In their editorial, Kious, Lewis, and Kim (Reference Kious, Lewis and Kim2023) make the startling and provocative claim that psychiatrists should resist calls for changes to clinical practice based on critiques centered around the concept of epistemic injustice. While disagreeing with the authors on many points they raise, I welcome the opportunity it presents to clarify the relationship between epistemic justice and medical practice. 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.

It is vital to note at the outset that Kious et al. are primarily focused on ‘testimonial injustice’ and that too in the circumscribed sense of the individual clinical psychiatric encounter, and yet the impression they generally convey, especially in the abstract which offers no qualification at all on the restricted nature of their critique, is that of a broad and sweeping criticism that challenges the clinical relevance of the framework of epistemic justice itself. Whatever the merits of their critique, this framing is unjustified. This is especially so when we consider that the implications of hermeneutical justice are far more radical for psychiatric practice than testimonial justice, and these implications have recently been productively theorized and debated in the philosophy of psychiatry community (e.g. Aftab, Reference Aftab2022; Knox, Reference Knox2022; Ritunnano, Reference Ritunnano2022).

Kious et al. show a remarkable discrepancy between how they approach matters of epistemic justice when it comes to psychiatric patients v. how they approach instances of epistemic injustice centered around gender or race. They recognize the relevance of racism and sexism but decline to extend the same attitude to epistemic discrimination against individuals with mental illness. A classic clinical scenario of epistemic injustice relevant to psychiatry, which I suspect even Kious et al. would accept as problematic on epistemic grounds, is that of an individual with psychiatric diagnosis who presents with a serious physical complaint in a medical setting and their complaint is dismissed as ‘psychosomatic’ or attributed to anxiety, depression, etc., rather than taken seriously and investigated because of their status as a psychiatric patient. It is bad clinical care, no doubt, but it is also a clear example of epistemic injustice.

This makes evident what Kious et al. appear to have difficulty understanding. Epistemic justice is not something that is outside of good clinical care. Good clinical care is inclusive of our best ethical practices; just as good clinical care cannot be racist or sexist, good clinical care cannot be epistemically unjust. We cannot appeal to good clinical care to justify ignoring epistemic justice because epistemic justice clarifies a vital aspect of what good clinical care ought to be.

Kious et al. construct a strawman when they construe critiques based on epistemic justice as asserting that ‘psychiatric practice is epistemically unjust.’ I believe we as psychiatric clinicians ought to be less defensive about the claim that ‘psychiatrists often perpetrate testimonial injustice’ and more concerned with the claim that psychiatrists can very well be, and at times are, guilty of testimonial injustice, just as psychiatrists can very well be, and at times are, guilty of sexism, racism, transphobia, homophobia, ageism, and sanism. The fact that we are capable of such forms of discrimination mandates that we exercise relevant vigilance.

Finally, Kious et al. appear to be driven by the fear the epistemic justice obligates us to ‘believe everything patients tell us.’ It would indeed be antithetical to appropriate clinical skepticism if that were the case, but that is in fact not the case. Epistemic justice does not obligate us to believe everything patients tell us, and I am not aware of any prominent epistemic justice theorist who has said so. Epistemic justice does not demand that we attribute to a belief a probability of being correct that deviates from our best epistemic assessment of it. Beliefs should be attributed the credence that is merited. Epistemic injustice is concerned with deviations from our usual epistemic standards when dealing with a certain marginalized class. It doesn't ask us to give up our usual epistemic standards.

Although ‘believe patients’ does not exist as a popular slogan or a rallying cry in the public consciousness, suppose for a moment that it did. The appropriate analogy here would be with the feminist injunction of ‘believe women.’ Critics, of course, make very similar complaints that this obligates us to believe everything that women tell us, which is antithetical to appropriate skepticism that is warranted in any legal prosecution, and the appropriate feminist response is: no, it doesn't. Here is how the philosopher Amia Srinivasan explains it:

‘Believe patients’ then, if it were to exist as an injunction, would similarly function as a corrective norm, a gesture of support for those individuals of marginalized classes (women, racial minorities, psychiatric patients, etc.) whose testimonies are treated in clinical settings – if not frequently, then often enough – as if they were inherently unreliable.

Kious et al. themselves acknowledge: ‘Admittedly, calls for epistemic justice in psychiatry are animated by real concerns… Psychiatric work involves value judgments that are often controversial. Psychiatry can be very intrusive and sometimes involves coercion and the deprivation of specific liberties; it sometimes even harms patients’ (Kious et al., Reference Kious, Lewis and Kim2023); and yet they seem to have difficulty openly acknowledging that all these ‘real concerns’ create a situation with a very real risk that epistemic injustice could be perpetrated, and is perpetrated in at least some instances, and for all anyone knows, may very well be more commonly perpetrated than we – as psychiatric professionals with our limited standpoints – imagine it to be.