Neurodiversity, epistemic injustice, and the good human life

Abstract

Epistemic injustice refers to harms that relate specifically to our status as epistemic agents, whereby our status as knowers, interpreters, and providers of information, is unduly diminished or stifled in a way that undermines the agent's agency and dignity. The concept was defined by Miranda Fricker (2007), who identifies two key forms of epistemic injustice. The first is testimonial injustice, which refers to cases where testimony is unduly dismissed because of prejudiced beliefs regarding minority groups. Hermeneutical injustice refers to cases where a community's shared vocabularies have been structured in a way that unfairly distorts or stifles understanding for, and of, a minority group. In each case, there is an instance of people being harmed specifically in their capacity as knowers: individuals capable of knowing or providing knowledge. Much work on epistemic injustice has identified the operation of negative stereotypes relating to gender and race; for instance, when someone's testimony is dismissed, doubted, or accorded low credibility due to racist or sexist prejudices on the part of the listener (Dotson, 2011; Fricker, 2007; Kidd et al., 2017; Medina, 2013). But in recent years research has drawn attention to epistemic injustice in healthcare generally, and more specifically within psychiatry, pediatrics, and among people with disabilities (Blease et al., 2016; Carel & Kidd, 2014; Crichton et al., 2016; Kidd & Carel, 2016, 2019; Potter, 2015). What has been revealed is the systematic stifling of the voices and interpretive tools available to both ill and disabled persons: in particular, their information providing, testimonies, and interpretations. These types of epistemic injustice have been associated with the medical deficit model that dominates much of medical and psychiatric discourse (Kidd & Carel, 2018, 2019). Moreover, physically disabled persons' claims that they are happy and living good lives have also been dismissed due to prejudices about the possibility of living well whilst disabled (Blease et al., 2016; Carel, 2016, ch. 6). Our interest here is in the possibility that epistemic injustice may stifle forms of flourishing or routes to wellbeing among individuals with neurodivergent disabilities. Here we will focus on one particular disability, namely autism, but we also suggest that this may shed light on the more general issue when it comes to other cognitive, neurodevelopmental, and psycho-social disabilities. In our discussion of the good life we are concerned both with subjective framings that focus on feelings of wellbeing and happiness, as well as more objective framings based on the notion of flourishing or objective goods. As we discuss below, autism is widely taken to be at odds—to varying extents—with both wellbeing and flourishing, and hence incompatible with both objective and subjective conceptions of the good life. While this is one dominant view, it has been challenged by proponents of the neurodiversity conception of autism. This recasts autism as a minority neurocognitive type that is primarily disabled and devalued under current social conditions, instead of it being a medical pathology (Chapman, 2019a; Singer, 1999). In de-pathologising, and instead politicizing, autistic disablement, and distress, this view opens the possibility that rather than autism being inherently at odds with living a good life, autistic wellbeing is impeded by contingent factors. It may even be that we have been rendered ignorant of the possibility of distinctly autistic forms of thriving in certain ways due to interlocking biases, stigma, and prejudice. In what follows we aim to show that epistemic injustice may not only unjustly reduce the credibility accorded to the autistic individual by her listeners, which may marginalize her account of everyday experiences and harms. It may also—despite there being good reason to think that autistic thriving is viable—block our ability to conceive of a good autistic life, as well as to recognize the testimonies of happy autistics as such. In practice, we show how this culminates in a catch-22 paradoxical situation whereby individuals are routinely seen as happy or autistic, but rarely both. This is practically important since it does not just deny recognition to happy autistics—it also means that the actual chances of autistic flourishing are severely diminished, much as any destination will be harder to find if it has not been included on the map. But it is also important for ethical theory more generally since it indicates that minority forms of human flourishing have been blocked from view. In light of this we suggest that a shift toward what's been called the neurodiversity paradigm (Walker, 2012) will place the possibility of autistic—and perhaps other forms of—flourishing on the map, making them visible and moreover salient through acknowledging that we are a neurologically diverse species. Beyond challenging dominant conceptions of normal functioning as it is standardly taken to (Chapman, 2019a; Singer, 1999; Walker, 2012), our argument will serve the further purpose of showing that neurodiversity also challenges us to radically broaden our conceptions of the good human life. On what we call the medical deficit view, autism is classified as a neurodevelopmental disorder, indicating that it is a harmful developmental trajectory that stems from underlying neurological dysfunction. The two key diagnostic traits that distinguish it from other similar classifications are (1) social and communication issues, and (2) restricted and repetitive habits, actions, and routines (APA, 2013, p. 31).1 1 There have been long-standing controversies on the diagnostic status of these categories and the DSM has shifted criteria for many of its disorders but especially for autism and Asperger Syndrome, with the latter being removed from the DSM 5 (Solomon, 2017). We are not uncritically accepting such categories but using them as a starting point for our critical discussion. Autism is also defined as a spectrum condition, with diagnoses being given in terms of its purported severity and correlating support needs. Diagnosis is further accompanied by clarifications regarding both verbal and general intellectual functioning. While the underlying biological mechanisms are complex and heterogenous, medical deficit accounts typically associate autism with empathy deficits alongside general cognitive and sensory processing issues that are in turn taken to have an underlying biological basis (Baron-Cohen, 2008; Frith, 2003). On the medical deficit view autism is also widely taken to be at odds (to varying extents on the of the with living a good human life. In widely to autism of of autistic being being or and the more widely to of or autism and in about more as an that be at and as an is a in about and have been for as a and or for of this of autism a of p. autism as and that to be as as p. On the of this may by the in which autism is associated with and low wellbeing & autism is associated with instance, many autistic of and et al., and are et al., these have taken autism to be inherently at odds with living a good life 2008; & 2015). here is the empathy deficit by autistic The as is who ability a life that is not a good human life, a life good is in of being to certain p. general cognitive deficits are also associated with harms. instance, how the associated with autistic the to more to 2013, p. This is not a view they are what we to be a widely view in In this and in a recent that of the of medical for a with autism living good life are & p. The medical deficit has been challenged in recent by neurodiversity proponents (Chapman, 2019a; Walker, 2012) have the neurodiversity paradigm as an to the dominant of psychiatric and cognitive disabilities. On the a restricted in terms of functioning if an individual of this and is also or disabled to a (APA, they will be taken to have a are to have a that them and it is this that is taken to the of to autistic ways of the notion of normal functioning has as the and in the that there is a restricted There are also issues that in to a functioning This is in the where the notion of is more based on than & the neurodiversity paradigm to be the and such as and for any human as such (Chapman, Singer, 1999). proponents aim to autism and instead neurodivergent and distress, and in a to the notion that at forms of are inherently harmful and also suggest that research on such issues be by neurodivergent people or at in to The neurodiversity much of its its proponents on social or of These neurodivergent and at in the of social and On the medical is the of and also the that is taken to from on by neurodiversity at a part of is or the of complex individual and On this view, for instance, the sensory associated with autism are as in part from sensory that minority sensory processing rather than from sensory processing of this which has been for in in the us to such as that are not inherently This is not to deny that they with toward certain only that they are harmful to the that they be disorders (Chapman, rather than as of harmful as they are taken to Here we will not about how the neurodiversity paradigm be when it comes to the autism These typically focus on cases of autism, with that it is to the neurodiversity a certain & et al., the of this we will that the neurodiversity be to the autism spectrum to at as even of the of the neurodiversity & et al., We also will not to a model of disability, instead that a of social and may be for of autism, challenging the notion that autism is an harmful dysfunction. our interest here in how this challenges not just dominant psychiatric conceptions of but also dominant ethical of the neurodiversity of the is at odds not just with dominant medical It is we at odds with both in the regarding human flourishing that autistic individuals & as well as the by p. p. that autism autistic to the that autistic individuals are inherently to wellbeing when to a this in we here in to the by social model that epistemic injustice our capacity to and autistic thriving and We that the neurodiversity of social of disability, as well as issues with the on accounts of reason to think that the medical deficit view regarding autism and the good life may be We will that the issue here is in part one of epistemic injustice, whereby autistic are to an epistemic that culminates in being in a as we will in this they credibility deficits that from negative stereotypes about with autism. This be as testimonial injustice (Kidd & Carel, that and in with the We will discuss injustice regarding autistic flourishing in the On the one more general testimonial injustice when it comes to autistic voices specifically due to prejudiced beliefs regarding autism. As autistic has of an autism spectrum is to a negative of capacity of p. This how an credibility deficit is prejudiced stereotypes about a testimonial injustice. Autism is associated with stereotypes that unjustly for autistic as and of social in understanding of social or As autistic to that have to autism in the capacity which any of that of epistemic and p. the is the that autistic people are that to other the social this theory has been to be (Chapman, and in & it is to the of autistic voices stereotypes a capacity to social in social and understanding of and due to These stereotypes the within autism and may credibility deficits to autistic individuals who in not have these instance, that when and the of autistic they by that the not be for instance, the was and the While this will that autistic voices are more to be dismissed when they a of of testimonies, here we to focus on testimonies about autistic wellbeing or This specifically to the that autism and are inherently at As the and to an autistic with support if the is not much of the discourse in both and or to the autism and or autism and to a p. This follows a of stereotypes widely about disabled whereby is to be incompatible with living good or happy lives being widely it is how many disabled in of wellbeing that are only than by who are not disabled p. in of wellbeing of people with a of and et in the the subjective by the objective by an objective such as and that are associated with only if they functioning or are associated with social our that the is to the p. 5 even and disability, such as and have been to have a on of wellbeing as such. a of with and that both the of on In both a similar of wellbeing et al., p. 6). In a of of life in and that general the from are and not support the that or to a of p. et that are only happy than et this of by a of and disabilities of of and autism from many cases of as autistic people to have low of as was disabilities are associated with low wellbeing if they are associated with of or functioning. this in it is to that how autistic voices have that any to autistic wellbeing and functioning is in terms of social stigma, and 2016; instance, and that a key reason autistic people to their wellbeing was to rather than their being autistic & and that wellbeing among the autistic was by how autistic individuals to rather than by how their cognitive was taken to they the social model & we not think We that one and and lives within We other people and our In we not to deny that of autism life inherently harder in important only that life being is not the as it is at odds with as such 2016, Carel, associated with and has been as toward happiness, as much as it be from it we not just the voices of autistic individuals who being but also the indicating that diminished autistic wellbeing be in to stigma, and disablement, good reason to think that a of the dominant view, that autism and wellbeing are inherently at is a prejudice. it is that wellbeing is low among the autistic toward this being a of and rather than to being It is important to that epistemic injustice of that wellbeing and being unfairly accorded low credibility are of that on wellbeing and to be taken account in our In the we to this issue and for epistemic injustice toward autistic that autistic claims regarding subjective wellbeing and are dismissed due to testimonial injustice. this it be that even if we that autistic individuals are the of epistemic injustice regarding claims to subjective happiness, there are good objective to think of autism as being inherently at odds with living a good human life. This a widely that cognitive is and to be a for both the individual and her p. of of subjective While such have been from a of we find the among who suggest that even autistic individuals who are happy are only because they not that they are objective of the good human life Here we will this view that is an issue of epistemic injustice. This it is a of injustice, in which the ways we have our of human flourishing unduly neurodivergent of On the of view we have in to what is of the has been on to who is capable of living a good life, a life of flourishing or This is a life in which an individual lives in with their the of their It is for instance, to be to in to as is not for to as of this view us what the is for a given has for p. it comes to autistic individuals the of being for them to the that part of that if they are to and in a p. with other & Potter, and who have on autism, the traits of autistic to not be and at odds with flourishing, the traits that are of Beyond this to individuals who the is also in the work of who has been in healthcare In will be we in to or normal p. the view we aim to here is of but not but also of such as What have in is the focus on what is of a from which an account of normal is which functioning our focus here is on accounts that are based on the notion of normal other who are not such as the Singer, have disabled people from conceptions of the good human life on further While it is that what we are will what's good for with flourishing has been as being unduly On the one conceptions of flourishing have to of who may to such as or in to their to the of the by the social 2016; This of especially who are people of On the accounts to be at odds with the in a given species. has that the notion that or even conceptions of show us how we may be both and toward minority disabled of flourishing p. to such a model to an to distinguish inherently flourishing on the one and disabled minority ways of being on the other when it comes to to living well as a disabled one autistic has how on the voices of rather than disabled and moreover to we call an has been to social In we that is even of the neurodiversity is to & et al., that there are many ways of it is not a to that will be diverse in terms of routes and forms of, As autistic has since and of autistic people are from of also in autistic people than it does in p. 6). This with the notion that what is good for us will on what we are but also that autistic people are from hence that autistic thriving will not thriving even if both are of the species. similar of has been by et p. suggest that a on regarding what is good conceptions of the good life to be to minority forms of On their view, when it comes to what the good life may in for on about not even when these and are by way of and point is that dominant conceptions of the good life, of flourishing, typically on regarding what is good or and a issue when with for neurodivergent of flourishing that may be in their argument is more about the underlying our is that the they point to also be as a of epistemic they that our conceptions of human flourishing, due to the that such conceptions neurodivergent of This the issue from a not testimonial injustice, for it us from being to minority of flourishing, as we have there being reason to think that such of flourishing the neurodiversity is or is to an given the of that comes with a neurologically diverse we there to be a of ways of flourishing within the human many of which from and of which may be rendered due to restricted conceptions of human The for this is by autistic ways to their with being autistic, or that autism as a of they not to of wellbeing as a of a of an that the and of autistic The of may even autistic people in ways that to It is important to that epistemic injustice is in of as it and the of minority its it not only the of but also that There was only one and that was which that a for in the of that and was the of a was and be to was and as as be and have to more p. the because a negative and this the of people with autism. functioning in our is for but is not the as being The we have but to in a where autism is of as a and a that further and p. In other the issue for is not that in is classified as a and a but rather that it is of as such. The that autistic is and further and This type of has been by and It when the and to a more and p. Epistemic the and an epistemic on the autistic more the disabled as and argument to at an on people with disabilities who to their and to the by the epistemic p. be for a there has to be that the is in way they are being or are or have of or are not their or p. In that autistic individuals a catch-22 situation we the if a who identifies as autistic and who the diagnostic criteria is living a good life, they are recognition of their autism. they are not living a good life, they are as autistic, and their low of life is to be by the autism even if they epistemic that autistic accounts are taken to that the is not happy or that they are not On the autistic and is not it is not to be both. On the latter if that is happy and their happiness, the and of and their that that is not We how the situation we have identified will be harmful for autistic as a that has been removed from will be much harder to will autistic individuals find it harder to aim at autistic thriving than because such thriving is not the only does this that autistic thriving is harder to or it also means that to by autistic individuals will be by for on cognitive and Carel, or other such as a or Our aim here has been to and how this catch-22 from interlocking that the way from everyday through psychiatric theory and practice, conceptions of the good human life. of the catch-22 we an which we in this We which may to epistemic injustice autistic and epistemic injustice within healthcare and The the medical deficit to about the and of autistic autistic and epistemic and We each in the medical deficit to autism. The issues with this in 1 and be through with the and its and We critical discussion of the with the medical deficit for further of the it the of of this about the of or critical of how of autism is What we have on here is a to the ways in which autism is seen as inherently harmful than which are with the DSM conception of It is also important to to to the medical deficit that a of such the to medical and if This important our of the by of of testimonial injustice to the and of autism. In particular, we the by autistic and which to the and that the medical deficit view is based on Walker, While we to a and & Carel, is a social of to view certain as and is to such as a medical p. This the harmful that is to the medical deficit and social and toward autistics from the which individuals to a and if they The further support in that or ill the of medical framings and find a certain in the but in varying the that the model that there is to about their and p. on the of and of autism is for a from a and understanding of autism through a medical whilst the to medical support and if conceptions of the good life. We that conception of the good life that are based on the are part of the We are not the as but we suggest that using this as the basis of how we human flourishing is not with autistic and other neurodivergent forms of this does not we on of flourishing as such. to the good life have the of understanding and as well as flourishing, in to objective about the instance, has from and toward to shift the focus how well individuals their instead of them the this because this to well with how disabled in on view, the way a to living a life may be part of what is of their individual to living a good life. We also find support in Carel who in discussion of the neurodevelopmental spectrum has the to our understanding of the in light of individual cognitive On her view, or be in to their individual rather than in to a This us to as shared but to the individual rather than the species. The a view of the good life and of flourishing, that is and from the focus on the we in to conceptions of the good life. We also autistic people and to their of their life and of this will from and the of autistic epistemic whereby autistics have been to shared and social that autistic and (Chapman, that at the autistics and other to be and for many but for our current is that the of vocabularies will be for further an and understanding of autistic forms of The may also be instance, Carel a for in a healthcare to support to to and of their condition, which are from medical of autism have also been in recent the ways autistic 2019). instance, the concept of the autistic as a to the in to on to the of autistic The of such will be for autistic relating to autistic In we suggest that our may more the of autism. As we have the by the medical deficit and the that it with conceptions of flourishing, is a key part of the issue when it comes to autism. our of the good life to the neurodiversity paradigm may be as important as neurodiversity proponents of in light of such a paradigm this is important not just for other disabilities are also routinely the people also similar forms of and epistemic injustice. Moreover, about neurodiversity have on autism, the concept is not to be and in recent years the concept has been to other disabilities it is also that similar may also for other disabilities. we also for instance, the possibility of flourishing of with understanding the ways people to us a situation where a of are While the we have here not to any other and will be in each case, our does good reason to similar are also at in other We may have a of forms of human thriving that will be to and in to two for their on how to the was in on their research at the of and to both their and the for their support that is in at work in of with a focus on neurodiversity and Carel is of at the of in of of was by in was as a of in was the for her work on the of is the of 2013, for the and of and in and is the of and in and of What