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The notion of trust is central to bioethical theories; however, until recently, the topic has received little explicit analysis in many of these theories. Over the last 15 years, a large body of recent philosophical and empirical social science and medical literature has examined the role, impact, and function of trust in bioethics. This entry brieﬂy examines the history of the concept of trust in the bioethics, particularly the role that trust played in medicine in the pre-bioethics era, the role that the lack of trust has played in the emergence of bioethics as an area of inquiry, as well as how the literature on trust has evolved in philosophy and bioethics. The prevailing philosophical concept of trust is discussed and reviewed, speciﬁcally its nature as an interpersonal attitude that one agent may harbor toward another and the conditions that justify its placement, including the controversial question of motivation. Finally, several ethical dimensions of trust are discussed from a theoretical perspective, namely, the role of trust within virtue ethics and feminist bioethics and critical views on trust as it relates to the practice of informed consent and public policy.
Trust plays a central role in human societies and is part of the social capital that creates harmony and cooperation within societies. Without trust, functioning in society is not possible, and thus trust has been a topic of great interest in various ﬁelds such as theology, politics, psychology, and sociology due to social developments in those ﬁelds. Although trust has not historically received the same degree of attention in ethics, it has been an implicit but integral part of many ethical theories. From Aristotle’s virtue ethics to Kant’s theory of deontological ethics, trust is central to all conceptions of the ideal moral community. First, trust between people is instrumentally crucial as a means of acquiring other things of value and to learn, cooperate, and enter into dealings with one another. Second, trust is fundamental to the relationships of respect between the members of an ideal moral community.
The notion of trust is also central to bioethics in a very fundamental way. It is noteworthy that the very evolution of bioethics as a discipline was hastened by well-publicized breaches of public trust in medicine and research. Today, the importance of building and preserving trust in healthcare providers, medical institutions, and scientiﬁc enterprise is increasingly regarded as a critical issue and has received widespread attention from within the bioethics and medical communities, as well as policy makers (Hall 2005). This is particularly true as more examples of patient mistreatment, healthcare provider misconduct, and biomedical scientiﬁc fraud publicly emerge. However, the majority of the literature on trust has focused on empirical studies of the perception of the trustworthiness of others, with little attention to the concept and role of trust in bioethics.
This entry brieﬂy highlights the history of the concept of trust as it has been delineated in the ethics and philosophical literature. It then outlines the conception of trust and its conditions. Finally, it discusses some areas of ethics and bioethics literature in which trust has been examined, such as virtue ethics, feminist bioethics, and rights based perspectives on the role of trust in medicine and public policy.
History And Development: Background Of The Issue
Despite the fact that the existence of trust between moral agents is a central assumption to many ethical theories’ concept of a good society, the western philosophical literature did not begin to systematically analyze the topic of trust until the late 1980s (Baier 1986; Govier 1992). This section examines the context in which the concept of trust evolved in the ﬁeld of bioethics and, in particular, how the concept prevailed as central to the practice of medicine during the pre-bioethics era, how trust of the medical profession fell out of favor during the 1970s as a general “culture of distrust” came to prevail, and how the concept of trust slowly came to be acknowledged in ethical discourse as an ineradicable ethical dimension of all relationships, personal and professional.
Trust in bioethics. In medicine, while the Hippocratic Oath in its original or modiﬁed forms does not make any explicit reference to the concept of trust, the notion of a professional oath in itself, as well as its content, was intended to promote public trust in the medical profession by having its members recognized as belonging to a special category of credible, trustworthy practitioners. This concept of trust of physicians formed the backdrop of Western medicine for hundreds of years, until it was fragmented by well-documented instances of violations of trust in the era of modern-day research and medicine.
The erosion of trust in medicine and biomedical research precipitated in the twentieth century due to a number of well-publicized cases of abuse of patients and research subjects. In the USA, for example, several medical cases in the early 1900s made it to the court and were examined under the Anglo-American battery theory of liability and later under the negligence theory of liability, which eventually led to the application of legal remedies of a disclosure-based concept of “informed consent.” Meanwhile in the mid-twentieth century, public prosecution of Nazi doctors and administrators for their role in carrying out non-consensual medical experiments on concentration camp inmates and other prisoners led to the development of the Nuremberg Code (1947) and, later, the Declaration of Helsinki (1964). In the 1960s, systematic abuses of human research subjects in the USA also came to light and led to US congressional inquiries through the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report produced by the Commission articulated three principles to guide ethical considerations of research with human subjects: respect for persons, beneﬁcence, and justice. This led to legislation requiring the establishment of institutional ethics boards and the regulation of these boards by the Ofﬁce for Protection from Research Risks. One can argue that these efforts were all directed, at least in part, at restoring the frayed public trust in medical and research institutions and in reestablishing the foundation for trust in the medical and research professions.
In bioethics, one of the main factors responsible for the resurrected interest in trust is skepticism about the suitability of a purely principle or rights-based approach to medical ethics. This has led to a great deal of empirical work on trust that is outside the scope of what will be covered here. The following section examines the concept and deﬁnition of trust as it has been presented in some key literature.
What is the nature of trust? The question arises as to what is the epistemic nature of trust; is it a belief, an emotion, or an attitude? In the majority of the philosophical literature on the topic, trust has been considered as a type of attitude that one may have toward another individual who one hopes will be trustworthy. Trust may be considered as an attitude when deﬁned as “accepted vulnerability to another’s possible but not expected ill will (or lack of good will) toward one” (Baier 1986). That said, trust is not an attitude that can necessarily be consciously willed in the absence of reason or justiﬁcation. Furthermore, trust is usually placed with respect to a speciﬁc type or domain of action, meaning that one normally places trust in others for actions for which they have personal or professional responsibility. The concept of a generic “blanket” trust in a person is perhaps less applicable to interpersonal relationships and more relevant in the context of trust or faith in the “universe” or in God, the latter of which has also been discussed in the philosophical literature (Peperzak 2013).
Trust may be considered as an emotion that carries with it distinct patterns of attention (Jones 1996) or “emotional attitudes with perceptual, behavioral, and cognitive dimensions” (McLeod 2002, p. 85). It may be argued that by putting trust in someone, one conﬁrms and honors that person as irreplaceable, even if they can be replaced within the limits of their skills and professional attributes (Peperzak 2013). Thus, trusting someone involves more than simply a correct evaluation of them according to some set of criteria and seems to entail an element of intuitive assessment. Nevertheless, many philosophers claim that trust and distrust can still be rational without the trustor having to necessarily follow a due process of sifting through relevant evidence to determine the trustworthiness of the trustee or even being aware of the existence of such supporting evidence (McLeod 2002). In the present discussion, trust is considered as an interpersonal attitude that one agent may harbor toward another; this is important as it forms the conceptual basis for discussion of other dimensions of trust, e.g., trust toward institutions.
Moral dimensions of trust. The question arises as to whether trust has a moral quality. In general, trust (as an attitude on part of the trustor) may be considered as distinct from trustworthiness (which is a moral quality of the trustee). Some might argue that the concept of trust does not generally have either a positive or negative moral quality, since one can enter into moral as well as immoral trust relationships of trust (Baier 1986). Although it is generally implied that the right thing to do is to keep trust, there are instances in which the right thing to do would be to break trust (e.g., when someone trusts you to carry out an immoral action). Other philosophers believe that trust is a moral notion because it involves holding someone morally responsible for something; thus trusting can be a form of recognition of the moral agency of a person (Ruokonen 2013).
Trust and trustworthiness are distinct, as the latter is considered a characteristic, not an attitude. The concept of trustworthiness as a moral characteristic is widely accepted, as trustworthiness is considered a virtue and strongly connected with other virtues such as honesty and integrity. It is never considered as a vice (like being untrustworthy) or as a morally neutral characteristic (like being clever).
According to some views, trust may be considered distinct from reliance. What distinguishes “trust” from mere “reliance” is that when someone trusts, he/she believes in the goodwill of the trustee toward him/her. However, when he/she relies, there are no assumptions about the motivation of the person/object that is relied upon. One may rely on someone (or something, e.g., a car) without placing any trust in that person or thing whatsoever, so if there is a failure to carry through, it results in mere disappointment, not a sense of betrayal. On the other hand, trust can be betrayed, not merely disappointed (Baier 1986).
Conditions of trust. Philosophers generally agree that in order for someone to be said to have an attitude of trust, the presence of certain conditions is necessary, including (1) risk of, or vulnerability to, betrayal, (2) thinking well or being optimistic of others in certain respects, and (3) a belief in the competence of others, at least in certain respects. From this, it follows that an attitude of trust is not possible if: there is no risk of vulnerability or betrayal for the trustor, if one is suspicious of the potential trustee, or if the trustor is not conﬁdent in the competence of the potential trustee to carry through with that which he/she is entrusted with.
Philosophers debate as to whether motivations of the trustee needs to be considered as a fourth condition of placing trust, and if so, what type of motive a trustor should how, and how the presence of that motive can be reasonably veriﬁed. Different views exist. Some simply believe that the central aspect of trustworthiness concerns the trustee simply having an ongoing commitment to the trustor (Hardin 2002). Another perspective is that the speciﬁc motives for the commitment matter, not just its existence or duration (e.g., self-interest or beneﬁcence). Four different views on this include the self-interest view, encapsulated interest view, the goodwill view, and the moral integrity view; these are explored below:
- Self-interests. According to the self-interest view, social norms, contracts, or constraints can help build the conditions for trust by acting as the primary motivating factor to fulﬁll trust (O’Neill 2002; Hardin 2002). For example, ethics boards, medical associations, and other professional and institutional rules and regulations can help build the conditions for trust because they impose consequences for the betrayal of trust in those settings. Here, the burden of trust is in large part fulﬁlled by the governance structures that effectively limit the trustee’s behavior. The problem with this view is that it is not entirely consistent with the common ethical understanding of what makes someone trustworthy. That is, it does make sense to say that a person is trustworthy if they are only motivated to fulﬁll a trust purely out of self-interest. Rather, it is more reasonable to say that trust is placed in the trustee primarily on account of his/her character and secondarily due to the guidelines that are in place to limit inﬁdelity to trust and/or encourage ﬁdelity to trust.
- Encapsulated interests. Another view is that the trustor must believe that the trustee is
motivated to uphold the trustor’s interests. According to this notion of trust encapsulated interest, trust is essentially a set of expectations that depend on rational assessments of the trustee’s motivations (Hardin 2002, p. 3–7). The trustor rationally assesses the interests of the trustee and encapsulates them; in other words, he/she is motivated to protect that person’s interests. However, this approach has been criticized for being too narrow, in the sense that it would preclude trust in a large number of cases where trust may be appropriate (Ruokonen 2013). For example, a patient who requests a healthcare provider to provide assistance with euthanasia and sees it as being in his/her interest to be killed can rationally assess that the healthcare provider does not encapsulate that interest, e.g., due to differences in values. If believing that someone encapsulates our interests is necessary for placing trust in that person, then it will preclude us from trusting those whose values conﬂict with our own, while those individuals may still be trustworthy for many other reasons (e.g., goodwill toward us or moral commitment to fulﬁlling their trusts).
- Goodwill. According to another common view, the trustor must believe that the trustee is motivated by goodwill toward him/her (Baier 1986; Jones 1996). This goodwill must extend toward the trustor (e.g., patient), what the trustee is entrusted with (the treatment for the patient), or both. This view is consistent with a Kantian deontological framework that also requires a person to be moved to act by good motives. However, the major criticism of goodwill as a condition for placing trust is that it is also too narrow and may preclude many individuals (presumably without goodwill toward the trustor) from being considered trustworthy. It also does not explain how one can place trust in strangers.
- Moral integrity. Finally, another view considers that belief in the trustee’s moral integrity is an essential condition of trust. This view is consistent with both virtue ethics and feminist ethics due to its emphasis on the integrity of the individual, although the deﬁnition of “moral integrity” that is used differs in each case. While virtue ethics has a more objective deﬁnition of moral integrity, according to a feminist view, for the trustee to be motivated by moral integrity means for him/her to be integrated with what he/she morally stands for and to act on values that he/she endorses (McLeod 2002). However, this prerequisite is also problematic. Such a deﬁnition of moral integrity is so broad and subjective that any value whatsoever seems to be acceptable. For example, a person may value racial supremacy and believes that people of color ought to be treated as second-class citizens; while this person may be integrated with what he/she stands for and act on those values, the content of those values is not consistent with the concept of moral integrity. Also, individuals may struggle to reach a common understanding of what they think to be similar values. For example, two individuals may both value gender equity, but their understanding of what it means to have gender equity may not be consistent.
These four views aside, there are also some general problems with motivation being considered as a condition for trust. The ﬁrst is the problem of mixed motives. Individuals rarely have a single clear motive but rather usually have mixed or multiple motives for acting (e.g., self-interest and goodwill). Second, an individual’s motives are not open to scrutiny; instead, one may only make inferences about those motives. Thus, if an individual’s motivation must be considered as a strict condition for placing trust, it is likely that one will never trust anyone due to the simple problem of not being able to fully and truly ascertain their motives. In order to address these issues in practice, one may ultimately place trust in a higher entity (“God”), or, within a secular framework, it becomes essential to take a more holistic (and perhaps more realistic) view of trusting individuals, which involves placing part of our trust in the environments and constraints in which individuals are acting. This removes at least part of the burden of trust from the individual trustee and transfers it to the governance structures or other systems of accountability that are in place that govern individual behavior.
Having explored some different notions of trust that have been covered in the literature, the following section examines what has been said about the role of trust in bioethics in a number of different ethical theories.
This section examines the role of trust in four distinct but overlapping areas of ethical discourse, namely, (1) ethics, (2) feminist ethics, (3) trust and autonomy from a deontological perspective, and (4) institutions and public policy:
- Trust in virtue ethics
The concepts of trust and trustworthiness have always been central in Aristotelian virtue ethics and in the medical professional more speciﬁcally. Trust has been emphasized as an “ineradicable” force in the history of medical ethics (Pellegrino 1991). In virtue ethics, the primary justiﬁcation for placing trust in the context of a patient-physician relationship is trust in the moral integrity of the physician as a professional. However, the well-publicized historical abuses of trust in the medical practice and research have resulted in the concept of trust in professional ethics being criticized as an ideal that is not achievable. The result has been a prevailing culture of distrust in the professions, with a move toward professional relationships being reduced to contractual agreements and strict systems of accountability being instated to monitor and oversee the actions of professionals. Virtue ethics upholds that this “ethics of distrust” is dangerous, self-defeating, and ultimately impossible in practice and wrought with inherent fallacies (p. 70). Instead, an ethics of trust is essential due to the ineradicability of trust, which in turn imposes some inescapable obligations on professionals and on patients.
Despite the history of abuses of trust in the context of medicine and biomedical research, a virtue ethics perspective upholds that attempting to replace trust relationships in the physician-patient interaction with the use of contracts (e.g., a disclosure-based model of informed consent) is futile, since a patient must necessarily trust that the things agreed to in the contract will be performed. Contracts cannot include all possible contingencies and must allow ﬂexibility for the exercise of judgment. Furthermore, contracts are best negotiated between parties who are relatively equal (e.g., in knowledge or power), whereas there are often signiﬁcant differences in the perceived and/or actual levels of knowledge and power in the patient-physician relationship, and these knowledge/power gaps are exacerbated by the vulnerability of the very ill or anxious patient. Finally, even in explicitly worded contracts, the issue of the interpretation of clauses by each party is problematic, and it is not clear whether a common understanding of the contract and what it means can ever be truly achieved. In reality, as O’Neill (2002) points, consent to these contracts is merely a “propositional attitude” developed in response to a proposal that is presented within a normative framework for communication. Therefore, trust is absolutely indispensable in the practice of medicine, even in the presence of formal structures and contracts.
The main critical reaction to such a perspective is that an emphasis on trust once again renders patients vulnerable to the paternalistic style of relationship that led to same abuses that have now become well documented in the history of bioethics. After all, medicine shifted away from the paternalistic model for good reasons. In response to this criticism, a virtue ethics perspective would uphold that a prevailing “ethics of trust” does not mean or require absolute or open-ended trust between physicians and patients. Rather, it entails a prevailing culture of trust that accepts the fact that while trust cannot be absolute, it is violable and ineradicable from the physician-patient relationship. These aspects of the physicianpatient relationship make ﬁdelity to trust a central obligation in professional relationships. The obligation to have ﬁdelity to trust entails that a physician develops relationships with his/her patients that promote an understanding of their values and the physician empowers his/her patients to make choices that serve their well-being, without manipulation, coercion, deception, or bias. Pellegrino (1991) argues that this ethics of trust goes beyond principleand duty-based ethics to an ethics of virtue. This trust is built over time through a proven track record of ﬁdelity to promises made.
Nevertheless, there are some serious systemic and arguably universal issues in the practice of medicine that pose a serious threat to an ethics of trust. First, the culture of trust depends on the presumption of a meaningful relationship between patients and their caregivers. However, the deeply compartmentalized, fragmented, and fast-paced modern-day practice of medicine, in which a very ill patient interacts with multiple specialists and other healthcare providers for short durations of time for treating different aspects (or even the same aspect) of his/her medical condition, is not conducive to developing a meaningful relationship between healthcare providers and patients. Most healthcare systems simply do not incentivize healthcare providers to take the time to engage in the mindful practice of facilitating conversations that are conducive to truly understanding patient values. Even family physicians tend to have a very limited scope of practice and are often so overwhelmed that they are unable to fully address even the very serious gap of care coordination. The same applies for nurses, who additionally face the challenge of fragmented interactions with a patient alongside dozens of other nurses in the course of shift work, and this applies to patient care in hospital, community, and long-term care settings.
Another serious challenge to establishing a culture of trust is that healthcare systems often strictly limit the range of options that can be provided to patients, and the options that are presented to patients involve a choice between an available “standard of care” and no treatment at all. Therefore, even if healthcare providers do reach a point of understanding their patients’ values, the practice of “evidence-based medicine” (although established for good reason) professionally limits physicians in the types of options they are free to offer to patients. For example, in Western medicine in particular, there is often little or no consideration of complementary and alternative medicines by healthcare providers in deciding what might be in the best interest of a particular patient. These facts can pose a threat to a culture of trust especially when patients are aware that other options are available which healthcare providers have limited ability/will to discuss, even though the patient might in fact beneﬁt from those options. Thus, the contemporary healthcare provider-patient relationship does not provide adequate context or opportunity for reasonable trust (O’Neill 2002).
In summary, many criticisms have been leveled against a simple prevailing ethics of trust in medicine. Thus it helps to draw upon other theories, such as feminist and deontological ethics, to arrive at a richer concept of trust in bioethics.
- Trust and feminist ethics
The concept of trust was explored in early literature primarily by female philosophers, who were generally critical of the lack of attention to this topic by male philosophers (Baier 1986; Govier 1992). One may argue that trust is an especially important concept in the ﬁeld of bioethics particularly from a feminist perspective. First, women and their bodies have historically been subject to gender inequalities and expectations. This has led to the medicalization of their bodies that continues until today. Second, it is commonly acknowledged and widely known that women tend to be more exposed to healthcare interactions than men, for various reasons such as their overall tendency toward more frequent access of the medical system. Third, literature has shown that doctors are more likely to dismiss female patient’s reports of pain and other symptoms as non-credible, illustrating that gender biases still play a signiﬁcant role in the practice of medicine today. The following explores some of the feminist literature on trust, as philosophers have argued that both trust in healthcare professionals and self-trust of patients are inﬂuenced by the aforementioned history.
A feminine “ethics of trust” asserts that trust is not only fundamental in interpersonal and interprofessional relationships, but institutions should also adopt strategies that promote this trust. In developing rules for social interactions, the central assumption in most traditional ethical theories is that the moral agents interacting with one another are more or less equal adult strangers. However one of the concerns is that this ignores the vulnerable in society, such as children, elderly parents, and very ill patients. Those individuals often have no choice but to trust others to care for them. Thus, in those cases, trust functions as an important alternative. The argument is that “we do, and should, trust precisely in those cases where we cannot control the other’s response”; otherwise, individuals pay great personal costs for failure to trust (Koehn 1998, p. 82).
Feminist authors pay special attention to the role of nurture and environment in learning to trust both oneself and others. For example, one author purports that individuals learn how to trust through typical case scenarios (“paradigm scenarios”) that give them the practical knowledge of how to categorize emotions and respond appropriately to different types of situations (McLeod 2002). These typical case scenarios differ across cultural contexts. Problems arise in the context of an oppressive environment, where the paradigm scenarios are themselves are so distorted such that it is difﬁcult for an individual to trust themselves and others. Self-trust and ability to trust others are both fundamental to an individual’s ability to act autonomously and make meaningful choices. Thus, oppressive environments are prohibitive to promoting the development or empowerment of individuals to act autonomously because of how they impact an individuals’ ability to trust themselves and others. This is a major ethical challenge as far as feminist ethics is concerned, and it is further expanded upon below in the context of the feminist notion of relational autonomy.
Feminist perspectives on autonomy and trust. It is well known that the principle of respect for autonomy in bioethics, as rooted in the broader principle of respect for persons, is a central theme in the ﬁeld of bioethics. As discussed earlier, the principle emerged in the Belmont Report with a historical backdrop characterized by abuses of trust in both medical and research practice. Not surprisingly, dominant conceptions of autonomy that emerged from this context were premised on the liberal, political ideal of persons as socially detached entities and paid little attention to the considerations of persons as individuals who are socially grounded in cultures, societies, and relationships that often signiﬁcantly shape their identities. This traditional conception of autonomy provoked many challenges and criticisms from feminists, who have proposed alternative concepts of relational ethics.
The term “relational autonomy” thus emerged as way of referring to a range of related alternative perspectives on autonomy that acknowledge that “persons are socially embedded and that agents’ identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants, such as race, class, gender, and ethnicity” (Mackenzie and Stoljar 2000, p. 4). A feminist “relational” approach to understanding autonomy thus pays attention to the broader social, socioeconomic, cultural, and political factors that impact a person’s ability to act autonomously.
Trust plays a critical role in this feminist conception of relational autonomy or at least in the relationships that support autonomy. According to this perspective, being autonomous is a skill that one acquires and exercises only in social environments where he/she can trust people to support it. For example, a lady who grew up in a culture where she must seek permission from a male relative even to receive even the most basic medical treatment may (at least at ﬁrst) ﬁnd it difﬁcult to exercise her autonomy in a medical setting even when presented with the opportunity to do so, because she was not nurtured to develop that competency. Thus relational autonomy can only exist with the help of people or institutions that are trustworthy, in the sense that they provide an environment that enables or empowers individuals to exercise their autonomy. This idea is further expanded on in the literature on self-trust.
Self-trust and autonomy. Feminist ethics emphasizes self-trust as a particularly important aspect of patient autonomy. According to one view, self-trust is a “legitimate although nonprototypical variant on trust in others,” where it shares many of the salient features of interpersonal trust (which is prototypical), with the exception of interpersonal relationality (McLeod 2002, pp. 5, 36–37). Self-trust entails being optimistic that one will live up to a certain moral commitment. This trust can be nurtured or broken by healthcare providers and by internalizing oppressive sexist norms. Self-trust is particularly relevant in the context of women’s reproductive health as a way to limit patient vulnerability. It is possible to develop self-trust even in oppressive contexts by comparing and contrasting with other paradigm scenarios in other settings, in order to remove or correct for the internalized distortion of one’s own perspectives. One can also cultivate self-trust even in a domain where he/she has shown little evidence of trustworthiness in the past, by striving to keep one’s attention on the evidence that exists in support of trustworthiness, as little as it may be. For example, an individual whose reproductive autonomy has been compromised due to his/her history of alcoholism may rebuild self-trust by calling to mind the areas where he/she has demonstrated resilience and ability to overcome difﬁcult challenges in the past, e.g., having survived a childhood of domestic abuse without succumbing to an abusive relationship. All of this requires the presence of broader social structures that allows for the fulﬁllment of a person’s basic needs, as a prerequisite for the individual to reach the point of self-reﬂection and therefore self-development, of which self-trust is but one component.
Having examined the prominent role of trust in both virtue ethics and feminist conceptions of relational autonomy, the following explores some key literature on the role of trust in more traditional deontological conceptions of autonomy and examines how this plays out at the institutional level and in the context of public policy.
- Critical views on trust and autonomy from a deontological perspective
There is no doubt that historical developments have led to great efforts, resources, and attention being dedicated to implementing the principle of respect for persons and respect for individual autonomy in biomedical practice. In recent years, this has also been coupled with stronger guidelines and regulations to protect patients, human subjects of research as well as the environment. One may normally expect that these efforts would have increased public trust in the ways in which medicine and science are practiced and regulated. However, quite the opposite, public trust has faltered in recent years, and in many countries there is evidence of increasing distrust in professions, experts, and public authorities. One must ask the question that if all of the conditions for trust existed, would there be a need for so much emphasis on individual autonomy? The following examines a view that interprets increasing public distrust as being a direct result of the neglect of the importance of trustworthiness, in favor of a more sterile framework of legal accountability (O’Neill 2002).
One of the key modern practices that is typically used for the purpose of legal accountability and which evolved out of a history of legal abuses of patients and human subjects of research is the Anglo-American doctrine of informed consent. O’Neill argues that informed consent has both theoretical and practical issues that limit its ability to act as an independent justiﬁcation for proceeding with a particular course of action. For example, decision making in the context of illness often involves rational deliberation; however, the vulnerability of patients often poses a signiﬁcant barrier to this. Second, treatment options are often unclear to patients, and decisions are made in the context of anxiety, insecurity, and pain. Given these and other issues, many patients can barely be said to fulﬁll the criteria for truly autonomous action.
For this reason, one may criticize the traditional doctrine of informed consent by challenging whether the principle of respect for autonomy is ultimately the ethical justiﬁcation for informed consent (Manson and O’Neill 2007). The argument is that current thinking about informed consent makes unreasonable assumptions about the true nature of communication, speciﬁcally that fully informed, or “fully speciﬁc or fully explicit” consent is possible. However, consent is merely a “propositional attitude” developed in response to a proposal that is presented within a normative framework for communication (p. 26). These normative frameworks are the context or milieu for the act of consent, and each person understands the act of consent according to their own interpretation of this framework. It is very difﬁcult for a physician or researcher to ascertain what a participant or patient has understood they have consented to. Therefore, fully informed consent is not possible and thus cannot be a goal of clinical practice, which means that informed consent certainly cannot be thought of as necessary or sufﬁcient for all justiﬁable action.
Rather, the key justiﬁcation for the actions is that informed consent must occur within good normative frameworks for practice that include standards of institutional and professional accountability within which professionals operate. For example, consider a research intervention offered to a patient within a public research hospital. This proposition carries the legitimacy of an afﬁliated university, a government-regulated public healthcare institution, and the constraints imposed by a research ethics board and numerous professional associations, among others. The situation would be perceived entirely differently if the same procedure were to be offered by the same professional in a private setting and/or within a jurisdiction in which there are no laws governing the professional’s actions.
In essence, systems of accountability act as the “safety net” by reducing the risk to the trustor and serve as a kind of justiﬁcation for the trustworthiness of propositions. Consent is, at most, a limited waiver of ethical and/or legal rights and obligations for a given purpose in light of intelligent placement of trust in these normative frameworks. This concept is very much in keeping with the view elaborated earlier that trustees are motivated by their self-interest (e.g., self-interest to not have one’s medical license revoked by failure to disclose a salient risk of treatment or self-interest not to have one’s reputation tarnished by being reprimanded by the ethics board at one’s institution). At the very least, it can be said that such accountability at least helps to justify the intelligent placement of trust for the purpose intended within the speciﬁc context.
O’Neill’s (2002) account is complementary to the virtue ethics perspective. Whereas the assumption of moral integrity of the medical professional may not be enough by itself to justify intelligently based trust, this need not lead to distrust, because of the existence of systems of accountability that provide licensure, accreditation, oversight, professional codes of conduct, and regulations for professional practice. This perspective is also complementary to the feminist perspectives since patients can feel more empowered and conﬁdent in making decisions within governance frameworks that help justify trust and help nurture meaningful autonomous action.
- Trust, institutions, and public policy
The importance of trust has broadly been acknowledged in the literature as being a central pillar for the functioning of public institutions. It is generally agreed upon that while institutions cannot have moral agency in the same way as individuals, they have unique characteristics and identities from the sum of the individuals within them, such that they can be treated as moral actors. Public trust in institutions is important because there are matters that cannot simply be entrusted at the individual level or where institutional intervention is required to facilitate and systematize human affairs. This forms the very basis of civilizations, rather than mere tribal societies. Furthermore, it is generally agreed that trust at one level (interpersonal, organizational, system) can help supplement trust at another level. Hall, for example, puts forward a three-tiered model of trust in which trust in an individual (e.g., a physician) can be augmented or supplanted by trust in a speciﬁc entity (e.g., a clinic) which can be augmented or supplanted by trust in a different institution (e.g., a health authority) or social system (Hall 2005).
Earlier, a distinction was drawn between trust and mere reliance within a relationship at the interpersonal level. Townley and Garﬁeld (2010) argue that trust and reliance are distinct forms of dependence and can coexist both in interpersonal relationships and relationships between institutions and the public. Just as individuals can rely upon or trust others, they can also rely upon or trust institutions. Likewise, just as trustors can either deliver what they were relied upon to do or fulﬁll their trusts, so can the governing bodies of institutions. Institutions play a central role in creating communities and societies, and can become “repositories and beneﬁciaries of public trust” by upholding the “requisite values” (p. 104).
While it might be possible to construct a society in which trust is essentially absent and enforcement is in place to guarantee accountability, this would exact a heavy social and moral price on society. In the absence of trust, it would be too difﬁcult and time consuming to verify that public institutions and their employees are meeting all of their commitments all of the time, and to require such monitoring would be “poisonous to the social order,” just as constant monitoring of a loved one in order to ensure that they uphold their commitments would be detrimental to that relationship (Townley and Garﬁeld 2010, p. 105). However, where trust is not possible, or where the stakes are high, it is necessary to ensure that mechanisms are in place to assure accountability.
In the context of healthcare, one argue that trust is both desirable in and of itself and because it creates conditions to provide better care (Dorr Goold 2001). Reliance and trust can coexist within the context of a healthcare organization and are in fact necessary for it to optimally function. Three conditions have been discussed in the literature that inﬂuence public trust in healthcare organizations, including (1) acceptance of decision-making power and the expectations that it entails on part of the organization; (2) knowledge of the trustee’s behavior, which relates to the concept of an organization’s reputation and transparency of process; and (3) shared values or “identiﬁcation-based trust” (pp. 30–32), also discussed earlier under the “encapsulated interest” view of trustee’s motivation.
Trust and public policy. Public policy plays a unique role as it can both help to establish the framework to maintain trust and to justify trust between institutions and the many individuals and interest groups that constitute the “public.” As discussed earlier, it has been established in the literature that public policy and governance can provide the basis for intelligently based trust. In this context, Hall (2005) describes three different approaches that are often taken toward trust in public policy: predicated, supportive, and skeptical. However, there are often signiﬁcant overlaps and gray areas among the three different approaches, which are brieﬂy outlined below.
The ﬁrst view is a “predicated” view of trust that presumes the existence of trust as a factual premise in order to justify a particular professional obligation at the public policy level (p. 157). This view fundamentally presumes that trust exists and aims to preserve it. Overall, this approach presumes a rather paternalistic view of the patient-physician relationship. For example, it assumes that patients rely upon and thus trust their physicians; therefore, physicians should reasonably divulge as much information as required for the patient to make an informed decision. Of course, from an empirical perspective, this may not be the most realistic presumption since, as discussed, the legal doctrine of informed consent was borne out of a history of violations of trust, and in healthcare in particular this practice evolved within the context of Anglo-American case law on assault and battery. Furthermore, in the context of modern medicine, patients are increasingly empowered with knowledge through the many avenues that are available to them, including the Internet, and feel less of a need to trust physicians. It is clear that this approach is generally not informed by evidence about whether trust does actually exist or not or whether the measures in place to “preserve” it in fact perform that function.
The second view is that public policy serves in a “supportive” role to instill trust in public institutions (p. 158). Through this approach, public policy organizations seek to promote trust through instating rules and regulations, particularly where trust is threatened or diminished. This view is responsive to empirical evidence about the degree in which trust/distrust exists. Its ultimate intent is to promote a “psychology of trust” among the trustors, as well as create the conditions for trust. The instatement of health privacy legislation may be an illustrative example of the use of this type of approach. According to O’Neill (2002), this view aims to create the conditions for intelligently placed trust. This approach does not presume any particular level of trust without empirical evidence but does rely on the assumption that it is possible to build/rebuild trust where it has been fractured.
The third view is a “skeptical” attitude about trust that is premised on an assumption that trust cannot be sustained or justiﬁed and “uses the absence or illegitimacy of trust as a premise for a regime that institutionalizes distrust” (Hall 2005, p. 158). This view is in line with what Pellegrino (1991) generally calls “an ethics of distrust” (p. 70). The author uses the example of the strict regulation of managed care (home care) in the USA that was instated in response to publication of accounts of abuses of vulnerable patients. This stance presumes a critical or skeptical view of the patient as someone who is actively questioning of medical authorities.
The second of these views is the most nuanced and consistent with what has been discussed in the current literature on trust and in keeping with the author’s own perspective. One may argue that key public policy issue is how to promote or incentivize the trustworthiness of individuals within organizations. Otherwise, any speciﬁc assumptions about trust require appropriate empirical validation in order to meaningfully inform policy. A great deal of literature goes into both empirical and theoretical detail on the role of public trust in speciﬁc contexts, such as biobanking; however, that is outside of the scope of the present work.
This entry has discussed the global concept of trust as covered by some traditional theorists as well as the different possibilities for the motivation of the trustee. It then presented a number of different lenses on trust, beginning with a virtue ethics perspective that promotes a refurbished ethics in which trust is not absolute but rather a necessary and ineradicable part of the healthcare provider-patient relationship. The central role of trust in feminist ethics was discussed, particularly in the context of relational autonomy and the social and environmental conditions that help to nurture it. The importance of trust was also outlined according to a deontological conception of autonomy, particularly as it impacts the practice of informed consent. Speciﬁcally, it emphasized the argument that the primary justiﬁcation for the practice of informed consent is not the principle of respect for autonomy but rather the frameworks of governance that ensure individual and organizational accountability and enable intelligent placement of trust. Overall, the analysis of the literature clearly demonstrates an interrelatedness between intrapersonal, interpersonal, and institutional levels of trust, the central role of policy in creating conditions that justify trust in the context of biomedical ethics, and the importance of the coexistence of both trust and reliance within sound biomedical institutional settings.
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