Know that Words Matter (Part 2 - Epistemic Injustice)

Introduction

This is Part 2 of the ‘Know that Words Matter’ article (you can find Part 1 here) and it has the title 'Epistemic Injustice'. It is the sixth article in a series of ten which have the collective title ‘On Working with Conflict’. I am very aware when writing these articles that as a white, western female in my 60’s, my privileges, values and experiences will have influenced the views I have expressed both in earlier articles and below.

Over the years I have become increasingly aware of the concept of epistemic injustice in relation to conflict, often with relevance to investigations and complaint handling. The word epistemic can be defined as “of or relating to cognition or knowledge, its scope, or how it is acquired”. Epistemic injustice is “injustice related to knowledge.

So in this article I want to explore epistemic injustice in a bit of detail in order to consider why words may not be heard and/or valued.

About Justice

First a bit about justice, as my learning from working with conflict is that this is often what people say they want when they raise a concern. Justice, in its broadest sense, embodies fairness, equality and moral rightness in how people are to be treated. The concept of justice often incorporates accountability, as in the holding of individuals and institutions to account for their actions and ensuring that they face consequences for violating laws or ethical standards. Western philosophers generally regard justice as the most fundamental of all virtues for ordering interpersonal relations and establishing and maintaining a stable political society. 

I am familiar with justice theory from my teaching days and how one of its uses is as a framework for understanding what drives satisfaction with complaint handling (see for example articles by Orsingher et al. 2010 and Jeanpert et al., 2021). I think this theory is also helpful when trying to understand satisfaction with conflict resolution more generally, as so much centres around fairness. I’ve written before about organisational justice (see Perceived Justice and Fairness) and how it can be explained as having different dimensions. I’ve set out these dimensions briefly below:

Procedural Justice concerns the fairness of the processes used to make decisions. The focus here is on the methods, procedures and rules governing decision-making rather than the outcomes themselves. Key aspects include consistency, accuracy and reliability, as well as ensuring that individuals have an equal opportunity to participate.

Distributive Justice (also sometimes referred to as substantive justice) refers to the perceptions of the fairness of the actual outcome – does the person raising a concern agree that they got what they think they deserved as a result of the process of decision-making – in terms of both decision and redress.

Interpersonal Justice involves the fairness of interpersonal treatment and interactions. It addresses the quality of relationships and consists of two main dimensions: respect (individuals being treated with dignity and consideration in their interactions with others) and fairness (individuals perceiving that decisions and actions taken by others are impartial, unbiased and free from favouritism or discrimination). 

Informational Justice concerns the fairness of the information provided. It has two main components: transparency (this refers to fairness in the acquisition, distribution, and use of information) and justifiability (which focuses on the adequacy and reasonableness of the explanations given for decisions).

Cohen and Headley (2023) explain that “Procedural justice theory takes root in social psychological concepts of justice that date back to Thibaut and Walker’s (1975) work on the influence of procedures in social interactions.” This work is a much referenced and influential book (Procedural justice: A psychological analysis) in which a social psychologist and a law professor consider whether ‘adversarial’ or ‘inquisitorial’ trial procedures better serve the purposes of justice – and found that disputants prioritised the fairness of the process as well as its outcomes. Cohen and Headley (2023) write that “The literature identifies four major components of procedural justice: neutrality, voice, respect, and trust.” Other writers (such as Orsingher et al., 2010) have found that interactional justice (how you are treated) can have a stronger effect on satisfaction than procedural justice.

My experience has been that these dimensions of justice are interrelated and often influence one another. If you would like to read more, I strongly recommend this 2020 Queen Margaret University Working Paper ‘Complaint handling and fair decision making in the financial industry’ by Jane Williams , Professor Chris Gill and Gavin McBurnie , which includes an excellent literature review.

About Epistemic Injustice

I had associated epistemic justice with informational justice, but I’ve learned that although related, they are distinct concepts. Both concepts emphasise fairness and equity in relation to knowledge and information. They also share concerns about who has access to knowledge, who is recognised as a legitimate source of knowledge and how information is disseminated and used. However, epistemic justice is broader, focusing on the recognition of individuals as knowers and on the societal structures that support or hinder this recognition, whereas informational justice is more specific to the processes and fairness of information flow in organisational or institutional contexts.

From my readings for this article I understand that Professor Miranda Fricker first used the term in her much referenced 2007 book ‘Epistemic injustice: Power and the ethics of knowing’. In this book Fricker argued that there is a “distinctively epistemic kind of injustice” which related to a wrong done to someone in their capacity as a knower. She identifies two forms of epistemic injustice: ‘testimonial’ injustice (where a speaker receives an unfair deficit of credibility from a hearer owing to prejudice on the hearer's part) and ‘hermeneutical’ injustice’ (where someone has a significant area of their social experience obscured from understanding owing to prejudicial flaws in shared resources for social interpretation). In my readings I learned that Hermeneutics’ is the theory and methodology of interpretation especially the interpretation of biblical texts, wisdom literature, and philosophical texts.

In Fricker (2017) she explains that “My chief purpose in invoking the label was to delineate a distinctive class of wrongs, namely those in which someone is ingenuously downgraded and/or disadvantaged in respect of their status as an epistemic subject”. Fricker recognises that both testimonial and hermeneutical’ injustice involve identity prejudice (prejudice against someone because of their social identity) and considers that epistemic injustice is fundamentally a form of (direct or indirect) discrimination. Fricker (2017) writes about hermeneutic injustice being structural saying that “This is due to the fact that it happens when a group of individuals is unfairly disadvantaged because they lack the conceptual language to make sense of their experiences which are outside of the experience of the dominant group and thus not treated equally as knowledge.”

Hand (2021), who has explored epistemic injustice and an ethic of care in public encounters, says that “Fricker (2007) suggests that a “virtuous hearer,” supported by an institutional ethos that aligns values, practices, and assessment of outcomes in order to promote justice and reduce domination can help mitigate epistemic injustice. A virtuous hearer recognizes bias and hermeneutical marginalization and works to avoid or correct for it within the interaction.”

More recent work by Fricker and others has identified many sub-forms of testimonial and hermeneutical injustice. And while Miranda Fricker's theory of epistemic injustice has been influential, it has also faced criticism and disagreement. For example, in her article ‘Epistemic justice as a virtue of social institutions’ (2012), Elizabeth Anderson acknowledges how Fricker recognises both transactional and structural forms of epistemic injustice, but that her remedies in both cases stress ‘individual virtue’. Anderson writes that “we also need to consider what epistemic justice as a virtue of social systems would require” and that “the structural forms of testimonial injustice are more pervasive than acknowledged in Fricker’s work.” My understanding here is that Anderson considers that even if you can change yourself (in accordance with individual virtue), institutional injustice may still take place.

Anderson helpfully explains that “In social psychology, “prejudice” denotes a kind of motivated cognitive bias, characterized by: stereotypes and attributions (causal explanations of actions and events connected to the group) that represent a group in a negative light; negative affects that appear to be merited by these stereotypes and attributions; and discriminatory behavior that reflects these affects. In Fiske’s classic typology, these biases vary along two dimensions: competence and warmth. In testimonial contexts, this means that prejudicial hearers may discount the credibility of speakers either because they perceive them to be ignorant or stupid (the competence dimension), or dishonest (the warmth dimension, reflecting the affective coldness of distrust), or both.”

I also valued Anderson writing on how “Reflection, which lies at the core of testimonial justice, is cognitively taxing and impossible to keep up in environments that demand rapid responses” – an observation that will be all too familiar to many who work with conflict.

Dotson (2011) writes about the different ways in which members of oppressed groups are silenced. In this much referenced article she says that “Epistemic violence in testimony is a refusal, intentional or unintentional, of an audience to communicatively reciprocate a linguistic exchange owing to pernicious ignorance.” And identifies two kinds of silencing: testimonial quieting (when an audience fails to identify a speaker as a knower) and testimonial smothering (when the speaker perceives their audience as unwilling or unable to gain the appropriate uptake of proffered testimony). She writes that “testimonial smothering is the truncating of one’s own testimony in order to ensure that the testimony contains only content for which one’s audience demonstrates testimonial competence.”

I’ve written in an earlier article in this series (see Develop and Use Empathy (Part 4)) about the role and influence of ‘street level bureaucrats’. Related to this, Hand (2021) says that “Inherent power asymmetries in public encounters create a setting ripe for epistemic injustice perpetrated or enforced by street-level bureaucrats; something more insidious than confusing rules, time consuming forms, or recalcitrant street-level bureaucrats who inflict costs (administrative burdens) on the citizen. Instead, epistemic injustice inflicts harm that remains unseen except between the parties directly involved in the interaction.”

I must admit to not reading José Medina’s book ‘The Epistemology of Resistance: Gender and Racial Oppression, Epistemic Injustice, and Resistant Imaginations’ (2013), but understand from other references to it that he emphasises the need to consider how testimonial injustice is embedded in broader social practices and power structures. Medina also argues that epistemic injustices are often experienced differently depending on the intersections of race, gender, class, sexuality and other social categories.

So from the work of Fricker and other related readings I understand that testimonial injustice occurs when the hearer/receiver allows their prejudice about the speaker’s social identity, which may include gender, ethnicity, race, disability, age, sexuality and accent, to undermine the credibility of the speaker and their knowledge. For example, Peled (2018), writing on how testimonial injustices may occur in healthcare, said that physicians “may unjustly perceive a patient as less intelligent based on the fact that the patient speaks with an accent that is often associated with less educated populations.” This means that a person's testimony can be regarded as anecdotal and not given the credibility or respect it deserves due to prejudices or stereotypes about their social identity. I also understand that hermeneutical injustice (sometimes referred to as interpretive injustice) can occur when a lack of resources (usually conceptual resources), puts someone at an unfair disadvantage when it comes to making sense of, and sharing, their experiences.

Institutional language

I wrote in Part 1 of this article that I have a thing about institutional language and want to look here at its contribution to epistemic injustice. Institutional language includes jargon which is ‘the specialized terminology associated with a particular field or area of activity’. Corporate jargon is the jargon often used in corporations, bureaucracies and similar workplaces. According to this Wikipedia entry “The use of corporate jargon is criticised for its lack of clarity as well as for its tedium, making meaning and intention opaque and understanding difficult.”

I think this blog post Lost in translation: navigating the language of social care by Isaac Samuels on the Think Local Act Personal website tellingly describes the impact of institutional language. He writes that “There is a lot of jargon, acronyms, legal talk, and system language used in the area of social care. Those of us who draw on care and support have to step into those really uncomfortable spaces of using language in a particular way to get ourselves heard. If I speak about the everyday, my message isn't heard.” He goes on to say “I think the key is recognising the power that language has and how it can be used well. We can use it to build empathy, reduce misunderstandings, encourage relationships and solve problems.”

In his always pertinent and readable Love, Belief and Balls blog, Mark Neary provides us with Parley Vouz Health & Social Care? (An A to Z of Carespeak). Entries include: Best Interests:  ‘What a group of professionals decide is the best way of living your life. Often involves removal from family home and incarceration in assessment and treatment unit’; Expert By Experience: ‘A term bestowed on a Carer to stop them whinging and for them to think they are involved in some fashion’; and Measurable Outcomes: ‘Having everything you do logged and judged’. I found reading this both funny and dispiriting – the latter because it reflects what is reality for many.

So why do institutions and organisations who are meant to care use language which can harm? I said in Part 1 that Bryony Shannon had written about Professional language in her blog about Rewriting social care. In this post she explores ten reasons why professionals continue to use vocabulary which is dehumanising, stigmatising and ‘othering’. These reasons (which she makes clear are not excuses) are that: it’s everywhere, we learn it (we teach and are taught these words), we like it (it offers an identify), it’s efficient (quicker to use acronyms and labels), it’s effective, it justifies our actions (our practices and priorities), it helps us cope, we are not challenged, we don’t challenge and prejudice.

Her ‘Professional language’ post includes a quote that “Practitioners use language as a way of creating distance. Occasionally this may arise from lack of confidence and institutional expectations.” And she writes that “Principles of social justice, human rights, collective responsibility, and respect for diversities are central to social work. And yet so much of our language is oppressive, designed to exclude rather than include. Eroding rather than upholding people’s rights and identity.” Do take the time to read this blog post in full.

In Understand Your Own Response to Conflict (Part 2) I referred to the article ‘Unpicking Social work practice skills’ (Mullins and Kirkwood 2022) and also summarised what it had to say in a separate article On Warmth and Respect in practice. The authors helpfully describe epistemic authority as “people’s rights and responsibilities to know things about themselves and their own experience”. And say that “Upholding a person’s right to know and speak about their own thoughts, feelings and experiences in interaction are central to conveying warmth and respect in everyday conversation. In certain institutional contexts, however, professionals may be afforded rights over another’s experiences.”

Mullins and Kirkwood (2022) write that “Institutional talk differs from everyday talk in three key ways: there are certain goals tied to the institutional identities (e.g. doctor/ patient, teacher/ student, social worker/ client), what is deemed allowable in the interaction is constrained by the institutional context, and the interaction involves inferential frameworks and procedures of that particular institutional context.” And of  particular relevance to working with conflict they write that “The nature of facework and demonstrating epistemic authority are complicated by the institutional context of social work practice … the professional role may involve offering accounts, descriptions and explanations that run counter to those offered by clients.”

In a 2024 paper on ‘Language as a Source of Epistemic Injustice in Organisations’, Wilmot writes about ‘wilful hermeneutic ignorance’ being perpetuated by managerial elites and the corporate language policies which they enact. She says that “Such dominantly situated knowers frequently fail to take into consideration how policies which are seemingly “neutral” to them, because of their social positions, are sources of epistemic injustice to others. This demonstrates not only epistemic insouciance, in which such elites show a lack of concern for potential epistemic harms created by the policies they enact, but also epistemic hubris - the feeling that they simply don’t need to know about harms experienced by others.”

I am aware that the language of academic research often includes ‘jargon’, so an explanation of some of the terms used in academic publications may be helpful. From my readings I have learned that ‘epistemic authority’ refers to the credibility or expertise that an individual or institution possesses in a particular field of knowledge or expertise. It's the trust or deference given to someone's opinions, assertions, or judgments because they are considered knowledgeable, experienced, or authoritative in that area. This authority can be conferred through various means such as education, experience, reputation, or position within a relevant community. ‘Epistemic asymmetry’ refers to situations where there is a disparity or imbalance in knowledge, information, or understanding between individuals or groups. ‘Epistemic privilege’ is about you having access to, and direct self-knowledge of, your own thoughts in a way that others do not.

A bit of an aside in saying how much I agree with views in this 2014 blog Academic jargon in the social sciences: self-indulgence or necessary evil? by Dr Warren Pearce, which includes “that the social sciences don’t do themselves any favours when it comes to promoting interdisciplinarity as much of their academic output is so hard to digest. In short, there is too much jargon.” I have some sympathy with the view that academic research “often requires complicated, technical language to communicate ideas, especially to fellow professionals in the field who read academic journals.” But do believe “that social scientists have a particular responsibility to communicate their findings in plain language, as their work is of great societal relevance.” And to this end I value greatly the outputs of The Conversation (which publishes research-based news and analysis) and The Bridge (which aims to connect public managers with current and relevant research - see also my post on this here).

Gendered language

I have an ongoing interest in gender effects on complaints (see my post), but am only going to touch briefly on gendered language here as I intend to write more about this at a future date. If you want to read more now, I recommend Deborah Cameron’s blog language: a feminist guide.

This helpful article on What Is Gendered Language? (from the University of Exeter online course on Understanding Gender Inequality) starts by saying that “One of the ways in which we can become aware of how our societies are inherently gendered is by examining how language is used (and is gendered) in everyday life.” It goes on to say that “Here we are not interested in grammatical gender, but the gendering of words and phrases, many of which we might take for granted, that shape our thinking about what is masculine and feminine, male and female and thus perpetuate assumptions and stereotypes in society. In essence semiotics explores the practices by which we attach significance or meaning to things through our social practices. In other words, it considers how something becomes ‘code for’ or a ‘signifier’ for something else.”

Academy 4SC, (who explain they are “dedicated to delivering an all-encompassing, interdisciplinary civics education for everyone”) have a video and article on Miranda Fricker’s Epistemic Injustice. This includes that “she dedicated much of her work to epistemic injustice for women, who experience diminished capacity as “knowers” in a male-dominated society.” In explaining hermeneutical injustice, they include how Fricker “offers an illustrative example of the term “sexual harassment,” which only came into popular use in the 1970s. Before that, people who were sexually harassed did not have a category for these experiences. Understanding and then communicating their experiences was unfairly difficult, which made it especially challenging to address the issue at hand.” 

Writing in a BBC Culture article on The subtle ways language shapes us, Nayantara Dutta includes Caroline Criado Perez (in her book Invisible Women: Data Bias in a World Designed for Men) saying that: “Seeing men as the human default is fundamental to the structure of human society.” Our culture and language follow a generic masculine framework where, she explains, “male bias is so firmly embedded in our psyche that even genuinely gender-neutral words [like doctor or actor] are read as male.”

Related to this, Files et al. (2017) write on how gender bias has been identified as one of the drivers of gender disparity in academic medicine. They suggest that bias may be reinforced by gender subordinating language or differential use of formality in forms of address and that professional titles may influence the perceived expertise and authority of the referenced individual. Their study found that “women introduced by men at Internal Medicine Grand Rounds were less likely to be addressed by professional title than were men introduced by men.” And that “Differential formality in speaker introductions may amplify isolation, marginalization, and professional discomfiture expressed by women faculty in academic medicine.”

Harris et al (2017) say that “There is growing evidence that societies with gendered language consistently display deeper gender inequality than societies with neutral language.” They also state that “one of the most powerful ways implicit bias can act is through language” and that “Language appears to play a particularly important role in molding individuals’ attitudes toward gender and occupation. The landmark study reported by Bem and Bem reported that women were significantly less likely to apply for jobs with masculine suffixes (-man vs –person).” Harris et al (2017) write that “Ultimately, in language, as in medicine, taking the position that our current approach is justified because “it has always been our approach” is not tenable…. Thus, we must be rigorous in establishing a nomenclature that promotes not only gender-inclusive language but also processes that represent the broad racial, social, and sexual identities of our colleagues.

Similarly, in her article (see above) Nayantara Dutta includes that “People may dismiss gender-neutral language, seeing it as unnecessary or purely ideological, but Pérez’s research shows that it actually impacts public opinion. His 2019 study with Margit Tavits revealed that using gender-neutral pronouns increases positive attitudes towards women and LGBTQ+ people, through reducing the prominence of male identity and subsequently causing less gender-based bias.”

With more direct relevance to conflict, my valued research colleagues Margaret Doyle and Varda Bondy have discussed the use of the term ‘Ombudsman’ (in their 2018 'What’s in a name? A discussion paper on ombud terminology') and in Manning’ the ombuds barricades which they posted on the Ombuds Research blog.  The latter includes referral to our 2014 mapping study The use of informal resolution approaches by ombudsmen in the UK and Ireland in which we considered whether to use the words ‘ombud/s’ or ‘ombudspersons’ rather than ‘ombudsman/men’ and the subsequent debate this generated following the launch of our study report. The blog post contains how “We welcome any such engagement, especially where it recognises the problematic nature of the terminology, but we are perplexed as to why the ombuds community is so intent on engaging in both linguistic and conceptual acrobatics by insisting that ‘man’ does not mean ‘man’.” Do read it to learn more.

My view is that gendered language matters when working with conflict as it often reflects and reinforces existing power structures. This means that men can be afforded more authority and credibility in conversations simply due to gendered language norms - and this can skew conflict resolution processes if voices are not valued equally. The WomenTech Network has a webpage on What Impact Do Gender Dynamics Have on Conflict Resolution Strategies in the Workplace? And they sum up my views in saying that “Gendered language significantly influences conflict dynamics and resolution. By recognizing and addressing the biases inherent in gendered language, conflict resolution processes can become more equitable, inclusive, and effective, leading to more sustainable and fair outcomes.”

Epistemic injustice in healthcare

In recent years I’ve had a particular interest in conflict relating to health and want to share some of my learning relating to this to help illustrate why I think that epistemic injustice matters when working with conflict. Although health specific and not always conflict-related, I think that what I am about to write below has relevance.

Dr Jonathon Tomlinson has a blog A Better NHS which explores the relationships between doctors and patients and health policy. This includes a post about Epistemic justice and trauma, in which he says that “Epistemic injustice in healthcare happens when a professional assumes that because of certain characteristics their patient is an unreliable narrator and interpreter of their own experiences. Consequently they fail to listen to or take seriously what their patient has to say. The only story that counts is the medical history and the only interpretation that matters is the diagnostic formulation. Patients experience not being seen or heard, i.e. invalidation.”

In their much cited 2014 paper ‘Epistemic injustice in healthcare: a philosophical analysis’ Carel and Kidd argue that “Ill persons are vulnerable to testimonial injustice through the presumptive attribution of characteristics like cognitive unreliability and emotional instability that downgrade the credibility of their testimonies. Ill persons are also vulnerable to hermeneutical injustice because many aspects of the experience of illness are difficult to understand and communicate and this often owes to gaps in collective hermeneutical resources.” They consider that “epistemic injustice arises in part owing to the epistemic privilege enjoyed by the practitioners and institutions of contemporary healthcare services - the former owing to their training, expertise, and third-person psychology, and the latter owing to their implicit privileging of certain styles of articulating and evidencing testimonies in ways that marginalise ill persons.”

Carel and Kidd (2014) also write that “it is not that modern healthcare practices are epistemically unjust but that certain policies, practices and cultural norms within modern healthcare practice are liable to generate epistemic injustice.” And that “Importantly, we do not suggest that these strategies are systematically employed consciously or deliberately and certainly not with malice (although they may be). Rather, we are pointing to a set of practices and behaviours based on presuppositions and assumptions that are rarely reflected on and are largely tacit.”

They also say that “it is useful to distinguish between warranted and unwarranted epistemic privilege, e.g. healthcare professionals warrant epistemic privilege in their interpretation of a CT scan, but not in deciding where a patient should die (e.g. in hospital or at home).” And that the “claim is not that ill persons are always epistemically reliable, for that is clearly not the case.”

Kidd and Carel (2017) consider that epistemological issues in healthcare are neither recognised nor addressed. They write that “An example is the increasing emphasis placed upon ‘communication skills’ that doctors ought to exercise, which tend to focus on superficial modifications of physical behaviour – such as adopting an open posture and making eye contact.” Also that “The use of reductive and simplistic questionnaires to glean information about ‘patient satisfaction’ is another such example, in which opinions are sought, but only in a confined and predefined form that is sensitive only to measurable and schematised variables of patient experience.”

While welcoming these efforts, Kidd and Carel (2017) write that “Such measures arguably fail to identify and challenge the deeper epistemic inequalities that characterise the relationship between patients and physicians” as “they tend to neglect the fact that those relationships are usually characterised by epistemic inequality and asymmetric power relations in a way that upsets comfortable hopes about the efficacy of superficial behavioural changes by physicians.”

Blease et al (2021), in their article ‘Patients, clinicians and open notes: information blocking as a case of epistemic injustice’, consider that epistemic injustice disproportionately affects what they call ‘marginalised patient populations’. They write that these vulnerable groups may suffer a “double injury”, being “more likely to be disbelieved (within the healthcare context) and at the same time, less likely to have access to the tools which might improve their care (such as access to their case notes).”

In his article ‘Explaining epistemic injustice in medicine’, Williams (2020) has written that “gulfs in perspective can be maintained and remain hidden from well-intentioned professionals or – when those gaps are intuited – be accounted for in ways that discredit patients’ views. It underlines not just why things go wrong, but also how our normal remedy for moral injuries is also impaired. Attempts to hold people and institutions responsible falter by virtue of the self-same epistemic problems: complaints about epistemic injustice are difficult to articulate and to make, and just as difficult to heed. Worse, blame and other penalties can actually move in the wrong direction – that is, against patients who try to bring their knowledge and experience to bear.”

In their article ‘Integrated care systems as an arena for the emergence of new forms of epistemic injustice’, Fletcher and Clarke (2020) describe “the different ‘species’ of epistemic injustice observed and reveals how these are unintentionally produced at frontline, management, commissioning and policy levels.” They say that “Most notably, there remains a privileging of clinical knowledge over other forms of knowledge, producing a ‘pathocentric epistemic complex’. In this article they acknowledge that much of the literature tends to focus on the pathologization and epistemic silencing of patients by health professionals. And that “Less attention is paid to identity prejudice between professional groups, or the ways in which the systems and institutions designed to support mental health can produce epistemic injustices that damage outcomes for patients in more insidious ways.” Essentially, this article makes the point that epistemic injustice can also take place between ‘professionals’ and that recognising that there are different but equally valid forms of knowledge is needed to form the basis of effective joint working relationships.

Epistemic injustice in practice

Over the years I have become increasingly aware of the unequal power dynamics which can operate in conflict situations and how epistemic injustice can undermine fairness and effectiveness. This includes individuals who raise concerns facing credibility deficits and encountering scepticism or dismissal from people in positions of authority, which can lead to further marginalisation and the perpetuation of injustices.

Kidd and Carel (2017) helpfully consider that two broad forms of epistemic complaints arise within contemporary healthcare practice. “The first are what one might call patient complaints, those made by ill persons and especially by those with prolonged and involved experience of modern healthcare, such as the chronically ill. These typically take the form of reports that healthcare professionals do not listen to their concerns, or that their reportage about their medical condition is ignored or marginalized, or that they encounter substantive difficulties in their efforts to make themselves understood to the persons charged with their diagnosis and treatment.”

They go on to say that “The second are physician complaints, understood broadly as those offered by healthcare professionals. They often complain that patients provide medically irrelevant information, make odd statements and superfluous remarks about their condition, or otherwise fail to contribute epistemically to the collection of medical data.” They say that “Taken together, a difficult epistemic situation emerges in which neither group can engage in effective testimonial and hermeneutical relations with the other.” I think this applies in many conflict situations.

I’ve written before on my Views and Learning about Patient Experience. This included how “I have learned about the importance of a (Health) Board questioning what they are not being told and asking about the voices and experiences of those who don't seem to be heard” and I asked for consideration of “Who is providing the dominant narratives?” Although not named as being epistemic injustice, my article included reference to the 2022 Report of the Independent Investigation into maternity and neo-natal services in East Kent (Reading the signals) which “found that there have been repeated failures to listen to the families involved.” This is not new as over ten years ago (in 2013) Sir Robert Francis (in the Mid Staffordshire UK NHS Trust report) was identifying failures of the Trust to take patient feedback and experience seriously.

I was interested to find this article by O’Donovan and Madden (2018) which explored why medical professional regulators in Ireland dismissed most complaints from members of the public. They observe that “Time and time again, poor communication with patients and their families has been found to be at the core of what goes wrong in medicine. It appears that the medical profession has prioritized matters of technical competence and not adequately recognized communication, respect, and empathy as decisive aspects of professional conduct or as crucial matters of fitness to practice.”

O’Donovan and Madden (2018) offer three possible explanations as to why medical professional regulators do not take patients’ complaints seriously (as in not warranting an inquiry). They write: “One explanation points to the “regulatory illiteracy” of many complainants, where the remit and threshold of seriousness of regulators is poorly understood by the general public. Another points to possible processes of “institutional epistemic injustice” that unjustly undermine the credibility of certain complainants, such as those with low levels of formal education. A third explanation highlights the marginalization of the general public from “symbolic power” to define what matters in medical professional regulation.”

They also write on how some remedial actions may be relatively straightforward, such as better public dissemination of regulatory knowledge and that others may require profound change in medical regulators’ institutional thinking. And say that “Most challenging of all, however, are remedial actions aimed at ensuring socially disadvantaged complainants and those with limited cultural and symbolic power are heard and have their complaints taken seriously.”

More recently, Kok et al (2022) have written about epistemic injustice in serious incident investigations in healthcare, essentially saying that enhancing personal reflectivity and/or genuine willingness to do justice to someone’s testimony is not enough, as there are social and institutional structures that promote biases, cause epistemic exclusion and prevent credible ‘actors’ from being valued as such. Their recommendations include mapping out the organisational structures that can make actors prone to suffer epistemic injustice, seeking input for the research questions at the start of an investigation with all those directly concerned (to prevent an all too narrow framing of the problem statement) and asking the actors involved: what do you need to be able to share your testimony?

The language of complaints

As well as the language used by institutions, I’ve always been interested in the language used by individuals when making a complaint. And I know that I have been guilty myself in the past of ignoring what I considered to be emotive language in order to concentrate on ‘the facts’.

Kidd and Carel (2017) comment on how “Marginalised groups may also be subject to ‘strategies of expression’ in which their particular forms of expression are taken as evidence of the group's lack of rationality and lack of understanding of the modes of expression that are recognised as appropriate by the dominant group. Here, a form of expression that a marginalised group uses in its efforts to make the case for the recognition of its hermeneutical resources can serve to undermine those very efforts. And this can lead to a vicious circle of increasing frustration, leading to more extreme styles of expression, which in turn lead to further epistemic disenfranchisement”. 

Blease et al (2017), in their very readable paper ‘Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome’ argue that patients with CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis) are negatively stereotyped and unfairly prevented from making sense of their experiences. They write that “this then deflates their credibility and undermines their hermeneutic and communicative efforts” and that “patient attempts at communication become more fraught and angry, thus making their expression less accessible to others.” I think that complaint handlers in particular will find this familiar.

O’Donovan and Madden (2018) write that “A striking feature of many of the complaints from members of the public that we reviewed was their emotional content where complainants relayed their emotional response to the alleged events as evidence of the depth and seriousness of harm caused, which in turn led them to conclude that the doctor’s behaviour ought to be considered as professional misconduct.” And that “The possible contribution of such emotional styles of communication to the unfair treatment of some complaints is worth considering.” Tellingly (I think), they also write that “the suggested injustice here is that there is no adequate process for dealing with complaints - many of which we found very disturbing to read - relating to issues that complainants define as matters of concern, frequently concerning poor communication and lack of respect and empathy.”

McCreaddie et al. (2018) provide an overview of the process and rhetoric of how patients formulate written complaints. This paper is an illuminating read .They write that “Our data evidenced complaints as individual narratives predicated on a moral imperative but laced with cynicism as demonstrated by the use of sarcasm, epistemic authority and the attempts at corroboration.” They found that complainants “expended considerable effort in persuasive rhetoric that sought to legitimise the complaint drawing upon different sources of epistemic authority.” And that “The zenith of the complainants’ ‘case’ is the use of epistemic authority to provide further corroboration by asserting formal or lay knowledge of a specific medical condition or intervention.”

The authors say that “Complaints are involved narratives often predicated on the expectation they will not be given due credence”. They acknowledge that complainants “probably know that they are unlikely to achieve a positive resolution and hence, any attempt at objectivity and non-emotive discourse is a forlorn hope. Ironically, this associated ‘noise’ may well work against the veracity of the complainant’s case and mitigate a successful outcome.” I think their paper well illustrates the epistemic injustice which can result from ‘hearers’ missing knowledge and information from ‘speakers’. I’ll refer to this paper again in Part 4 of this article, along with a 2021 paper by the same authors which looks at complaint responses.

‘Inadmissible evidence’

Many conflict situations involve investigations and the use of evidence. In my own work with conflict (as a tribunal member, complaint investigator/reviewer and mediator) I know that more weight (and credibility) can be given to the testimony of ‘professionals’ and organisations than to individuals who contest decisions or make complaints (including workplace grievances). And I am now more aware of this being an epistemic injustice. Related to this, I value greatly the work of The Patient Experience Library who say that they were inspired by the Baroness Cumberlege First Do No Harm report (2020), which focused on how the health system responded when patients and their families raise concerns about the safety of treatments (vaginal mesh, sodium valproate and hormone pregnancy tests).

The Patient Experience Library alerted me to this review and thematic synthesis of the literature on women’s experiences of and perspectives on transvaginal mesh surgery (see their weekly newsletter link here), in which Motamedi et al. (2020) find that women’s experiences were “epistemologically incongruent with their surgeon’s understandings of success and outcomes. This meant that both after initial surgery, and after complications were acknowledged, women did not receive recognition of harms, or support to rectify these harms. The inability of surgeons to recognise women’s suffering constituted both hermeneutic and testimonial injustice.” Also that “Women’s experience of epistemic injustice was the main mechanism for the compounding of their medical and psychological trauma. The failure of the health care system to provide women with just health care services was primarily caused by a recurring pattern of miscommunication between women and health care professionals.”

The ‘First Do No Harm’ report included that patient experience "must no longer be considered anecdotal and weighted least in the hierarchy of evidence-based medicine". The Patient Experience Library set out their mission in their Inadmissible evidence report which asks why healthcare seems unable to accept patient feedback as a valid form of evidence. Their report “points to a double standard which takes medical research seriously, while dismissing the experiences of patients as ‘anecdotal’.” And includes that “When a health professional flags up something that has gone wrong, it is called an incident report. But when a patient does the same, it is called a complaint. The word “complaint” is synonymous with words like “objection”, “grievance,” and “criticism”. In contrast with the calm objectivity of “incident report”, the term “complaint” sets a negative tone.”

The Inadmissible evidence report says that “Patient feedback “is frequently described as “anecdotal evidence”, saying that “The term indicates a tendency to see patient feedback as subjective, irrational, and potentially unreliable. The phrase “soft evidence” is also used to distinguish patient feedback from the “hard evidence” of statistics.” And that “There is an evidence blind spot in healthcare. Medical evidence is taken seriously and embedded in policy and practice. Patient experience evidence – meant to have equal standing – is looked at askance. The disparity is not accidental. But neither is it deliberate, in a conscious or conspiratorial kind of way. It is cultural.” I think there is much learning in this report for all involved in the investigation of concerns. And my view is that many investigations would benefit from being more knowledge based and by giving more credence to both lived experience and practice wisdom.

Travaglia (2022) writes that “Understanding and addressing the risk of epistemic injustice is profoundly important for patient safety and that “Denial of patients’ (families’ and communities’) concerns do the people involved a significant symbolic violence as well as actual harm.” Related to this, Dr Henrietta Hughes, the Patient Safety Commissioner for England, has written in a blog post about epistemic injustice (We must combat epistemic injustice) on how the views of the parents of Martha Mills “were dismissed, ignored and they were treated disgracefully.” She writes “By listening and acting on patients and families voices we can keep people safe, learn and prevent future harm.”

Epistemic Justice

So far I have been writing about epistemic injustice. So nearing the end of this article, I thought it might be helpful to turn things around and consider what epistemic justice might look like. In A Brief Guide to Epistemic Injustice/Justice, the Epistemic Justice in Community Engagement Project explains that epistemic justice takes two forms. “Testimonial justice occurs when knowledge is communicated interpersonally unfettered by identity-based bias in a way that affirms the credibility (and by extension the humanity) of the knower and builds the understanding of the knowledge receiver. Hermeneutical justice occurs when institutions and society holds space for, and values, diverse ways of knowing how to make sense of the human experience”.

Carel and Kidd (2014)’ say that “In testimonial justice the testimonies of ill persons are recognised, sought out, included within epistemic consideration, judged to be relevant and articulate (where they are) and, at least in certain respects, judged as epistemically authoritative.” They consider that “An ill person experiences hermeneutical justice, by contrast, when the interpretations of ill persons are recognised, sought out, included within epistemic consideration, judged to be relevant and articulate (where they are) and, at least in certain aspects, judged as epistemically authoritative.”

To (try and) sum up

So why does epistemic injustice matter in relation to conflict? My learning in writing this article is that epistemic injustice is unfairness related to knowledge. Kidd and Carel (2017) have written that “Since the social and epistemic practices of giving information to others and interpreting our experiences is integral to our rationality, identity, agency and dignity, it is evident that injustice which harms our testimonial and hermeneutical capacities will be a source of deep harm.” The Wikipedia article on Epistemic injustice says that epistemic injustice includes exclusion and silencing, systematic distortion or misrepresentation of meanings or contributions, undervaluing of status or standing in communicative practices, unfair distinctions in authority and unwarranted distrust.

From the work of Miranda Fricker on epistemic injustice I understand that testimonial injustice occurs when a speaker is unfairly accorded a lower level of credibility as a result of prejudice and that hermeneutical injustice is a collective shortfall in our shared conceptual resources. Kidd and Carel (2017) make the point that “Testimonial injustice occurs in cases of prejudicial credibility deficit.” Luong et al. (2024) have written that “Epistemic injustice results from two things: (1) social power dynamics that give some individuals control over others, and (2) identity prejudice that is associated with discriminatory stereotypes.”

Hand (2021) says that “Public encounters provide a black box that allows for epistemic injustice to happen with little visibility  … This means it is up to thehearer, in this case, the street-level bureaucrat and associated public organization, to mitigate epistemic injustice.” And recognises Fricker arguing (in 2013) “that the way to correct for the influence of prejudice in credibility judgments is for individuals to cultivate skills as “virtuous hearers,” supported by an institutional ethos with justice as its foundation. A virtuous hearer recognizes bias and hermeneutical marginalization and works to avoid or correct for it within the interaction.” Fisher (2023) has also written on how “epistemic injustice calls for a correction or amelioration on the part of the hearer.”

Anderson (2012) pointed to the limitations of individual level remedies for epistemic injustice. She writes that “in the face of massive structural injustice, individual epistemic virtue plays a comparable role to the practice of individual charity in the context of massive structural poverty. Just as it would be better and more effective to redesign economic institutions so as to prevent mass poverty in the first place, it would be better to reconfigure epistemic institutions so as to prevent epistemic injustice from arising. Structural injustices call for structural remedies.” So while it is important to promote individual ‘epistemic virtues’, it is also vital to implement structural changes that can address the root causes of epistemic injustice.

Other readings, such as Byskov (2021), have reinforced how “Unfair and unjust communicative structures, institutions, and practices have the potential to reproduce and further exacerbate existing socio-economic inequalities and injustices”. I’ve also learned that the same characteristics which can lead to a credibility deficit can also lead to a credibility excess, where a testimony is believed more by the listeners due to certain aspects of the speaker’s personal characteristics.

In a 2023 Public Interest Research Centre (PIRC) post Epistemic injustice: an invitation to ask new questions Emily Kenway writes “Fricker suggests we might undo epistemic injustice by improving participation. So, we should notice who is excluded from spaces of power and remedy that with inclusion. But participation, when viewed as an amendment to already-existent spaces and ways, is not the same thing as power. Marginalised voices have been ‘participating’ in political systems – establishment and otherwise – for a long time, but decisions and practices rarely alter in their favour.”

I’ve learned that epistemic harm describes “the injurious effects and consequences that individuals are subject to when they experience epistemic injustice” (Luong et al. 2024). So epistemic justice is about ensuring that these harms do not occur and that all voices are heard, respected and given credence. This helps prevent dominance by more powerful parties. Epistemic justice can reduce biases by addressing testimonial injustice (where a speaker's credibility is unjustly deflated due to prejudice), attend to gaps in understanding (ensuring that all experiences are understood and meanings shared), build trust (when parties see that their knowledge and perspectives are respected) and promotes ethical and fair processes.

Hopefully this article has demonstrated the importance of language and how enabling epistemic justice is central to conflict resolution as it addresses fairness in the distribution of knowledge and the recognition of individuals as legitimate knowers (that they are credible sources of knowledge). This ensures that individuals are heard, believed and treated with dignity and respect, which in turn empowers people to participate more fully in the resolution process. Luong et al (2024) endorse developing epistemic humility, writing that “Developing humility involves being realistic about the limitations of what we know, restricting our confidence about what we can understand, and actively seeking others' perspectives so that knowledge can be created collaboratively.”

I would suggest that conflict practitioners who have an awareness of epistemic injustice can work (both as individuals and within organisations) to achieve more inclusive, equitable and sustainable conflict outcomes - and I intend to write more on this in Part 4 of this article. But first (in Part 3) I want to look at metaphor and stories.

References

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