Aug 21, 2023Liked by Awais Aftab

Personal anecdote:

Me: Propavan doesn't work for me anymore.

Psychiatrist: Of course it does, people don't build up a tolerance to Propavan.

Me: But I used to fall fast asleep from half a pill. Now I take two, and still lie awake all night.

Psychiatrist: No, that's not how Propavan works. You don't build up a tolerance to Propavan, they work just as well after many years as they did initially.

Me: -----

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Aug 21, 2023Liked by Awais Aftab

Very well put!

If there's no need to discuss epistemic injustice in particular, because we already have the broader concepts of good/bad clinical practice, why stop there? Let's ditch all that talk about Good Clinical Practice and stick to ETHICS! Since ethics covers all of human life, it also covers clinical encounters. We should just ask ourselves whether a clinician behaved ethically or unethically with their patients, no need for all these special concepts! (Sarcasm.)

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On a possibly related note, from recent Swedish news: A patient in a psychiatric ward tells the staff that a squirrel got into their room. They have to "work hard" to convince the staff that this is really the case. After staff realizes that a panicking squirrel really is running around all over the place, they call the police (!) who explains that squirrels aren't their area. The police still puts them in touch with some wildlife center who managed to help them out.

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Dr. Aftab is surely right that psychiatrists ought not take an antagonistic stance toward the concept of

epistemic justice. Equally, psychiatrists need to recognize that the patient's narratives and experiences should be heard and considered with open-minded respect and contextually-appropriate credence.

That said--as per my earlier comments in this forum [see "for context"], I am not sure that the construct of "epistemic justice" or "injustice" is conceptually or logically coherent; or that it is needed to carry out sensitive, empathic and clinically valid psychiatric treatment.

A good example is provided by Prof. Jeppsson and her experience with a psychiatrist who dismissed her report that "Propavan doesn't work for me anymore." Propovan [propiomazine] is a sedating antihistamine with a very complex receptor blocking profile [1], and is structurally related to promethazine and the phenothiazines. Tolerance to sedating antihistamines is well-known to experienced psychiatrists and sleep specialists; e.g., "Tolerance to sedating antihistamines can develop with long-term use, meaning higher doses are required to achieve sedation." [2]

So, the psychiatrist who insisted that, "You don't build up a tolerance to Propavan" was almost

certainly wrong on the pharmacological facts, and compounded the error by being obstinate and dismissive. Do we really need to invoke this highfalutin term--"epistemic justice"--to point out that psychiatrists ought to know whereof they speak, and should treat their patients' reports with respect and humility? Or is the term "epistemic justice" really an example of "talking on stilts"? By way of Occam's Razor, I have my misgivings!


Ronald W. Pies, MD

1. https://go.drugbank.com/drugs/DB00777

2. https://bspss.org/wp-content/uploads/2022/09/BSPSS-Insomnia-Factsheet.pdf

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Aug 21, 2023·edited Aug 22, 2023Author

There is nothing conceptually or logically incoherent about the notion of epistemic injustice. SEP characterizes it as a form of recognitional injustice https://plato.stanford.edu/entries/justice/ and there is a wealth of philosophical literature on it, and AFAIK the philosophical coherence of the concept isn't really in dispute among philosophers. The concept also didn't emerge in the context of medicine or psychiatry, and was only applied to it subsequently.

I don't think that psychiatrists need to explicitly invoke the concept to carry out, as you say, sensitive, empathic and clinically valid psychiatric treatment. Clinicians can do fine without, just as they can do fine without many other philosophical concepts. But the concept is available to us to clarify certain forms of injustice that can arise in clinical settings. It is also the case that many instances of epistemic justice involve other forms of poor clinical reasoning and vices such as obstinacy. What makes epistemic justice distinctive here is the focus it offers on dynamics of knowledge production, both when it comes to the individual clinical encounter as well as broadly in the clinical and scientific communities generally (on hermeneutic justice in psychiatry: https://www.tandfonline.com/doi/full/10.1080/00071773.2022.2031234 ). Hermeneutic justice is linked, in my mind, to other approaches in philosophy of science, such as standpoint epistemology and social objectivity, that focus on the dynamics of how knowledge is generated, critiqued, and accepted. All that is very difficult to do philosophically if we restrict ourselves to talk of "treating patient reports with respect and humility."

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