Trust in the system

The latest edition of the American Journal of Bioethics features a fascinating serious of articles on doctor-patient trust and Shared Decision Making (SDM). The target article of the edition – written by Drs Maureen Kelly (Oxford) and Sandra Soo-Jin Lee (Stanford) et al – considers how patients perceive consent to Research on Medical Practices (ROMP).

As the authors observe, “research on medical practices (ROMP)—including medical record reviews, comparative effectiveness research, quality improvement interventions, and point-of-care randomization—is critically important to improving medical care, reducing risks to patients, and decreasing costs.”

They argue against more general informed consent procedures and in favour of a personalised, collaborative approach:  “We propose an approach that promotes engagement grounded in the principle of respect for persons, either as patients or as research participants.”

From a study of focus groups in different hospitals, the authors found that developing relationships of trust was crucial to ensure patient confidence: “The simple act of 'being asked' bolstered a sense of trust … Given our findings, taking this time will be essential for ensuring support for research in medical practice by addressing what is most important for many patients—conversations with their physicians.”

 They recommend shared decision as a prudent way to approach ROMP:

“…we suggest that shared decision making (SDM) can serve as a valuable model for managing disclosure, consent, randomization, and data sharing…SDM can support collaborative physician–patient decision making that addresses uncertainty and bridges the power gap between patient and physician knowledge while promoting transparency and trust…”.

Commenting on the article, Harvard health policy lecturer Emily A. Largent said that doctors need to be transparent with patients about the distinction between care and research (what is directed at helping the patient vs. what is being done for the good of society and future generations):

“…The ultimate success of learning health care systems rests on fostering the appropriate kinds of trust in physicians, investigators, and institutions. The importance of patient trust in learning health care systems underscores the importance of maintaining the research–care distinction…”

Drs Sabine Salloch and Jan Schildmann et al commented on the relevance of this new research to Cambridge academic Onora O’Neill’s account of trust in bioethics. O’Neill’s account might help us to clarify what kind of trust we are looking to foster:

“O’Neill’s account of principled autonomy might be seen as a 'third way' that mediates between the danger of misplaced trust and an inadequate interference with the wishes of patients for a trustful relationship with their physicians.” 

MORE ON THESE TOPICS | doctor-patient relationship, informed consent, learning healthcare system, trust

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