narratives are about finding that insight as illness is transformed into a means for the ill person to become someone new. (shrink)

This book presents a unique examination of mental illness. Though common to many mental disorders, delusions result in actions that, though perhaps rational to the individual, might seem entirely inappropriate or harmful to others. This book shows how we may better understand delusion by examining the nature of compulsion.

Especially troublesome in this dispute is the status of the natural sciences, and this is where Hacking finds some of his most telling cases, from the conflict ...