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

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)

We expand on Della Croce’s ambition to interpret “epistemic injustice” as a specification of non-maleficence in the use of the influential four-principle framework. This is an alluring line of thought for conceptual, moral, and heuristic reasons. Although it is commendable, Della Croce’s attempt remains tentative. So does our critique of it. Yet, we take on the challenge to critically address two interrelated points. First, we broaden the analysis to include deliberations about hermeneutical injustice. We argue that, if due consideration of (...) epistemic injustice is to require more than negative ethical obligations in medicine, dimensions of hermeneutical injustice should be explored as an avenue to arrive at such positive duties. Second, and relatedly, we argue that this may encompass moral responsibilities beyond the individual level, that is: positive obligations to take action on a structural level. Building on Dotson’s concept of “contributory injustice” and Scheman’s concept of “perceptual autonomy,” we suggest that the virtues of testimonial and hermeneutical justice may provide additional content not only to negative prohibitions of action (i.e. non-maleficence) but also to positive requirements of action, like respecting patient autonomy. (shrink)

There is a long tradition of employing a phenomenological approach to gain greater insight into the unique experience of psychiatric illness. Researchers in this field have shed light upon a distur...

ABSTRACT Epistemic social oppressions such as ‘epistemic partiality’, ‘epistemic injustice’, ‘epistemic harms and wrongs’, ‘epistemic oppression’, ‘epistemic exploitation’, ‘epistemic violence’, or ‘epistemicide’ are terms with increasing theoretical importance and empirical applications. However, less literature is devoted to social strategies to overcome such oppressions. Here the Sorelian and Gramscian concept of social myth is considered in that sense. The empirical case is the myth of ‘The last Indigenous peoples of Europe’ present in the Basque Country, divided between France and Spain and (...) with a historical national culture under their statist powers. The myth has a renewal in a recent social movement, the Biltzarre platform and its Basque Cultural Instinct Team, currently followed through a Participatory Action Research. The results show how such social myth gives coherence and empowers the Basque identity against the loss of identity caused by the French and Spanish powers. Finally, progress is being made on how epistemic oppressons can end, ironically, because of the success of an epistemicide. Presumably, social myths counteract epistemic oppression, strengthening the social identity and self-esteem of the subject, as a form of empowerment in social and political issues. (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)

Niche construction theory highlights the active role of organisms in modifying their environment. A subset of these modifications is the developmental niche, which concerns ecological, epistemic, social and symbolic legacies inherited by organisms as resources that scaffold their developmental processes. Since in this theory development is a situated process that takes place in a culturally structured environment, we may reasonably ask if implicit cultural biases may, in some cases, be responsible for maladaptive developmental niches. In this paper we wish to (...) argue for an affirmative answer. In order to do so, we first propose to conceptualize implicit bias as embodied perceptual habits, and then proceed to show that these habits are at least partially responsible for maladaptive developmental niches of children with Down syndrome and autism. With this framework we thus hope to bring together two fields of research that haven’t been explicitly connected: implicit bias and niche construction theory. Linking these two theories may bring benefits both to implicit bias researchers, who can extend this concept to characterize other sets of processes as biased, as well as to niche construction theorists, who will have a useful theoretical tool to diagnose maladaptive features of niches brought about by sociocultural biases. (shrink)

This paper offers an overview of the philosophical work on epistemic injustices as it relates to psychiatry. After describing the development of epistemic injustice studies, we survey the existing literature on its application to psychiatry. We describe how the concept of epistemic injustice has been taken up into a range of debates in philosophy of psychiatry, including the nature of psychiatric conditions, psychiatric practices and research, and ameliorative projects. The final section of the paper indicates future directions for philosophical research (...) of epistemic injustices and psychiatry, concerning neurocognitive disorders, identity prejudices in psychiatric illness, concepts of epistemic privilege in psychiatry, and the prospects for combining phenomenological psychopathology and epistemic justice. We argue that much remains to be done in the conceptualization of these epistemic injustices and suggest that this future work should be multidisciplinary in character and sensitive to the phenomenology of psychiatric conditions. (shrink)

ABSTRACT This paper offers an account of institutional testimonial justice and describes one way that it breaks down, which we call institutional opacity. An institution is opaque when it becomes resistant to epistemic evaluation and understanding by its agents and users. When one cannot understand the inner workings of an institution, it becomes difficult to know how to comport oneself testimonially. We offer an account of an institutional ethos to explain what it means for an institution to be testimonially just; (...) we then describe how an ethos of institutional testimonial justice can break down when the institution becomes opaque. An opaque institution is especially problematic for individuals and groups already rendered epistemically vulnerable during their interactions with that institution, which we call epistemically vulnerabilised individuals. We articulate the features of an encounter between an epistemically vulnerabilised individual and an opaque institution. We end by tracing ameliorative strategies that could help repair a deteriorated institutional ethos of testimonial justice. (shrink)

Dans ce texte, je suggère que les personnes souffrant d’anorexie mentale s’infligent une forme particulière de violence épistémique lorsqu’elles ignorent volontairement les symptômes de leur maladie. Pour ce faire, dans une démarche inspirée par celle de Havi Carel, je présente d’abord le rapport particulier qu’entretiennent les personnes souffrant d’anorexie avec leur corps, et ce, à l’aide de trois axes d’analyse empruntés à Susan Bordo, soit le dualisme Corps/Esprit, les idéaux de contrôle et d’autonomie, et les rapports de genre. Je propose (...) ensuite le concept de violence épistémique auto-infligée en montrant que l’ignorance volontaire de la faim a pour objectif de préserver l’identité des personnes vivant avec cette maladie comme autonomes et en contrôle, autrement dit comme n’étant pas « malades ». (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)

Naturalistic understandings that frame human experiences and differences as biological dysfunctions have been identified as a key source of epistemic injustice. Critics argue that those understandings are epistemically harmful because they obscure social factors that might be involved in people’s suffering; therefore, naturalistic understandings should be undermined. But those critics have overlooked the epistemic benefits such understandings can offer marginalised individuals. In this paper, I argue that the capacity of naturalistic understandings to obscure social factors does not necessarily cause epistemic (...) injustice and can even help people to avoid some epistemic injustice. I do this by considering how some individuals with bipolar disorder deploy the neurobiological understanding of their disorder, highlighting three functions it fills for them: explanation, disclamation, and decontestation. In performing these functions, the neurobiological understanding does marginalise alternative, social perspectives on bipolar disorder. However, this can be understood as a feature rather than a bug. By marginalising alternative explanations, the neurobiological understanding can help individuals with bipolar disorder resist epistemic injustice, including, for example, the trivialisation of their experiences. Given this, critics seeking to undermine naturalistic understandings of mental disorder and other experiences in the pursuit of epistemic justice themselves risk exacerbating epistemic injustice. (shrink)

Journal of Social Philosophy, EarlyView.

The phenomenological method has been fruitfully used to study the experience of illness in recent years. However, the role of illness is not merely that of a passive object for phenomenological scrutiny. I propose that illness, and pathology more generally, can be developed into a phenomenological method in their own right. I claim that studying cases of pathology, breakdown, and illness offer illumination not only of these experiences, but also of normal function and the tacit background that underpins it. In (...) particular, I claim that the study of embodiment can be greatly enhanced, and indeed would be incomplete, without attending to bodily breakdown and what I term bodily doubt. I offer an analogy between illness and Husserl’s epoché, suggesting that both are a source of distancing, and therefore motivate a reflective stance. (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)

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)

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)