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)

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

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

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)

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)

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)

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)

People who have mental health diagnoses are often subject to sanist microaggressions in which pejorative terms to describe mental illness are used to represent that which is discreditable. Such microaggressions reflect and perpetrate stigma against severe mental illness, often held unconsciously as implicit bias. In this article, I examine the sanist attitudes that underlie sanist microaggressions, analyzing some of the cognitive biases that support mental illness stigma. Then I consider what responsibility we have with respect to microaggressions. I argue that (...) all people share in a collective responsibility to engage in acts of epistemic resistance that challenge sanist attitudes so that it is easier for bystanders who witness microaggressions, and targets of microaggressions in particular, to identify microaggressions and to point out biased behavior. The act of pointing out bias is best understood as an act of epistemic resistance that is more effective and meaningful in the context of other acts of epistemic resistance. Ultimately, whether to point out bias is an individual decision that one must make after weighing the risks involved; engaging in a range of acts of epistemic resistance, on the other hand, is a moral responsibility everyone shares. (shrink)

Deep Self views of moral responsibility have been criticized for positing mysterious concepts, making nearly paradoxical claims about the ownership of one’s mental states, and promoting self-deceptive moral evasion. I defend Deep Self views from these pervasive forms of skepticism by arguing that some criticism is hasty and stems from epistemic injustice regarding testimonies of experiences of alienation, while other criticism targets contingent features of Deep Self views that ought to be abandoned. To aid in this project, I provide original (...) naturalistic analyses of “Self” and “internality” that replace the view’s metaphorical language with common-sensical concepts that make clear their usefulness. (shrink)

Epistemic injustice has rapidly become a powerful tool for analysis of otherwise hidden social harms. Yet empirical research into how resistance to knowing and understanding can be generated and replicated in social programmes is limited. We have identified a range of subtle and not-so-subtle inflections of epistemic injustice as they play out in an intervention for people with chronic depression in receipt of disability benefits. This article describes the different ‘species’ of epistemic injustice observed and reveals how these are unintentionally (...) produced at frontline, management, commissioning and policy levels. Most notably, there remains a privileging of clinical knowledge over other forms of knowledge, producing a ‘pathocentric epistemic complex’. This, combined with the failure of different agencies with competing ideologies to adequately understand each other, and a vicious policy context, added to the injustices already faced by people with mental health issues, generating multiple harms. This has important implications for a range of integrated care and welfare interventions – not least by drawing attention to their unintended potential for replicating epistemic injustice as an institutionalised complex. Careful evaluation and design of such programmes, applying the philosophical and epistemic resources illustrated here, can help mitigate this outcome. Further, by raising awareness of epistemic injustice among programme participants, we can generate epistemic structures that secure programme integrity locally, and promote better policy. (shrink)

Menschen mit psychischer Erkrankung sterben statistisch gesehen früher als die Allgemeinbevölkerung. Ein Grund hierfür ist, dass sie eine schlechtere somatische Gesundheitsversorgung erhalten. Wir argumentieren, dass ableistische Netzwerke sozialer Bedeutung zu einer Abwertung der epistemischen Kompetenz von Menschen mit psychischer Erkrankung führen. Diese Abwertung kann mit dem Konzept der testimonialen Ungerechtigkeit erfasst werden. Testimoniale Ungerechtigkeit bezeichnet das ungerechtfertigte Herabstufen der Glaubwürdigkeit einer*s Sprecher*in aufgrund eines Vorurteils gegen ihre*seine soziale Identität. Wir analysieren ethische und epistemische Folgen testimonialer Ungerechtigkeit als wichtige Ursachen der (...) schlechteren Gesundheitsversorgung von Menschen mit psychischer Erkrankung. Testimoniale Ungerechtigkeit kann zu medizinischen Behandlungsfehlern führen und für Betroffene schwerwiegende gesundheitliche Folgen nach sich ziehen. Zudem kann sie zu einem Vertrauensverlust von Menschen mit psychischer Erkrankung in das Gesundheitssystem führen. Daher trägt testimoniale Ungerechtigkeit zur strukturellen Diskriminierung von Menschen mit psychischer Erkrankung bei. Vor diesem Hintergrund diskutieren wir, wie die somatische Gesundheitsversorgung unter ethischen Gesichtspunkten verbessert werden kann. (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)

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)

The significance of critical phenomenology for psychiatric praxis has yet to be expounded. In this paper, I argue that the adoption of a critical phenomenological stance can remedy localised instances of hermeneutical injustice, which may arise in the encounter between clinicians and patients with psychosis. In this context, what is communicated is often deemed to lack meaning or to be difficult to understand. While a degree of un-shareability is inherent to subjective life, I argue that issues of unintelligibility can be (...) addressed by shifting from individualistic conceptions of understanding to an interactionist view. This takes into account the contextual, historical and relational background within which meaning is co-constituted. I conclude by providing a corrective for hermeneutical injustice, which entails a specific attentiveness towards the person’s subjectivity, a careful sensitivity to contingent meaning-generating structures, and a degree of hermeneutical flexibility as an attitude of openness towards alternative horizons of possibility. (shrink)

To verify the occurrence of a singular instance of testimonial injustice three facts must be established. The first is whether the hearer in fact has an identity prejudice of which she may or may not be aware; the second is whether that prejudice was in fact the cause of the unjustified credibility deficit; and the third is whether there was in fact a credibility deficit in the testimonial exchange. These three elements constitute the facts of the matter of testimonial injustice. (...) In this essay we argue that none of these facts can be established with any degree of confidence, and therefore that testimonial injustice is an undetectable phenomenon in singular instances. Our intention is not to undermine the idea of testimonial injustice, but rather to set limits to what can be justifiably asserted about it. According to our argument, although there are insufficient reasons to identify individual acts of testimonial injustice, it is possible to recognize recurrent patterns of epistemic responses to speakers who belong to specific social groups. General testimonial injustice can thus be characterized as a behavioral tendency of a prejudiced hearer. (shrink)