Domestic violence and abuse (DVA) are at last coming to be recognised as serious global public health problems. Nevertheless, many women with personal histories of DVA decline to disclose them to healthcare practitioners. In the health sciences, recent empirical work has identified many factors that impede DVA disclosure, known as barriers to disclosure. Drawing on recent work in social epistemology on testimonial silencing, we might wonder why so many people withhold their testimony and whether there is some kind of (...) epistemic injustice afoot here. In this paper, I offer some philosophical reflections on DVA disclosure in clinical contexts and the associated barriers to disclosure. I argue that women with personal histories of DVA are vulnerable to a certain form of testimonial injustice in clinical contexts, namely, testimonial smothering, and that this may help to explain why they withhold that testimony. It is my contention that this can help explain the low rates of DVA disclosure by patients to healthcare practitioners. (shrink)

The American Journal of Bioethics, Volume 12, Issue 10, Page 34-36, October 2012.

Is there any witness to death? As detailed by Jacques Derrida, any testimony is detached from the direct perception of the event it reports. Thus, a testimony may report one’s encounter with death, not only with the death of the other, but also with one’s own death, even though it can never by experienced as such. In particular, reports from “survivors” ought to be taken un-metaphorically as they confront us with what Maurice Blanchot related as “the encounter of (...) death with death.” In line with such testimonies, Donald Woods Winnicott helps us here in considering an “anterior death,” a death that already happened without being experienced as such and which may haunt the subject until it remembers it. But how may one remember a past that has never been present? And how may one remember death without dying? In dialogue with Maurice Blanchot, we are guided toward a manner of considering silence as an oblivious remembrance of that which can be brought back from death. (shrink)

Testimony about the future dangerousness of a person has become a central staple of many judicial processes. In settings such as bail, sentencing, and parole decisions, in rulings about the civil confinement of the mentally ill, and in custody decisions in a context of domestic violence, the assessment of a person’s propensity towards physical or sexual violence is regarded as a deciding factor. These assessments can be based on two forms of expert testimony: actuarial or clinical. The (...) purpose of this paper is to examine the scientific and epistemological basis of both methods of prediction or risk assessment. My analysis will reveal that this kind of expert testimony is scientifically baseless. The problems I will discuss will generate a dilemma for factfinders: on the one hand, given the weak predictive abilities of the branches of science involved, they should not admit expert clinical or actuarial testimony as evidence; on the other hand, there is a very strong tradition and a vast jurisprudence that supports the continued use of this kind of expert testimony. It is a clear case of the not so uncommon conflict between science and legal tradition. (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)

Avec la perte d’influence de la psychothérapie institutionnelle et la montée en puissance du new management public, j’observe une remise en question de la clinique éducative au profit de démarche plus orientée vers la notion de performance. Cette évolution ne me semble pas pertinente au regard des enjeux portés par les professionnels et les publics qui demandent d’avantage semble-t-il de co-production ou de co-élaboration de la réponse sociale. Ces enjeux dépassent le clivage entre métier et profession et engagent la réflexion (...) sur le sens de l’action et fondamentalement ce que l’on nomme la clinique éducative. Les résultats mettent également en exergue une bonne collaboration entre les deux professions, les champs de tension qui apparaissent ainsi que les éléments qui l’influencent. (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)

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)

There is great skepticism about the admittance of expert normative ethics testimony into evidence. However, a practical analysis of the way ethics testimony has been used in courts of law reveals that the skeptical position is itself based on assumptions that are controversial. We argue for an alternative way to understand such expert testimony. This alternative understanding is based on the practice of clinical ethics.

A recent Supreme Court decision, Kumho Tire Co., Ltd. v. Carmichael, may have substantial impact on psychological expert testimony. Previous criteria for admissibility of scientific expert testimony now apply broadly to expert testimony, not just testimony narrowly grounded in scientific evidence. Judges will determine the relevance and reliability of all expert testimony, including that based on clinical experience or training. Admissible testimony will either satisfy the criteria established in Daubert v. Merrell Dow Pharmaceuticals, (...) Inc. or meet similarly rigorous standards judged appropriate to the particular field involved. Because psychological testimony has varied in its evidentiary basis, sometimes relying on science and otherwise on clinical training or experience, court decisions will gradually determine the precedent for its admissibility. We also discuss long-term consequences for the credibility of psychological expert testimony and the relation between psychology and law. (shrink)

Three clinical cases of very ill neonates exemplifying extreme ethical situations for nurses are interpreted through Arendt's concepts of life and natality, and Agamben's critique of bare life. Agamben's notions of form-of-life, as the inseparability of zoe/bios, and testimony are offered as the potential foundation of nursing ethics.

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)

The following is adapted from the testimony, on 6 June 1984, of Dr T. G. Krontiris before the U.S. House Science and Technology Subcommittee on Investigations and Oversight, on the subject of oncogene research. In a previous report (BioEssays, 1, 3), the testimony of Dr C. J. Sherr, describing the molecular biology of oncogene action was given. Here, Krontiris describes the challenges in applying the new5ndings in diagnosis and therapy.

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)

Many individuals who have mental disorders often report negative experiences of a distinctively epistemic sort, such as not being listened to, not being taken seriously, or not being considered credible because of their psychiatric conditions. In an attempt to articulate and interpret these reports we present Fricker’s concepts of epistemic injustice (Fricker, 2007, p. 1) and then focus on testimonial injustice and hermeneutic injustice as it applies to individuals with mental disorders. The clinical impact of these concepts on quality (...) of care is discussed. Within the clinical domain, we contrast epistemic injustice with epistemic privilege and authority. We then argue that testimonial and hermeneutic injustices also affect individuals with mental disorders not only when communicating with their caregivers but also in the social context as they attempt to reintegrate into the general society and assume responsibilities as productive citizens. Following the trend of the movement of mental health care to the community, the testimonies of people with mental disorders should not be restricted to issues involving their own personal mental states. (shrink)

The rapid advancement from single-gene testing to whole genome sequencing has significantly broadened the type and amount of information available to researchers, physicians, patients, and the public in general. Much debate has ensued about whether genomic test results should be reported to research participants, patients and consumers, and at what stage we can be sure that existing evidence justifies their use in clinical settings. Courts and judges evaluating the utility of these results will not be immune to this uncertainty. (...) As scholars increasingly explore the duty of care standards related to reporting genomic test results, it is timely to provide a framework for understanding how uncertainty about genetic and genomic tests influences evidentiary considerations in the court room. Here, we explore the subtleties and nuances of interpreting genetic data in an environment of substantial discord related to the value that individuals should place on genetic and genomic tests. In conjunction, we discuss the roles courts should play in qualifying experts, expert testimony, and genetic and genomic tests given the intricate and complex nature of genetic and genomic information. (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)

This collection addresses whether ethicists, like authorities in other fields, can speak as experts in their subject matter. Though ethics consultation is a growing practice in medical contexts, there remain difficult questions about the role of ethicists in professional decision-making. Contributors examine the nature and plausibility of moral expertise, the relationship between character and expertise, the nature and limits of moral authority, how one might become a moral expert, and the trustworthiness of moral testimony. This volume engages with the (...) growing literature in these debates and offers new perspectives from both academics and practitioners. The readings will be of particular interest to bioethicists, clinicians, ethics committees, and students of social epistemology. These new essays promise to advance discussions in the professionalization and accreditation of ethics consultation. (shrink)

This article offers a hybrid rhetorical-qualitative discourse analysis of the FDA’s 2011 Avastin Hearing, which considered the revocation of the breast cancer indication for the popular cancer drug Avastin. We explore the multiplicity of stakeholders, the questions that motivated deliberations, and the kinds of evidence presented during the hearing. Pairing our findings with contemporary scholarship in rhetorical stasis theory, Mol’s (2002) construct of multiple ontologies, and Callon, Lascoumes, and Barthe’s (2011) “hybrid forums,” we demonstrate that the FDA’s deliberative procedures elides (...) various sources of evidence and the potential multiplicity of definitions for “clinical benefit.” Our findings suggest that while the FDA invited multiple stakeholders to offer testimony, there are ways that the FDA might have more meaningfully incorporated public voices in the deliberative process. We conclude with suggestions for how a true hybrid forum might be deployed. (shrink)

Healthcare practitioners have access to a range of ethical guidance. However, the normative role of this guidance in ethical decision-making is underexplored. This paper considers two ways that healthcare practitioners could approach ethics guidance. We first outline the idea of deference to ethics guidance, showing how an attitude of deference raises three key problems: moral value; moral understanding; and moral error. Drawing on philosophical literature, we then advocate an alternative framing of ethics guidance as a form of moral testimony (...) by colleagues and suggest that a more promising attitude to ethics guidance is to approach it in the spirit of ‘critical engagement’ rather than deference. (shrink)

Research question and aimClinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020,...

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society (...) for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here. (shrink)

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict (...) or come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

In recent years, there has been a lively (bio-)ethical debate on the nature of moral expertise and the concept of moral experts. However, there is currently no common ground concerning most issues. Against this background, this paper has two main goals. First, in more general terms, it examines some of the problems concerning moral expertise and experts, with a special focus on moral advice and testimony. Second, it applies the results in the context of medical ethics, especially in the (...) clinical setting. By situating the debate in the clinical setting, one arrives at some important conclusions to better understand the relevant concepts and vital problems in the general discussion on moral expertise and the requirements of who counts as a moral expert. (shrink)

Patient or public involvement in health research is increasingly expected as a matter of policy. In theory, PPI can contribute both to the epistemic aims intrinsic to research, and to extrinsically valued features of research such as social inclusion and transparency. In practice, the aims of PPI have not always been clear, although there has been a tendency to encourage the involvement of so-called ordinary people who are regarded as representative of an assumed patient perspective. In this paper we focus (...) on the epistemic potential of PPI, using theoretical work in epistemology to develop a nuanced account of patients’ experiential knowledge and how this might contribute directly to conceptual development, hypothesis generation and data interpretation. We also consider how some features of health research pose barriers to this kind of epistemic contribution. Drawing on Miranda Fricker’s idea of testimonial injustice, we explore how disciplinary indicators of credibility in clinical and academic health research contexts might be wrongly applied to those involved in PPI, undermining their potential to contribute. Finally we argue for a range of strategies to maximize opportunities for patients to engage with research teams and make epistemologically significant contributions to research. (shrink)

The purpose is to identify common and distinctive features of concepts and methodology of the problem of subject within different discourses, implicitly or explicitly relevant to the definition of "clinical" mode of human existence. The research methodology combines techniques of discourse analysis and basic principles of historical and philosophical studies. Scientific novelty of the research lies in definition of the clinical philosophical discourse as a special communicative process, where utterances not only focus on disease syndromes, and reveal phenomenology (...) of inner experience of a pathological self, but also structure a certain type of sociality. Clinical discourse represents the space where the patient is treated not as a subject but as an object of disease. Ontology of clinical discourse prevails over ontology of disease, since its structures determine the notion of disease as such. Categorization of the disease, the idea of disease as a phenomenon subdued to professional authority leads to the idea of the need for patient's isolation from the natural environment and removing him to special social institutions. A great while authenticity of the individual had been determined through the testimony of others and manifestation of one's connection to others; then authenticity begun to establish trough the discourse, which individual was able or obliged to deliver about himself/herself. The clinicist doctrines share the intention to reduce the patient's self to its bodily dimension, while ignoring social determinants of psychological deviations. Conclusions of the study are summarized in the following positions: the current clinical discourse is based on the positivist-biological trend in humanitarian knowledge and it is the basis for the production and reproduction of medical and pharmaceutical repressive ideology; philosophical clinical discourse opens the possibility of overcoming the dominance of purely clinicist discourse; such a transformation is possible only after a paradigm shift in understanding the category of subject. (shrink)

Pediatricians provided expert testimony that, in the case of Baby K, provision of ventilator support goes beyond accepted standards of care for anencephalic infants and so is medically futile. This argument, however reasonable, does not persuade those who believe in the absolute value of even a fraction of human life. In Baby K, court records indicate that Ms. H, Baby K's mother, persistently adheres to the sanctity-of-life principle on religious grounds.While I think that quality-of-life considerations have a role in (...) medical decision making, those who reject such considerations must be respected. This article makes the following claims, on behalf of religious dissenters: the Baby K case should be interpreted in light of the freedom of religion guaranteed in the First Amendment ; religious beliefs should not be trivialized in clinical ethics, even if reason, not belief, is the language of the public forum; the time-honored free exercise clause is essential to the American experiment in liberty and should not be overridden in the name of a concept as vague as futility; and free exercise of religion deserves serious discussion in the futility debate, and significant religious accommodation must be included in any hospital or societal futility policies. In the concluding section, issues are raised regarding the balance between religious consideration and resource allocation. (shrink)

Pediatricians provided expert testimony that, in the case of Baby K, provision of ventilator support goes beyond accepted standards of care for anencephalic infants and so is medically futile. This argument, however reasonable, does not persuade those who believe in the absolute value of even a fraction of human life. In Baby K, court records indicate that Ms. H, Baby K's mother, persistently adheres to the sanctity-of-life principle on religious grounds.While I think that quality-of-life considerations have a role in (...) medical decision making, those who reject such considerations must be respected. This article makes the following claims, on behalf of religious dissenters: the Baby K case should be interpreted in light of the freedom of religion guaranteed in the First Amendment ; religious beliefs should not be trivialized in clinical ethics, even if reason, not belief, is the language of the public forum; the time-honored free exercise clause is essential to the American experiment in liberty and should not be overridden in the name of a concept as vague as futility; and free exercise of religion deserves serious discussion in the futility debate, and significant religious accommodation must be included in any hospital or societal futility policies. In the concluding section, issues are raised regarding the balance between religious consideration and resource allocation. (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)

Australian immigration detention has been called state sanctioned abuse and a crime against humanity. The Australian healthcare community has been closely involved with these policies, calling for their reform and working within detention centres to provide healthcare. As well as having a devastating impact on health, immigration detention changes the scope and nature of healthcare, with its delivery described as a Sisyphean task. In this article I will explore the guidance that is available to clinicians who work within detention centres (...) and argue that codes, guidelines and positions statements provide little help in relation to ethical decision making. First I will outline guidance that can be found in codes of ethics and position statements, focusing on particularly relevant principles, such as advocacy, clinical independence and the clinicians’ relationship to human rights. I will then highlight the disparity between this guidance and the delivery of healthcare within detention by drawing on the testimony of clinicians who formerly worked in these environments. While this disparity should be cause for alarm and at a minimum call into question how codes and positions statements are being used, there are more fundamental reasons why codes and position statements fail to provide guidance in these circumstances. I will outline a more general criticism of codes of ethics and use this to suggest a way forward, including looking beyond codes and position statements to guide action within Australian immigration detention. (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)

Australian immigration detention has been called state sanctioned abuse and a crime against humanity. The Australian healthcare community has been closely involved with these policies, calling for their reform and working within detention centres to provide healthcare. As well as having a devastating impact on health, immigration detention changes the scope and nature of healthcare, with its delivery described as a Sisyphean task. In this article I will explore the guidance that is available to clinicians who work within detention centres (...) and argue that codes, guidelines and positions statements provide little help in relation to ethical decision making. First I will outline guidance that can be found in codes of ethics and position statements, focusing on particularly relevant principles, such as advocacy, clinical independence and the clinicians’ relationship to human rights. I will then highlight the disparity between this guidance and the delivery of healthcare within detention by drawing on the testimony of clinicians who formerly worked in these environments. While this disparity should be cause for alarm and at a minimum call into question how codes and positions statements are being used, there are more fundamental reasons why codes and position statements fail to provide guidance in these circumstances. I will outline a more general criticism of codes of ethics and use this to suggest a way forward, including looking beyond codes and position statements to guide action within Australian immigration detention. (shrink)

Ibogaine is a hallucinogenic alkaloid, derived from Tabernanthe iboga, a plant unique to the rainforests of West Africa. Its traditional use as an epiphanic sacrament in local magico-religious practice inspired its appropriation by Western drug addicts by whom it is now hailed as both a catalyst of psychospiritual insight and an effective alleviator of cravings and withdrawal. While scientific and early clinical studies confirm its role in reducing physical withdrawal and craving, debate continues concerning the significance of its “visionary” (...) properties. An analysis of many addicts’ testimonies of recovery, however, places the visionary experience at center stage. I set out to understand mechanisms of transformation and healing, via a comparative phenomenological exploration of this experience, through the opposing lenses of psychoanalysis and cultural constructivism. I propose that at the heart of the healing encounter is a culturally shaped creative journey to an imaginal unspoilt state in personal or collective history. How this experience is recovered and integrated into life is critically considered. I argue a secular account is vital as the ibogaine scene strives toward social and medical legitimacy. If and how such a framework can sit alongside spontaneously emergent spiritual and religious idioms and experience will also be tentatively explored. (shrink)

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

Bioethics is not merely a theoretical discipline but a practice as well. Indeed, bioethics is a sort of moral trade. Bioethicists serve on ethics committees, give expert testimony to courts, provide guidance for healthcare policy, and receive payment for these services. The difficulty is that their role as experts able to guide clinical choice and public policy formation is brought into question by the diversity of moral understandings regarding central moral issues at the heart of the culture wars (...) in healthcare. The disconfirmation of the expert role of bioethicists by their apparent actual role as partisans of particular moral schools and perspectives could be set aside, were there an avenue to moral consensus, a door to a common moral vision to guide this new profession of moral experts. This brief article addresses the hunger for consensus in bioethics, its impossibility with respect to the controversial issues that mark the field, and the inclination nevertheless to deny this manifest diversity by appeals to a consensus that could allow bioethicists to function as ethics experts able substantively to guide clinical choices and public policy. (shrink)

Discussions of the nature or possibility of moral expertise have largely proceeded in atheoretical terms, with little attention paid to whether moral expertise depends on theoretical knowledge of morality. Here I argue that moral expertise is more theory-dependent than is commonly recognized: Moral expertise consists, at least in part, in knowledge of the correct or best moral theory, and second, that knowledge of moral theory is essential to moral experts dispensing expert counsel to non-experts. Moral experts would not be moral (...) experts absent knowledge of moral theory, nor could they play the testimonial role we would expect them to play in moral inquiry and deliberation absent such knowledge. (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)

Historically, the standard of care in medical negligence provided considerable scope for external evaluation of clinical judgment. Under the Bolam test, however, determining the standard was seen by the courts as essentially a matter for the medical profession, to be resolved by expert testimony with minimal court scrutiny. In recent years, courts have become more willing to probe such testimony and challenge the credibility of medical experts, although they would very rarely override clinical judgment. The House (...) of Lords' decision in Bolitho may be construed as inviting courts to reach their own conclusions on the reasonableness of clinical conduct, along standard risk–benefit lines, after having made their own assessment of the expert opinion. Closer scrutiny of such opinion is the more welcome in the light of current concerns about partisanship in expert testimony. (shrink)

. On June 13, 2013, the Supreme Court issued a unanimous decision in Association for Molecular Pathology v. Myriad Genetics, holding that a naturally occurring DNA segment that has merely been “isolated” is not patent eligible, and effectively overturning a longstanding policy that had allowed for patents to be issued on thousands of human genes. Drawing largely on the expert testimony and arguments presented during the court proceedings, this paper provides an overview of the discovery and patenting of the (...) BRCA1 and BRCA2 genes at issue in the case, the impacts of gene patents on biomedical research and innovation and clinical practice, and the legal analysis presented by the plaintiffs throughout the case for how patents issued on genes violate the Patent Act and the U.S. Constitution. Finally, it discusses how the Court’s decision in this case marked an extraordinary victory not only for the plaintiffs directly involved, but more generally for women, patients, researchers, civil liberties, and the future of medicine. (shrink)

Smartphone apps might offer a low-threshold approach to the detection of mental health conditions, such as depression. Based on the gathering of ‘passive data,’ some apps generate a user’s ‘digital phenotype,’ compare it to those of users with clinically confirmed depression and issue a warning if a depressive episode is likely. These apps can, thus, serve as epistemic tools for affected users. From an ethical perspective, it is crucial to consider epistemic injustice to promote socially responsible innovations within digital mental (...) healthcare. In cases of epistemic injustice, people are wronged specifically as epistemic agents, i.e., agents of the production and distribution of knowledge. We suggest that epistemic agency relies on different resource- and uptake-related preconditions which can be impacted by the functionality of passive self-tracking apps. We consider how this can lead to different forms of epistemic injustice (testimonial, hermeneutical, and contributory injustice) and analyze the influence of the apps’ use on epistemic practices on an individual level, in mental healthcare settings, and on the structural level. (shrink)

We sometimes seek expert guidance when we don’t know what to think or do about a problem. In challenging cases concerning medical ethics, we may seek a clinical ethics consultation for guidance. The assumption is that the bioethicist, as an expert on ethical issues, has knowledge and skills that can help us better think about the problem and improve our understanding of what to do regarding the issue.The widespread practice of ethics consultations raises these questions and more:What would it (...) take to be a moral expert?Is anyone a moral expert, and if so, how could a non-expert identify one?Is it in any way problematic to accept and follow the advice of a moral expert as opposed to coming to moral conclusions on your own?What should we think and do when moral experts disagree about a practical ethical issue?In what follows, we address these theoretical and practical questions about moral expertise. (shrink)

Literary accounts of traumatic events can be more informative and insightful than personal testimonials. In particular, reference to works of literature can give us a more vivid sense of what it is like to receive a devastating diagnosis. In turn this can lead us to question some common assumptions about the nature of autonomy, particularly for patients in these circumstances. The literature of concentration camp and labour camp experiences can help us understand what it is like to have one's life-plans (...) altered utterly and unexpectedly. Contrary to common views of autonomy which have difficulty in characterising autonomous action when long-standing assumptions are suddenly lost, these examples show that autonomy is possible in these circumstances. We need a theory of autonomy which can deal with traumatic events and is useful in the clinical context. (shrink)

Modern health care relies extensively on the use of technologies for assessing and treating patients, so it is important to be certain that health care technologies perform their professed functions in an effective and safe manner. Philosophers of technology have developed methods to assign and evaluate the functions of technological products, the major elements of which are described in the ICE theory. This paper questions whether the standard of evidence advocated by the ICE theory is adequate for ascribing and assessing (...) technologies employed in health care. The paper proposes that the general problem with the standard of evidence embodied in the ICE theory is too permissive for assessing medical technologies, in that it does not take into account the relative benefit and harm of medical technologies in ensuring safe functional performance in patients. The paper illustrates how evidence-based medicine has demonstrated the value of clinical research methods, including observational studies, randomized and non-randomized clinical trials, and formal techniques, such as meta-analysis, to measure therapeutic effectiveness. I argue, therefore, that evidence from clinical research studies should take precedence over the testimonial evidence and other types of non-clinical evidence, in providing justification for health technologies. (shrink)