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There will always be debates in medical ethics about whether any particular value can be considered foundational, but there are reasons for thinking that ‘trust’ is the ground upon which many other important values is built. Sisela Bok remarks:
If there is no confidence in the truthfulness of others, is there any way to assess their fairness, their intentions to help or to harm? How, then, can they be trusted? Whatever matters to human beings, trust is the atmosphere in which it thrives.1 p31
The idea that trust in what others tell us is the bedrock on which human relationships and other values are built seems plausible, but how trust is created, nurtured and sustained is perhaps the challenge for medical ethics. Annette Baier noted that trust occurs within the context of a relationship of some sort, be that with another person or an institution.
“Trust me!” is for most of us an invitation which we cannot accept at will—either we do already trust the one who says it, in which case it serves at best as reassurance…2 p244
Giving thought to the function of trust, both between individuals and toward an institution can shed light on why it occurs and is needed. Niklaus Lumann observes that there is a conceptual relationship between trust and vulnerability: trust is a way of controlling for the uncertainties that the future holds. The need to trust therefore follows from the fact that the future contains many more possibilities than could ever be realised in the present.3 The idea that vulnerability about what might happen in the future explains the need for trust, chimes naturally with how we can view many relationships within healthcare. In mental health settings whether or not a mental health worker is thought ‘trustworthy’. often determines whether or not that relationship is recovery oriented.4
The Journal of Medical Ethics has published a number of papers in recent years on the concept of epistemic injustice, which occurs when the testimony of someone, often a patient, is not given the credibility that it should.5 6 We can view epistemic injustice via the lens of trust and vulnerability too: when someone’s experiences are not heard, it undermines the likelihood that they will expect a therapeutic response to their future vulnerabilities.
In this issue of the JME, Priest discusses the significance of trusting the testimony of non-binary adults seeking puberty suppression. She claims:
Medicine’s ethically insecure history within the LGBT community justifies scepticism towards physicians’ scepticism of LGBT testimony…we must remember that both values and experience can impact suffering. Judging norm deviant preferences as ‘misguided’ (without further reason) is not only epistemically suspect, it violates the patient’s right to autonomy.7
She observes that suffering can be partly constituted by a person’s values and experiences and that means in order for medicine to be genuinely therapeutic and respectful of non-binary adults, their testimony should be trusted.
Gille and Brall turn their attention to the importance of trust for biobanks, and they consider some of Lumann’s points about the importance of institutions acting in ways that enable donors to have confidence that their future interests will be appropriately regarded.8 Their account of trust draws on him when they say:
In this article, we understand trust as a relational construct existing between at least two actors where the trusting actor A anticipates that the trusted actor B will, in the future, do or not do what the actor B is trusted for.8
The multiple ways in which tissue samples could be used in the future is a paradigmatic example of the challenges created by trying describe every possible future use and gain consent to these uses. Instead, institutions that hold collections of human tissue should demonstrate themselves to be worthy of their donors’ trust. Gille and Brall suggest: “The biobank as a research institution needs to communicate that appropriate governance frameworks including oversight and accountability mechanisms are in place.”8
Some jurisdictions have introduced legislation that requires healthcare institutions to act in ways that enable patients to know that they will be informed in a full and open manner when things go wrong and they are at risk of harm. Inkster and Cuddihy discuss how the “duty of candour” can be managed based on their experiences of an infection control incident at a children’s hospital.9 This demonstrates how the way in which an institution communicates is important, in addition to the fact of them being open. So being ‘trust-worthy’ requires more of an institution than simply being open about error.
The JME welcomes further debate and scholarship on trust and what that means within a healthcare setting. Paying attention to these structural considerations and the values guiding institutions, moves scholarship in medical ethics beyond the microcosm of clinical ethics.
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Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.