Abstract
In a way, we enter a doctor’s office already willing to trust the physician. As part of our assumption that physicians are trustworthy, we expect the doctor to adhere to an ethic of responsibility for our well-being. Attention to objective ethical rules, however, does not seem adequate to the whole experience of the medical encounter. After all, we expect doctors to “do the right thing” not because they are obeying a rule, but because they have developed a certain way of being that includes a sensitivity for persons in need and the knowledge to help. Although someone may not seek medical help for many reasons, generally when one does there is not a great deal of reflection or calculation required because we “naturally” assume that physicians know what they are doing and will act in our interests.
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Notes
Although he does not use the term, Luhman seems to associate confidence with “habit.” As long as a person, institution, or thing functions as expected, we tend, without direct or deliberative reflection, to take it for granted; we interact in a habitual fashion.
Another case where trust comes into play is when others know something about themselves or the world that I do not, and when what I ought to do depends on the extent of my ignorance of these matters. An agreement between myself and these others may call upon them to disclose their information, but can I trust them to be truthful (see [55], pp. 51-52]). A patient must trust the doctor, i.e., rely on the doctor’s actions under conditions of identifiable and unidentifiable risks. Also, the notion of trust has something to do with relationships of mutual dependency. Unfortunately, this sense of mutual dependency often is transformed into patient dependency upon the physician (see [119], pp. 184-202).
More specifically, the fiducia was a contract of sale to a person by mancipation, coupled with a sacred agreement or oath that the purchaser should sell the property back upon the fulfillment of certain conditions. The oath became the basis for trust on which the exchange relationship was founded [286].
It is this sense of trust or faithfulness that is represented by covenant relationship as opposed to contract in medical relationships. Contracts, today, generally are made because of a lack of or insufficient basis for trust. In a contract arrangement, the “parts” of the relationship are carefully described and proscribed. For a summary article on the covenant-contract discussion, see [46].
Trust provides an element of certitude that extends beyond the vicissitudes of momentary experience; C.f., Heb. 11:1; Ps. 141:8.
“[Faith] as trust, its ties with certifiable knowledge of God and of the human good loosened, is put under heavy pressure to posit in and for itself value absolutes — ideals and/or beings worthy of unconditional loyalty” ([117], pp. 222-224).
Faith is an emotionally charged condition which in the extreme becomes an unquestioning acceptance that excludes doubt. However, we cannot do without some perspective, and therefore faith rests upon interpretation and relationship ([115], p. 63; [202], p. 118).
Such a definition tells us that trust is better seen as a threshold point, located on a probabilistic distribution of more general expectations, which can take a number of values suspended between complete distrust and complete trust, centered around a midpoint of uncertainty. Accordingly, either blind trust or distrust represents the predisposition to assign the extreme values of probability and maintain them unconditionally over and above the evidence ([55], pp. 51-52).
Trust reduces complexity in social systems [168]. Trust is a “social good. … When it is destroyed, societies falter and collapse” ([20], p. 26).
This sociological argument rests on the ontological presupposition that there is order upon which the natural and social world depends, a presupposition that is necessary to make talk of trust meaningful. For a discussion of the ontological presuppositions or foundations on which society depends, see [287].
Luhman echoes Parsons’s systematic analysis of trust and distrust in social relationships; see [169]. The dialectical relationship between trust and distrust operates like the “carrot” and the “stick.” The use of one without the other will not be as effective as the use of both.
George Lundberg claims that modem doctors are better trained and more competent to deal with practically every kind of treatment problem and prevention strategy — and wonders why the profession is undergoing reappraisal [170]. David Mechanic sees the growth of public disillusionment accompanying magnificent medical advances [185].
A 1984 survey by the AMA indicated a growing public perception that physicians were becoming too interested in money, spending less time with their patients, and expressing little interest in them (see [89, 263]). The medical profession is concerned with these perceptions. In the last ten years applications to medical schools have declined. One reason cited by Marvin Dunn is that college students “… began to see medicine as more of a business than a profession.” For this reason, he concludes, physicians must work to preserve the values that define medicine as a true profession [62].
Businessmen might express dismay at Lundberg’s disassociation of business and professional ethics. Also, for a comment on the business aspects of medicine, see [25].
For an alternative position, see [71].
Some physicians and others argue that bioethics actually interferes with “good” medical care [Bennett, 1980]; [Greenberg, 1974].
After all, the manner in which the doctor conceives, thinks, and views “his own knowledge and understanding directly shapes the manner in which he perceives, thinks about, and treats the patients who are the objects of that knowledge” ([277], p. 33). The same is true for patients. If physician and patient have contrary ideas about the character and claims of medical knowledge, they are likely to end up with conflicting notions about the nature, terms, and mutual obligations of the professional relationship.
Freidson describes medicine as one of the “learned” professions that, traditionally, are the occupations of the educated and high born ([87], pp. 20-35). In modern usage the word “profession” is often defined in terms of technical expertise sold for a fee, but the more traditional meaning describes a group that professes a vow to an ideal of service [64]. The word profession comes from the Latin profiteri which means “to declare aloud,” and a professional may be defined as one who “professes, who takes an oath, a scared vow” [52]. For further discussion of the “professional” nature of medicine, see [31].
If we distinguish between status professions and occupational professions, occupational professions are those groups whose members use their knowledge and skill primarily to make a living ([67], pp. 14, 32). A status profession is one which is given qualitatively higher status because it is assumed that financial reward is a secondary concern to its members ([7], p. 671).
Trait theory assumes that a profession is an organized community, based on shared identity, values, and role definitions, whose authority is accepted by the public [100]. For a critique of trait theory, see [30].
William May, Talcott Parsons, and Bernard Barber are scholars who use a functional or role method in describing the profession’s defining characteristics (see [176]; [215], pp. 34-49; and [7]).
In reviewing Talcott Parsons’s work on the physician-patient relation, Renée Fox discusses the importance of the “competence gap” that exists between physician and patient which binds the two parties together in a semicollegial relationship ([77], p. 500).
Parsons sees illness not merely as a biophysical condition. It is an integral part of a social process that is governed by the institutionalized roles of the medical profession, which has as its particular function the “management” of disease and illness. His analysis of medical practice also recognizes the physician’s semicollegial relationship with the patient whose “sick role” is complementary to that the physician ([220]; [216], pp. 428-479).
Parsons stresses the innate relationship of medicine with science. The use of science to bolster knowledge, and in turn better enable doctors to perform their function, increases the impact of the argument that scientific medicine and technology improve the doctor’s ability to act for the patient’s good. Parsons sees the medical profession as the embodiment of the “primacy of cognitive rationality” ([217], pp. 536-547).
For a description of the particular institutional conditions which lead to the development of objectivity as a characteristic attitude, see [14, 187]. In order to function effectively, the doctor must establish his or her authority through technical expertise and affective neutrality. The primacy of cognitive rationality in medicine allows for functional specificity and affective neutrality. Therefore, an emphasis on technical roles in therapeutic relations serves to exclude considerations that would undermine the efficacy of physician’s function and impede performance. The alliance of science with medicine fosters this combination of technical skill and affective neutrality, thus actually reinforcing trust in the therapeutic relationship ([145], pp. 35-36).
Johnson claims that the functionalist emphasizes the gatekeeper role as ahistorical and homogeneous among (status) professionals ([145], pp. 36-37). Also, Berlant critiques Parsons’s functionalist theory of the medical profession by noting that Parsons claims to present a descriptive argument. Minimally, however, it contains an implicit explanatory theory for the institutionalization of the profession’s normative structure ([17], p. 12).
Johnson and Freidson argue that the functionalist perspective is too unilinear in concept. Instead they favor a social analysis of professions as social institutions. Professions are those collegial occupational groups that exercise control over their work (see [83, 85, 145].
Daniels notes that, for the profession, the autonomy of the physician is not desired out of self-interest, but is a requirement for offering the best possible service in the public interest ([54], p. 39). Such an argument, echoing Parsons, is used as an apologia for public trust. However, “it may be that the characteristic claim of service to mankind which professions make is as much an unquestioned assertion that everything and anything a professional does is by definition service to humanity as it is an assertion that professionals are obliged to determine what it is that does serve humanity and how they might better strive to do so” ([84], p. 13). Therefore, codes function as a device to retain or advance monopolistic control of work, as a means for receiving government sanction of an exclusionary shelter in the marketplace. Knowledge, skill, and service orientations are no longer regarded as objective characteristics of the institution of medicine. These characteristics become ideological devices to establish autonomy, as the means to gain or preserve social status and privilege (see [85]).
Patients have limited access to the medical knowledge and technical skill of physicians, and limited ability to question the need for medical procedures. They are dependent on their physicians’ judgments. Thus, it is important for patients to be able to trust their physician ([73], p. 4). It should be noted that physicians are caught in a double bind. They are given the social function and responsibility to make medical decisions. However, they are dependent on their patients in many ways: for truthful medical histories, for compliance with medical directives, and for the opportunity to practice the art of medicine. Therefore, it is important for a physician to be able to trust his or her patient.
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© 1995 Springer Science+Business Media Dordrecht
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DuBose, E.R. (1995). Trust and the Medical Profession. In: The Illusion of Trust. Theology and Medicine, vol 5. Springer, Dordrecht. https://doi.org/10.1007/978-94-011-0481-4_2
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