In this chapter, we consider ethical and philosophical aspects of trust in the practice of medicine. We focus on trust within the patient-physician relationship, trust and professionalism, and trust in Western (allopathic) institutions of medicine and medical research. Philosophical approaches to trust contain important insights into medicine as an ethical and social practice. In what follows we explain several philosophical approaches and discuss their strengths and weaknesses in this context. We also highlight (...) some relevant empirical work in the section on trust in the institutions of medicine. It is hoped that the approaches discussed here can be extended to nursing and other topics in the philosophy of medicine. (shrink)

Over the past decades, public trust in medical professionals has steadily declined. This decline of trust and its replacement by ever tighter regulations is increasingly frustrating physicians. However, most discussions of trust are either abstract philosophical discussions or social science investigations not easily accessible to clinicians. The authors, one a surgeon-turned-philosopher, the other an analytical philosopher working in medical ethics, joined their expertise to write a book which straddles the gap between the practical and theoretical. Using an (...) approach grounded in the methods of conceptual analysis found in analytical philosophy which also draws from approaches to medical diagnosis, the authors have conceived an internally coherent and comprehensive definition of trust to help elucidate the concept and explain its decline in the medical context. This book should appeal to all interested in the ongoing debate about the decline of trust - be it as medical professionals, medical ethicists, medical lawyers, or philosophers. (shrink)

In this chapter, we consider ethical and philosophical aspects of trust in the practice of medicine. We focus on trust within the patient-physician relationship, trust and professionalism, and trust in Western (allopathic) institutions of medicine and medical research. Philosophical approaches to trust contain important insights into medicine as an ethical and social practice. In what follows we explain several philosophical approaches and discuss their strengths and weaknesses in this context. We also highlight (...) some relevant empirical work in the section on trust in the institutions of medicine. It is hoped that the approaches discussed here can be extended to nursing and other topics in the philosophy of medicine. (shrink)

Trust relations in medicine are argued to be a requisite response to the special vulnerability of persons as patients. Even so, the problem of motivating trust remains a vital concern. On this score, it is argued that a strong motivation can be found in recognizing that professional self-interest actually entails cultivation of patient trust as a means to maintain professional self-governance. And while the initial move to restore trust must be provoked from such narrow concerns, (...) the process of sustaining trust will require educational initiatives aimed at restoring attitudes and skills suggestive of Percival's concept of empathic care. By including such initiatives, future waves of medical professionals are apt to sustain trust with deepened commitments to character, care, and trust as constitutive properties of their professional mission. (shrink)

Trust is taken to be one of the foundational values in the doctor-patient relationship, facilitating access to the benefits of health care and providing a guarantee against possible harms. Despite this foundational role, some doctors betray the trust of their patients. Trusting involves granting discretionary powers and makes the truster vulnerable to the trustee. Patients trust medical practitioners to act with goodwill and to act competently. Some patients carry pre-existing vulnerabilities, for reasons such as gender, poverty, age, (...) ethnicity, or disability, and these vulnerabilities can be exacerbated when such patients extend their trust to a doctor. Gender stereotypes reduce women's ability to challenge and thereby assess their doctor's competency. In addition, women are more likely to be distrusted by their doctors and have their experiences of medical symptoms discounted. In this paper, we analyze two extreme examples of breaches of medical trust that exploited the vulnerability of women in the health care system: the "unfortunate experiment" at the National Women's Hospital in New Zealand and the Harold Shipman murders of elderly patients in the United Kingdom, examining the potential role of gender in the outcomes with regard to trust. Major breaches of medical trust such as these typically lead to government inquiries, revisions of ethical guidelines, and substantive policy change in an effort to re-establish public and patient trust. We argue that the medical profession has an ethical obligation to put mechanisms in place to protect vulnerable patients from abuses of trust, to monitor colleagues' competence, and to be prepared to blow the whistle to protect patients who are not in a position to recognize misplaced trust. Such mechanisms will act disprosportionately to reduce harm to women as patients. (shrink)

Medical mistrust has a well‐documented harmful impact on a range of patients’ health behaviors and outcomes. It can have such egregious downstream effects on so many aspects of medicine—from clinical trial participation to health care use, timely screening, organ donation, and treatment adherence—that it is sometimes described as one of the social determinants of health. In the article “Trust, Risk, and Race in American Medicine,” Laura Specker Sullivan makes the compelling case that trust is essential to (...) building a therapeutic alliance in which effective, high‐quality health care can be delivered and received. As a complement to her suggestion that health care providers take an active role in mitigating mistrust by demonstrating “not only their capacity to be honest and forthright but also their ability to respond to the potential truster's needs,” we recommend that key health care professionals commit to five actions. (shrink)

This paper sets out an account of trust in AI as a relationship between clinicians, AI applications, and AI practitioners in which AI is given discretionary authority over medical questions by clinicians. Compared to other accounts in recent literature, this account more adequately explains the normative commitments created by practitioners when inviting clinicians’ trust in AI. To avoid committing to an account of trust in AI applications themselves, I sketch a reductive view on which discretionary authority is (...) exercised by AI practitioners through the vehicle of an AI application. I conclude with four critical questions based on the discretionary account to determine if trust in particular AI applications is sound, and a brief discussion of the possibility that the main roles of the physician could be replaced by AI. (shrink)

Truth, Trust and Medicine investigates the notion of trust and honesty in medicine, and questions whether honesty and openness are of equal importance in maintaining the trust necessary in doctor-patient relationships. Jackson begins with the premise that those in the medical profession have a basic duty to be worthy of the trust their patients place in them. Yet questions of the ethics of withholding information and consent and covert surveillance in care units persist. This (...) book boldly addresses these questions which disturb our very modern notions of a patient's autonomy, self-determination and informed consent. (shrink)

What accounts for the prestige of quantitative methods? The usual answer is that quantification is desirable in social investigation as a result of its successes in science. Trust in Numbers questions whether such success in the study of stars, molecules, or cells should be an attractive model for research on human societies, and examines why the natural sciences are highly quantitative in the first place. Theodore Porter argues that a better understanding of the attractions of quantification in business, government, (...) and social research brings a fresh perspective to its role in psychology, physics, and medicine. Quantitative rigor is not inherent in science but arises from political and social pressures, and objectivity derives its impetus from cultural contexts. In a new preface, the author sheds light on the current infatuation with quantitative methods, particularly at the intersection of science and bureaucracy. (shrink)

In clinical practice, decision-making is not performed by individual knowers but by an assemblage of people and instruments in which no one member has full access to every piece of evidence. This is due to decision making teams consisting of members with different kinds of expertise, as well as to organisational and time constraints. This raises important questions for the epistemology of medicine, which is inherently social in this kind of setting, and implies epistemic dependence on others. Trust (...) in these contexts is a highly complex social practice, involving different forms of relationships between trust and reasons for trust: based on reasons, and not based on reasons; based on reasons that are easily accessible to reflection and others that are not. In this paper, we focus on what it means to have reasons to trust colleagues in an established clinical team, collectively supporting or carrying out every day clinical decision-making. We show two important points about these reasons, firstly, they are not sought or given in advance of a situation of epistemic dependence, but are established within these situations; secondly they are implicit in the sense of being contained or nested within other actions that are not directly about trusting another person. The processes of establishing these reasons are directly about accomplishing a task, and indirectly about trusting someone else’s expertise or competence. These processes establish a space of reasons within which what it means to have reasons for trust, or not, gains a meaning and traction in these team-work settings. Based on a qualitative study of decision-making in image assisted diagnosis and treatment of a complex disease called pulmonary hypertension, we show how an intersubjective framework, or ‘space of reasons’ is established through team members forging together a common way of identifying and dealing with evidence. In dealing with images as a central diagnostic tool, this also involves a common way of looking at the images, a common mode or style of perception. These frameworks are developed through many iterations of adjusting and calibrating interpretations in relation to those of others, establishing what counts as evidence, and ranking different kinds of evidence. Implicit trust is at work throughout this process. Trusting the expertise of others in clinical decision-making teams occurs while the members of the team are busy on other tasks, most importantly, building up a framework of common modes of seeing, and common ways of identifying and assessing evidence emerge. It is only in this way that trusting or mistrusting becomes meaningful in these contexts, and that a framework for epistemic dependence is established. (shrink)

Trust in medicine is often conceived of on an individual level, with respect to how people rely on particular clinicians or institutions. Yet as discussions of trust during the Covid‐19 pandemic highlighted, trust decisions are not always as individual or interpersonal as this conception suggests. Rather, individual instances of trusting behavior are related to social trust, which is conceived as a willingness to be vulnerable to people in general, based on a sense of shared norms. (...) In this essay, I propose that individual and social trust are connected to each other in what can be termed a “climate of trust.” I explain how masking trends during the pandemic facilitated a “climate of distrust,” and I consider the role that clinicians might play in transforming climates of distrust into climates of trust. (shrink)

Why has autonomy been a leading idea in philosophical writing on bioethics, and why has trust been marginal? In this important book, Onora O'Neill suggests that the conceptions of individual autonomy so widely relied on in bioethics are philosophically and ethically inadequate, and that they undermine rather than support relations of trust. She shows how Kant's non-individualistic view of autonomy provides a stronger basis for an approach to medicine, science and biotechnology, and does not marginalize untrustworthiness, while (...) also explaining why trustworthy individuals and institutions are often undeservingly mistrusted. Her arguments are illustrated with issues raised by practices such as the use of genetic information by the police or insurers, research using human tissues, uses of new reproductive technologies, and media practices for reporting on medicine, science and technology. Autonomy and Trust in Bioethics will appeal to a wide range of readers in ethics, bioethics and related disciplines. (shrink)

Bioethics as a field began some years before it was finally named in the early 1970s. In many ways, bioethics originated in response to urgent matters of the moment, including the controversy over disconnecting Karen Quinlan's respirator, the egregious paternalism of Donald Cowart's doctors in the famous “Dax” case, the abuse of research subjects in the notorious Tuskegee Syphilis Study, and the need to devise an intellectual framework for the development of federal regulations to protect human subjects of research. The (...) phrase “new and unprecedented” became a common description of the topics and issues to which people who later came to be called “bioethicists” responded. It should come as no surprise that bioethics and its practitioners soon came to the self-understanding that their work was new and unprecedented, much as the innovations of biomedical science and their clinical applications were thought to be. (shrink)

Bioethics as a field began some years before it was finally named in the early 1970s. In many ways, bioethics originated in response to urgent matters of the moment, including the controversy over disconnecting Karen Quinlan's respirator, the egregious paternalism of Donald Cowart's doctors in the famous “Dax” case, the abuse of research subjects in the notorious Tuskegee Syphilis Study, and the need to devise an intellectual framework for the development of federal regulations to protect human subjects of research. The (...) phrase “new and unprecedented” became a common description of the topics and issues to which people who later came to be called “bioethicists” responded. It should come as no surprise that bioethics and its practitioners soon came to the self-understanding that their work was new and unprecedented, much as the innovations of biomedical science and their clinical applications were thought to be. (shrink)

In this essay, we explore consequences of the systemic failure to track and to publicize the prevalence of patient‐safety threats in American medicine. Tens of millions of Americans lose trust in medical care every year due to safety shortfalls. Because this loss of trust is long‐lasting, the corrosive effects build up over time, yielding a collective maelstrom of mistrust among the American public. Yet no one seems to notice that patient safety is a root cause, because no (...) one is counting. In addition to identifying the origins of this purblindness, we offer an alternative policy approach. This would call for government to transparently track safety threats through the systematic collection and reporting of patients’ experiences. This alternative strategy offers real promise for stemming the erosion of trust that currently accompanies patient‐safety shortfalls while staying consistent with Americans’ preferences for a constrained government role with respect to medical care. (shrink)

In clinical practice, decision-making is not performed by individual knowers but by an assemblage of people and instruments in which no one member has full access to every piece of evidence. This is due to decision making teams consisting of members with different kinds of expertise, as well as to organisational and time constraints. This raises important questions for the epistemology of medicine, which is inherently social in this kind of setting, and implies epistemic dependence on others. Trust (...) in these contexts is a highly complex social practice, involving different forms of relationships between trust and reasons for trust: based on reasons, and not based on reasons; based on reasons that are easily accessible to reflection and others that are not. In this paper, we focus on what it means to have reasons to trust colleagues in an established clinical team, collectively supporting or carrying out every day clinical decision-making. We show two important points about these reasons, firstly, they are not sought or given in advance of a situation of epistemic dependence, but are established within these situations; secondly they are implicit in the sense of being contained or nested within other actions that are not directly about trusting another person. The processes of establishing these reasons are directly about accomplishing a task, and indirectly about trusting someone else’s expertise or competence. These processes establish a space of reasons within which what it means to have reasons for trust, or not, gains a meaning and traction in these team-work settings. Based on a qualitative study of decision-making in image assisted diagnosis and treatment of a complex disease called pulmonary hypertension (PH), we show how an intersubjective framework, or ‘space of reasons’ is established through team members forging together a common way of identifying and dealing with evidence. In dealing with images as a central diagnostic tool, this also involves a common way of looking at the images, a common mode or style of perception. These frameworks are developed through many iterations of adjusting and calibrating interpretations in relation to those of others, establishing what counts as evidence, and ranking different kinds of evidence. Implicit trust is at work throughout this process. Trusting the expertise of others in clinical decision-making teams occurs while the members of the team are busy on other tasks, most importantly, building up a framework of common modes of seeing, and common ways of identifying and assessing evidence emerge. It is only in this way that trusting or mistrusting becomes meaningful in these contexts, and that a framework for epistemic dependence is established. (shrink)

“Public Trust in Expert Knowledge: Narrative, Ethics, and Engagement” examines the social, cultural, and ethical ramifications of changing public trust in the expert biomedical knowledge systems of emergent and complex global societies. This symposium was conceived as an interdisciplinary project, drawing on bioethics, the social sciences, and the medical humanities. We settled on public trust as a topic for our work together because its problematization cuts across our fields and substantive research interests. For us, trust is (...) simultaneously a matter of ethics, social relations, and the cultural organization of meaning. We share a commitment to narrative inquiry across our fields of expertise in the bioethics of transformative health technologies, public communications on health threats, and narrative medicine. The contributions to this symposium have applied, in different ways and with different effects, this interdisciplinary mode of inquiry, supplying new reflections on public trust, expertise, and biomedical knowledge. (shrink)

Health care systems can positively influence our personal decision-making and health-related behavior only if we trust them. I propose a conceptual analysis of the trust relation between the public and a healthcare system, drawing from healthcare studies and philosophical proposals. In my account, the trust relation is based on an epistemic component, epistemic authority, and on a value component, the benevolence of the healthcare system. I argue that it is also modified by the vulnerability of the public (...) on healthcare matters, and by the system’s credibility. I apply my proposed analysis of public trust in health care systems to the phenomenon of vaccine hesitancy, a tendency to question vaccine policies, and to seek alternative vaccine schedules or to refuse vaccination. Understanding the role of trust and its components can be key to understanding the phenomenon. (shrink)

ABSTRACT Defining a nonpaternalistic yet achievable form of trust in medicine in an era of simultaneous patient empowerment and institutional control has been and remains an important task of bioethics. The ‘crisis of trust’ in medicine has been viewed mainly as the problem of getting patients to trust their health care providers, especially physicians. However, since paradigmatic cases of trust are mutual, bioethicists must pay more attention to physician trust in patients. A physician’s (...) view of the reasonableness of trust in a particular patient is affected not just by his or her relationship with that patient, but also by what is going on institutionally, professionally, legally, and politically with regard to a given treatment or intervention. Since general moral principles are insufficient in determining the moral value and reasonableness of trust in particular instances, I discuss in detail the role of trust and distrust in the specific case of treating patients with medications implicated in drug abuse. I conclude that it is important to become aware, first, of the clinical significance of physician trust and distrust in patients, and second, of the many factors which inform both of these moral attitudes. These two claims together suggest that a central, but overlooked, virtue of medical practice is reflective, context‐responsive trust in patients. (shrink)

Artificial intelligence (AI) is expected to revolutionise the practice of medicine. Recent advancements in the field of deep learning have demonstrated success in variety of clinical tasks: detecting diabetic retinopathy from images, predicting hospital readmissions, aiding in the discovery of new drugs, etc. AI’s progress in medicine, however, has led to concerns regarding the potential effects of this technology on relationships of trust in clinical practice. In this paper, I will argue that there is merit to these (...) concerns, since AI systems can be relied on, and are capable of reliability, but cannot be trusted, and are not capable of trustworthiness. Insofar as patients are required to rely on AI systems for their medical decision-making, there is potential for this to produce a deficit of trust in relationships in clinical practice. (shrink)

In 2015 scientists called for a partial ban on genome editing in human germline cells. This call was a response to the rapid development of the CRISPR–Cas9 system, a molecular tool that allows researchers to modify genomic DNA in living organisms with high precision and ease of use. Importantly, the ban was meant to be a trust-building exercise that promises a ‘prudent’ way forward. The goal of this paper is to analyse whether the ban can deliver on this promise. (...) To do so the focus will be put on the precedent on which the current ban is modelled, namely the Asilomar ban on recombinant DNA technology. The analysis of this case will show (a) that the Asilomar ban was successful because of a specific two-step containment strategy it employed and (b) that this two-step approach is also key to making the current ban work. It will be argued, however, that the Asilomar strategy cannot be transferred to human genome editing and that the current ban therefore fails to deliver on its promise. The paper will close with a reflection on the reasons for this failure and on what can be learned from it about the regulation of novel molecular tools. (shrink)

In this paper, I develop and defend a moralized conception of epistemic trust in science against a particular kind of non-moral account defended by John (2015, 2018). I suggest that non-epistemic value considerations, non-epistemic norms of communication and affective trust properly characterize the relationship of epistemic trust between scientific experts and non-experts. I argue that it is through a moralized account of epistemic trust in science that we can make sense of the deep-seated moral undertones that (...) are often at play when non-experts (dis)trust science. (shrink)

This article deals with the question how technologycontributed to the performing of objective assessmentsof health risks and to the public trust in theinsurance institution. Many authors have pointed tothe relevance of medical or statistical technologywith regard to the constitution of objectivity,because these technologies should be capable ofdiminishing the influence of social interactions – the``human element'' – on the process of producingknowledge about health risks. However, in this articleit is shown that the constitution of objective riskassessments and public trust (...) cannot be seen as theproduct of one particular type of technology, but thatit is the product of a socio-technical network, inwhich several heterogeneous elements becomeinterrelated and interdependant. The historicalreconstruction of this network also sheds a new lighton the role of `the human element' in the constitutionof objectivity and trust. It shows that elements inthe network which regulate the social interactionbetween the subjects involved are of no lessimportance to generate trust than technologies whichtend to abstract from this interaction. In otherwords, objective and subjective elements areintertwined much more than is often recognized, andpublic trust is to a fairly large degree depends onconventions in social interaction. (shrink)

The participation of minors in clinical trials is essential to provide safe and effective medical care to children. Because few drugs have been tested in children, pediatricians are forced to prescribe medications off-label with uncertain efficacy and safety. In this article, we analyze how the enrollment of minors in clinical trials is negotiated within relationships of mutual trust between clinicians, minors, and their parents. After a brief description of the problems associated with involving minors in clinical research, we consider (...) how existing “relationships of trust” can be used as a place where the concerns of research subjects can be more fully discussed and addressed. Building on the tacit recognition of trust found in The European Clinical Trials Directive we make policy recommendations that allow for clearer, more ethically informed guidelines for enrolling minors in clinical research. (shrink)

In reference to the different approaches in philosophy(of medicine) of the nature of (medical) technology,this article introduces the topic of this specialissue of Theoretical Medicine and Bioethics, that is,the way the different forms of medical technologyfunction in everyday medical practice. The authorselaborate on the active role technology plays inshaping our views on disease, illness, and the body,whence in shaping our world.

Bioethicists have long been concerned that seriously ill patients entering early phase (‘phase I’) treatment trials are motivated by therapeutic benefit even though the likelihood of benefit is low. In spite of these concerns, consent forms for phase I studies involving seriously ill patients generally employ indeterminate benefit statements rather than unambiguous statements of unlikely benefit. This seeming mismatch between attitudes and actions suggests a need to better understand research ethics committee members’ attitudes toward communication of potential benefits and risks (...) of early phase studies to potential subjects. We surveyed the members of two U.S. research ethics committees using a phase I gene transfer study scenario, and compared the results to a previous survey of potential subjects’ perceptions and attitudes toward benefit and risk for the same protocol. The results show that there is indeed a gap between the subjects’ perceptions and the committee members’ views on what is appropriate to be communicated to research subjects. This discrepancy is the product of both the commonly assumed optimism of the subjects and to a “protective pessimism” of the research ethics committee members. We discuss this discrepancy using “frameworks of trust” and demonstrate the need to incorporate these frameworks into the existing model of informed consent. (shrink)

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances of intentional wrongdoing, by males in nonacademic medical settings, with oversight problems and a selfish motive such as financial gain or sex. More than half of cases involved a (...) wrongdoer with a suspected personality disorder or substance use disorder. Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions. (shrink)

The use of black box algorithms in medicine has raised scholarly concerns due to their opaqueness and lack of trustworthiness. Concerns about potential bias, accountability and responsibility, patient autonomy and compromised trust transpire with black box algorithms. These worries connect epistemic concerns with normative issues. In this paper, we outline that black box algorithms are less problematic for epistemic reasons than many scholars seem to believe. By outlining that more transparency in algorithms is not always necessary, and by (...) explaining that computational processes are indeed methodologically opaque to humans, we argue that the reliability of algorithms provides reasons for trusting the outcomes of medical artificial intelligence. To this end, we explain how computational reliabilism, which does not require transparency and supports the reliability of algorithms, justifies the belief that results of medical AI are to be trusted. We also argue that several ethical concerns remain with black box algorithms, even when the results are trustworthy. Having justified knowledge from reliable indicators is, therefore, necessary but not sufficient for normatively justifying physicians to act. This means that deliberation about the results of reliable algorithms is required to find out what is a desirable action. Thus understood, we argue that such challenges should not dismiss the use of black box algorithms altogether but should inform the way in which these algorithms are designed and implemented. When physicians are trained to acquire the necessary skills and expertise, and collaborate with medical informatics and data scientists, black box algorithms can contribute to improving medical care. (shrink)

The UK Government’s Code of Conduct for data-driven health and care technologies, specifically artificial intelligence -driven technologies, comprises 10 principles that outline a gold-standard of ethical conduct for AI developers and implementers within the National Health Service. Considering the importance of trust in medicine, in this essay I aim to evaluate the conceptualisation of trust within this piece of ethical governance. I examine the Code of Conduct, specifically Principle 7, and extract two positions: a principle of rationally (...) justified trust that posits trust should be made on sound epistemological bases and a principle of value-based trust that views trust in an all-things-considered manner. I argue rationally justified trust is largely infeasible in trusting AI due to AI’s complexity and inexplicability. Contrarily, I show how value-based trust is more feasible as it is intuitively used by individuals. Furthermore, it better complies with Principle 1. I therefore conclude this essay by suggesting the Code of Conduct to hold the principle of value-based trust more explicitly. (shrink)

The UK Government’s Code of Conduct for data-driven health and care technologies, specifically artificial intelligence -driven technologies, comprises 10 principles that outline a gold-standard of ethical conduct for AI developers and implementers within the National Health Service. Considering the importance of trust in medicine, in this essay I aim to evaluate the conceptualisation of trust within this piece of ethical governance. I examine the Code of Conduct, specifically Principle 7, and extract two positions: a principle of rationally (...) justified trust that posits trust should be made on sound epistemological bases and a principle of value-based trust that views trust in an all-things-considered manner. I argue rationally justified trust is largely infeasible in trusting AI due to AI’s complexity and inexplicability. Contrarily, I show how value-based trust is more feasible as it is intuitively used by individuals. Furthermore, it better complies with Principle 1. I therefore conclude this essay by suggesting the Code of Conduct to hold the principle of value-based trust more explicitly. (shrink)

Trust is a core feature of the physician-patient relationship, and risk is central to trust. Patients take risks when they trust their providers to care for them effectively and appropriately. Not all patients take these risks: some medical relationships are marked by mistrust and suspicion. Empirical evidence suggests that some patients and families of color in the United States may be more likely to mistrust their providers and to be suspicious of specific medical practices and institutions. Given (...) both historical and ongoing oppression and injustice in American medical institutions, such mistrust can be apt. Yet it can also frustrate patient care, leading to family and provider distress. In this paper, I propose one way that providers might work to reestablish trust by taking risks in signaling their own trustworthiness. This interpersonal step is not meant to replace efforts to remedy systemic injustice, but is an immediate measure for addressing mistrust in occurrent cases. (shrink)

We argue why interpretability should have primacy alongside empiricism for several reasons: first, if machine learning models are beginning to render some of the high-risk healthcare decisions instead of clinicians, these models pose a novel medicolegal and ethical frontier that is incompletely addressed by current methods of appraising medical interventions like pharmacological therapies; second, a number of judicial precedents underpinning medical liability and negligence are compromised when ‘autonomous’ ML recommendations are considered to be en par with human instruction in specific (...) contexts; third, explainable algorithms may be more amenable to the ascertainment and minimisation of biases, with repercussions for racial equity as well as scientific reproducibility and generalisability. We conclude with some reasons for the ineludible importance of interpretability, such as the establishment of trust, in overcoming perhaps the most difficult challenge ML will face in a high-stakes environment like healthcare: professional and public acceptance. (shrink)

The AMA Council on Ethical and Judicial Affairs (CEJA) has initiated an important discussion on medical professionalism and the use of social media by issuing thoughtful and practical guidance for physicians and medical students. The implications of online activities for trust in the profession, as well as for trust between patient and doctor, however, will need further exploration as digital life expands and evolves.

Data-intensive science comes with increased risks concerning quality and reliability of data, and while trust in science has traditionally been framed as a matter of scientists being expected to adhere to certain technical and moral norms for behaviour, emerging discourses of open science present openness and transparency as substitutes for established trust mechanisms. By ensuring access to all available information, quality becomes a matter of informed judgement by the users, and trust no longer seems necessary. This strategy (...) does not, however, take into consideration the networks of professionals already enabling data-intensive science by providing high-quality data. In the life sciences, biological data- and knowledge bases managed by expert biocurators have become crucial for data-intensive research. In this paper, I will use the case of biocurators to argue that openness and transparency will not diminish the need for trust in data-intensive science. On the contrary, data-intensive science requires a reconfiguration of existing trust mechanisms in order to include those who take care of and manage scientific data after its production. (shrink)

Trust constitutes a fundamental strategy to deal with risks and uncertainty in complex societies. In line with the vast literature stressing the importance of trust in doctor–patient relationships, trust is therefore regularly suggested as a way of dealing with the risks of medical artificial intelligence (AI). Yet, this approach has come under charge from different angles. At least two lines of thought can be distinguished: (1) that trusting AI is conceptually confused, that is, that we cannot (...) class='Hi'>trust AI; and (2) that it is also dangerous, that is, that we should not trust AI—particularly if the stakes are as high as they routinely are in medicine. In this paper, we aim to defend a notion of trust in the context of medical AI against both charges. To do so, we highlight the technically mediated intentions manifest in AI systems, rendering trust a conceptually plausible stance for dealing with them. Based on literature from human–robot interactions, psychology and sociology, we then propose a novel model to analyse notions of trust, distinguishing between three aspects: reliability, competence, and intentions. We discuss each aspect and make suggestions regarding how medical AI may become worthy of our trust. (shrink)

In this paper we aim to discuss a theoretical explanation for the positive relationship between patients’ knowledge and their trust in healthcare personnel. Our approach is based on John Dewey’s notion of continuity. This notion entails that the individual’s experiences are interpreted as interrelated to each other, and that knowledge is related to future experience, not merely a record of the past. Furthermore, we apply Niklas Luhmann’s theory on trust as a way of reducing complexity and enabling action. (...) Anthony Giddens’ description and analysis of the high modern society provides a frame for discussing the preconditions for patient-healthcare personnel interaction. High modernity is dominated by expert systems and demands trust in these. We conclude that patient knowledge and trust in healthcare personnel is related because both knowledge and trust are future- and action-oriented concepts. The traits of high modernity provides opportunities and challenges as the personnel can and must perform discretion. This discretion must be made in a context where knowledge is considered uncertain and preliminary. (shrink)

What are the moral challenges that confront doctors as they manage healthcare institutions? How do we build trust in medical organisations? How do we conceptualize moral action? Based on accounts given by senior doctors from organisations throughout the UK, this book discusses the issues medical leaders find most troubling and identifies the moral tensions they face. Moral Leadership in Medicine examines in detail how doctors protect patients' interests, implement morally controversial change, manage colleagues in difficulty and rebuild (...) class='Hi'>trust after serious medical harm. The book discusses how leaders develop moral narratives to make sense of these situations, how they behave while balancing conflicting moral goals and how they influence those around them to do the right thing in difficult circumstances. Based on empirical ethical analysis, this volume is essential reading for clinicians in leadership roles and students and academics in the fields of healthcare management, medical law and healthcare ethics"--Provided by publisher. (shrink)

The ethical implications of the growth of for-profit health care institutions are complex. Two major moral criticisms of for-profit medicine are analyzed. The first claim is that for-profit health care institutions fail to fulfill their obligations to do their fair share in providing health care to the poor and so exacerbate the problem of access to health care. The second claim is that profit seeking in medicine will damage the physician-patient relationship, creating conflicts of interest that will diminish (...) the quality of care and erode patients' trust in their physicians and the public's trust in the medical profession. The authors conclude that while the continued expansion of for-profit health care may exacerbate in some respects problems of access, trust and conflicts of interest, it is a mistake to consider these problems as unique to for-profit health care; they are problems for not for-profit health care as well. Though these issues justify continuing moral concern, they do not at this time provide decisive grounds for substantially curbing or eliminating for-profit enterprise in health care. (shrink)

Obtaining human genetic samples is vital for many biobank research purposes, yet, the ethics of obtainment seems to many fraught with difficulties. One key issue is consent: it is by many considered ethically vital that consent must be fully informed (at least ideally speaking) in order to be legitimate. In this paper, we argue for a more liberal approach to consent: a donor need not know all the specifics of future uses of the sample. We argue that blanket consent is (...) ethically defensible, and that this is buttressed by considerations of (justified) trust-relations. Given robust institutional oversight, blanket consent is a permissible form of consent in the bio-banking context. (shrink)

Moral concerns about the authority, power, and trustworthiness of physicians have become important topics in clinical ethics during the past three decades. These concerns have come to greater prominence with the increasing involvement of large-scale private institutions in the organization and delivery of medical services, especially managed care organizations, and with the increasing involvement of government in the payment for and organization and delivery of medical services. When physicians act as the agents of large institutions or governments, the power of (...) physicians over their patients increases. The purposes of this article are (1) to reflect briefly on the historical origins of the moral problem of physicians' power in medicine, and (2) to introduce the articles in the 1999 annual number of the Journal of Medicine and Philosophy on topics in clinical ethics. (shrink)

Trust between a patient and a medical doctor is normally both justified and taken for granted, but sometimes it may need to be negotiated. In this paper I will present how trust can be interpreted as both an explicit and implicit phenomenon, drawing on literature from the social sciences and philosophy. The distinction between explicit and implicit interpretations of trust will be used to address problems that may arise in clinical consultations. Negotiating trust in any way (...) very easily brings distrust into a situation, but sometimes this can be helpful for building a more functional patient-doctor relationship. (shrink)

What does Artificial Intelligence (AI) have to contribute to health care? And what should we be looking out for if we are worried about its risks? In this paper we offer a survey, and initial evaluation, of hopes and fears about the applications of artificial intelligence in medicine. AI clearly has enormous potential as a research tool, in genomics and public health especially, as well as a diagnostic aid. It’s also highly likely to impact on the organisational and business (...) practices of healthcare systems in ways that are perhaps under-appreciated. Enthusiasts for AI have held out the prospect that it will free physicians up to spend more time attending to what really matters to them and their patients. We will argue that this claim depends upon implausible assumptions about the institutional and economic imperatives operating in contemporary healthcare settings. We will also highlight important concerns about privacy, surveillance, and bias in big data, as well as the risks of over trust in machines, the challenges of transparency, the deskilling of healthcare practitioners, the way AI reframes healthcare, and the implications of AI for the distribution of power in healthcare institutions. We will suggest that two questions, in particular, are deserving of further attention from philosophers and bioethicists. What does care look like when one is dealing with data as much as people? And, what weight should we give to the advice of machines in our own deliberations about medical decisions? (shrink)

Corruption is a word used loosely to describe many kinds of action that people find distasteful. We prefer to reserve it for the intentional misuse of the good offices of an established social entity for private benefit, posing as fair trading. The currency of corruption is not always material or financial. Moral corruption is all too familiar within churches and other ostensibly beneficent institutions, and it happens within medicine and the pharmaceutical industries. Corrupt behavior reduces trust, costs money, (...) causes injustice, and arouses anger. Yet it persists, despite all efforts since the beginnings of societies. People who act corruptly may lack conscience and empathy in the same way as those with some personality disorders. Finding ways to prevent corruption from contaminating beneficent organizations is therefore likely to be frustratingly difficult. Transparency and accountability may go some way, but the determined corruptor is unlikely to feel constrained by moral and reporting requirements of this kind. Punishment and redress are complicated issues, unlikely to satisfy victims and society at large. Both perhaps should deal in the same currency—material or social—in which the corrupt dealing took place. (shrink)

In biomedical research lack of trust is seen as a great threat that can severely jeopardise the whole biomedical research enterprise. Practices, such as informed consent, and also the administrative and regulatory oversight of research in the form of research ethics committees and Institutional Review Boards, are established to ensure the protection of future research subjects and, at the same time, restore public trust in biomedical research. Empirical research also testifies to the role of trust as one (...) of the decisive factors in research participation and lack of trust as a barrier for consenting to research. However, what is often missing is a clear definition of trust. This paper seeks to address this gap. It starts with a conceptual analysis of the term trust. It compares trust with two other related terms, those of reliance and trustworthiness, and offers a defence of Baier’s attribute of ‘good will’ a basic characteristic of trust. It, then, proceeds to consider trust in the context of biomedical research by examining two questions: First, is trust necessary in biomedical research?; and second, do increases in regulatory oversight of biomedical research also increase trust in the field? This paper argues that regulatory oversight is important for increasing reliance in biomedical research, but it does not improve trust, which remains important for biomedical research. It finishes by pointing at professional integrity as a way of promoting trust and trustworthiness in this field. (shrink)

This book offers an easy-to-read, yet comprehensive introduction to practical issues in doctor–patient relationships in a typical low- and middle-income country setting in India, examining in detail the reasons for erosion of trust and providing guidance on potential research areas in the field. It strikes a balance between empirical work and theoretical normative analysis, while adopting mixed-method research in exploring important constructs in the doctor–patient relationship, such as trust, solidarity, advocacy, patient-centeredness, privacy, and confidentiality. Since the concept of (...) trust has direct implications for the ethical practice of medicine, the book is a valuable resource for academics and researchers in the field of medical, clinical, and applied ethics. (shrink)

The aim of this paper is to enhance doctors’ awareness of implicit understandings between doctors and patients in the context of pre-operative communication of risks. This paper draws on insights from the philosophy of language – in particular pragmatic analysis tools – that make explicit the implicit understandings of the interaction. Mastering not only _what is said_ but also _what is unsaid_ allows doctors to improve their communication with their patients. I suggest that being aware of the implications of the (...) interactions is useful for improving both the doctor’s and the patient’s experience, further strengthening the therapeutic alliance. In this article I analyze actual cases involving pre-operative evaluation before cardiac surgery from a philosophy of language perspective. The paper is structured as follows: a description of the relevant philosophy of language tools that I will apply; an overview of the risk-communication context; an explanation of the link between “the implicit dimension” and trust, addressing whether the doctor needs to convey the whole truth; and the analysis of real cases. In conclusion, I re-emphasize the importance of implicit meanings during risk communication. (shrink)

Without trust there is no credible human health research (HHR). This article accepts this truism and addresses a crucial question that arises: how can trust continually be promoted in an ever-changing and uncertain HHR environment? The article analyses long-standing mechanisms that are designed to elicit trust—such as consent, anonymization, and transparency—and argues that these are best understood as trust represented by proxies of trustworthiness, i.e., regulatory attempts to convey the trustworthiness of the HHR system and/or its (...) actors. Often, such proxies are assumed to operate as markers that trust exists or, at least, has not been lost. But, since trust can neither be “built” nor “secured,” this is a precarious assumption. Worryingly, there is no existing theoretical account of how to understand and evaluate these proxies of trustworthiness as part of a trusted HHR ecosystem. To remedy this, the paper argues for a radical reimagining of trust and trustworthiness as performative acts that ought to be understood in relation to each other and by reference to the common values at stake. It is shown that proxies of trustworthiness are the operational tools used to perform trustworthiness. It advocates for a values-based approach to understanding the relationship between trust and trustworthiness. This establishes a strong basis for an evaluative framework for proxies of trustworthiness, i.e., to determine how to perform trustworthiness well. Five common proxies in HHR are scrutinized from a values perspective. The contribution is to provide a far-reaching normative and practical framework by which existing and future proxies of trustworthiness can be identified, assessed, maintained, or replaced in rapidly changing HHR regulatory ecosystems where trust itself is crucial to the success of the entire HHR enterprise. (shrink)