Alternative models for public health relationships: Deference, reliance, and trust

As public health ethics gains increasing prominence as a subfield of bioethics, novel contexts promise to shed new light on long-standing ethical problems. In this presentation, I examine the common claim that public health policy formation and implementation ought to aim at sustaining and improving public trust. A push for trust is sometimes motivated by instrumental advantages; without trust, cooperative efforts may fall short of success. Rather than taking this norm for granted, the central challenge that faces public health ethicists is to assess the appropriateness of trust as a public health ideal. In this presentation I address two important elements of such an assessment: first, I consider the potential of two alternative forms of relationship public health professionals can form with citizens, including deference and reliance; second, I articulate potential conceptualizations of public trust. I contend that ethically sound public health policy must take seriously the diverse conceptual and empirical work done on trust in philosophy, political science, and sociology. Of particular interest is empirical and conceptual work that attempts to capture a capacity for trust at different stages of life, as well as over successive generations. I conclude that public health ethics presses bioethicists to reconsider accepted understandings of trust, especially insofar as they may be currently drawn from the context of curative clinical practice. The case of trust in public health illustrates the potential of public health ethics, both to articulate a unique vision of professional ethics, but to reinvigorate and provoke bioethics to reexamine present assumptions.