Symposium: Doctors, Drugs and Devices

Trust and suspicion in the doctor-patient relationship

Justin Oakley, Monash University

Jonathan B. Imber Trusting Doctors: The Decline of Moral Authority in American Medicine, Princeton, Princeton University Press, 2008 (275 pp). ISBN 9-780-69113574-8 (hard cover) RRP $82.95.

Facing wave after wave of new transparency measures, such as internet report cards on surgeon performance and a MyHospitals website (Roxon 2010), many Australian medical practitioners have lamented aloud, ‘whatever happened to good old-fashioned trust’? This question might well seem misplaced, given the recent jailing of surgeon Dr Jayant Patel for the manslaughter of three patients at the Bundaberg Hospital (Bentley 2010), and government inquiries into patient safety at several hospitals in New South Wales, Western Australia, and the ACT (Faunce & Bolsin 2004). But as Jonathan Imber explains in Trusting Doctors: The Decline of Moral Authority in American Medicine, public trust in the medical profession has been on the wane for some time.

Relinquishing an image of doctors as infallible and unassailable in favour of a more realistic picture is, of course, to everyone’s benefit. However, many observers both here and overseas report rising levels of patient suspicion and distrust of doctors and the medical profession. Defensive practices by doctors nervous about possible lawsuits, and the pervasive and often subtle influence of pharmaceutical marketing on doctors’ prescribing, have undoubtedly contributed to this greater public distrust. But the perception of doctors as exemplars of righteousness began to change long ago. So, what did happen to good old-fashioned trust in doctors, and how did the medical profession gain such a lofty reputation in the first place?

THE RISE AND FALL OF MEDICAL TRUST IN AMERICA

Imber paints a compelling picture of how American medicine initially gained its exalted status due to the advent of scientific medicine in the late 19th century, which supplanted the influence of Christianity on the profession, and promoted newfound trust in doctors by giving them better diagnostic skills and more tools with which to combat disease.

At leading American medical schools in the late 19th century, it was very common for the graduation address to be given by well-known Protestant clergymen. Drawing on a fascinating series of such graduation speeches, Imber conveys vividly how doctors at that time were urged to aspire to ideals of personal integrity and ‘high moral character’, in order to be worthy of the trust placed in them by patients. Indeed, personal and professional integrity appear to have been regarded as synonymous, whereas today’s doctors’ tend to see professional integrity as a matter of serving the goals of medicine in their professional roles, whether or not they have high standards of personal integrity outside that professional context. Also, at that time, healers were required to appreciate what some see as the spiritual aspects of consoling and healing patients—such an appreciation was particularly important when medical interventions were often quite ineffective.

Imber also traces the efforts of Catholic moralists to influence clinical practices at the time. For example, a number of Catholic thinkers argued strongly against the use of fetal craniotomy, a common method used in pregnancy termination, and urged doctors instead to encourage women to continue with their pregnancies so that attempts could be made to deliver the baby alive by Caesarian birth instead.

However, the rise of scientific medicine in the latter part of the 19th century began to undermine the influence of Christian character ideals on medical education and practice, and gave doctors new forms of moral authority in the minds of patients which the counsel of clergy could not match:

What seems clear in retrospect, after more than a hundred years of the institutional displacement of religious authority in the United States, is the inevitability with which physicians, in particular, were regarded as the successors to ministers in matters of individual moral guidance, at least insofar as the behaviors so guided had medical implications (p. 18).

What happened to good old-fashioned trust in doctors?

This replacement of Christian proselytising by more scientific approaches to medicine did not take place in a uniform way. Imber describes how in 1871, the recovery of Edward (the Prince of Wales) from typhoid ‘after special prayers were offered on his behalf’ (p. 51) sparked fierce debates about the possible health effects of prayer, and about whether any such effects could be measured. Nevertheless, ‘the balance of authority between the two professions was shifting’ (p. 73), and this gulf widened further during the 20th century.

American medicine reached the zenith of its upward trajectory of cultural authority immediately after World War II. But after this time, doctors were not spared the vociferous challenges to many forms of professional and governmental authority that arose during the 1960s. Imber attributes much of the resulting change in the public reputation of medicine to the rise of feminism and women’s health movements, such as the Boston Women’s Health Collective, which produced the best-selling book Our Bodies, Ourselves, in 1973 (Boston Women’s Health Collective 1973). But Imber does not discuss the impact of the mass media, which, in helping to create unrealistic expectations, left some patients with unwarranted ill-feelings towards doctors unable to achieve medical miracles (see Hooker & Pols 2006).

THE INFLUENCE OF BIOETHICS

During the late 1960s, the civil rights movement, Vietnam War protests, and growing concerns about environmental degradation led many philosophers to engage again with issues of public concern. They began to examine ethical questions about medical practice, reproduction, and new developments in genetics, and such investigations formed the core of a field which shortly became known as ‘bioethics’. Many bioethicists raised important ethical questions about the proper uses and limits of new medical technologies, and went on to successfully challenge the prevailing medical paternalism of that time. The emergence of bioethics also contributed significantly to the decline of trust in American medicine.

Bioethics is often said to have taken off with the establishment of the Institute of Society, Ethics and the Life Sciences (now known as the Hastings Center) in upstate New York, by philosopher Dan Callahan and psychiatrist Willard Gaylin in 1969. In his relatively brief discussion of the subsequent growth and impact of bioethics on medical trust, Imber argues that Catholic moral theology and notions of pastoral medicine inspired early work in bioethics by Callahan and others on topics such as abortion, medical paternalism, and genetic intervention. Imber also documents the influence on bioethics of writing by Episcopal priest Joseph Fletcher, Presbyterian theologian Paul Ramsey, and Catholic priest Ivan Illich. Religious and theological views on medical and reproductive ethics were also targeted by secular bioethicists in the US. Critiques of such views have likewise been important in Australian bioethics, as seen in the extended critical analyses by Peter Singer (Singer & Wells 1984) and Helga Kuhse (1987), respectively, of Catholic views on reproductive technologies and on the sanctity of human life in end-of-life decision-making.

American medicine reached the zenith
of its cultural
authority just after World War II.

Imber’s account of the religious roots of early bioethical writing is illuminating, but he overestimates the influence of religion on the origins of bioethics, and on bioethicists’ successful challenges to the widespread medical paternalism of the time. For some bioethicists saw the prevalence of unjustifiable medical paternalism as a symptom of the insularity of professional role-based ethical standards themselves. That is, codes of medical ethics in America, which had supported attitudes of medical condescension and made no mention of respecting patients, were attacked as self-serving and outdated, and as lacking adequate moral authority. Robert Veatch, for example, urged doctors to reject a professionally-generated ethic altogether and rely solely for guidance on broad-based ethical theories such as Kantianism or Utilitarianism:

The real problem is the use of professional ethical standards rather than those rooted in some more universally accessible source of morality. One is forced to conclude that the use of a professionally-generated ethic … makes no sense in theory or in practice’ (1981, p. 106).

So, instead of paternalistically withholding treatment information from patients, doctors were told that they must inform patients about the risks of medical procedures, since doing so respects patients’ rights, maximises utility, or is required by the virtue of truthfulness. This appeal to broad-based ethical theories was quite independent of any religiously-inspired challenges to medical authority.

Many bioethicists subsequently came to see this rejection of a professionally-generated medical ethic as an overreaction. Instead, they argued that an appropriate conception of the internal morality of medicine could be legitimately invoked by doctors without condoning the unethical behaviour of the past. For example, in his influential article ‘Reviving a distinctive medical ethic’, Larry Churchill (1989) argued that doctors should be guided in their professional behaviour not only by universalist ethical theories such as Utilitarianism and Kantianism, but also by a sense of what it is right for them, qua doctor, to do in the circumstances, considering the distinctive values and goals of medicine—such as doctors’ commitments to act in their patients’ best interests.

This reintroduction of the distinctive goals of medicine to ethical debates about what doctors ought to do helped rehabilitate the idea of professional integrity in medicine, whereby doctors can justifiably refuse to provide futile interventions—even if autonomously requested by patients—on the grounds that such interventions would be contrary to their role as a healer (see, for example, Miller & Brody 1995). The revival of a distinctive medical ethic also paved the way for applications to medicine of an approach known as virtue ethics, according to which actions are right if they are what a person with a virtuous character would do in the circumstances. This approach to ethics was becoming influential in philosophy at the time, and led to the development of new accounts of medical virtues, such as medical beneficence, courage, trustworthiness, and humility (Pellegrino & Thomasma 1993; May 1994; Oakley & Cocking 2001; Radden & Sadler 2010). It is therefore not accurate to suggest, as Imber does, that ‘beyond attempts to observe and document the motives and behaviour of “corrupt”, “impaired”, or “deviant” doctors, little attention has been paid in recent decades to basic questions about the definition and development of professional character in general’ (p. xii).

During the late 1960s philosophers began to examine questions of medical ethics.

Imber analyses the rise of bioethics as a broad social movement and as a fundamentally equalising force, challenging the dominance of doctors and clergy over moral questions regarding health and reproduction. The development of health consumer groups over the last 40 years, and their insistence on the importance of informed consent in clinical practice, has also helped reshape community expectations of doctor-patient relationships. So, ‘physicians [who] were once principally responsible for defining the social and ethical questions facing the profession … have become answerable to a host of outsiders, including courts and legislatures, clinical epidemiologists, women’s health advocates, and bioethicists’ (p. 140). Somewhat ironically, the scientific approach which in the early 20th century helped build doctors’ reputation and authority, and their independence from religion, eventually grew beyond the confines of medicine itself and overwhelmed doctors’ lofty status—which in the end lasted for a relatively brief period, in historical terms. Medical ethics teaching also changed significantly as a result of these demands for more patient involvement in decision-making and better accountability, and doctors were taught to develop greater humility and to become less judgmental towards their patients.

American medical practice is now notorious for its litigiousness, and Imber provides a plausible explanation for how this came about:

The increase in malpractice suits during the 1970s and 1980s reflected the distrust of the profession as well as the demands for even higher levels of quality in medical care. These demands were the consequence of the increase in medical specialties and subspecialties, creating more insistence on effective treatment and less tolerance for error (p. 114).

However, the development of bioethics and the renewed interest in virtue ethics have led many medical educators to return to more rounded and less narrowly technical notions of professional character and competence, which offer hope for alleviating this poisonous trend. For, as Imber insightfully explains, in seeing their doctor’s humanity patients can be more inclined to forgive rather than to sue, when things go wrong or don’t work out.

HAS PUBLIC TRUST IN AUSTRALIAN DOCTORS DECLINED?

Trusting Doctors is a well-researched and absorbing account of how American medicine gained and then lost its social cachet. What of the medical profession in Australia? The more scientific approaches to medicine being developed in the early 20th century clearly boosted the reputations of doctors in Australia, as in America and Great Britain. The various Australian state branches of the British Medical Association (BMA) were federated in 1912, when a unified code of professional ethics, dealing mainly with the regulation of advertising and etiquette toward patients, was introduced (Armit 1924; Egan 1988). Following World War I, Australian medical schools began to include brief instruction in the ethical obligations of physicians, and there was public discussion of issues such as abortion, methods of birth control, and confidentiality in relation to patients with sexually transmitted diseases. However, religion exercised less influence on medical ethics and conceptions of professional character in Australia than it did in the United States.

Today much more is expected of doctors than in the past.

Australian doctors carrying out research found themselves under more scrutiny from 1957, when the first recorded institutional research ethics committee was set up at the Royal Victorian Eye and Ear Hospital in Melbourne (McNeill 1993). While the regulation of biomedical research in Australia was less reactive than it was in the United States, which had witnessed some well-publicised scandals in the 1960s, the development of the concept of informed consent in research also helped Australian patients gain recognition of the importance of this concept in the context of clinical practice.

Australian doctors also found their moral authority being challenged by the widespread social changes of the 1960s. Patients became more assertive, and as in the United States, greater emphasis on women’s rights, an easing of restrictions on abortion, and the emergence of the self-help movement were all important in undermining Australian doctors’ moral authority. However, litigation against doctors has been a less significant factor in this country than in the United States. Also, here as in the United States, dissatisfaction with entrenched medical paternalism led some patients to turn away from conventional medical practitioners in favour of complementary medicine (Clark-Grill 2010).

Bioethics began to develop in Australia around a decade after the United States, and initially focused on new reproductive technologies, but legal recognition in the 1980s of patients’ rights to refuse medical treatment was influential in changing doctors’ roles in end-of-life decision-making. As in the United States, the development of new medical technologies and organ transplantation procedures led to greater understanding by doctors that the appropriateness of such interventions depended very much on patients’ own assessments of what the quality of their lives might be afterwards. Like many of their overseas counterparts, several Australian medical schools began to strengthen their teaching of ethics to medical students in the 1970s and 1980s. And, after the 1988 National Inquiry into Medical Education, all Australian medical schools began to include a substantive medical ethics component in their undergraduate programs (Oakley 2003). In 1992, the Australian Medical Association issued a significantly revised Code of Ethics, which placed greater emphasis on the importance of doctors’ respecting patient autonomy than did previous versions of this code.

Today much more is expected of doctors than in the past. Medical graduates are required to be effective communicators and to have a much better understanding of ethical principles and practice than their predecessors, and the unstoppable medical transparency movement places doctors under unprecedented public scrutiny. Despite well-publicised medical errors, surgical scandals, and the pervasive influence of pharmaceutical companies, public trust in Australian doctors remains relatively high (Hardie & Critchley 2008). But where such trust was often taken for granted in the past, patients now commonly expect doctors to earn their trust, and to maintain it through demonstrating good evidence-based practice in what they do (see, for example, Lupton 2003). This change is not to be lamented. To suggest that trust is devalued by providing patients with more information about their doctor’s performance is to paint a false dichotomy. Trust is enhanced when we know that doctors and the profession are performing well, and are upholding the priorities that the community entrusted them to have when granting their monopoly of expertise in the first place.

The medical profession has lost the elevated social standing it once had. But if doctors can continue to demonstrate that they are meeting their commitments to act in patients’ best interests, first and foremost, then there is good reason to think that ‘the delicate fabric of trust’ (p. xv) between the medical profession and the public will remain intact into the future.

REFERENCES

Armit, H.W. 1924, ‘Medical practice’, Medical Journal of Australia, 25 October, pp. 413–421.

Bentley, A. 2010, ‘Seven years’ jail for killer surgeon’, The Sydney Morning Herald, 2 July.

Boston Women’s Health Collective, 1973, Our Bodies, Ourselves, Simon and Schuster, New York.

Churchill, L.R. 1989, ‘Reviving a distinctive medical ethic’, Hastings Center Report, vol. 19, no. 3, pp. 28–34.

Clark-Grill, M. 2010, ‘When listening to the people: lessons from complementary and alternative medicine (CAM) for bioethics’, Journal of Bioethical Inquiry, vol. 7, no. 1, pp. 71–81.

Egan, B. 1988, Nobler than missionaries: Australian medical culture c. 1880–c. 1930, PhD thesis, Monash University, Melbourne.

Faunce, T. & Bolsin, S.N.C. 2004, ‘Three Australian whistleblowing sagas: Lessons for internal and external regulation’, Medical Journal of Australia, vol. 181, no. 1, pp. 44–47.

Hardie, E.A. & Critchley, C.R. 2008, ‘Public perceptions of Australia’s doctors, hospitals and health care systems’, Medical Journal of Australia, vol. 189, no. 4, pp. 210–214.

Hooker, C. & Pols, H. 2006, ‘Health, medicine, and the media’, Health and History, vol. 8, no. 2, pp. 1–13.

Kuhse, H. 1987, The Sanctity-of-Life Doctrine in Medicine: A Critique, Clarendon Press, Oxford.

Lupton, D. 2003, Medicine as Culture: Illness, Disease and the Body in Western Societies, 2nd edn., Sage, London.

May, W.F. 1994, ‘The virtues in a professional setting’, in Medicine and Moral Reasoning, eds K.W.M. Fulford, G. Gillett & J.M. Soskice, Cambridge University Press, Cambridge.

McNeill, P.M. 1993, The Ethics and Politics of Human Experimentation, Cambridge University Press, Cambridge.

Miller, F.G. & Brody, H. 1995, ‘Professional integrity and physician-assisted death’, Hastings Center Report, vol. 25, no. 3, pp. 8–17.

Oakley, J. 2003, ‘Medical ethics, History of: Australia and New Zealand’, in Encyclopedia of Bioethics, ed. S.G. Post, vol. 3, 3rd edn., Macmillan, New York, pp. 1553–1555.

Oakley, J. & Cocking, D. 2001, Virtue Ethics and Professional Roles, Cambridge University Press, Cambridge.

Pellegrino, E. & Thomasma, D. 1993, The Virtues in Medical Practice, Oxford University Press, New York.

Radden, J. & Sadler, J.Z. 2010, The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice, Oxford University Press, New York.

Roxon, N. 2010, ‘MyHospitals website’, Media release, Office of the Minister for Health and Ageing, Canberra [Online], Available: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/12A961272D345750CA2.pdf [2010, Sep 16].

Singer, P. & Wells, D. 1984, The Reproduction Revolution, Oxford University Press, Oxford.

Veatch, R.M. 1981, A Theory of Medical Ethics, Basic Books, New York.

Associate Professor Justin Oakley is Director of Monash University Centre for Human Bioethics. He has published widely on virtue ethics, medical ethics, and ethical theory, and teaches clinicians in the Master of Bioethics program. He is co-editor (with Steve Clarke) of Informed Consent and Clinician Accountability, The Ethics of Report Cards on Surgeon Performance Cambridge University Press, 2007), and is currently working on a project on virtue ethics and medical conflicts of interest.