In a recent Editorial, Kious, Lewis, and Kim (Reference Kious, Lewis and Kim2023) put forward the claim that psychiatrists should resist calls to integrate concerns about epistemic injustice into their practice as this concept not only fails to add significantly to the current professional standards but would also lead to deleterious clinical outcomes. We believe their claim is mistaken, as it arises from several misconceptions about both the nature of epistemic injustice and its clinical relevance. First, epistemic justice is conflated with what the authors term ‘a quest for social justice’ that could ‘sideline principles of good clinical reasoning’ (Kious et al., Reference Kious, Lewis and Kim2023, p. 4). Second, the claim about the impracticality and/or counterproductivity of epistemic injustice as a critical tool within psychiatric practice reflects a series of misconceptions about the normative framework from which this concept derives, so the standards they evaluate it against are ill-chosen. Pace Kious et al., fostering epistemic justice in any area of knowledge and inquiry could not – unwittingly or otherwise – inhibit the consideration of relevant evidence, restrict sound argument or facilitate the casual treatment of testimonies at face value. Third and final, this claim obfuscates some immediate ways in which a focus on epistemic justice as an integral goal will strengthen psychiatric practice according to its own internal standards. The following discussion will expand on these three critical points in turn.
Doing justice to ‘epistemic justice’
Kious et al. seek to respond to perceived allegations that psychiatry is epistemically unjust since many psychiatrists perpetrate epistemic injustice against their patients (Reference Kious, Lewis and Kim2023, p. 2). The kind of injustice under consideration is testimonial. It occurs when, for instance, a psychiatrist treats a psychiatric patient as less credible an informant merely in virtue of their being a psychiatric patient. So, the focus is on truthful patient reports that have been discarded by clinicians as unreal because they are interpreted as a symptom of a mental disorder, e.g. a patient with delusions of grandeur is presumed to be delusional when he truthfully reports that he is related to a high-ranking foreign official.
Kious et al. assume that cases such as the above are the evidence base for the perceived allegations that psychiatry is unjust and proceed to demonstrate that, for all that we know, such cases, if at all problematic, might be unavoidable accident, not expressions of injustice. In so doing, the authors fail to appreciate that these cases might be used to illustrate some normative and theoretical arguments for the relevance of epistemic justice to psychiatry. The validity of such arguments would not rest on how often a particular illustration happens to be replicated or not in clinical practice.
This conflation between illustrative material and evidence base indicates a graver misconception about the point of achieving epistemic justice in psychiatry. As Kious et al. (Reference Kious, Lewis and Kim2023, p. 4) point out: ‘In an environment where epistemic justice is emphasized, we worry that the scales could be tilted too far away from truth-finding’. This worry derives from the authors' apparent inability to grasp that epistemic justice has an inherent epistemic dimension: it provides us with the critical tools to investigate and counteract the ways in which unacknowledged social prejudices, if left unchecked, would distort, undermine and prevent both knowledge production and its communication and translation into practice. The particular attention to input from vulnerable and underprivileged contributors serves the purpose of removing inappropriate epistemic barriers while reinforcing and applying consistently appropriate checks to counter unmerited epistemic privilege. For both undue epistemic barriers and undue epistemic privilege lead to universal loss of knowledge, where everyone is adversely affected. Examples include core social practices, such as holding each other responsible where irrelevant modes of reasoning might impact our collective deliberations due to social prejudice, thus leading to collective loss of vital insights (Radoilska, Reference Radoilska2021). In this context, counselling psychiatrists to steer away from epistemic justice as ‘antithetical to appropriate clinical scepticism’ (ibid.) is extremely unfortunate, leading to missed opportunities to foster shared knowledge and understanding, with direr practical implications for unduly underprivileged, but direr epistemic implications for unduly privileged contributors.
Who's afraid of epistemic justice?
The lack of recognition for the epistemic core of epistemic justice and respectively injustice has a further unfortunate upshot, the sharp contrast between a moral wrong and just a mistake that Kious et al. (Reference Kious, Lewis and Kim2023, p. 3) employ to show that many of the instances of testimonial injustice in psychiatry that their opponents identify can be interpreted as honest mistakes and should therefore be deemed as irrelevant to questions of epistemic (in)justice. The thought seems to be that honest mistakes can occasionally result from following the correct procedures and forming a clinical judgement on the basis of the evidence available at a particular moment in time. Later on, this evidence might be superseded, thus retrospectively giving reason for a very different clinical judgement. Yet, the discovery of such a mistake – if indeed it can be called that – is no ground for abandoning evidence-based reasoning in one's future clinical practice, which the authors wrongly assume is the only way to secure testimonial justice for psychiatric patients (see, however, Medina, Reference Medina2013; Radoilska, Reference Radoilska2020).
Yet, as shown earlier, a commitment to epistemic, including testimonial justice does not require anyone to abandon evidence-based reasoning in these or any other cases. For issues of testimonial injustice do not arise from the fact that we are somehow constrained by the relevant evidence as opposed to our interlocutors' wishes that we believe them anyway. Instead, these issues derive from discounting relevant evidence by, for instance, excluding some sources as unreliable without good reason. Importantly, testimonial injustice is typically not committed intentionally. In this sense, it may be qualified as ‘just a mistake’ as long as we do not lose sight of it being systematic and an insidious moral wrong as well as a grievous epistemic harm. This is what makes epistemic injustice extremely difficult to address without any critical tools specifically developed for this purpose and drawing on both expertise by experience and a wide range of disciplines, including but not limited to epistemology, ethics, law, economics and sociology.
Why should psychiatry be epistemically just?
As a branch of medicine, psychiatry understands the risks of bias, and adopted the phenomenological turn to engage the subjectivity that underlies psychopathology while minimising the effects of prior prejudice. When we ‘put the world in brackets’, we assess subjective phenomena in their own terms, with our own reality also considered in terms of our subjectivity. Ever since Aristotle, we have understood justice to mean treating equal things equally and unequal things unequally, which implies we should seek reliability and validity in the application of values as much as we do when we adduce factual evidence. Epistemic justice tries to address the very question Kious et al. elide, which is, how can we reduce bias in values? Evidence-based models of medical decision-making explicitly integrate values into the decision process (Hunink et al., Reference Hunink, Glasziou, Siegel, Weeks, Pliskin, Elstein and Weinstein2001), but without epistemic justice we do not have a robust methodology to limit bias in how values are included and integrated with factual evidence. The facts do not disappear when we turn to values, but instead are re-created as testimony, and Kious et al. do not consider that expert opinion is expert testimony, which should be evaluated differently from naïve testimony, even though both have a validity and reliability of their own. By failing to do so, they draw the wrong conclusion that the processes of establishing epistemic justice silence professionalism. That would be hermeneutic injustice, which Kious et al. do not discuss.
Clearly, testimonial values may conflict. Within biomedical ethics, Beauchamp and Childress (Reference Beauchamp and Childress1994) have discussed this extensively and provide a solution, if we consider that testimonial justice towards patients is captured by their principle of respect for autonomy. They point out that, in practice, conflict between principles is the rule, rather than the exception, when principles are accurately specified in terms of real circumstances. They recommend a process of dialectic and balancing to find an optimal solution, which however will depend on the values recruited, and how they are weighted. Epistemic justice is about developing a methodology that can address those questions. So, it is central to the practice of good medicine, unlike Kious et al. claim.
Conclusion
We have shown that Kious et al. have misunderstood epistemic justice, and hence its value to psychiatry. It is not synonymous with social justice, nor does it deny the value of expertise. Instead, the conceptual tools associated with it offer a method for improving reliability and validity in the realm of values. It is now accepted that practice should be based on more than mere opinion. Working with epistemic justice enables us to adduce evidence to support values which we have previously only been able to assert, frequently in the face of contrary ones. So, epistemic justice represents an advance in our methodology of values, and should become as much part of psychiatric culture as advances in statistical theory or brain visualisation.
