A conceptual analysis of trust in medicine: its definition, decline, and significance

Abstract

Over the past decades, trust in medicine has steadily declined. The purpose of this thesis is to present a definition of 'trust', which helps us (a) understand what trust means in medicine, (b) analyse whether and if so why we have reason to be concerned, and (c) explain why it has declined.

In the absence of a coherent and comprehensive definition of 'trust', I propose a 'pattern-based definition' derived from a conceptual analysis of trust. On this account trust is a justified expectation of the truster regarding the trustworthiness (i.e. competence and commitment) of the trustee. It presupposes conditions of uncertainty and the conscious acceptance of the trust-inherent risk by the truster and leads to a feeling of betrayal in case of a breach of trust. This definition enables us to differentiate trust from related concepts (such as confidence and reliance), helps us understand the role of trust in the patient-physician-relationship, and explains the decline of trust as well as the instrumental and moral significance of trust.

The decline of trust can be explained by physicians' loss of various types of authority (making trust appear unjustified) as well as changes of risk perception and risk acceptance (making trust appear irresponsible). Trust can be shown to be instrumentally useful (it offers advantages not compensated for by alternative strategies) and morally significant (illustrated by the feeling of betrayal caused by a breach of trust and underpinned by the concept of an 'obligation-ascription').

I conclude that this pattern-based account of trust (even though it may not be the only possible definition) is internally coherent and robust. Moreover, it has both discriminatory and explanatory power (i.e., it differentiates trust from related concepts and it helps to explain the decline of trust and the instrumental and moral value of trust).