Epistemic injustice and the mental health service user.

John Rawles (2004, p. 230) famously asserted that ‘Justice is the first virtue of social institutions, as truth is of systems of thought’. Truth and justice, he argued, are not to be compromised, and laws and institutions must be abolished or reformed if found to be unjust. Nevertheless, justice tends not to be the first principle of appeal or consideration in ethical deliberations in mental health care. For example, breaching people’s autonomy through involuntary or coercive treatment, or containment through the use of practices, such as seclusion (reviewed by Happell in this edition), are common but profoundly ethical problems within mental health services. Such practices are typically justified with reference to the principle of beneficence, that they are in the person’s best interests, and/or non-intervention would lead to harm to the individual or others. Justice does not typically enter the equation, except in the sense of ‘procedural justice’, that is, ensuring that people are seen to be dealt with fairly by having access to second opinions, timely reviews, and otherwise competent treatment. There are, however, other important conceptions of justice that are at least as relevant to mental health service provision. Some mental health services or systems which have treated people poorly in the past have embarked on a process of reconciliation with former service users, which might be described as a process of ‘restorative justice’. Often one hears that mental health services have not received a fair allocation of resources relative to other areas of health expenditure (an appeal to distributive justice). Occasionally too, people make impassioned pleas to address ‘social injustice’ and mental health, or the stigma, discrimination, marginalization, and violation of human rights associated with being labelled as having a mental illness or different. For example, Johnstone (2001, p. 208) in one of the rare occasions in which any conception of justice has been explicitly addressed in this Journal, argued that ‘it is a moral imperative of the first order’ to listen to those construed as socially deviant because of mental health problems and to overturn the stigma of difference. Most readers would acknowledge that many people who come to use mental health services also experience and are deeply affected by ‘social injustice’ as a consequence of a range factors, such as poverty, class, ethnicity, and gender. However, there is a tacit acceptance of social injustice as inevitable, and addressing structural inequalities (poverty, systemic racism etc.) is more often than not considered beyond the purview of mental health services or nursing practice to address. More recently, Fricker (2007) described two forms of epistemic injustice which cause harm by diminishing people’s capacity as knowers and ultimately undermining their status as citizens. ‘Testimonial injustice’ occurs when prejudice causes a hearer to ascribe a deflated level of credibility to a speaker’s words or testimony. Actual and potential testimonial injustice is endemic within mental health service delivery. For example, central to mental health legislation is the idea that some people lack the capacity to make decisions and it follows that what they might say, how they construe problems, their choices and preferences lack coherence, logic, or credibility. It is not surprising then that the testimony of all or most people who use mental health services might be considered suspect. For example, I recall feeling profoundly affected by a small dose of a commonly prescribed psychotropic drug. When I reported this to the prescriber, my claims were met with incredulity, as the reaction I experienced was quite unusual. As a professional, the veracity of my reporting of the symptoms or behaviour of others had never been called into question in the manner that it was when I was in the position of patient. Since the advent of behaviourism and subsequent development of neuro-imaging technologies, the self-reports (or introspections) of patients more often require corroboration or more ‘objective’ verification. Often when observations or self-reports are translated onto a scale, the number is ascribed greater significance than a person’s testimony, and epistemic injustice is subtly perpetuated. Instances of testimonial injustice might not seem to have the gravity of other ethical problems, such as coercion. However, the significance of testimonial injustice is that it is foundational to other forms of injustice. International Journal of Mental Health Nursing (2010) 19, 151–153 doi: 10.1111/j.1447-0349.2010.00680.x