Troubles with trust

By Edwin Jesudason

Our doctor says it’s something major, citing deadly-sounding results. We’re panicked. They talk about treatment options and evidence for each; about cherished benefits and gut-churning harms. They calmly seek our choice of treatment and our consent to proceed. Frozen, we don’t know which option to trust.

A recent paper by philosophers at Oxford and Cambridge has suggested that, essentially, we need trust only when we don’t know. They say that knowing negates the need for trust and can’t really build trust. My new paper responds that trust is perhaps more nuanced: that in some ways we never know, so trust remains essential; that knowing more can help us feel greater trust; that sometimes our trust has to be developed socially ie together.

Trust plays a role throughout our lives. We can sense this at several points in the consultation above. We trust our doctor. They trust their tests and the labs that analyse the results. They trust their training and the published evidence of researchers. They trust their own judgment and their ability to advise ethically. We have to trust our health to one or other option, uncertain of the result. Placing trust in a prescription may even help us as a placebo. In other words, trust may have a direct hand in how healthy we feel.

Of course, this matters far beyond the individual doctor’s office. We need to trust our institutions and they need our trust. Whether they’re storing our confidential health data, doing surgery for children, making or enforcing law, our institutions should be trustworthy. This returns us to the question. Do we trust them because of what we know or what we don’t?

Perhaps of greatest concern here are those cases where we can’t afford not to trust; where our institutions are viewed as too vital to be seen to fail. What then are we to do when it turns out that our judiciary discriminates, our policing can be corrupt and our hospitals can fail and cover up? What are we to do when trust is broken by those with such power?

My paper sketches out how we use verification (testing, trials, checks etc) to help us cope. For example, in an earlier paper, I’ve argued that we can have ethical obligations to improve verification including eg to routinely video surgery as a “black box” safety measure. Opponents may argue that we ought to trust our surgeons rather than watch them. A verse from the Tirukkural suggests we would do better to watch them – then trust them.

Trust without trial – doubt of one tried – both

Yield trouble without end

 The Tirukkural attributed to Thiruvalluvar (somewhere between 1st Century BCE and 5th Century CE), translated from Tamil by Thomas Hitoshi Pruiksma (2021)

These options also highlight that, like kindness, trust has a discretionary element; one that means we may be prone to unfairness when choosing whom and how far we trust.

The dearth of easy answers is illustrated by the longevity of such discussions. Quoted above, the Tirukkural is a Tamil work of ethics, written in poetic form, dated somewhere between the 1st Century BCE and the 5th Century CE. In a section, “Knowing and Trusting”, it teases out relationships between trusting, verification (trial) and trouble. When citizens doubt that their leaders were fairly elected, that vaccines work or that pandemics are real, the Tirukkural warns there may be trouble ahead.


Paper title: Verification and trust in healthcare

Author: Dr Edwin Jesudason

Affiliations: NHS Lothian, Astley Ainslie Hospital, Edinburgh.

Competing interests: None

Social media account: @Edwin1432

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