Le concept d’injustice épistémique s’intéresse à la manière dont la capacité d’un sujet à produire du savoir peut être déniée ou minorée. Nous nous proposons ici d’étudier son intérêt en psychiatrie, de la pratique clinique à la nosographie.
Matériels et méthodes
Après avoir défini les principales injustices épistémiques, nous étudions leur application à la relation médecin-malade. Nous cherchons enfin à comprendre quel pourrait être l’apport de ce concept dans la clinique psychiatrique mais aussi dans la classification des troubles mentaux.
Les patients souffrant de troubles mentaux sont particulièrement vulnérables aux injustices épistémiques. Des facteurs prédisposants peuvent être identifiés, certains communs à tous les troubles psychiatriques, d’autres spécifiques à chaque pathologie. Les classifications en psychiatrie reflètent aussi l’existence d’un déséquilibre épistémique entre usagers et communauté scientifique. L’inclusion des usagers dans l’élaboration de la nosographie est de plus en plus consensuelle, car elle pourrait permettre d’améliorer leur validité, avec un impact sur la pratique clinique, sur les questions de stigmatisation ou encore le financement de la recherche.
La notion d’injustice épistémique pourrait constituer un cadre conceptuel pour mettre en évidence les situations dans lesquels le discours du patient n’est pas suffisamment pris en compte alors qu’il constitue un savoir pertinent. Il nous semble donc utile dans une approche intégrative visant à mieux articuler savoirs médical et expérientiel, sous réserve du développement d’outils pour mieux recueillir ce savoir expérientiel.Le texte complet de cet article est disponible en PDF.
The concept of epistemic injustice was developed in 2007 by Miranda Fricker. It designates a specific category of prejudices, where the subject's capacity to produce knowledge is denied or undermined. Several authors have applied this concept to the field of health and argue that people with a medical condition are more vulnerable to epistemic injustices than healthy people. In psychiatry, some authors believe that patients are even more vulnerable to such injustices in clinical practice than patients of other specialties. Some others identify certain forms of epistemic injustice in the classifications of mental disorders, and postulate that it could lead to epistemic losses in classifications, diagnoses and care. In France, this concept is relatively unexplored in psychiatry. The aim of this paper is to identify and summarize the potential contributions of the concept in psychiatry, from the clinical practices to the definition of mental disorders.
Materials and methods
First, we will define the main types of epistemic injustice described by Fricker. We will then see how these injustices can occur in the field of health. Finally, we will study why patients with a mental disorder are particularly affected by these injustices, the potential impact on psychiatric nosography and the ways to address these epistemic injustices.
There are two types of epistemic injustice. In testimonial injustices, a person's speech is unwittingly considered to be of little or no credibility by his interlocutor, because of negative prejudices against him or his community. Hermeneutic injustice occurs when a person fails to convey their experience, due to a lack of hermeneutical resources to interpret and communicate it. In healthcare, the credibility of the patient's testimony can be diminished by several factors and general prejudices. Additionally, there is a lack of interpretive resources to understand and share many aspects of the experience of illness. In addition to this, the epistemic privilege accorded to healthcare professionals, particularly physicians, leads to accentuating the epistemic imbalance. The type of doctor-patient relationship, and its evolution, also impact the respective epistemic positions. In psychiatry, patients are seen as more vulnerable to epistemic injustices. Crichton thus identifies three common factors to all mental disorders, including a general prejudice of irrationality and unreliability. In addition, each pathology has specific factors exposing patients to a weakening of their epistemic capacity. To correct these injustices, several tools have been proposed, such as including the study of epistemic injustice in physician's training or using a phenomenological toolbox. Anke Bueter also suggested the existence of a specific form of testimonial injustice in psychiatric classifications, known as “pre-emptive”, which excludes the possibility for ill people and their relatives to testify. However, taking these testimonies into account could act as a corrective mean in the construction of nosography. This nosography is indeed based, in psychiatry, on value judgments, due to the lack of objective data. Several authors, including Bueter, therefore call for a better integration of users in the revisions of classifications, to improve their validity. This could have implications for the clinic, research and its funding, and other issues such as stigmatization. However, how exactly the users’ point of view could be integrated still needs to be defined. Several proposals have been found in the literature.
We consider that the concept of epistemic injustice is a useful tool towards a better articulation between experiential and medical knowledges. In clinical practice, if the clinician is trained in this concept, he will be able to identify situations at risk of epistemic injustice, attempt to neutralize this imbalance and thus carry out a more exhaustive clinical examination and more appropriate care for the patient. Regarding nosography, strengthening the epistemic position of users and integrating their knowledge could improve the validity of classifications. The question of the validity of psychiatric nosography is a problem that the scientific community has faced for a long time, and it therefore seems interesting to continue this reflection through the concept of Fricker. In both cases, it is necessary to continue developing tools to better define, analyze and integrate this experiential knowledge.Le texte complet de cet article est disponible en PDF.
Mots clés : Alliance thérapeutique, Désavantage cognitif, Injustice épistémique, Nosographie psychiatrique, Recherche clinique
Keywords : Biomedical research, Classification, Cognitive disadvantage, Epistemic injustice, Therapeutic alliance