Research Paper on Trust

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Outline

I. Trust Between Patients and Providers

A. Changing the Standards of the Patient-Provider Relationship

B. Implementing the Fiduciary Standard

II. Trust and Family Members

III. Other Areas of Trust in Healthcare

IV. The Morality of Trust

V. Conceptual Relationships

VI. The Literature on Trust

I. Trust Between Patients and Providers

Trust between patients and providers is a central topic for bioethics. Consider the trust (or distrust) involved when someone contemplates major surgery: First of all, there is the relation between the surgeon and patient. The patient needs from the physician both a high level of competence (both judgment and skill) and a concern for the patient’s well-being. For healthcare professionals to behave in a responsible or trustworthy way requires both technical competence and moral concern—specifically, a concern to achieve a good outcome in the matter covered, which is sometimes called “fiduciary responsibility,” the responsibility of a person who has been entrusted in some way. The moral and technical components of professional responsibility have led sociologist Bernard Barber to speak of these as two “senses” of trust. However, if the patient trusts the surgeon, it is not in two senses; the patient trusts the surgeon simply to provide a good, or perhaps the best, outcome for the patient. To fulfill that trust, the surgeon needs to be both morally concerned for the patient’s well-being (or at least health outcome) and technically competent.

Because the exercise of professional responsibility characteristically draws on a body of specialized knowledge that is brought to bear on the promotion or preservation of another’s welfare, to trust someone to fulfill a professional responsibility is to trust that person to perform in a way that someone outside that profession cannot entirely specify, predict, or often even recognize. In drawing attention to this point, Trudy Govier says that trust is “open-ended.” The point is not captured in the frequent suggestion that trust is necessary because the trusting party cannot control or monitor the trusted party’s performance. It would do the patient little good to have full prescience of all the events in the operation, or even the ability to guide the surgeon’s hand, unless the patient also happened to be a surgeon. Although a typical patient might be able to recognize some acts of gross malpractice, such as being stitched up with foreign bodies left inside, the patient would not know the implications of most of what he or she saw and would have no idea of how to improve the surgeon’s performance. For this reason, from the point of view of the patient, there are no good alternatives to having trustworthy professionals. There are no good alternatives in these circumstances because the patient must rely on the discretion of the practitioner.

Philosophers like John Ladd and legal theorists like Joel Handler have drawn attention to the role of discretion in many areas of professional practice. They have argued that because of the role of discretion, the criteria for morally responsible practice cannot be specified in terms of rules or rights alone. The centrality of discretion makes it all the more difficult to separate competence (having adequate knowledge and skill) and moral elements (exercising sufficient concern for the client’s well-being) in the professional’s behavior.

The provider—in this case the surgeon—also must trust the patient. At a minimum, the surgeon depends on the patient to disclose all information relevant to the case so as to minimize the risks of unexpected events in the operating room. If the patient disappoints the surgeon and does not disclose all relevant information, the negative consequence for the surgeon is, at most, to impair the surgeon’s professional performance. The disappointment does not carry a risk of death or disability for the surgeon. The difference in the severity of risk is one of the many aspects of a trust relationship that is counted as a difference of power in that relationship. The lesser severity of consequence for the provider—in this case the surgeon—can obscure the mutuality of trust in the patient-provider relationship.

When the provider is a nurse or physical therapist rather than a surgeon, the provider’s central tasks often require an understanding of the patient’s experiences, hopes, and fears. Although some nursing, such as the work of the surgical nurse who assists in the operating room, does not depend on an understanding of the patient’s experience, most nursing does. Postsurgical nursing care is a good example. This care typically includes motivating the patient to do things such as coughing and breathing deeply in order to reduce the risk of postoperative lung infection. These acts are often quite uncomfortable. Such nursing requires an understanding of the individual patient’s state of mind and the ability to motivate the patient—the ability to inspire confidence and hope in patients.

A. Changing the Standards of the Patient-Provider Relationship

When sociologist Talcott Parsons put forward his influential theory that professionals function as trustees, or in a “fiduciary” capacity, the standard for the so-called fiduciary aspects of the relationship between patients and physicians was that the provider furthered the patient’s well-being by being entrusted to make medical decisions in the best interests of that patient.

The doctrine of informed consent for medical procedures was adopted only gradually over the next two decades as a check on provider discretion. This doctrine has been implemented to require informed consent only for a very circumscribed set of procedures. To treat competent persons against their will is considered battery, in legal terms. Therefore, there is a foundation in law for the prohibition of forced or nonconsensual treatment of all types. In practice, however, information is often given only for major procedures, and practitioners tend to assume consent for lesser interventions, including most medical tests. Although patient-oriented practitioners will offer an explanation of why they are ordering a particular test, others will explain only when explicitly asked. For procedures other than surgery, formal requests for consent are rare unless there is a significant risk of death or severe disability from the procedure.

Furthermore, most patients are well informed only about the risk of death or significant permanent injury in circumstances in which informed consent is legally or institutionally mandated. Significant risk—such as becoming temporarily psychotic as a result of the trauma of open-heart surgery, as a result of intensive-care procedures, or from the sleep deprivation that often results from those procedures—is rarely disclosed to patients. The rationale for not telling a patient about to have bypass surgery or enter intensive care is that the risk will seem so shocking that the patient will refuse needed care.

Although the standard of informed consent is enforced by law and institutional practice only for certain risks of major procedures, the U.S. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (President’s Commission) has urged that the informed-consent standard be replaced by another, more comprehensive standard, the standard of shared decision making.

The President’s Commission’s 1982 report, Making Health Care Decisions, advocated such a shift, which would presumably apply to most significant healthcare decisions. The rule of informed consent requires only the recognition of the patient’s right of veto over the alternatives that the provider has presented to the patient. In contrast, shared decision making requires participation of the patient in setting the goals and methods of care and, therefore, in formulating the alternatives to be considered. This participation requires that patients and practitioners engage in complex communication, which the practitioners have a fiduciary responsibility to foster. This new standard is particularly appropriate for a pluralistic society, in which the responsible provider may have an idea of the patient’s good that is significantly different from the patient’s own idea.

The responsibility to foster shared decision making requires significant skill on the part of medical professionals in understanding patients of diverse backgrounds and in fostering communication with them in difficult circumstances—circumstances in which their communication may be compromised by fear and pain as well as by a lack of medical knowledge. Although some physicians, notably primary-care providers, have sought the skills to fulfill the responsibility to foster such communication, this responsibility is not one that medical education prepares physicians to accept.

B. Implementing the Fiduciary Standard

Ironically, although the fiduciary responsibility in healthcare has often been viewed primarily as the responsibility of physicians, as was noted above, it is other classes of providers, especially nurses, who are educated in a way that prepares them to understand patients’ experience. Although there is much to recommend the new fiduciary standard in healthcare, its realization requires either a major change in medical education or a change in the relations among members of the healthcare team, so that those who are prepared to oversee and foster shared decision making have the authority to do so. Without such changes, the trust that one’s healthcare will be shaped by one’s own priorities and concerns is not well founded.

In many cases, distrust of either individual providers or medical institutions has been warranted, especially for women, people of color, and the poor, whose experience has often been discounted or who have been viewed as less rational or less competent than white males. Annette Dula argues that historical events, from the Tuskegee syphilis study to the experience with screening for sickle-cell carrier trait, confirm that trust of the healthcare system on the part of African- Americans is often not warranted (Dula, 1992). The problem is one of the need not only for assurance but also for evidence that the former conditions no longer prevail.

Many poor or uninsured people have not even had a significant patient-provider relationship; when they are able to obtain healthcare, it is often with a provider whom they see in only a single clinical encounter. It is therefore impossible to establish a trusting relationship that would serve the patient’s health interest. If society is obliged to provide decent healthcare for its citizens, this failure of the healthcare system is a betrayal of trust not by individual providers but by society and its healthcare institutions.

II. Trust and Family Members

Trust among family members is at least as important an issue for healthcare as is trust in the provider-patient relationship. The trustworthiness of parents and guardians to decide the care of children and other dependent family members is widely discussed, and trust among family members is beginning to receive more attention in connection with the writing of living wills and health proxy statements. The issues of the competence of family members to give various forms of care or to make technical decisions, and the sufficiency of their concern for the patient’s well-being, parallel those issues for providers. The matter is further complicated by the phenomenon of psychological denial that interferes with decision making about the healthcare of a person who is important in one’s own life. Denial, as well as incompetence or lack of commitment to the patient’s welfare, may compromise a person’s decisions or care when the health or life of a close friend or relative is gravely threatened. Therefore, warranted trust in family members to provide or decide one’s care requires confidence not only in their competence and in their concern for one’s well-being but also in their psychological ability to come to terms with the situation.

III. Other Areas of Trust in Healthcare

There is also the question of the public’s trust in a class of professionals, which is distinct from the question of the public’s concern that, should they become clients of these professionals, their interests will be well served. For example, Sissela Bok (1978) has examined the concern about the trustworthiness of lawyers, not by their clients but by the public. Of particular concern is lawyers’ commitment to keep the crimes of their clients confidential, even certain ongoing or planned crimes. The public believes that lawyers should not violate usual ethical norms for the sake of their clients’ interests. The corresponding issue in healthcare is the fear that providers will, in protecting patient confidentiality, put the public health or the safety of individuals at undue risk. The question of ethical criteria for breaking confidentiality is regularly discussed, especially in the case of a sexually transmitted disease or a patient intent on harming another person. However, there is no widespread public concern that healthcare providers may be going so far in protecting patient confidentiality that they are derelict in protecting the public.

In addition to the public’s trust of providers, the trust or distrust of medical technology is often a significant factor. The risk is particularly salient in the case of artificial organs, joints, and other body parts. In place of the components of competence and concern of a trusted provider, the qualities required of a technology to warrant trust are its performance (it performs the function it was designed to perform) and its relative safety (it is relatively unlikely to cause accidents or to have other injurious side effects). Of course, with such life-critical technologies as artificial organs, the performance issue is itself a safety issue.

There are many aspects of the healthcare system on which patients rely but which most rarely consider. Many people become fully aware of their trust only when that trust is disappointed. A case in point is the discovery that research misconduct occurred in a major breast cancer study. The belated revelation of misconduct made patients aware of their trust in medical research.

IV. The Morality of Trust

Although Sissela Bok has discussed trust as a moral resource since the 1970s, the question of the morality of trust relationships—the question of the circumstances under which, from a moral point of view, one ought to trust—was not explicitly discussed until Annette Baier’s 1986 essay, “Trust and Anti-Trust.” Two earlier essays were important in laying the foundation for this major turn in the discussion. In 1984, Ian Hacking provided a devastating assessment of the use of game theory to understand moral questions, such as the Prisoner’s Dilemma, which will be discussed below. Baier herself argued in 1985 for broadening the focus in ethics from obligations and moral rules to the subject of who ought, as a moral matter, to be trusted and when. As Kathryn Addelson points out, Baier’s change of focus establishes a general perspective on ethical legitimacy that is shared by all—both the powerful and those whom society labels deviant—rather than privileging the perspective of those who make, instill, and enforce moral rules.

Baier’s general account of the morality of trust illuminates the strong relation between the trustworthy and the true. A trust relationship, according to Baier, is decent to the extent that it stands the test of disclosure of the premises of each party’s trust (Baier, 1986). For example, if one party trusts the other to perform as needed only because the truster believes the trusted is too timid or unimaginative to do otherwise, disclosure of these premises will tend to insult the trusted party and give him or her an incentive to prove the truster wrong. Similarly, if the trusted party fulfills the truster’s expectations only through fear of detection and punishment, disclosure of these premises may lead the truster to suspect that the trusted would betray the trust, given an anonymous opportunity to do so.

Although explicit discussion of moral trustworthiness is relatively recent, both professional ethics and the philosophy of technology have given considerable attention to the concept of responsibility. Since being trustworthy is key to acting responsibly in a professional capacity, or to being a responsible person if one considers responsibility a virtue, the literature on responsibility provides at least an implicit discussion of many aspects of the morality of trust, much of which is relevant to the subject of trust in healthcare.

V. Conceptual Relationships

Trust involves both confidence and reliance. Annette Baier (1986) argues that if we lack other options, we may continue to rely on something even when we no longer trust it. Similarly, we may have confidence in something, or confidence in our expectations concerning it, without relying on it. To rely only on what we can trust is a fortunate circumstance.

Niklas Luhmann (1988) urges a different distinction between confidence and trust, suggesting that trust be used only when the truster has considered the alternatives to trusting. Such use is incompatible with unconscious trust, a phenomenon to which Baier draws attention. Luhmann’s discussion of the distinction between trust and confidence highlights the element of risk in trusting. Risk or vulnerability does characterize situations in which trust is necessary, in contrast to situations in which one’s control of the outcome makes trust unnecessary. However, the element of risk taking in trust is captured in the notion of reliance when trust is understood as confident reliance. Being vulnerable in one’s reliance does not require that one have considered the alternatives, if any, to such reliance.

Although one often trusts people, their intentions and goodwill, there is also trust in mere circumstances or events: One may trust that a taxi will come along shortly, even if no taxi has been ordered, without believing anything about another person’s reliability in providing a taxi.

The risk taken in trusting does leave the truster liable to disappointment (or worse), whether that trust is of persons or events. But only when trust is in other people, and not merely in the events involving them, can one be let down by them. Suppose that a person is awakened every weekday by another person’s calling for a neighbor. If the first person has come to rely on being awakened, but one day the other person does not come for the neighbor or does so quietly, the first person’s expectations will be disappointed. But the person will not have been disappointed or let down by the one who usually picks up the neighbor. To be disappointed by another person, that person must at least be aware of doing or not doing the act in question. Here the person doing the calling for the neighbor is not aware of waking up the first party, much less of being trusted to do it. As Baier mentions (1986), it is possible for there to be trust of which the trusted person is unaware, and so one might let down another without being aware of letting that person down.

Niklas Luhmann (1979) has shown how trust simplifies human life by endowing some expectations with assurance. To consider all possible disappointments, defections, and betrayals by those on whom we rely, the possible consequences of those disappointments, and any actions that one might take to prevent those disappointments or change their effect is prohibitively costly in terms of time and energy. Trust reduces that burden.

VI. The Literature on Trust

Sociologists like Bernard Barber and Luhmann (1979, 1988) have written on many facets of the notion of trust, and legal theorists have reflected on the distinct, though related, notion of a legal trust. Until the 1980s, however, the explicit attention given to the common notion of trust, or confident reliance, in Anglo-American philosophy was largely in relation to such questions as how the “prisoners” in the so-called Prisoner’s Dilemma might solve their problem of assurance with regard to one another’s behavior so as to cooperate in achieving a mutually beneficial outcome. (In the Prisoner’s Dilemma, each of two prisoners will receive a light sentence if neither confesses to a crime, and a more severe sentence if both confess; but if one confesses and the other does not, the latter will be freed, but the former will receive the most severe sentence of all. Without assurance about each other’s behavior, and in spite of knowing that both would be better off if neither confesses, both are likely to confess and be less well off.)

Recent literature on trust has examined trust in a variety of different social circumstances, involving a wide range of objects and systems, persons in a wide variety of roles, and matters in which they might be trusted or distrusted. For example, some writers focus on cases of the breakdown of trust in war, under the influence of the Mafia, or in some other extreme situation. Differences in the domain of application of the notion of trust lead to an unusually wide range of estimates of its character and importance. They also lead to disparate distinctions between trust and such notions as reliance, faith, vulnerability, and confidence, as well as to different conclusions about the moral value and the moral risks associated with trust.

Those who write about trust in a market context often take economic rationality—according to which each person simply seeks to maximize his or her goals by the most efficient means—as their model. They then often regard trust as a way of coping with imperfect rationality, understood as uncertainty about the facts or about one another’s behavior, and how to estimate the consequences for the achievement of one’s goals. The economic model of rationality is not readily applicable in considerations of ethics because it was designed to avoid consideration of values other than efficiency, and it treats moral considerations as nonobjective personal preferences. Where a market context is assumed, the relatively minor risk of being a “sucker” is likely to be mentioned as a barrier to trust. (See, for example, Dasgupta.) In discussions of trust among family members or between nations (Bok, 1990a), much more is recognized to be at stake.

Feminists like Trudy Govier argue that attention to trust relationships will bring attention to other relationships, such as those between parents and children, that have been neglected when contracts are the focus of attention. Such relationships, however, together with the features of trust that are prominent in them, continue to be ignored in much of the literature on trust. For example, Geoffrey Hawthorn mentions a parent’s nonegotistic motives toward his or her child, only to turn immediately to “more ordinary” instances of nonegoistic motives.

Bernard Williams, who begins his own essay with a discussion of the Prisoner’s Dilemma, argues that the problem of how nonegoistic motivation is to be encouraged and legitimated does not have a general solution. He argues that the problem of trust or cooperation is not one that can be solved in a general way at the level of decision theory, social psychology, or the general theory of social institutions. To ensure cooperation in a given situation requires an understanding of the ways in which the people in that situation are motivated. Williams believes that solutions to the problem of cooperation are found only for particular historically shaped societies, rather than for society in general. He argues that investigating the sorts of combinations of motivations that make sense in that society might lead to a general perspective on the problems of cooperation in such a society. However, as he says, “there is no one problem of cooperation: the problem is always how a given set of people cooperate” (p. 13). Those whose cooperation is of the greatest interest in bioethics are patients, their families, the healthcare providers, and the policymakers who shape the healthcare system.

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