Medicine needs our trust. We need to be able to rely on individual clinicians and researchers, and we need to be able to have confidence in hospitals and clinics. Yet the organization of our healthcare institutions is not designed to promote that trust. In fact, the structure of our medical institutions seems to undermine our faith.

In this paper, I claim that the doctor-patient relationship can be viewed as a vessel of trust. Nonetheless, trust within the doctor-patient relationship has been impaired by managed care. When we conceive of trust as social capital, focusing on the role that it plays in individual and social well-being, trust can be viewed as a public good and a scarce medical resource. Given this, there is a moral obligation to protect the doctor-patient relationship from the cost-containment mechanisms that compromise its (...) ability to produce trust. (shrink)

: Two basic criticisms of managed care are that it erodes patient trust in physicians and subjects physicians to incentives and pressures that compromise the physician's fiduciary obligation to the patient. In this article, I first distinguish between status trust and merit trust, and then argue (1) that the value of status trust in physicians is probably over-rated and certainly underdocumented; (2) that erosion of status trust may not be detrimental if accompanied by an increase in well-founded merit trust; and (...) (3) that under conditions of managed care the physician's commitment to traditional medical ethics cannot serve as an adequate basis for merit trust. Next, drawing on an analogy between managed care organizations and polities, I argue that (4) the most appropriate basis for merit trust in managed care is a conception of organizational legitimacy that includes procedural justice, empowerment of constructive criticism within the organization, and organizational accommodation of the noninstrumental commitment to patient well-being that is distinctive of medical professionalism. I then explore the conditions necessary for robust competition for merit trust among managed care organizations and indicate the kinds of public policies needed to facilitate such competition. Finally, I show how the account of organization-based merit trust can accommodate the special fiduciary obligation of medical professionals, without indulging in the delusion that it is the physician's fiduciary obligation always to provide all care that is expected to be of any net benefit to the patient. (shrink)

This paper explores the relationship between the bonds of practitioner/patient trust and the notion of a justified lie. The intersection of moral theories on lying which prioritize right action with institutional discretionary power allows practitioners to dismiss, or at least not take seriously enough, the harm done when a patient's trust is betrayed. Even when a lie can be shown to be justified, the trustworthiness of the practitioner may be called into question in ways that neither theories of right action (...) nor contemporary discourse in health care attends to adequately. I set out features of full trustworthiness along Aristotelian lines. (shrink)