In this paper we argue that ill persons are particularly vulnerable to epistemic injustice in the sense articulated by Fricker (Epistemic injustice. Power and the ethics of knowing. Oxford University Press, Oxford, 2007). Ill persons are vulnerable to testimonial injustice through the presumptive attribution of characteristics like cognitive unreliability and emotional instability that downgrade the credibility of their testimonies. Ill persons are also vulnerable to hermeneutical injustice because many aspects of the experience of illness are difficult to understand and communicate and this often owes to gaps in collective hermeneutical resources. We then argue that epistemic injustice arises in part owing to the epistemic privilege enjoyed by the practitioners and institutions of contemporary healthcare services—the former owing to their training, expertise, and third-person psychology, and the latter owing to their implicit privileging of certain styles of articulating and evidencing testimonies in ways that marginalise ill persons. We suggest that a phenomenological toolkit may be part of an effort to ameliorate epistemic injustice.
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This scene was observed by one of the authors (Carel), whilst shadowing a paediatrician consultant at a UK hospital (details redacted to ensure patient confidentiality).
These discourses may vary greatly; we are not suggesting that there is only one such discourse.
Perhaps it is also a sort of epistemic injustice to complain that a person’s style of testimony is no good (inarticulate, etc.) but do nothing to ameliorate this (e.g. by critically reflecting upon the reasons that one has for using these unhelpful formats rather than others). Epistemic injustice might arise because (a) one buys into epistemically unjust structures or because (b) one fails to challenge those structures.
For an engaging discussion of the relationship between epistemic injustice, standpoint, and solidarity, see Medina (2012).
More generally, we are not denying the existence of epistemic asymmetries, but call for discussion on how these should be managed in those cases where they do exist and where clinicians are aware of them. We would agree that a teacher who dismisses students or talks down to them, on the basis of their epistemic inferiority, is not a very good teacher. Dialogical openness is compatible with epistemic asymmetry and can serve to address the imbalance. Distinguishing the stance adopted by a clinician from the perceived and actual epistemic status of claims made by clinician and patient might be useful. We thank an anonymous referee for emphasising this point.
The Baron Münchausen (1720–1797) was a German war hero who travelled around Germany describing his military adventures. There is no evidence that he feigned disease or duped people into caring for him. As Feldman (2004) notes, Rudolph Erich Raspe appropriated the Baron’s name for the title of a 1785 pamphlet of outrageous and patently false tales, Baron Munchausen’s Narrative of His Marvelous Travels and Campaigns in Russia.
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These examples are taken from responses to a query we posted on a patient mailing list in 2012.
Self-censoring is another form of epistemic injustice, in which the negative stereotyping is internalised by the patient herself, leading her to downgrade her own testimony. .
A vivid and tragic example is the series of systematic failures which led to the death of hundreds of patients, uncovered by the Mid Staffordshire NHS Foundation Trust Public Inquiry, led by Sir Robert Francis in the UK. See: http://www.midstaffspublicinquiry.com/report (accessed on 10 June 2013).
The fact that the medical community has these forms of social and epistemic power does not, of course, entail that they always exercise that power in a robustly procedural manner (see Kidd forthcoming a).
Many religious persons who experience depression will often consult persons they recognise as having spiritual authority—priests, say—as well as to psychiatrists and other mental health professionals (cf. Scrutton forthcoming and Kidd forthcoming b).
The case of some mental disorders, e.g. psychosis, would be different. In these cases the patient may be considered altogether irrational and unable to make true assertions at all.
These comments were collected during three consultative sessions: one with a group of GPs took place on 14 June 2012 and two patient group sessions took place on 14 and 21 September 2012, all in Bristol, UK.
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This paper was written during Havi Carel’s British Academy Fellowship. She is grateful to the British Academy for enabling this period of research leave. Ian James Kidd wrote this paper during an Addison Wheeler Fellowship. We are also grateful to Miranda Fricker for her encouragement and to the men and women who generously shared their illness testimonies with us.
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Carel, H., Kidd, I.J. Epistemic injustice in healthcare: a philosophial analysis. Med Health Care and Philos 17, 529–540 (2014). https://doi.org/10.1007/s11019-014-9560-2
- Epistemic injustice
- Patient experience
- Patient toolkit