Trust and the Ethics of Health Care Institutions: Though Trust Is Essential to Relationships between People, Including That between Patient and Clinician, Its Role in Organizational Ethics Is Largely Unexplored. Nonetheless, Trust Is Also Ideally a Part of the Relationship between Patient and Health Care Institution, Both Because It Is Desirable in and of Itself, and Because It Makes for Better Medical Care
Goold, Susan Dorr, The Hastings Center Report
It is widely acknowledged that trust is a vital component of and basis for relationships between clinicians and patients. These interpersonal trust relationships have moral content--fidelity to trust is morally praiseworthy, betrayal of trust morally blameworthy. (1) The need for trust and reliance on trust are especially important in health care because of patients' acute vulnerability to suffering, lost opportunity, and lack of power. Patients' vulnerability to organizations is arguably even greater than to physicians, yet while physicians acknowledge consequent ethical obligations, most institutional obligations are couched in contractual terms. This contract model assumes a level playing field for its parties, even though most would agree that "consumer sovereignty" is far from the norm in the health care marketplace.
My aim in this paper is to describe the relationship between individuals and health care institutions, using trust as a conceptual framework, then to draw conclusions for the ethics of health care organizations. In the last section, I will discuss what conditions or circumstances could influence trust in health care institutions, and contrast them with conditions that influence trustworthiness. It is my belief that a sociological understanding of institutional trust provides insight into the relationships between individuals and health care institutions and hence the morality of organizational actions.
Can an Organization Be Ethical?
Since organizations do not clearly have the same sort of "moral agency" attributed to people, philosophers have debated whether they have any intrinsic moral obligations. Most philosophers and organizational theorists agree, however, that organizations have an identity distinct from the sum of the individuals within them, and thus can be treated as moral actors. (2)
There is no question that organizations are dominant actors in modern society. Organizations expand our abilities in ways that allow common people to do uncommon things: a trauma center is able to achieve what no individual, no matter how skilled or talented, could hope to accomplish. As dominant actors in health care, organizations merit our moral attention for several reasons. First, they create role expectations that have moral content. For example, nurses and physicians in a trauma center are expected to be patient advocates, and the center's administrator is expected to engineer the system so as to maximize efficiency. Organizations shape behavior through these role expectations, and through their policies, practices, and culture. Nurses have traditionally been granted less authority than physicians, for instance, but their authority varies across different types of organizations.
In addition to creating role expectations, organizations as actors respond to social conditions. (3) Hospitals, physician groups, and insurers, for instance, respond to the medical marketplace with utilization review, prices, and changes in benefits. Finally, organizations have a normative structure. They set goals and express values and norms in addition to creating role expectations. (4) In health care, changes in organizations, changes in delivery and financing arrangements, changes in the context of care, change the experiences of health care for individual patients, including which and how much care they receive, when they receive it, and how it is received. Organizational decisions also affect potential future patients, employees, other organizations, and the community. Given the dominant place of organizations in modern society, and in particular the change occurring in health care organizations, it behooves scholars to examine the ethics of health care organizations. What framework, what theory of right behavior, can be used to examine organizational ethics in health care?
Interpersonal Trust in Health Care
Theories and principles of bioethics rely to varying degrees on intrinsic or instrumental justifications for imposing moral duties on clinicians. …