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)

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)

Epistemic injustice is a harm done to a person in their capacity as an epistemic subject by undermining her capacity to engage in epistemic practices such as giving knowledge to others or making sense of one’s experiences. It has been argued that those who suffer from medical conditions are more vulnerable to epistemic injustice than the healthy. This paper claims that people with mental disorders are even more vulnerable to epistemic injustice (...) than those with somatic illnesses. Two kinds of contributory factors for epistemic injustice in psychiatric patients are outlined: global and specific. Some suggestions are made to counteract the effects of these contributory factors, for instance we suggest that physicians should participate in groups where the subjective experience of patients is explored, and learn to become more aware of their own unconscious prejudices towards psychiatric patients. (shrink)

This paper argues that epistemic errors rooted in group- or identity- based biases, especially those pertaining to disability, are undertheorized in the literature on medical error. After sketching dominant taxonomies of medical error, we turn to the field of social epistemology to understand the role that epistemic schemas play in contributing to medical errors that disproportionately affect patients from marginalized social groups. We examine the effects of this unequal distribution through a detailed case study of (...) ableism. There are four primary mechanisms through which the epistemic schema of ableism distorts communication between nondisabled physicians and disabled patients: testimonial injustice, epistemic overconfidence, epistemic erasure, and epistemic derailing. Measures against epistemic injustices in general and against schema-based medical errors in particular are ultimately issues of justice that must be better addressed at all levels of health care practice. (shrink)

Epistemic injustice has undergone a steady growth in the medical ethics literature throughout the last decade as many ethicists have found it to be a powerful tool for describing and assessing morally problematic situations in healthcare. However, surprisingly scarce attention has been devoted to how epistemic injustice relates to physicians’ professional duties on a conceptual level. I argue that epistemic injustice, specifically testimonial, collides with physicians’ duty of nonmaleficence and should thus be actively (...) fought against in healthcare encounters on the ground of professional conduct. I do so by fleshing out how Fricker’s conception of testimonial injustice conflicts with the duty of nonmaleficence as defined in Beauchamp and Childress on theoretical grounds. From there, I argue that testimonial injustice produces two distinct types of harm, epistemic and non-epistemic. Epistemic harms are harms inflicted by the physician to the patient qua knower, whereas non-epistemic harms are inflicted to the patient qua patient. This latter case holds serious clinical implications and represent a failure of the process of due care on the part of the physician. I illustrate this through examples taken from the literature on fibromyalgia syndrome and show how testimonial injustice causes wrongful harm to patients, making it maleficent practice. Finally, I conclude on why nonmaleficence as a principle will not be normatively enough to fully address the problem of epistemic injustice in healthcare but nevertheless may serve as a good starting point in attempting to do so. (shrink)

Chronic fatigue syndrome or myalgic encephalomyelitis remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Fricker’s concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret (...) clinical studies of treatments. Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by health professionals, and many patients vocally oppose the effectiveness, and the conceptualization, of their illness as psychologically treatable. We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice. We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the marginalization of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness. (shrink)

Epistemic injustice is a kind of injustice that arises when one’s capacity as an epistemic subject is wrongfully denied. In recent years it has been argued that psychiatric patients are often harmed in their capacity as knowers and suffer from various forms of epistemic injustice that they encounter in psychiatric services. Acknowledging that epistemic injustice is a multifaceted problem in psychiatry calls for an adequate response. In this paper I argue that, given (...) that psychiatric patients deserve epistemic respect and have a certain epistemic privilege, healthcare professionals have a pro tanto epistemic duty to attend to and/or solicit reports of patients’ first-person experiences in order to prevent epistemic losses. I discuss the nature and scope of this epistemic duty and point to one interesting consequence. In order to prevent epistemic losses, healthcare professionals may need to provide some patients with resources and tools for expressing their experiences and first-person knowledge, such as those that have been developed within the phenomenological approach. I discuss the risk of secondary testimonial and hermeneutical injustice that the practice of relying on such external tools might pose and survey some ways to mitigate it. (shrink)

The concept of epistemic injustice is the latest philosophical tool with which to try to theorise what goes wrong when mental health service users are not listened to by clinicians, and what goes right when they are. Is the tool adequate to the task? It is argued that, to be applicable at all, the concept needs some adjustment so that being disbelieved as a result of prejudice is one of a family of alternative necessary conditions for its application, (...) rather than a necessary condition all on its own. It is then argued that even once adjusted in this way, the concept does not fit well in the area where the biggest efforts have been made to apply it so far, namely the highly sensitive case of adult patients suffering from delusions. Indeed it does not serve the interests of service users struggling for recognition to try to apply it in this context, because there is so much more to being listened to than simply being believed. However, the concept is found to apply smoothly in many cases where the service users are children, for example, in relation to children’s testimony on the efficacy of treatment. It is suggested that further research would demonstrate the usefulness of the concept in adult cases of a similar kind. There are no data in this work. (shrink)

Miranda Fricker’s influential concept of epistemic injustice has recently seen application to many areas of interest, with an increasing body of healthcare research using the concept of epistemic injustice in order to develop both general frameworks and accounts of specific medical conditions and patient groups. This paper illuminates tensions that arise between taking steps to protect against committing epistemic injustice in healthcare, and taking steps to understand the complexity of one’s predicament and treat (...) it accordingly. Work on epistemic injustice is therefore at risk of obfuscating legitimate and potentially fruitful inquiry. This paper uses Chronic Fatigue Syndrome/Myalgic Encephalomyelitis as a case study, but I suggest that the key problems identified could apply to other cases within healthcare, such as those classed as Medically Unexplained Illnesses, Functional Neurological Disorders and Psychiatric Disorders. Future work on epistemic injustice in healthcare must recognise and attend to this tension to protect against unsatisfactory attempts to correct epistemic injustice. (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)

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)

In this paper, we discuss epistemic and ethical concerns brought about by machine learning (ML) systems implemented in medicine. We begin by fleshing out the logic underlying a common approach in the specialized literature (which we call the _informativeness account_). We maintain that the informativeness account limits its analysis to the impact of epistemological issues on ethical concerns without assessing the bearings that ethical features have on the epistemological evaluation of ML systems. We argue that according to this methodological (...) approach, epistemological issues are _instrumental_ to and _autonomous_ of ethical considerations. This means that the informativeness account considers epistemological evaluation uninfluenced and unregulated by an ethical counterpart. Using an example that does not square well into the _informativeness account_, we argue for ethical assessments that have a substantial influence on the epistemological assessment of ML and that such influence should not be understood as merely informative but rather regulatory. Drawing on the case analyzed, we claim that within the theoretical framework of the informativeness approach, forms of epistemic injustice—especially _epistemic objectification_—remain unaddressed. Our analysis should motivate further research investigating the regulatory role that ethical elements play in the epistemology of ML. (shrink)

ABSTRACT:One recent body of work has concerned medicalization and how it can create epistemic injustice. It focuses on medicalization as a hermeneutical process that shapes the conceptual framework(s) we use to refer to some conditions/experiences. In parallel, some scholars with lived experience of madness have started to explore the epistemic harms suffered by the Mad community. Building on this, I argue that the process of medicalization in psychiatry affects the Mad community in a specific way that has (...) been overlooked in the literature on medicalization and epistemic injustice. That is, medicalization can create what is called "contributory injustice." This form of injustice occurs when marginalized communities have been able to create alternative hermeneutical resources, but these resources are dismissed or discredited by the dominant group. I argue that the emerging field of Mad Studies is a victim of this type of injustice when Mad experiences are unilaterally medicalized. (shrink)

I’m grateful to the commentators for their thoughtful and thought-provoking replies. Psychiatric service-users often feel disempowered relative to a profession (psychiatry) and so sometimes enlist the aid of another profession (philosophy) to redress the balance. All well and good, but it is vital in this context not to set one’s critical faculties on one side. Although Dr Kious1 thinks that is just what I have done, what I was trying to do was to call a halt to the uncritical use (...) of a piece of philosophy, the concept of testimonial injustice. It is a fine tool in many contexts, it is the newest tool in the …. (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)

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians. However, even in countries that have (...) implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to epistemic injustice. Nonetheless, we conclude that the marginalisation of patients’ access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety. (shrink)

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians (‘open notes’). However, even in countries (...) that have implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to (oftentimes, non-intentional) epistemic injustice. Nonetheless, we conclude that the marginalisation of patients’ access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety. (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)

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)

The dominant discourse in chronic disease management centres on the ideal of person-centred healthcare, with an empowered patient taking an active role in decision-making with their healthcare provider. Despite these encouraging developments toward healthcare democracy, many person-centred conceptions of healthcare and programming continue to focus on the healthcare institution’s perspective and priorities. In these debates, the patient’s voice has largely been absent. This article takes the example of patient empowerment to show how the concept has been influenced by a variety (...) of competing and shifting influences that have led to conceptualisations and programming designed for the patient, but developed without the patient. The framework of epistemic injustice is proposed to unravel the complexity of these omissions. The concept can be defined as a wrong done to someone specifically in their capacity as a knower. It occurs when a person is ignored or not believed due to a prejudice of some kind. It has been applied to healthcare in order to better understand barriers for patient participation and will be used to better understand the problems with current empowerment definitions and implementation strategies. The article will end by proposing some methodologies to facilitate patient-developed concepts of empowerment. (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)

We are in the midst of a global crisis of climate change and environmental degradation to which the healthcare sector directly contributes. Yet conceptions of health justice have little to say about the environment. They purport societies should ensure adequate health for their populations but fail to require doing so in ways that avoid environmental harm or injustice. We need to expand our understanding of health justice to consider the environment and do so without reinforcing the epistemic (...) class='Hi'>injustice inherent in the field of bioethics. This paper considers what work in philosophy related to the environment should be applied to help build that understanding and develops ideas about the healthcare sector’s responsibilities of justice to the environment. It first introduces the dominant multivalent environmental and ecological justice (EJ) concept in philosophy and each of its dimensions: distribution, participation, recognition and well-being. It then shows why applying that conception alone to broaden our understanding of health justice will reinforce epistemic injustice within bioethics. Drawing on EJ literature from the global South, the paper demonstrates that different ontological and experiential starting points identify additional EJ dimensions—power and harmony—and give rise to a nuanced understanding of the recognition dimension relative to the dominant EJ conception. The paper concludes by applying them to articulate healthcare sector responsibilities of justice to the environment, demonstrating they ground responsibilities beyond reducing its carbon emissions. (shrink)

Bridget Pratt and Jantina de Vries1 have made an insightful contribution to enhancing epistemic justice in global health ethics. Their elaboration details intellectual (external) exclusion—described as non-representation—across three levels, and at its core, proposes inclusion to rectify this. To extend this work, we contend that it is worth probing the nuances and challenges associated with inclusion as a response to epistemic injustice. These include (A) the meaning of inclusion outside binary vocabularies of north and south; (B) the (...) possibility of forms of inclusion that produce exclusion and (C) inclusion as a politics of belonging with intellectual confinement as a possible epistemic harm. How the problem of injustice is described influences the substantive meaning of inclusion. In describing epistemic injustice, north and south (centre and periphery) are used as relational markers of power, inclusion, authority and exclusion. While this binary vocabulary is seductive, it can appear to confer proprietary rights to the concepts, theories and values described as originating in the global north (and south). However, such inscriptions of ownership are not always a correct reading of the problem. Sometimes, the ostensible western-ness and non-western-ness of ideas are taken for granted, particularly …. (shrink)

In ‘Epistemic injustice, children and mental Illness,’1 Edward Harcourt uses Miranda Fricker’s concept of testimonial injustice 2 to make sense of claims, from mental health service users, that clinicians do not listen to them. Being listened to matters. It is a sign of respect as a person and associated with better clinical outcomes. TI involves suffering an unfair credibility deficit because of prejudice, so seems like a promising way of understanding service users’ complaints. Harcourt quickly concludes, however, (...) that it is inadequate. Since many service users are not wholly rational, the credibility deficits they suffer could be fair, and thus cannot constitute TI. Undaunted, Harcourt tries to reimagine TI so it can help. He observes that many children are also unfairly discredited by clinicians. Perhaps they are victims of TI, too, in a way that could help resurrect the concept? It may at first seem not: although providers who work with children often discredit them, this may result from mere ignorance, not prejudice. We should not let clinicians off the hook so easily, however, since they work with children, and should know their real capacities. Since they still discredit children, they must be prejudiced. And even further kinds of TI could be perpetrated by clinicians. Fricker assumes that …. (shrink)

Virtue signaling—using public moral discourse to enhance one’s moral reputation—is a familiar concept. But, what about profile pictures framed by “Vaccines work!”? Or memes posted to anti-vaccine groups echoing the group’s view that “Only sheep believe Big Pharma!”? These actions don’t express moral views—both claims are empirical (if imprecise). Nevertheless, they serve a similar purpose: to influence the judgments of their audience. But, where rainbow profiles guide their audience to view the agent as morally good, these acts guide their audience (...) to view the agent as epistemically good. They are instances of epistemic virtue signaling. The first goal of this paper is to offer an account of epistemic virtue signaling. I argue that epistemic virtue signaling occurs through both behavioral and propositional signals, and serves purposes similar to those of moral virtue signaling across a wide variety of discourses. The second is to show that there is much work for this concept to do. In particular, this concept illuminates a double bind faced by those who suffer from and seek to overcome testimonial injustice. I close by demonstrating how this double bind arises in the dissolution of medical autonomy, focusing on the care gap faced by pregnant women of color in the United States today, as compared with their white counterparts. (shrink)

An episiotomy is ‘an intrapartum procedure that involves an incision to enlarge the vaginal orifice,’1 and is primarily justified as a way to prevent higher degrees of perineal trauma or to facilitate a faster birth in cases of suspected fetal distress. Yet the effectiveness of episiotomies is controversial, and many professional bodies recommend against the routine use of episiotomies. In any case, unconsented episiotomies are alarmingly common, and some care providers in obstetric settings often fail to see consent as necessary (...) in context. In their article, ‘The ethics of consent during labour and birth: episiotomies,’ van der Pijl et al reiterate that consent is necessary for episiotomies. They specify, further, that the antenatal period is crucial for exchanging information, establishing trust between the birthing subject and provider, and exploring the birthing subject’s—rather than the care provider’s—values and preferences regarding episiotomies. They recommend an individualised approach, which would enable birthing subjects to choose how and when they want to give consent. I applaud van der Pijl et al on their practicable recommendations regarding consent for episiotomies. This is certainly a step in the right direction where respect for birthing subjects’ bodily autonomy and integrity is concerned. Still, we must be reminded that consent alone is not coextensive with autonomy. The conditions for securing informed consent in healthcare does not guarantee that one’s decision is truly reflective of their values. After all, even valid consent does not rule out ‘normatively significant external influence’.2 Consent acquisition for obstetric procedures present no …. (shrink)

Leading paradigms of clinical ethics consultation closely follow a biomedical model of care. In this paper, we present a theoretical reflection on the underlying biomedical model of disease, how it shaped clinical practices and patterns of ethical deliberation within these practices, and the repercussions it has on clinical ethics consultations for patients with chronic illness. We contend that this model, despite its important contribution to capturing the ethical issues of day-to-day clinical ethics deliberation, might not be sufficient for patients presenting (...) with chronic illnesses and navigating as “lay experts” of their medical condition(s) through the health care system. Not fully considering the sources of personal knowledge and expertise may lead to epistemic injustice within an ethical deliberation logic narrowly relying on a biomedical model of disease. In caring “for” and collaboratively “with” this patient population, we answer the threat of epistemic injustice with epistemic modesty and humility. We will propose ideas about how clinical ethics could contribute to an expansion of the biomedical model of care, so that important aspects of chronic illness experience would flow into clinical-ethical decision-making. (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)

Pozzi provides a thought-provoking account of how machine-learning clinical prediction models (such as Prediction Drug Monitoring Programmes (PDMPs)) may exacerbate testimonial injustice.1 In this response, I generalise Pozzi’s concerns about PDMPs to traditional models of clinical practice and question the claim that inaccurate clinicians are necessarily preferential to inaccurate machine-learning models. I then explore Pozzi’s concern that such models may deprive patients of a right to ‘convey information’. I suggest that machine-learning tools may be used to enhance, rather than (...) frustrate, this right, through the perspective of hermeneutical justice. Pozzi objects to the introduction of machine-learning risk prediction tools in clinical care, due to their being ‘epistemically opaque’, often inaccurate, and a threat to patients’ testimonial justice. Through the example of psychiatry, I suggest this stance idealises traditional models of clinical practice. I propose that clinicians’ judgements are often equally vulnerable to opaque subjectivity, bias and epistemic injustice. For instance, the use of clinical observation or collateral interviewing might be conceptualised as a threat to testimonial justice, by neglecting patients’ own perspectives or voices. In practice, clinical risk prediction often follows inconsistent and somewhat subjective clinical heuristics, which are difficult to summarise or evaluate. Further, although Pozzi diminishes machine-learning …. (shrink)

In my paper entitled ‘Testimonial injustice in medical machine learning’,1 I argued that machine learning (ML)-based Prediction Drug Monitoring Programmes (PDMPs) could infringe on patients’ epistemic and moral standing inflicting a testimonial injustice.2 I am very grateful for all the comments the paper received, some of which expand on it while others take a more critical view. This response addresses two objections raised to my consideration of ML-induced testimonial injustice in order to clarify the position (...) taken in the paper. The first maintains that my critical stance toward ML-based PDMPs idealises standard medical practice. Moreover, it claims that the ML-induced testimonial injustice I discuss is not substantially different from situations in which it emerges in human–human interactions. The second claims that my analysis does not establish a link to issues of automation bias, even if these are to be considered the core of testimonial injustice in ML. In the following, I address each objection in turn. Gillett3 argues that my critical stance towards using risk prediction tools such as PDMPs implies the idealisation of standard (ie, non-ML-mediated) modes of clinical practice. Considering certain uses of ML in a different setting, that is, psychiatry, the author goes as far as claiming that ‘traditional models of clinical practice in psychiatry are far from a utopia, free from epistemic injustice, which Pozzi’s argument risks proposing’. Since this statement does not represent what I intend to suggest, I am glad to have the possibility to clarify …. (shrink)

I defend an empirically-oriented approach to the analysis and remediation of social injustice. My springboard for this argument is a debate—principally represented here between Tommie Shelby and Elizabeth Anderson, but with much deeper historical roots and many flowering branches—about whether racial-justice advocacy should prioritize integration (bringing different groups together) or community development (building wealth and political power within the black community). Although I incline toward something closer to Shelby’s “egalitarian pluralist” approach over Anderson’s single-minded emphasis on integration, many of (...) Shelby’s criticisms of integrationism are misguided, and his handling of the empirical literature is profoundly unbalanced. In fact, while both Shelby and Anderson defend the importance of social science to their projects, I’ll argue that each takes a decidedly unempirical approach, which ultimately obscures the full extent of our ignorance about what we can and ought to do going forward. A more authentically empirical tack would be more epistemically humble, more holistic, and less organized around what I’ll call prematurely formulated “Grand Unified Theories of Social Change.” I defend a more “diversified experimentalist” approach, which rigorously tests an array of smaller-scale interventions before trying to replicate and scale up the most promising results. (shrink)

Pozzi1 has thoroughly analysed testimonial injustices in the automated Prediction Drug Monitoring Programmes (PDMPs) case. Although Pozzi1 suggests that ‘the shift from an interpersonal to a structural dimension … bears a significant moral component’, her topical investigation does not further conceptualise the type of collective knowledge practices necessary to achieve epistemic justice. As Pozzi1 concludes: ‘this paper shows the limitations of systems such as automated PDMPs, it does not provide possible solutions’. In this commentary, we propose that an Ubuntu (...) perspective—which, so far, has received little attention in connection with epistemic injustice in medical machine learning (MML)—can fill this gap. This perspective can be used to mitigate some of the harmful effects of epistemic injustices by encouraging community involvement and forward-looking responsibility. It may be instructive to note first and foremost that the debate on epistemic justice and artificial intelligence in medicine has mostly been restricted to the Western World, that is, Europe and North America. There has been very little insight or accommodation of insights from the Global South. Ubuntu is a concept originating from Southern Africa that focuses on the close connections and mutual …. (shrink)

I explain the notion of contributory injustice, a kind of epistemic injustice, and argue that it occurs within psychiatric services, affecting those who hear voices. I argue that individual effort on the part of clinicians to avoid perpetrating this injustice is an insufficient response to the problem; mitigating the injustice will require open and meaningful dialogue between clinicians and service user organisations, as well as individuals. I suggest that clinicians must become familiar with and take (...) seriously concepts and frameworks for understanding mental distress developed in service user communities, such as Hearing Voices Network, and by individual service users. This is especially necessary when these concepts and frameworks explicitly conflict with medical or technical understandings of users’ experiences. I defend this proposal against three objections. (shrink)

La création récente du diagnostic de trouble dysphorique prémenstruel (TDPM) dans le DSM-5 a été contestée sous de multiples angles. Les principales critiques mettent en avant les lacunes en faveur de la validité du TDPM, ainsi que le risque de pathologisation et de stigmatisation des changements physiques et comportementaux vécus par les femmes pendant leur phase prémenstruelle. Pour éclairer cette controverse, j’emprunte certains outils du cadre conceptuel des injustices épistémiques (IE) développé par Miranda Fricker. Plus précisément, je vais me baser (...) sur de récents travaux qui ont tenté d’appliquer ce cadre aux processus de catégorisation en médecine et en psychiatrie. Cela me permettra de mettre au jour un angle mort du débat actuel sur le TDPM, soit les perspectives des personnes touchées par ces symptômes. Ces points de vue ont été généralement négligés, mais le cadre des IE nous permet de recentrer le débat sur les intérêts et les besoins des personnes affectées par les processus de catégorisation psychiatrique. (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)

This volume considers forms of information manipulation and restriction in contemporary society. It explores whether and when manipulation of the conditions of inquiry without the consent of those manipulated is morally or epistemically justified. The contributors provide a wealth of examples of manipulation, and debate whether epistemic paternalism is distinct from other forms of paternalism debated in political theory. Special attention is given to medical practice, science communication, and research in science, technology, and society. Some of the contributors (...) argue that unconsenting interference with or "conceptual engineering" of people’s beliefs and ability of inquire is consistent with, and others that it is inconsistent with, efforts to democratize knowledge and decision-making. (shrink)

This volume considers forms of information manipulation and restriction in contemporary society. It explores whether and when manipulation of the conditions of inquiry without the consent of those manipulated is morally or epistemically justified. The contributors provide a wealth of examples of manipulation, and debate whether epistemic paternalism is distinct from other forms of paternalism debated in political theory. Special attention is given to medical practice, for science communication, and for research in science, technology, and society. Some of (...) the contributors argue that unconsenting interference with people’s ability of inquire is consistent with, and others that it is inconsistent with, efforts to democratize knowledge and decision-making. -/- These differences invite theoretical reflection regarding which goods are fundamental, whether there is a clear or only a moving boundary between informing and instructing, and whether manipulation of people’s epistemic conditions amounts to a type of intellectual injustice. The collection pays special attention to contemporary paternalistic practices in big data and scientific research, as the way in which the flow of information or knowledge might be curtailed by the manipulations of a small body of experts or algorithms. (shrink)

The topic of epistemic injustice in global health ethics is complex, important and vast. While presenting as nuanced and complete a picture of the challenge as we possibly could, we were acutely aware of our positionality and how it gave us a certain viewpoint that would need to be expanded by others with different positions and experiences. We were, therefore, delighted to receive the collected commentaries by Atuire,1 Abimbola,2 Frimpong-Mansoh,3 Nyamnjoh and Ewuoso,4 Tangwa,5 Ambrogi et al.6 We would (...) like to thank these authors for furthering our account by raising questions, pointing out gaps or complementing our analysis. The points raised by these authors—and many points that will undoubtedly be raised by others in future—should be critically engaged with as we collectively define and work towards a more epistemically just global health ethics. Specifically, two points stand out. First, Frimpong-Mansoh accurately diagnoses our ambiguity about being drawn into debates about relativism in bioethics. We …. (shrink)

In this paper, I provide an epistemic evaluation of the harms that result from the widespread marketing of direct-to-consumer (DTC) genetic tests. While genetic tests are a valuable accessory diagnostic tool when ordered by a medical practitioner, there are different implications when they are sold directly to consumers. I aim to show that there are both epistemic and non-epistemic harms associated with the widespread commoditization of DTC genetic tests. I argue that the epistemic harms produced (...) by DTC genetic tests have been disregarded in discussions on the topic. Drawing on the notion of contributory epistemic injustices, I highlight two pertinent epistemic harms: (1) a failure to uptake an individual’s articulations about their identity and (2) the presiding reductionist framework dismisses useful hermeneutical resources. I then propose ways to mitigate these harms. (shrink)

Epistemic injustice sits at the intersection of ethics, epistemology, and social justice. Generally, this philosophical term describes when a person is wrongfully discredited as a knower; and within the clinical space, epistemic injustice is the underlying reason that some patient testimonies are valued above others. The following essay seeks to connect patterns of social prejudice to the clinical realm in the United States: illustrating how factors such as race, gender identity, and socioeconomic status influence epistemic (...) credence and associatively, the quality of healthcare a person receives. After describing how epistemic injustice disproportionately harms already vulnerable patients, I propose a narrative therapy intervention. This intervention can help providers re-frame their relationships with patients, in such that they come to view patients as valuable sources of unique knowledge. Though I identify this intervention as a valuable step in addressing clinical epistemic injustice, I call upon medical educators and practitioners to further uplift the voices, perspectives, and stories of marginalized patients. (shrink)

Harcourt argues that in clinical contexts, children and young people with mental health illness can experience epistemic, specifically testimonial, injustice when their perspectives are unjustifiably discounted by health service providers.1 Our goal in this commentary was to illustrate how caregivers, a critical component of CYP treatment triad, can also engage in testimonial injustice towards CYP patients. Testimonial injustice occurs when one suffers a credibility deficit and that credibility deficit is based on prejudice.2 Harcourt expands Fricker’s account (...) of testimonial injustice by arguing that for CYPs, the credibility deficits attributed to them by clinicians, for example, may result from epistemic arrogance in that CYPs are viewed as having unreliable knowledge about their condition. Harcourt writes: ‘Being a CYP is treated as a heuristic for epistemic unreliability across a wide range of domains’, including clinical settings. Harcourt’s expansion of Fricker’s account thus includes epistemic arrogance as an alternative necessary condition, in addition to prejudice, to apply the concept of testimonial injustice. We think Harcourt’s argument can also be extended to caregivers, who are central to the CYP treatment triad. We illustrate how this may be the case by drawing from research we conducted to understand the perspectives of clinicians and prospective families, both caregivers and paediatric patients with obsessive–compulsive disorder about the possibility of …. (shrink)

Some physicians, in their care of patients at risk of misusing opioids, use machine learning (ML)-based prediction drug monitoring programmes (PDMPs) to guide their decision making in the prescription of opioids. This can cause a conflict: a PDMP Score can indicate a patient is at a high risk of opioid abuse while a patient expressly reports oppositely. The prescriber is then left to balance the credibility and trust of the patient with the PDMP Score. Pozzi1 argues that a prescriber who (...) downgrades the credibility of a patient’s testimony based on a low PDMP Score is epistemically and morally unjustified and contributes to a form of testimonial injustice. This results in patients being silenced, excluded from decision-making processes and subjected to structural injustices. Additionally, the use of ML systems in medical practices raises concerns about perpetuating existing inequalities, overestimating their capabilities and displacing human authority. However, almost the very same critiques apply to human-based systems. Formalisation, ML systems included, should instead be viewed positively,2 and precisely as a powerful means to begin eroding these and other problems in ethically sensitive domains. In this case, the epistemic virtues of formalisation include promoting transparency, consistency and replicability in decision making. Rigorous ML systems can also help ensure that models …. (shrink)

Noninvasive prenatal testing promises to enhance women's reproductive autonomy by providing genetic information about the fetus, especially in the detection of genetic impairments like Down syndrome. In practice, however, NIPT provides opportunities for intensified manipulation and control over women's reproductive decisions. Applying Miranda Fricker's concept of epistemic injustice to prenatal screening, this article analyzes how medical professionals impair reproductive decision-making by perpetuating testimonial injustice. They do so by discrediting positive parental testimony about what it is like (...) to raise a child with DS. We argue that this testimonial injustice constitutes a twofold harm: people with DS and their family members who claim that parenting a child with DS may be a rewarding and joyous experience are harmed when they are systematically silenced, disbelieved, and/or denied epistemic credibility by medical professionals, and pregnant women are harmed since they might make poorly informed choices without access to all relevant information. The broader implication of the analysis is that epistemic justice is a precondition of reproductive autonomy. We conclude by calling for federal oversight of the acquisition and dissemination of information that prospective parents receive following a positive diagnosis of DS to ensure that it is comprehensive and up to date. (shrink)

In a feature article in the Journal of Medical Ethics entitled ‘Where is knowledge from the global South? An account of epistemic justice for a global bioethics’,1 Pratt and de Vries give a highly persuasive account of global injustices within global bioethics especially health ethics against the global South that every bioethicist needs to read and to reflect on. The opening three sentences of the abstract of this account capture the ethical essence of the whole article. > The (...) silencing of the epistemologies, theories, principles, values, concepts and experiences of the global South, constitutes a particularly egregious epistemic injustice in bioethics. Our shared responsibility to rectify that injustice should be at the top of the ethics agenda. That it is not, or only is in part, is deeply problematic, and endangers the credibility of the entire field.1 It is quite significant that both authors of this article are scholars of the global North with research interest in the global South; so where are the scholars of the global South, the putative conceptualisers and creators of global South knowledge who should be complaining about the injustice in question? The answer to this question is part and parcel of the question itself that has been so boldly raised by Pratt and de Vries. They go on to describe in some detail the general conditions and requirements of epistemic justice for global health ethics and bioethics including even a consideration …. (shrink)

Philosophy of medicine has traditionally examined two issues: the scientific ontology for medicine and the epistemic significance of the types of evidence used in medical research. In answering each question, philosophers have typically brought to bear tools from traditional analytic philosophy. In contrast, this volume explores medical knowledge from the perspective offered by social epistemology.While many of the same issues are addressed, the approach to these issues generates both fresh questions and new insights into old debates. In (...) addition, the broader purview offered by social epistemology opens up opportunities to address new topics such as the role of consensus conferences, epistemic injustice, the value of medical knowledge, continuing medical education, and industry funding. This article situates and summarizes the contributions to this special issue. (shrink)

Doctors Pratt and de Vries propose a well-structured and courageous approach to analyse and repair an insufficiently recognised discussion about epistemologies and knowledge production in bioethics.1 The authors invite researchers, scholars, public health experts and bioethicists from the global North to reflect about their lack of imagination regarding different sources of narratives produced by the global South. There is a critical analysis of injustices and an urgent call for global bioethicists to reorient their field and focus on the analysis and (...) development of ethical interventions to achieve a comprehensive epistemic justice for global health ethics. Feminist bioethicists from the global South already argued about the importance of the voices and biographies of the people and groups in the communities to reframe the bioethical reasoning regarding the meaning of individual’s needs during public health and humanitarian emergencies.2 Over a decade ago, Diniz and Guilhem described the role and goal of feminist bioethics in Latin America, shaped in an oppressive context promoted and created by …. (shrink)

In the article ‘Testimonial injustice in medical machine learning’, Pozzi argues that the prescription drug monitoring programme (PDMP) leads to testimonial injustice as physicians are more inclined to trust the PDMP’s risk scores over the patient’s own account of their medication history.1 Pozzi further develops this argument by discussing how credibility shifts from patients to machine learning (ML) systems that are supposedly neutral. As a result, a sense of distrust is now formed between patients and physicians. While (...) there are merits to Pozzi’s main argument of epistemic injustice caused by PDMPs, Pozzi mentions but ultimately glosses over the problem of automation bias. In this commentary, I will discuss automation bias and the affect it has on clinical decision making as well as a technical problem exacerbated by the usage of PDMPs that can potentially cause physical harms. It is reiterated in the article that the confidence physicians have in the PDMP’s risk scores over the patient’s testimony leads to misplaced trust in the ML systems. What Pozzi describes here is known as automation bias, which occurs when there is an over-reliance on ML systems. …. (shrink)

This paper argues that the current discourse on epistemic injustice in social epistemology itself perpetuates epistemic injustice, namely hermeneutic injustice with regards to class and classism. The main reason is that debates on epistemic injustice have foremost focussed on issues related to gender, race, and disability while mostly ignoring class issues. I suggest that this is due to (largely unwarranted) fears about looming class reductionism. More importantly, this is omission is not innocuous, but (...) problematic insofar as it has an unlikely ally in neoliberal propaganda which features as one main goal stifling class consciousness. While this “allyship” is unwitting, this presents grounds for the discourse of epistemic injustice to consider re-centring class issues and classism. (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)