Health Care Anal DOI 10.1007/s10728-015-0293-z

Trust and Its Role in the Medical Encounter Stephen Holland1 • David Stocks1

Ó Springer Science+Business Media New York 2015

Abstract This paper addresses two research questions. The first is theoretical: What is trust? In the first half of this paper we present a distinctive tripartite analysis. We describe three attitudes, here called reliance, specific trust and general trust, each of which is characterised and illustrated. We argue that these attitudes are related, but not reducible, to one another. We suggest that the current impasse in the analysis of trust is in part due to the fact that some writers allude to these distinctions, but unclearly so, whilst others elide them altogether. The second research question focuses on doctor–patient interaction. Trust is often said to be central in medical encounters but this strikes us as too vague. The success of doctor–patient relations in part depends on adopting the most appropriate of the three attitudes we delineate. We argue that reliance is the appropriate attitude for most medical encounters. When circumstances do require trust, the distinction between specific trust and general trust is crucial. We describe medical encounters requiring specific trust. General trust is less often required in medicine; but it is appropriate in some cases and, when called for, it is called for strongly. Keywords Betrayal  Doctor–patient interaction  Interpersonal relations  Reliance  Trust

Introduction The success of interpersonal relations in part depends on attitudes adopted by interlocutors. One set of such attitudes centres on trust. Successful interactions are facilitated by people appropriately trusting one another; interpersonal relations suffer when trust is placed inappropriately or disappointed. This has generated a & Stephen Holland [email protected] 1

Department of Philosophy, University of York, York YO10 5DD, UK

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sizable philosophical literature on trust and cognate attitudes such as confidence in, and reliance upon, others [15, 21]. Two points in this literature are noteworthy by way of introduction to this paper. First, there is no settled consensus on the correct analysis of trust. In the first half of this paper we address this by presenting a distinctive tripartite analysis. This distinguishes three relevant attitudes which we call reliance, specific trust and general trust. Each of these is described and illustrated. We argue for the distinctiveness of these attitudes, and defend our analysis against objections. By juxtaposing our analysis with alternatives, it appears that some writers on trust allude to the three attitudes we delineate, but do so unclearly, whilst other writers elide our distinctions. This suggests that the current analytic impasse is at least in part due to a lack of clarity in distinguishing between the attitudes that comprise our tripartite analysis. Second, much of the philosophical literature on trust is epistemological, focusing on the epistemic status of knowledge claims based on testimony [5, 10]. But trust is an interpersonal attitude crucial to a whole range of interpersonal relations. In the latter half of this paper we focus on one set of interactions, that between doctors and patients. Although trust is often said to be central in medical encounters, this strikes us as overblown. We propose a more fine-grained account of trust in medicine; successful doctor–patient interaction requires discrimination between attitudes. We suggest that the appropriate attitude for most medical encounters is reliance, not trust. Of course, trust is sometimes required in medicine; but when it is, the distinction between what we call specific trust and general trust is crucial. We describe circumstances in which specific trust is appropriate. General trust is less often called for in medical encounters; but when it is appropriate, there is a strong obligation on doctors to respond.

The Analysis of Trust Trust is here examined as an interpersonal attitude; this essay is therefore not concerned with trust towards institutions or systems. We suggest that there are three related but non-reducible attitudes: two species of trust, which we call general trust and specific trust; and reliance, which is not a species of trust. Our analysis is nonreductive in that we retain the complexity that results from delineating these three attitudes. We begin with reliance. Reliance Reliance is a common attitude towards those we expect to fulfil their role: we rely on a plumber who arrives on time; who likes to do a good job; who ensures that we are satisfied and so on. When A relies on B to do x, then the motivation of B to do x is internal to B and is not dependent on B’s relationship with A beyond satisfaction of the external, contractual nature of the job, such as being paid on time. Of course we prefer to work with people who are pleasant and polite, but such factors are not necessary for reliance: for example, a passenger in a taxi is concerned with the

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behaviour of the driver and not with his state of mind; it would normally be thought impolite to enquire too far into such personal matters. Reliance is the quotidian attitude which carries us through innumerable interactions and it is underpinned by shared normative standards of behaviour. Specific Trust In this species of trust A is vulnerable to B but has the attitude that B will accomplish x because of the importance of x for A. It is much more reflexive than reliance: A perceives that B acknowledges the state of mind of A and that this gives B particular reason not to exploit A’s vulnerability. Suppose that A relies on B, a taxi driver, to take him to the station for the early train each Monday. The situation continues for years without much conversation between them; then one day the driver takes a different route. In adopting an attitude of reliance, A might question why the deviation has occurred, for he has never enquired into the motivation of B. In specific trust, by contrast, A would still feel sure that B would get him to the station on time; he might presume there were road works on the usual route. The point is that A is vulnerable to B but does not feel suspicious: trust is an attitude to doubt which presupposes A’s favourable interpretation of B’s actions [1]. General Trust Here A trusts B without any intrusion of x. A is vulnerable to B but has the attitude that B would not harm him. General trust is uncommon in comparison with the first two attitudes described above; it is also harder to describe because it is an unfamiliar state of mind to adults. It is usually found only in intimate relationships. An example would be Isaac’s trust of Abraham, his father, in the book of Genesis in the Old Testament. Despite the preparations being made for his sacrifice, Isaac accepts what is to come because of the transformative nature of general trust. As Hertzberg ([12]: 310) points out, Isaac’s attitude towards Abraham, does not simply enter into his relation to the objects of his fear, but rather establishes a new relation to them: while he may still fear them, he has now at the same time come to see them as things to be accepted, maybe even sought for. Something now speaks in favour of enduring the fear, or the pain. The ‘new relation’ is a hallmark of general trust and is akin to Wittgenstein’s [24] observation of ‘the experience of feeling absolutely safe’, something impossible from the worldly point of view but indicative of the transformative nature of this attitude. Wittgenstein thought ‘safe’ here was being used as a simile, a pushing against the boundaries of our understanding. This is not a state of magical inviolability, though in some way, hard to understand, we are not harmed even though our bodies might be injured. A commonplace example would be the trust young children have in their parents when brought to the nurse for immunisations: they come to dread the pain of the injection and yet accept what is to come because of what we call their general trust in their parents.

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The Non-reducibility of the Three Attitudes We claim that the three attitudes are non-reducible for the following reasons. Firstly, when we reflect on our interpersonal relationships we become aware of clear distinctions between our attitudes. For example, we might have to rely on all our colleagues to get the work done, but we would find ourselves trusting only some of them. Secondly, in reliance we concern ourselves with behaviour, whereas in trust we perceive something of the internal qualities of the other person. In particular, our vulnerability is much more marked in trust compared with reliance. In failures of reliability we might blame ourselves for not making sufficient enquiry or for taking someone at face value; we think we should have known better. In failures of trustworthiness we might similarly blame ourselves for being taken in by appearances, but we also blame the other for exploiting our vulnerability. This makes for varying degrees of vulnerability and blameworthiness, most marked in general trust where failures are not simply disappointing but devastating because of our extreme vulnerability. Thirdly, the three attitudes have different geneses. General trust has its origins in infancy when the baby, if well cared for, has its needs met in a timely fashion. This is the species which coincides with Wittgenstein’s ‘safety’, a primal feeling of being at one with others, and in fortunate children it has secure foundations in the love of the parents towards the child. General trust is lost sight of when the child learns that not everyone is concerned with its welfare, indeed that others are in competition for resources. Specific trust comes later when the child learns to discriminate, not simply between individuals, but between the varying abilities of others; so a child might trust an adult in particular and circumscribed ways, for example, to do x, but not y or z. It is difficult for adults to access a state of general trust and—to put the point in terms derived from Transactional Analysis—to do so the adult needs to be in the Child ego-state. Specific trust, on the other hand, is attained through the Adult ego-state, which is the usual state of mind of problem-solving adults. The Adult ego-state is characterised by worldly, calculative approaches, such as estimation of risk and benefit. Fourthly, the attitudes have independent salience; one attitude can be retained when another falls away. A man might be unfaithful to his wife and so lose her general trust in him but she might retain specific trust that he will look after their children and continue to rely on him to provide money for their household expenses. Similarly, a man might have complete general trust in his wife and yet come to see that she is unreliable in certain matters. Furthermore, such distinctions can clarify the strengths and weaknesses of our relationships: the man who cannot rely on his wife can be comforted by the thought that she would never intend him harm despite failings with practical matters. In short, we can still rely on people when trust has broken down [1]. Reliance, after all, is satisfied with behaviour: A is satisfied with the behaviour of B and is not concerned with the commitment of B to respect A’s vulnerability. In this respect, reliance is non-reflexive from the psychological point of view.

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Relations Between the Three Attitudes Although the attitudes are non-reducible to one another, as the previous paragraph suggests they are closely connected, and in this section we illustrate these connections. There are various sorts of expectations we have of others which, metaphorically speaking, can be represented as a pyramid. The largest and lowest stratum is reliance, characterized by mundane expectations and minimal decency.1 The middle stratum corresponds to specific trust, the smallest and highest stratum comprising general trust. As one moves up the pyramid, interactions are based on attitudes of increasing partiality as our claims on one another become more intense and intimate. It is our hypothesis that interpersonal trust of both sorts—specific and general—is less common than might be supposed. It seems to be widespread, but this is because it is so soothing that we want to find it everywhere. This is why we describe our relationships as one of trust when the situation falls short of that state. An example would be to describe our attitude towards other drivers on the road as one of trust when it actually comprises reliance [18]. We tend to imagine that our relationships are more important to others than is the case. Just as we say we love one another in a conversational way, without suffering the pain of others should misfortune occur, so we claim to trust others when we have not in fact made ourselves vulnerable to them. There seems, at first glance, to be an indeterminate slide between these attitudes, but we think the process is best described as one of step-wise changes in interpersonal relations. When we rely on colleagues we have an understanding of what might reasonably be expected of them, but we would not expect only minimal decency from colleagues, nor would we always expect them to be trustworthy. Alongside the tendency to inflate the importance of our attachments, there is a counteractive force which results from fear of being drawn into a relationship with expectations too overwrought for our inclination, so we pull back, emotionally at least, into mechanical performances. An example of this retreat down the pyramid is described by Mo¨llering ([17]: 172) in his studies of the printing industry: one interviewee did not want to characterise his negotiations with paper suppliers as one of trust, preferring to see the suppliers as more or less reliable. Our expectations are not settled, we step from one level of the pyramid to another. It is just because trustworthiness puts such demands upon us that we need discrimination in wisely judging our responses as involving trustworthiness or reliability. Trust is best seen as a particular, rather peculiar, attitude which is appropriate in conditions of uncertainty where there is concern that we might be taken advantage of, in the sense that one cannot rely on others to take one’s important interests into account.2 It is a taut attitude, rather rarefied, at the top of the pyramid of 1

This corresponds to Goffman’s [9] notion of ‘civil inattention’. Incidentally, the metaphor of a pyramid could be misleading in that it might suggest an evaluative hierarchy of attitudes, from the ‘base’ attitude of reliance to the more rarefied general trust. But none of these attitudes is better or more important than others, per se, any more than that one stratum of a pyramid is more important than others. Rather, our point is that interlocutors need to adopt the appropriate attitude for the context; only in that contextrelative sense is one attitude better than another. 2

‘Trust, I will suggest, is a distinctive kind of attitude involving a distinctive state of mind’ (Holton [13]: 63).

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expectations. The serious problem with the diffuse, conversational usage is that trust becomes so attenuated that it loses its essential nature, and this leads to a blunting of our responses and to an impoverishment of delicacy and fine-tuning. We hold in such regard our ability to bond with each other in warm and friendly ways that we imagine and wish that all our relationships are founded on sincere mutual regard. This makes it harder to appreciate that relationships can be measured or nuanced and yet serve their purpose. To describe a relationship as one of reliance, not trust, is not to ascribe any inferiority to it; trust is not necessarily superior to reliance in achieving our aims. The difference between the two species of trust is harder to grasp but one important contrast concerns volition. Much has been made in recent literature of the leap of faith or trust, and this seemingly irrational step is a necessary condition for general trust.3 It is clear that we cannot will ourselves to trust in this way; yet children, and adults in the Child ego-state, readily achieve this ‘leap’. We can decide to place trust in some situations of specific trust, usually when the value of x is small. An early description of this concerns ‘Therapeutic Trust’ placed in children in reform schools as a means of rehabilitation; they were given money to run errands and were expected to return with the correct change [14]. We suggest that adults in such situations achieve a trusting state by means of weighing up evidence of trustworthiness as might be available, and taking a measured step to achieve trust. One further distinction between the two species of trust can also be attributed to the two ego-states. Divided opinions on whether trust is ‘free from doubt’, as described by Thomas Hobbes, or contains doubt within it, can be settled by seeing that specific trust, which belongs in the Adult ego-state, necessarily contains sequestered doubt within it, while general trust has much of the innocent quality of childhood. This is a live distinction: Dunn ([4]: 73) distinguishes between trust as a ‘human passion’ and trust as a ‘modality of human action’, the latter being ‘ineluctably strategic’, which we suggest reflects the Adult ego-state; on the other hand, Williamson ([23]: 29) states that it is ‘mind-boggling to contemplate the absence of calculativeness’, and this in turn suggests how difficult it is to perceive of access to the Child ego-state from the perspective of the ‘adult’ world of analytic philosophy. Such distinctions support the idea that reliability is necessary for specific trust4 but is not necessary for the more expansive attitude of general trust.

The Analytic Impasse The central problem we identify in the extensive trust literature is a failure to distinguish correctly the three attitudes described above. The fact that so many authors—a representative sample of which we discuss in this section—have tried 3

See, for example, Mo¨llering [17]: Chapter 5.

4

That reliance is necessary for specific trust helps explain why it might seem natural, and not a misuse of the term, to speak of trust in providers of contractually regulated and behaviour-led services (taxi drivers, plumbers, etc.). We are arguing that such conversational usage obscures the important distinctions we draw between interpersonal attitudes.

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to differentiate them, especially reliance from trust, points to a widespread expectation that they are indeed different; however, confusion remains and is, we believe, an obstacle to understanding. Hertzberg [12] made a major contribution to the subject in distinguishing trust from reliance by trying to identify a grammar of usage. For Hertzberg, reliance concerns retaining our judgement about others, and this would correspond to our attitude to the taxi-driver taking a deviant route, described above; yet Hertzberg denies that reliance amounts to an attitude toward others. He does not distinguish between the two species of trust, though he does describe the development of trust, especially in children, and this corresponds to what we call general trust. An example of this would be: ‘in so far as I trust someone, there will be no limits, given in advance, of how far or in what respects I shall trust him’; yet for children at school, in their dealings with teachers, there might be ‘a middle ground between trust and reliance which I apparently have failed to allow for’ ([12]: 314–5). This latter comment, although not a formal recognition of different species within the genus of trust, does seem to allude to what we call specific trust. Baier ([1]: 236) also distinguishes reliance from trust, but in her case trust amounts to an entrusting model: trust is ‘a three-place predicate (A trusts B with some valued thing C)’, and this equates to our specific trust; yet, as with Hertzberg, she alludes to something else when she states that this ‘will involve some distortion and regimentation of some cases, where we may have to strain to discern any definite candidate for C’. We suggest that this reflects, but fails to properly capture, what we call general trust. As well as this allusion to our third category, Baier creates a further type of analytic impasse by eliding distinctions which we make. She recognises that we ‘can still rely where we no longer trust’ (p. 234) yet later in the paper she states: ‘Trust, I have claimed, is reliance on others’ competence and willingness to look after, rather than harm, things one cares about which are entrusted to their care’ (p. 259). This elides reliance and trust which we take pains to keep separate. Holton ([13]: 67) does distinguish between reliance and trust: ‘Trust is a three-place relation: one person trusts another to do certain things [...] You can trust a person to do some things without trusting them to do others’. He sees ‘the participant stance’ as central to trust; like us, he sees betrayal as pertaining to breaches of trust but not of reliance. But like Baier he seems not to distinguish reliance and trust, seeing trust as a special sort of reliance: ‘When you trust someone to do something, you rely on them to do it, and you regard that reliance in a certain way: you have a readiness to feel betrayal should it be disappointed, and gratitude should it be upheld’. While we agree with the comments about betrayal, we do not believe that trust merely amounts to reliance with something added on. Holton ([13]: 70) states: ‘Typically, to decide to rely on a person is to decide to trust them, since in relying one automatically takes the stance of trust’. We believe that this conflation of reliance and trust is mistaken; there is no automaticity in our stepping from one attitude to another, as is shown by the example of our relying on all of our colleagues at work but trusting only some.

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A further impediment to the analysis of trust is the predisposition of analytic philosophy to favour overly rationalistic explanations.5 Trust based on evidence of trustworthiness would be one example: Gambetta’s [8] approach, based on risk, is calculative and rational; Hardin’s [11] ‘encapsulated interest’ model is a prominent example in the literature. Rational choice models have the attraction of a sort of cognitive efficiency, but their limitations have been recognised. The chief weakness, we would suggest, is that such accounts of trust come up, sooner or later, against variations of the Prisoner’s Dilemma and there get ‘stuck’. This is because there is no satisfactory solution to the Dilemma if rationality presupposes a determination not to be taken advantage of, and this in turn stems from viewing interpersonal relationships as based on a foundation of suspicion. This leads to an impasse, distorting our understanding, which Hertzberg, in the paper described above, has done most to overcome. We suggest that such overly rational approaches specifically tend to omit what we call general trust because of its origins in early childhood; indeed our return to such levels of understanding, when we enter the Child ego-state as adults, might well be thought a regressive step from the point of view of austerely cognitive philosophers.

Trust in Medicine The main point of the preceding discussion is that there are three distinct but related attitudes governing personal interactions, which we call reliance, specific trust and general trust. What are the practical implications of this claim? Here we focus on one set of interactions. Trust is much discussed, both conceptually and empirically, in the context of the medical encounter between doctors and patients [19, 20]. How does our tripartite analysis apply to this?

Current Views on Trust in Medicine The analytical confusion between the three attitudes is reflected in confusion in medical practice. There is a widespread presumption that patients should be able to trust their doctors, that doctors should be trustworthy, and that patient–doctor interactions need to be based on this stratum of interpersonal expectation; yet we believe that much of modern regulation of the profession, such as appraisal and revalidation, seems aimed at making doctors simply more reliable, not more trustworthy. While we agree that doctors should be trustworthy, we regard this requirement as a personal virtue, and not necessarily a professional virtue which needs to be made manifest at every consultation. A patient might well be nervous and worried before seeing a doctor, but if the doctor’s trustworthiness were routinely brought to mind then that would suggest the possibility of betrayal lurking 5

The tension between rational and experiential understanding of distrust is shown in Part 2, Chapter 8 of Tolstoy’s Anna Karenina when Karenin begins to suspect his wife. The abyss he looks into captures the sense of disintegration as his general trust in his wife breaks down.

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between them, of the doctor taking advantage of the patient’s vulnerability, and that would be a bad basis on which to proceed, as well as adding to the patient’s distress. Downplaying the importance of trust in this way sounds counterintuitive, but consider the following: patients who are nervous commonly give a confused account of their symptoms; they find it difficult to come to the point, to say what fears have prompted their decision to seek medical advice. Doctors are well acquainted with this frustration, but they do not imagine that patients are untrustworthy as a result: the problem lies in a lack of clarity due to fearfulness, not in deceit. Doctors presume that patients are doing their best to tell the truth until experience suggests otherwise. Similarly in the other direction: patients might think the doctor has not grasped the point, that he or she has been distracted or overworked. Again this does not point to untrustworthiness, rather to professional failings resulting from poor organisation of the practice. The point is that most interactions are characterised by problem solving at a mundane level of expectation where ordinary standards of behaviour come to the fore. These normative standards are characterised by both willingness and inefficiency, concerned with reliability not trustworthiness, where mistakes result from human failings, not deception. Analogously, a judge might describe a witness as unreliable when the failure to give a clear account is attributed to incapacity rather than to an intention to mislead. To posit trust as opposed to reliance as the attitude appropriate to such interactions is mistaken. Although doctors might describe themselves as trustworthy, there are structural features within medical practice which prevent professional trustworthiness being taken for granted. Doctors can be pulled in different directions, as in the following examples: 1.

2.

3.

4.

Patients are individuals and members of a community; tension arises when the interests of the community take precedence over the individual, as in the control of infectious diseases. Patients confined against their wishes might believe that their trust has been betrayed. Patients sometimes sense that the doctor is more interested in their disease than in themselves.6 Serious medical scandals, such as at Tuskegee and Alder Hey, can be attributed to doctors being more interested in the study of disease than the treatment and rights of patients coming before them. New treatments necessarily require early patients to act as stepping stones to success. The pioneer cardiac transplant surgeons were seized with a grandiosity which prevented them questioning their work when mortality rates started to rise.7 Trust has been described by Veatch ([22]: 113) as ‘an ambiguous word in medical ethics’. The Hippocratic Oath, the foundational code of behaviour for

6 This was first suggested by Foucault [6] in his description of the setting up of medical clinics; this attitude of ‘the medical gaze’ now seems embedded in medical practice. 7

Referring to an implantable cardiac prosthesis, Dr Denton Cooley said, ‘I felt it was partly my patriotic duty to see that this was first attempted in our country’ ([7]: 189).

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doctors, concerns itself with responsibilities towards colleagues as much as towards patients; when in conflict the doctor is pulled in opposing directions. If it were assumed that trust/trustworthiness are always called for then patients in the above examples would be disappointed; doctors too would be bewildered to find their best efforts spurned. We believe that doctors and patients need to discriminate between interpersonal attitudes delineated in this paper and adopt that which is most appropriate to their context of interaction. At the other end of the spectrum, patients who are suspicious can find themselves prevented from forming any relationship with doctors. This occurs in mental illnesses and in patients who have been obliged to see a doctor against their will. Here expectations are so low that the consultation can barely get going. Such experiences illustrate how much of the work of medicine rests on the foundation of appropriate levels of attitudinal expectation, and if the appropriate stratum is settled on at the beginning then the work can proceed all the more easily. These attitudinal strata can be compared with registers of speech: children learn to use the appropriate register dependent on the situation in which they find themselves. It can be clumsy and gauche to be too informal in certain situations; similarly jarring notes are heard when doctors and patients become misaligned, with time and energy then being spent on correcting wrong impressions and sometimes missing the point entirely. A good bedside manner largely consists of being attuned to the importance of such attitudinal congruence.

Successful Doctor–Patient Interactions Successful interactions depend on acquiring the most appropriate of the three attitudes described above. This can be illustrated as follows. Reliance Reliance and reliability are appropriate for most medical encounters. Reliance is a sturdy attitude which is foundational for good medical practice. Consider having a flu jab: one relies on such things as being seen on time, or nearly so, that the injection has been checked and is at the correct temperature and within date of expiry; that you are indeed the expected patient, have no allergies, are not unwell, and so on. Much of the health care work will be concerned with such a check list, and if there is little time left for conversation, then that might have to wait for another time. The focus is on the job in hand, in getting it right. Reliance and reliability carry the work forward in a brisk and regular manner. Furthermore, this is the appropriate attitude for much more complex tasks. We want a surgeon to be fully focussed on the work in hand, with a high level of responsibility and competence. This is best for the patient and for the surgeon too: the concentration helps to dispel from the surgeon’s mind any distractions which he or she might have brought to work. Indeed it might be said that trust and trustworthiness would be inappropriate in the operating theatre: we do not wish to

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be aware of the state of mind of the surgeon, presuming that he or she is in a competent state to do the job. A surgeon should leave any internal conflicts at the door of the hospital; we do not want to think that they might be conflicted in any way.8 Safe medical practice depends on high levels of competence from staff, and trust cannot make good any deficiency in this fundamental aspect. Reliance, it must be reiterated, is not a second best attitude. Specific Trust Reliance, though essential, is not a substitute for trust. Reliance comes into its own when competence and experience carry doctor and patient forward to predictable outcomes. Trust is called for when risks are unknown and experience is limited. Here the bluff robustness and depersonalised quality of reliance and reliability become insufficient, and if trust does not come into play the patient can be left dangerously unsupported. When trust is called for then it is strongly called for; or perhaps better put, when a patient needs to trust to get through a medical encounter this needs to abut onto the doctor’s trustworthiness. Here are some examples: 1.

2.

3.

Doctors who offer new or experimental treatments need to be trusted if anxiety is to be contained. An example would be the now familiar, then novel, prescribing of chemotherapy for women diagnosed with breast cancer in order to prevent metastatic disease from gaining hold. If the doctor makes a mistake then anxiety arises which can pitch doctor and patient into other strata of expectation, with distrust a danger for them both, especially if the patient senses the doctor’s withdrawal. Trust can arise, however, if the doctor has the maturity to apologise, to explain their actions and to support the patient afterwards. Some patients stay with the doctor who has harmed them, thinking that he or she might be the one who can put things right; but if this arises from the sense that the patient has no choice then that would amount to reliance. Only if the patient chooses to stay with the doctor would we speak of trust arising between them. Trust is called for when unexpected consequences might arise. Dasgupta ([3]: 53) makes the point that ‘trust covers expectations about what others will do or have done (or what message they will transmit) in circumstances that are not explicitly covered in the agreement’. Here we are outside the world of predictable outcomes. Reliance and reliability are mostly concerned with what is likely to happen; trust and trustworthiness, by contrast, deal with what is implicit and so keep in view the unexpected with might arise. Trust and trustworthiness have a diffuse penumbra about them, faintly illuminating distant contingencies.

8

As Primo Levi ([16]: 30), describing a moving though misguided attempt to prevent an explosion, wrote: ‘Competence has no surrogates’.

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General Trust This species of trust comes to the fore in particular cases, and here it is strongly required and is indeed a distinctive feature of good doctoring. General trust is the most intense of the interpersonal attitudes and comes into play when the patient is most vulnerable. It is called for when patients are dying, when the patient leaves behind a sense of what might be done further and focuses on how death is to be approached; this is just when the focus on attaining x falls away and the patient needs to feel that primitive sense of safety described above. Strong interpersonal bonding is required, and here much depends on the character, not just the competence, of the doctor. This entails that the doctor has to give a great deal of themselves in personal, not just professional, terms; and this emotionally demanding state of affairs might be the reason why doctors are usually most comfortable when they align themselves low down the pyramid on the reliability stratum. Young children especially are hardly able to distinguish between specific and general trust and so are all the more vulnerable; similar considerations apply to people with learning difficulties and to those adults who lack the maturity and sophistication to appreciate where they are on the pyramid of expectations: all these groups are likely to do best when they trust their doctors in this personal sense and when the doctor responds from the same stratum. The point has been made above that general trust is impervious to evidence, and this is especially true at this personal level; here betrayals are likely to be very destructive because ill patients are in no state to weigh up any evidence of trustworthiness. Betrayal here is profound and shocking, causing intense psychological harm; the harm penetrates all the deeper because trust at this stratum is stripped bare of any of the psychological defences present in other interpersonal attitudes. We recognize that our claim that general trust is called for in certain sorts of medical encounters is contentious. In particular, one might question whether this interpersonal attitude is ever appropriate to a professional relationship, for example, on the grounds that it is too demanding or open-ended, and belongs exclusively to intimate personal relations (such as that between parent and child). But to reiterate, general trust is required in medicine and health care only very rarely and only in certain specific sorts of circumstances; and the implications for the doctor do not extend beyond the medical encounter. To disavow general trust altogether would be to fail to recognize that a doctor can find themselves in an encounter that requires an attitude that goes beyond reliability and specific trust. This, we suggest, is a distinctive and challenging feature of a doctor’s role.9

9

It is perhaps worth adding that one of the present authors, Stocks, is at the end of a long career in General Practice, one which has involved first-hand experience of the sorts of medical encounters requiring what we call general trust. Of course, this is ad hominen; but such experiences motivated our research interest in this area and support our claim that general trust is sometimes, and strongly, required of a doctor.

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Ascent and Descent of the Pyramid Patients and doctors can move up and down the pyramid of expectations. The steplike quality of these changes is illustrated in the following examples: 1.

2.

3.

4.

5.

Parents worried about the safety of childhood immunisations might find any conflict of advice so bewildering that they ask the doctor what they would do for their own child. This is an invitation to move from the ‘business-as-usual’ world of reliability to the more demanding world of trustworthiness. If the doctor simply repeats the official advice or practice policy then we can see this as a rebuttal of the parents’ wish to adopt a more interpersonally expectant state of mind.10 A similar picture is found in women who suffer from benign breast disease. This can be a risk factor for breast cancer later in life, and so women are commonly recalled to clinics for examinations. Further lumps can then be removed, but this is not without risk: the woman might face repeated operations leaving the breasts hardened and scarred. A surgeon who feels on balance that a lump can be left without excision might be leaving the woman at risk, and his own reputation might suffer too. This would be a move from reliance to trust for the woman, and to feel safe with this decision the woman and the surgeon would have to share a sense of responsibility for the rightness of the decision: the risk would be shared between them. Patients who see themselves as special might wish to pass all responsibility to the doctor on the basis that a special relationship with the doctor guarantees success. This is dangerous practice, and doctors can keep themselves and their patients safe by treating all similar patients under one policy of treatment. This represents a descent to the level of reliability where procedures and policies are planned beforehand, the check list approach here protecting the patient against any unintended deficiencies which special relationships can entail. Doctors who become patients have been known to fall into this trap. Some doctors who favour idiosyncratic approaches might present themselves as focussed on patient care rather than following prescribed approaches. They pride themselves on being able to get to the heart of the matter, cutting corners and favouring strength of character over mundane compliance with received practice. Such doctors would do better descending to the reliable stratum rather than flaunting a putative trustworthiness. Dying patients are sometimes told that ‘nothing further can be done’. This might be true from the biomedical point of view with regards to cure of the disease, but it is an abrogation of duty if it is followed by emotional withdrawal of the doctors from the patient and relatives. Trustworthiness is characterised by standing by the patient and bearing witness to their pain; such attitudes are the

10 This is illustrated in the health visitor’s reported remark in a study of the MMR vaccine: ‘‘We would give it to them and say this is what is recommended, it is recommended, this is the information and if they ask you what your personal view is you have to say well I’m not allowed to give you that (laughter)’’ [2].

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mark of caring doctors at the highest level of the pyramid and should not be neglected.

Concluding Remarks We see doctors and patients placed on a pyramid of attitudinal expectations, and it is our claim that doctors and patients need to find the correct stratum which best suits their situation. For the majority of interactions reliance and reliability are adequate, and we think that safety is best achieved by dependence on tried and tested treatments and procedures. Patients are usually anxious about seeing a doctor; this tends to pitch them into high levels of expectation which the contingencies of medical practice can barely sustain. This is an occupational hazard and needs to be managed. Doctors who are experienced and wise in their manner of speaking to patients can lead patients to the appropriate stratum. We argue against ‘attitudinal inflation’ which imagines that all interactions should be characterised by trust and trustworthiness, for this leads to a diffusion of the essential nature of trust. When trust is required then it is strongly called for, and good doctoring cannot rest on reliable behaviour alone. Nevertheless, trust and trustworthiness can be likened to strong medicines which have a definite place in treatment but which should be prescribed judiciously after weighing up the advantages and disadvantages of such a step.

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Trust and Its Role in the Medical Encounter.

This paper addresses two research questions. The first is theoretical: What is trust? In the first half of this paper we present a distinctive tripart...
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