What does epistemic justice add to good clinical practice?

Here's another attempt at answering this question

For context, see:

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“What does epistemic injustice add to existing standards of good clinical practice?” Kious et al. ask in their response to letters (including mine) in Psychological Medicine. So I will attempt another answer here.

Good clinical practice (GCP) isn’t something fixed or well-defined. There isn’t, for example, an authoritative manual of GCP that we can refer to. There are many different, overlapping codes of ethics and practice guidelines/recommendations from many different organizations. There are also standards of practice as they exists in many different institutions, disciplines, and training programs, often implicitly understood or transmitted via hidden curricula.

GCP consists of various methodological instructions to ensure clinical rigor, such as taking an adequate history, obtaining collateral information, doing a physical examination, etc. It also includes certain principles and ideals, such as respect for a person’s autonomy. These principles and ideals are enmeshed with our best ethical understanding of issues relevant to medicine, and as our moral understanding evolves, so does GCP (what passed for “good psychiatric practice” looked very different when homosexuality was considered a disorder, e.g.). GCP is also dependent on our current medical knowledge and how to best address clinical suffering, in the form of various practice guidelines, which are also updated continually.

Here’s the basic question:

Does GCP include respect for the patient as a knower? That is, does GCP include the ideal that patients should not be wrongfully discredited as knowers.

If respect for the patient as a knower is a part of GCP, then testimonial justice is a component of GCP, and by making testimonial justice explicit as an ideal, we clarify an important aspect of GCP. If GCP doesn’t include respect for the patient as a knower, then testimonial justice adds to GCP by articulating this as an explicit ideal.

Kious et al. write: “our view is that simply by trying to practice good medicine, which requires good clinical reasoning, psychiatrists can avoid being epistemically unjust.” Ok, but that conflates methodological instructions for clinical practice (take a detailed history, obtain collateral information, etc.) with the ideals that these instructions are intended to safeguard. Psychiatrists may very well be able to avoid being epistemically unjust by following good clinical reasoning, but that says nothing about whether testimonial justice adds to GCP or not.

A parallel with racism and sexism would be instructive here. Psychiatrists may very well be able to avoid being sexist or racist by following good clinical reasoning, but it would be very odd to ask “What does racial justice add to good clinical practice?” or to assert that we don’t really need to give racial justice much importance as long as we follow good clinical practice.

There are, furthermore, good reasons not to simply rely on “existing standards” of GCP.

The methodological instructions of GCP are easily rationalized in service of the biases of the clinician. What constitutes an adequate history or whether collateral information was necessary depends on the judgement of the clinician, and clinicians — constrained by time and resources — often have to settle for incomplete information. A clinician acting on biases would in most instances be able to justify their decision as reasonable within a certain context.

Two, standards of medical care and practice recommendations are fallible and subject to constant updating, and one of the ways in which physicians can recognize areas of deficiency are by paying attention to — and taking seriously— the testimonies of their patients. For instance, reports of severe and protracted withdrawal reactions with antidepressants weren’t taken (and still aren’t) seriously by many physicians, leading to delay in official recognition. Patient testimony is an important source of information which can be used to identify gaps in GCP, and this is particularly so when patient testimony conflicts with current medical knowledge, and we can’t do that if we blindly override patient testimony.

Kious, et al. write: “We agree that EI is, when truly present, wrong; we simply reject the idea that it is often useful to say so, because what is wrong in these scenarios already has a perfectly adequate label: bad clinical reasoning.” Again, bad clinical reasoning is not mutually exclusive with epistemic injustice, or sexism, or racism, or sanism, or any other form of discrimination, and we should not confuse methodological instructions for clinical practice with the ideals we should uphold in clinical practice.

Kious, et al. object to my parallels with epistemic discrimination based on sex and race, and write: “recall that in our original essay we observed that, while epistemic marginalization on the basis of race is virtually always wrong, since race is irrelevant to epistemic ability, the same is not true for having a psychiatric diagnosis; having a psychiatric diagnosis often is epistemically relevant.”

I accept that mental illness is often epistemically relevant, and that skepticism towards patient testimony is warranted in some instances of mental illness in ways it is not warranted when it comes to gender and race. However,

a) We are still justified in drawing a parallel between racial justice and epistemic justice when it comes to standards of GCP, e.g. when I point out that it is rather odd to ask, “What does racial justice add to good clinical practice?”. Because clinical skepticism is justified in some instances of mental illness doesn’t say anything about whether epistemic justice adds to, or clarifies an important element of, GCP.

b) As many clinicians and patients are aware, skepticism towards testimonies of patients with psychiatric diagnoses can be taken too far. It is easy for clinicians to get jaded in the course of clinical work and to dismiss patients as malingerers, attention-seekers, hysterical, etc. Testimonial justice offers a corrective ideal. A fundamental respect for patient testimony ensures that even when we practice appropriate clinical skepticism in psychiatry, that skepticism is kept in check by a counterbalancing force.

I will end by restating:

“The central message I wish to convey is that the epistemic justice is an essential component of good psychiatric practice and there is no reason for the attitude of psychiatrists toward this framework to be one of antagonism. Medicine and psychiatry, practiced virtuously, are on the side of epistemic justice.” (Aftab, 2023)

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