Integrated Care Systems as an Arena for the Emergence of New Forms of Epistemic Injustice

Andrew Fletcher,Jeremy Clarke

doi:10.1007/s10677-020-10111-1

Abstract

Epistemic injustice has rapidly become a powerful tool for analysis of otherwise hidden social harms. Yet empirical research into how resistance to knowing and understanding can be generated and replicated in social programmes is limited. We have identified a range of subtle and not-so-subtle inflections of epistemic injustice as they play out in an intervention for people with chronic depression in receipt of disability benefits. This article describes the different ‘species’ of epistemic injustice observed and reveals how these are unintentionally produced at frontline, management, commissioning and policy levels. Most notably, there remains a privileging of clinical knowledge over other forms of knowledge, producing a ‘pathocentric epistemic complex’. This, combined with the failure of different agencies with competing ideologies to adequately understand each other, and a vicious policy context, added to the injustices already faced by people with mental health issues, generating multiple harms. This has important implications for a range of integrated care and welfare interventions – not least by drawing attention to their unintended potential for replicating epistemic injustice as an institutionalised complex. Careful evaluation and design of such programmes, applying the philosophical and epistemic resources illustrated here, can help mitigate this outcome. Further, by raising awareness of epistemic injustice among programme participants, we can generate epistemic structures that secure programme integrity locally, and promote better policy.

Highlights

The concept, epistemic injustice, is at once simple to grasp yet imbued with the potential to take multiple hidden forms, twisting in response to the diverse contexts in which it often surfaces silently
The active debate in this relatively young field has expanded on those initial distinctions to include notions around contributory injustice (Dotson 2012: 31–32), pathocentric epistemic injustice (Kidd and Carel 2019) and institutional epistemic injustice (Fricker 2007; Anderson 2012; O’Donovan and Madden 2018), maintained by epistemic communities (McHugh 2017)
Instead of focusing on the dynamics between professionals and service users, our study examined the relationships between experts in social care and welfare, mental health professionals, their managers, commissioners and policymakers, to identify several different forms in which epistemic injustice played out: 1) prior assumptions combined with experiences on the programme led to identity prejudice between practitioners; 2) communications software and bureaucratic processes unfairly filtered out some valuable forms of knowledge in conversations around clients; 3) ideological and political disagreement led to managers and commissioners failing to understand each other’s positions; and 4) this was underpinned by a vicious welfare policy that, through the use of sanctions, undermined clients’ trust in the system and the programme

Summary

Introduction

The concept, epistemic injustice, is at once simple to grasp yet imbued with the potential to take multiple hidden forms, twisting in response to the diverse contexts in which it often surfaces silently. The act of treating someone unfairly “in their capacity as a knower” (Fricker 2007: 1), and the distinctions of hermeneutical and testimonial injustice, provide a fruitful conceptual territory that continues to be explored and developed in theoretical and empirical realms. The active debate in this relatively young field has expanded on those initial distinctions to include notions around contributory injustice (Dotson 2012: 31–32), pathocentric epistemic injustice (Kidd and Carel 2019) and institutional epistemic injustice (Fricker 2007; Anderson 2012; O’Donovan and Madden 2018), maintained by epistemic communities (McHugh 2017). Some scholars have warned about perpetuating oppression through defining epistemic injustice in ways that could exclude important contributions to the discussion, and argue that the concept should be considered open (Dotson 2012; Pohlhaus Jr. 2017). Our evaluation of an integrated health and welfare programme in the UK provides a useful meso-level stage for catching glimpses of emergent forms

Objectives

Methods

Conclusion