In Aeschylus’ Agamemnon, Cassandra gives voice to the cruelty of her curse when she says, “Ever since that fault I could persuade no one of anything” [1]. Cassandra was a Trojan princess and prophetess who was cursed by Apollo to speak true prophecies that no one would believe. After Troy fell, she was taken to Greece by Agamemnon and was later killed by Clytemnestra. Her tragedy is therefore not simply that she knows the truth, but that truth becomes powerless when the speaker is denied credibility.
This myth offers a useful metaphor for modern healthcare. Patients often know that something is wrong before medicine can name, measure or explain it. Pain, fatigue, dizziness and sensory disturbance may all be real and disabling, while remaining partly invisible to examination or investigation. NICE’s category of chronic primary pain, where pain has no clear underlying cause or appears out of proportion to observable disease, shows how clinically serious suffering can exist without a simple visible lesion [2]. The patient is often the first witness to illness, but the clinical problem is that this witness may not always be believed.
Modern medicine rightly values objective evidence. Blood tests, imaging and guidelines protect patients from unsafe assumptions, but they do not exhaust the reality of illness. Symptoms are often first made available through testimony, and the history remains one diagnostic tool. Ethical tension arises when absence of objective confirmation is treated as evidence that nothing is wrong. Epistemology is the branch of philosophy concerned with knowledge and justified belief [3]. In medicine, this matters because illness is known not only through tests or images, but also through the patient’s account of symptoms and suffering.
Fricker’s concept of epistemic injustice describes a wrong done to someone specifically in their capacity as a knower [4]. In healthcare, Carel and Kidd argue that ill persons are vulnerable to this injustice when their accounts are dismissed as confused, exaggerated or unreliable [5]. Cassandra therefore anchors this problem because she shows how truth can lose force when the speaker is not recognised as credible. In the clinic, this does not mean that every patient account must be accepted without question. Rather, it suggests that ethical medicine requires neither blind belief nor cynical doubt, but respectful, critical trust, expressed through serious attention to patient testimony, validation of suffering, proportionate investigation and humility about what current tools can and cannot capture.
Cassandra and the problem of credibility
Cassandra’s story is powerful because it separates truth from credibility. She does not fail because she lacks knowledge. She fails because her knowledge is not socially received. This distinction matters in medicine because illness often enters the consultation through speech before it is visible through signs or tests. A patient says that pain has changed, fatigue is no longer normal tiredness, or low mood has become frightening. Such statements may not yet amount to a diagnosis, but they are the first shape that illness takes in language and require careful interpretation.
The patient therefore occupies a distinctive epistemic position. Clinicians have scientific training and access to investigations, but they cannot inhabit the patient’s body or directly feel pain, exhaustion or fear. They must rely on testimony while interpreting it through clinical reasoning. This is not a weakness of medicine, but a routine clinical feature. Narrative medicine similarly reminds clinicians that illness stories help make suffering, chronology and meaning intelligible [6].
The ethical danger is that some patients are granted less credibility before their testimony has been properly heard. A confident, articulate patient may be understood as reliable, while another may be labelled anxious, dramatic, difficult, drug-seeking or lacking a clear diagnosis. Such judgements may be shaped by gender, race, class, disability, mental health history or previous interactions with healthcare. In Fricker’s terms, testimonial injustice occurs when prejudice produces a credibility deficit [4]. In the clinic, that deficit can alter how a story is heard, whether pain is treated and whether follow-up is offered.
Cassandra therefore clarifies a moral as well as diagnostic problem. Her tragedy lies in the fact that truth is not enough when the speaker has already been denied credibility. In medicine, this danger is especially clear in pain, where the patient may be the only direct witness to the severity, character and meaning of suffering. The issue is not that clinicians should accept every account uncritically, or that patients always know the cause. Rather, clinicians must ask whether diagnostic uncertainty has begun to turn into disbelief. Like Cassandra, the patient may not lack truth. They may lack an audience willing to treat testimony as knowledge.
Testimony as medical evidence
Medicine is often imagined as a discipline of measurable facts, yet evidence-based medicine was never intended to replace judgement or patient values with data alone. Sackett et al. defined evidence-based medicine as the integration of best research evidence with clinical expertise and the values of the patient [7]. Patient testimony belongs within this integration because symptoms, priorities and lived experience are part of how responsible clinical judgement is formed. The clinical history is often the first place where illness begins to take shape, and Hampton et al. showed that many diagnoses are formed through the patient’s story before examination or investigation adds clarity [8].
This is especially important because many clinically significant experiences are not directly observable. Pain cannot be inspected like a rash. Fatigue cannot be captured by a single blood test. Breathlessness, dizziness, palpitations and emotional distress all require the patient to describe what is happening and how it affects daily life. Even an abnormal result becomes meaningful only within this narrative context. A raised inflammatory marker or scan abnormality does not speak for itself. It must be interpreted alongside the patient’s history [6,8].
The hierarchy of evidence is valuable for judging research quality, but it can be misunderstood as a hierarchy of reality. If measurable findings are treated as more real than subjective experience, patients with invisible illness become vulnerable to dismissal. Normal investigations often answer only specific questions. A normal scan may make serious structural pathology less likely, but it does not disprove pain, and normal inflammatory markers do not make fatigue insignificant. Symptoms may remain invisible because pathology is functional, early, fluctuating, poorly captured by current tests, or not yet fully understood. The risk is that invisibility becomes mistaken for unreliability. A responsible approach therefore treats testimony as evidence to be weighed carefully, not as noise to be filtered out.
Pain and epistemic injustice in the clinic
Pain provides the clearest example of how testimony can be both clinically necessary and ethically vulnerable. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage [9]. This matters because visible tissue damage is not required for pain’s reality. Pain may be profound even when imaging and blood tests cannot demonstrate a lesion, and Scarry argues that pain is difficult to communicate because it resists language and cannot be fully shared from the outside [10]. The patient may know their suffering with certainty, while the clinician approaches it indirectly through history, examination and differential diagnosis.
The ethical problem is not that clinicians must interpret pain, since interpretation is essential to safe medicine. The difficulty arises when uncertainty about cause makes the patient’s testimony carry less weight than it should. Severe pain may be minimised when investigations are normal, symptoms are recurrent, or previous consultations have not produced a diagnosis. In these situations, epistemic injustice may appear not as open denial but as a narrowing of clinical curiosity, where pain becomes less likely to prompt reconsideration, follow-up or explanation. In pain, this is the Cassandra problem in its most intimate clinical form. The body speaks through suffering, yet the person who can best describe that suffering may still struggle to be heard as credible.
Endometriosis shows how testimonial injustice can settle into the ordinary language of gender, where pelvic pain is too easily heard as expected, emotional or excessive before it is recognised as illness. Endometriosis UK reported in 2024 that the average time to diagnosis in the UK was 8 years and 10 months, with many attending repeatedly while the severity of their symptoms was questioned [13]. Against this background, NICE guidance reminds clinicians to consider symptoms, pain diaries, daily living, fertility, psychosexual wellbeing, work and study [14]. The epistemic problem is not only that endometriosis can be clinically difficult to identify. It is also that repeated testimony about menstrual and pelvic pain may be culturally trivialised before it is diagnostically explored.
Sickle cell pain crises expose a different moral failure, where pain that should command urgency can instead become entangled with suspicion. These acute episodes can be severe and unpredictable, and NICE recommends pain scoring and analgesia within 30 minutes of hospital presentation [15]. Delay in analgesia can communicate suspicion, especially when patients are assumed to be drug-seeking or clinicians are anxious about opioids. Here, disbelief intersects with race and stigma. Hoffman et al. found that false beliefs about biological differences between black and white patients were associated with biased pain perceptions and treatment recommendations [16]. A patient who understands their disease and usual analgesic needs may therefore be treated less as an expert witness than as a suspicious narrator.
Fibromyalgia reveals a quieter form of epistemic vulnerability, where suffering is named in medical language yet still struggles to be believed in clinical encounters. It is a recognised condition involving widespread pain, often alongside fatigue, sleep disturbance, cognitive symptoms and other somatic symptoms [17]. However, because it lacks a simple biomarker, symptoms may be shifted too quickly into a psychosomatic frame. Psychological distress can shape illness, but psychosomatic explanation should widen care rather than reduce credibility. When psychological framing begins to weaken trust in the patient’s account, patients may be left without adequate symptom control, functional support, follow-up or validation. In this shift, testimonial injustice takes shape because the difficulty of explaining suffering becomes a reason to doubt the sufferer. The absence of a clear diagnosis should not diminish the credibility of the patient’s account, nor make suffering appear less deserving of care.
Long COVID offers one of the clearest examples of hermeneutical injustice, where patients were not silent, but medicine did not yet have the shared language needed to fully hear them. Many described fatigue, breathlessness, cognitive dysfunction, post-exertional worsening and fluctuating disability before clinical language had caught up. Qualitative work by Ireson et al. described these patients experiencing invisibility, disbelief and a need to seek validation outside conventional healthcare spaces [18]. The condition was not brought into existence by medical recognition, but recognition altered whether patients’ experiences could be named, investigated and incorporated into care. Hermeneutical injustice is present when medicine lacks, resists or delays the concepts needed to understand the experience being described [4]. Like Cassandra, patients may speak before their audience has learned how to listen.
Taken together, these examples show that epistemic injustice in pain rarely appears as explicit denial. It more often emerges through doubt, delay, minimisation and unequal credibility. It also operates structurally, through myths about women’s pain, racialised suspicion, stigma around contested illness, and systems that privilege quick measurement. In such cases, the patient’s testimony may be the primary route through which suffering becomes clinically visible.
The clinician’s dilemma: belief, scepticism and responsibility
The ethical challenge is not to choose between belief and scepticism, but to practise trust disciplined by evidence. This matters because believing a patient’s suffering is not the same as accepting every proposed diagnosis, investigation or treatment without question. Medicine must still guard against overdiagnosis, unsafe prescribing, unnecessary investigation and false reassurance. A patient may know the reality, severity and meaning of pain while still being uncertain about its cause. Equally, a treatment request may be clinically inappropriate even when the distress behind it is genuine. The moral task is to hold these truths together, believing the patient as a witness to suffering while remaining responsible in interpretation and treatment [5,11,19].
A more defensible response is not suspicion disguised as caution, but respectful, critical trust. Respectful trust means taking the patient seriously, validating suffering and not allowing uncertainty to harden into disbelief. Critical trust means examining carefully, considering red flags, weighing alternatives and recognising potential harms. The National Academies’ report describes diagnosis as a complex process of clinical reasoning, information gathering and collaboration with patients and families [19]. That model captures the balance well. The patient is not an oracle, but neither is the clinician a detached judge who can ignore testimony until a test confirms it.
Shared decision-making offers a way of holding this tension without collapsing into unquestioning belief or defensive scepticism. It recognises that clinical expertise and lived experience are not rival forms of knowledge, but different contributions to responsible medical judgement. GMC guidance emphasises listening to patients, acknowledging their knowledge and experience, explaining the reasons for management options, and taking steps to alleviate pain and distress [11]. NICE similarly presents shared decision-making as a collaborative process grounded in both evidence and the person’s values [12]. The clinician remains accountable for safe care, but that accountability should keep the conversation honest rather than closed. Ethical scepticism should help name uncertainty, explore possibilities and protect the patient from harm, not become a way of withdrawing trust.
Practical ethical duties
If Cassandra’s story exposes the harm of truth without credibility, practical ethics must ask how clinicians can respond in ordinary consultations. Attentive listening is central because it is the moment when the patient’s testimony first enters clinical reasoning. It requires attention to moments when credibility is reduced by labels in the notes, repeated attendance, mental health history, social assumptions or clinician frustration. To listen ethically is to guard the space in which the patient can still be received as credible, even when diagnosis remains uncertain.
Validation does not require the clinician to surrender judgement, but to recognise suffering without making certainty a condition of compassion. It recognises the reality, seriousness and personal impact of suffering without prematurely fixing its cause. Such validation preserves diagnostic openness and dignity. It also creates the conditions for shared decision-making, because patients can participate more honestly when their account has been taken seriously [11,12]. In this sense, validation is not a promise that medicine already knows the answer. It is a commitment not to make the patient bear uncertainty as disbelief.
Proportionate investigation is another expression of moral responsibility. Ethical practice must avoid both premature dismissal and excessive or unfocused investigation. The clinician’s task is not only to decide whether tests are indicated, but to explain what those tests can show and what uncertainty remains. Negative findings may make some diagnoses less likely, but they should not become a final judgement on suffering. Where symptoms persist or evolve, care should continue through safety-netting, follow-up, symptom control and readiness to revise earlier assumptions. Such practices prevent diagnostic uncertainty from becoming abandonment.
Care must not wait at the threshold of certainty while the patient continues to suffer. Patients with unresolved or invisible symptoms may still need practical support while diagnostic understanding develops. Cassell’s claim that relief of suffering belongs at the centre of medicine is therefore particularly significant [20]. It reminds clinicians that care is not exhausted by the search for pathology. Medicine has a duty to remain with the person living inside distress, limitation and fear while explanation is incomplete. The Cassandra warning is that suffering can be spoken truthfully long before it is fully recognised.
Conclusion
Returning to Cassandra shows why the myth remains ethically powerful. It does not ask clinicians to treat every patient account as diagnostically complete, nor to accept every request as clinically appropriate. Its value lies in naming the harm of being truthful about suffering and yet unheard. Cassandra captures the gap between speaking and being recognised as credible.
Medicine must continue to value objective evidence. Investigations, imaging, guidelines and trials are essential safeguards. Yet ethical medicine should not confuse absence of explanation with absence of illness. Patient testimony is often one of the first forms evidence takes, especially in pain and invisible illness. To dismiss it too quickly is to risk diagnostic delay, undertreatment and loss of trust.
The clinician’s task is to hold a difficult balance, allowing scientific caution to remain careful rather than dismissive, scepticism thoughtful rather than cynical, and uncertainty honest rather than abandoning. It is both clinical work and moral duty. The ethical task is not to become an oracle who always knows the truth, but to avoid leaving patients in Cassandra’s position, present in the room, speaking from suffering, and still not fully believed.
References
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