Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Yale Medicine Thesis Digital Library School of Medicine 1996 Reconsidering trust in the physician-patient relationship Julie Anne Rothstein Yale University Follow this and additional works at: http://elischolar.library.yale.edu/ymtdl Recommended Citation Rothstein, Julie Anne, "Reconsidering trust in the physician-patient relationship" (1996). Yale Medicine Thesis Digital Library. 3102. http://elischolar.library.yale.edu/ymtdl/3102 This Open Access Thesis is brought to you for free and open access by the School of Medicine at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Yale Medicine Thesis Digital Library by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. YALE UNIVERSITY CUSHING/WHITNEY MEDICAL LIBRARY Digitized by the Internet Archive in 2017 with funding from The National Endowment for the Humanities and the Arcadia Fund https://archive.org/details/reconsideringtruOOroth Reconsidering Trust in the Physician-Patient Relationship A Thesis Submitted to the Yale University School of Medicine in Partial Fulfillment of the Requirements for the Degree of Doctor of Medicine Julie Anne Rothstein 1996 KAe cl L i? "71)3 +Yi^- Gl30 YALE MEDICAL LIBRARY . Abstract Since Hippocratic times, trust has been considered a fundamental aspect of the physician-patient relationship. During recent years, the trust between doctor and patient has deteriorated. Many factors have contributed to this development, including the cultural environment, technology, and changes in health care delivery. One might also say that despite the importance of the notion of trust to medicine, the actual meaning and limits of trust are poorly defined. Because of these factors, one writer has claimed that in today’s world, trust between physician and patient is an “incoherent” concept. To explore the applicability of trust to the physician-patient relationship, this thesis will examine the notion of trust generally, considering the many ways and levels in which trust functions in our everyday lives. Through this analysis, certain principles and aspects of trust will emerge that will help to clarify the concept. Also, factors that allow trust to flourish will be explored. A case study will be used to show how the refined concept of trust functions in the physician-patient relationship. Instead of holding onto a romanticized and imprecise notion of trust or dismissing the concept as incoherent, this thesis will show that trust is a crucial and irreducible aspect of the physician-patient relationship. In order for it to function maximally in today’s medical world, a clearer and more realistic notion of trust should be embraced. Recommendations for enhancing the environment for trust are provided. 2 Acknowledgements The questions addressed in this thesis arose during conversations with James Nelson at the Hastings Center from 1990-2. When talking about communication between physician and patient, the notion of trust came up again and again. We realized that despite the alleged importance of the concept historically in the history of medicine and bioethics, trust was actually a rather ambiguous and poorly defined topic. This thesis is an attempt to begin to clarify trust in the physician-patient relationship. During the three years since I started this investigation, many people have been extremely helpful and supportive. I cannot possiblly name all of the faculty, students, and residency interviewers who contributed their opinions and experiences. I thank the Office of Student Research, which provided summer funding to support this effort. James and Hilde Nelson, as always, were wonderful listeners, readers, and editors, lending a conceptual clarity to which I can only aspire. Margaret Farley also lent me her ear and sent me looking toward useful sources. Discussions with Sara Swenson added many useful perspectives and ideas. She was a wonderful big sister at Yale Med, answering so many questions over the years. Sara also was a guide and compatriot for addressing philosophical issues in the sometimes vaguely ethical world of medicine. Marna Howarth and Jenn Stuber of the Hastings Center were, as always, invaluable for their timely research support and friendship. Even from the distance of Buffalo, New York, Richard Hull has provided amazing encouragement and opportunity for me to complete and share this work. Nancy Angoff took time to read, critique, and help this thesis through its final phase. Through our many discussions, I have learned much from her about trust in the physician-patient relationship. I am especially indebted to my advisor Robert J. Levine. Since day one of this project, he has listened, suggested, debated, corrected, edited, and guided this endeavor with wonderful enthusiasm. His commitment in terms of time and effort was remarkable and very much appreciated. I know that a project of this type would not have had the same level of support at other medical schools, and Bob's encouragement helped to make this thesis not only possible but productive here at Yale. I must, of course thank my parents, family, and friends, with whom I shared the joys and toils of the work. And to Howard, for carrying the computer on your shoulder with us back and forth to New York, New Haven, and Chicago, and for being there for me during this entire process. He has such a wonderful and insightful way of pointing out ethical inconsistency and keeping me on track. Thank you, thank you, thank you. 3 Table of Contents Chapter One: Reconsidering Trust 4 Chapter Two: Historical Review of Codes as Explications of Trust in the Physician- Patient Relationship: Code within the Context of the Time 15 Chapter Three: How Trust Works in Everyday Life: A Phenomenology of Trust 40 Chapter Four: Levels of Trust 56 Chapter Five: The Purpose and Importance of Trust 73 Chapter Six: Enhancing the Environment of and for Trust 89 Chapter Seven: Trust and the Physician-Patient Relationship 99 Chapter Eight: Conclusions and Recommendations 119 Bibliography 137 4 Chapter One: Reconsidering Trust "It is every bit as urgent to preserve the minimum of trust that is the prime constituent of the social atmosphere in which all human interaction takes place. To be sure, a measure of caution and distrust is indispensable to most human interaction. Pure trust is no more conducive to survival in the social environment than is pure oxygen in the earth's atmosphere. But too high a level of distrust stifles efforts at cooperation as much as severe pollution impairs health."1 As Jay Katz notes in The Silent World of Doctor and Patient, at least since Hippocratic days, physicians have asked patients to trust them without question.2 For an appropriate medical encounter, the physician demanded that the patient yield to the physician's authority and competence. The patient was expected to trust that the physician was working with the patient's best interests at heart. A careful perusal of American history would show that the level of trust in the physician-patient relationship has fluctuated substantially through time. Such an examination is not the purpose of this thesis. Acknowledging the limitations in current conceptions of trust, this thesis will attempt to redefine an appropriate vision of trust in the physician-patient relationship for the end of the twentieth century. Such sources as Paul Starr can explain how the medical profession established a high level of authority and trustworthiness around the end of the nineteenth century. The medical profession rose from mediocrity to superiority over other healers. Advances in science and monopolistic practices by the medical profession contributed to the esteemed position of physicians. These factors combined with deference to authority by lay persons and institutionalized forms of dependence (including urban life and industrial capitalism) to provide the high societal position that the medical profession enjoyed by the twentieth 1 Sissela Bok, "Can Lawyers Be Trusted?" University of Pennsylvania Law Review, 138, 1990, p. 920. 2Jay Katz, The Silent World of Doctor and Patient. 1984, p. xi. 5 century.3 The public accepted medicine, on the whole, as a higher calling. In this way, medicine distinguished itself from other professions. The profession had a major claim of trustworthiness because it consisted of committed and dedicated physicians joined in a professional organization. The goals of the profession included curing the sickness of patients, protecting the health of the public, and researching the mechanisms and treatments of disease. By the middle part of the twentieth century, medicine was enjoying its golden age, in which the healers gained more control of polio and bacterial infections thanks to the new discoveries of vaccines and antibiotics. The Federal government created the National Institutes of Health, solidifying medical research as a major recipient of financial and social support, entrusting the profession with much money and power to continue its work.4 Despite the earlier position of the profession vis-a-vis public trust, today trust between the profession and patients is extremely low. A Harris survey noted that from 1966 to 1993 the percentage of people saying that they had great confidence in the medical profession dropped from 73% to as low as 22%.5 A separate poll, however, discovered that although trust in the profession may be low, many patients continue to 3Paul Starr, The Social Transformation of American Medicine, 1982, pp. 140-44. Starr provides a comprehensive survey of nineteenth century American medicine with its lack of authority. Due to a lack of scientific approach to healing, physicians were less able than they are today to affect health outcomes. Physicians still worked toward the patient's best interests, but they were less capable of actually having a positive impact therapeutically, but judgment and personal interaction were crucial factors in the good outcomes that were attained.