1 Comment

This is an important and interesting discussion, Awais--so thank you! Having read the Kious et al piece and your rejoinder, I have just a few observations and concerns.

1. I find the term "epistemic injustice" problematic from the standpoint of conceptual categories. The term seems to conflate two separate branches of philosophical discourse: epistemology and ethics. The first has to do with what we know or can validly claim to know; the second, with what is "right", "just" or "moral." There are, of course, connections and "bridges" between these two categories--for example, can we ever "know" whether or not there is an objective standard of moral behavior?--but I am still concerned that the term "epistemic injustice" entails a category mistake of the sort Gilbert Ryle

warned against. To put it in crude terms: is not the term "epistemic injustice" a bit like the term

"geometrical dishonesty"? Triangles are neither honest nor dishonest. Knowledge claims are neither just nor unjust--though they may be unfounded.

2. It seems to me that the debate is less about "epistemic injustice" than about a careful, fair-minded, and respectful approach to what patients tell us. I suspect few psychiatrists would argue against that stance. But being careful, fair-minded and respectful does not compel us, reflexively or credulously, to "believe patients."

3. As you rightly point out, Awais, "Beliefs should be attributed the credence that is merited." I would add, "No more and no less." And what is "merited" depends crucially on the psychiatric context of the patient's beliefs, and upon the psychiatric diagnosis. If a patient is diagnosed with delirium and insists that a vicious lion is present in the emergency room, that belief does not merit the "credence" that we would attach to the same patient's saying, "I feel sick to my stomach", or "The nurse was rude to me."

There is no prima facie reason to diminish the credibility of these two claims, merely because the patient is delirious.

3. A psychiatrist who insists (against the best available evidence) that a patient's depression is nothing more than a meaningless chemical imbalance is simply being an incompetent and ignorant psychiatrist. We know on the basis of decades of research that depression has manifold

"meanings" to our patients, relating to self-esteem, self-blame, guilt, the opinions of significant others, etc. I do not see any need to invoke the term "epistemic injustice" to characterize the hypothetical psychiatrist's narrow-minded claim. And I would add that very few psychiatrists, in my forty years of experience, would hold to such a simplistic view of depression.

4. Notwithstanding my concerns with the term "epistemic injustice", it is the case that psychiatric patients are often dismissed in utterly inappropriate ways. One of my teachers in residency used to say, for example, that "Hysteria is the last diagnosis a patient will ever receive"--because any complaint can be dismissed as "hysterical." So we need to be very careful in avoiding this sort of prejudice, and being scrupulous in our diagnostic efforts.

Thanks again for the interesting discussion!

Ronald W. Pies MD

Expand full comment