• general medicine/internal medicine
• philosophical ethics
• health workforce

Joshua Parker has made many interesting points1, and we welcome the opportunity to develop the ideas of ‘Too Much Medicine, Not Enough Trust’.2 We will address: (i) the asymmetry between the trust that patients extend to doctors, and the trust that doctors extend to patients; (ii) our reasons for doubting that litigation or complaints reflect a betrayal of the patient–doctor relationship and (iii) the importance of institutional trust, both for the doctor and the patient.

First, though, a clarification. We do not say that, in general, to trust someone requires thinking that they have ‘our best interests at heart’. We think that claim and others like it are false.3 What we say is that in the specific case of a patient trusting a doctor, the patient will expect that the doctor has their best interests at heart; and that living up to that expectation is part of the particular obligations that the doctor takes on.

The patient’s attitude to the doctor will normally be very different. There is certainly no expectation that the patient will have the doctor’s best interests at heart; most patients will come to a consultation with rather more self-interested concerns. This is not to deny that, in a good case, the doctor will trust the patient. In our paper, we spoke of trusting the patient to report their symptoms accurately, and of trusting them to come back if things get worse. Perhaps here we rather misdescribed the typical attitude. We doubt that many doctors will feel let down, let alone betrayed if they discover their patient has …