Minding the epistemic gap in covid-19 and beyond

It is heartening to see The BMJ publishing information based on lived experience of covid-19. Perspectives such as Boyes’s are vital in understanding its harms, along with other qualitative data.1

Boyes extends knowledge in two ways—flagging issues such as memory loss, sleep difficulties, and fear, which might prove generalisable as part of the clinical picture of covid-19, and offering lessons about the kind of clinical needs that get overlooked because they did not pre-exist in the minds of clinicians so were not part of predetermined clinical routines.

In busy clinical routines—and what could be busier than the current circumstances—procedures must be “porous” to patient thought and experience. Boyes illustrates the kind of epistemological gap2 that can arise when they are not: some of his most distressing symptoms simply found no place in clinical consultation.3

But if the costs of “closed” procedures are in part borne by patients, they are also in part borne by those striving to understand the illness. Fricker describes the “lose-lose” of epistemic injustice—a form of injustice that occurs when relevant testimony is excluded not on the basis of its importance but on who is presenting it, such as a patient rather than a professional.4

A grave example was the London Metropolitan Police’s failure to interview the key witness to the murder of Stephen Lawrence, because Duwayne Brooks was, being a young black man, considered an unreliable witness.5 Brooks was wronged, of course, but so was the whole British criminal justice system.

Qualitative data indicate that doctors are both skilful and polite in refusing to engage with patient questions that do not match their pre-existing knowledge and sense of competence.6 Although psychologically understandable, this is an ignorance trap. Maintaining porosity to new information seems essential, especially in the face of a new disease.