The 130th Annual Meeting of APHA

Abstract #42971

Patricia M.L. Illingworth, JD, PhD, Social Medicine, Harvard Medical School, Division of Medical Ethics, 96 Larchwood Drive, Cambridge, MA 02138, 617-492-8369, pillingw@lynx.neu.edu

I begin with an overview of two conceptions of trust. On the “encapsulated interest” account, trust is to be identified with the trustee’s interest in being trustworthy. The entruster will trust the trustee when she can see that it is in the interest of the trustee to be trustworthy. The “economic theory” of trust focuses on the individual entruster and how she comes to believe in the trustworthiness of others. Under fee-for-service, physicians have an interest in cultivating trust between themselves and their patients because they have a desire for a long-term relationship with their patients and a desire to live up to professional values. Under managed care, patients cannot count on continuity of care, and capitation is fraught with conflicts of interest. Thus, the trust typically associated with the trustee’s interest is undermined. The economic approach suggests that patients come to the physician with pre-established levels of trust. As patients learn more about managed care both through personal experience and the media, they are likely to approach their physicians with distrust. The doctor-patient relationship has the potential to be an important vessel of trust. When we conceive of trust as social capital, we can more clearly identify the role that the doctor-patient relationship plays in social well-being. Social epidemiologists have shown that high levels of social capital have a number of advantages, including improved health outcomes. Others have argued that social capital is at the heart of our ability to engage in cooperative activity. The doctor-patient relationship is a scarce medical resource and a morally important public good.

Learning Objectives:

• Identify two conceptions of trust
• Identify how the doctor-patient relationship produces trust.
• Understand the connection between trust and social capital
• Identify how managed care organizations undermine the potential for the doctor-patient relationship to create trust and social capital
• Recognize and articulate the morally important consequences of identifying the doctor-patient relationship as a public good.

Keywords: Ethics, Managed Care

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.