TY - JOUR AU1 - Powell, Rhonda AB - What would healthcare look like if it were governed by trust between patients and health professionals? This is the central question addressed in Mark Henaghan's treatise, Health Professionals and Trust: The Cure for Healthcare Law and Policy. It is a question well worth asking, and in seven detailed-yet-concise chapters, Henaghan moves confidently towards an answer. Health Professionals and Trust is a fitting contribution to the Biomedical Law and Ethics Library (series editor: Sheila McLean), a collection of analytical works on thought-provoking topics in medical law and ethics. The essential concept behind the book is that quality healthcare depends upon mutual trust; ‘[p]atients have to trust healthcare professionals to fulfil their professional duties on a daily basis. Healthcare professionals have to trust their patients to give them accurate information about the patients' health’ (p. 128). Henaghan posits that many problems between health professionals and patients result from a breakdown in trust and that these problems can be prevented or cured by building trust. Henaghan starts, in Chapter 1, by considering the dynamic role of trust in healthcare.1 He notes a number of well-known crises in medical ethics such as the Cartwright Inquiry (New Zealand) into non-consensual experimentation on cervical cancer patients,2 the Tuskegee syphilis experiment (the US) in which subjects were not told of the development of penicillin which could have saved their lives,3 and the Shipman Inquiry (UK) into a doctor who is believed to have systematically killed over 200 patients,4 as well as policy developments, such as the increase in external regulation, all of which have contributed to eroding trust in health professionals (pp. 2–6). And yet, Henaghan notes that on the whole public opinion polls show that health professionals are some of the most trusted members of society.5 Interestingly, the most vulnerable groups of society, such as ethnic minorities and the unemployed, exhibit the least trust for health professionals (pp. 7–8, 10), possibly because we tend to trust those who are most like ourselves.6 In Chapter 2, Henaghan explores the plethora of theoretical literature on trust,7 particularly that of Annette Beier and Onora O'Neil.8 He adopts Beier's argument that trust is best fostered by equalisation of power (p. 24). According to Henaghan, the role of power and its relationship to trust in healthcare is important. It is not uncommon for a normally assertive person to feel disempowered in hospital, as they are subject to the hospital's systems and policies. Furthermore, assertions of authority by health professionals can lead to a reduction in patient trust, as can a change in focus from individual healthcare providers to healthcare systems, even though these systems themselves depend upon trust. Henaghan argues that the converse is also true; by attempting to equalise power a health professional can increase trust and improve the therapeutic relationship (p. 27). Trust is particularly important in medical emergencies, which are one of the few exceptions to the prohibition on treating patients without their consent (if the emergency renders the patient unconscious or otherwise unable to consent). In Chapter 3, Henaghan examines the importance of trust in medical emergencies.9 He identifies a public interest in emergency treatment being provided without fear of tortious liability as the strongest justification for this exception (pp. 36–38). Additionally, failure to act in an emergency can contribute to eroding trust in the health professions. Henaghan identifies that health professionals who take responsibility to save the greatest number of lives with the lowest morbidity in medical emergencies provide evidence that the health professions are capable of being trusted (p. 50). He argues that the guiding principle in emergency healthcare, to save the greatest number of lives with the least morbidity, should be the guiding principle in non-emergency healthcare too (p. 50). But one problem within healthcare is that, on the whole, complaints against health professionals are increasing (pp. 57–61).10 Studies show that when not managed well, complaints processes can lead to health professionals feeling shame and guilt, and patients feeling ignored.11 In Chapter 4, Henaghan presents ways in which trust can be built through the complaints process.12 He suggests that a complaints process that contributes to an equalisation of power and in which the complainants are respected and listened to and lessons are learned to benefit other patients, could help restore trust in healthcare (pp. 61–66). Henaghan argues that the complaints process can enhance trust by (i) changing the way in which health professionals are perceived and how they perceive themselves, (ii) making apology, repentance, and forgiveness central to the process rather than blame and punishment, (iii) simplifying and quickening the complaints process, and (iv) making structural changes that reduce the opportunities for health professionals to betray trust and to lose trust in their patients (pp. 66–81). The first of these proposals, linked to the importance of equalising power, is based on a recognition that although health professionals are licenced to practice in their area of specialisation due to their experience and knowledge, they still do not know everything and they are not always right. For example, the range of factors which influence patient decision-making may be broader than the range of clinical factors considered relevant to a health professional. So, the ‘best choice’ for a particular patient may depend on the patient's social and cultural context as much as the clinical context. Although this is not made explicit, presumably Henaghan means that the tendency for some health professionals to see themselves or to be seen as ‘all-knowing’ leads to poor decision-making and, therefore, more complaints. Henaghan suggests that structural changes that equalise power and build trust between healthcare professionals and reduce the ability for individual doctors to make mistakes, such as providing legal protection to those who acknowledge mistakes to encourage open disclosure (but we are not told how this would be achieved) or universal implementation of the WHO surgical safety checklist,13 would also be steps in the right direction (pp. 79–81). Examples of breakdown in trust between health professionals and patients are not hard to find, and in Chapter 5 Henaghan considers a number of New Zealand case studies in which a breakdown in trust exacerbated a medical emergency.14 One involved a breakdown in trust between a pregnant woman and obstetric hospital staff. The doctors' insistence upon a planned Caesarean section, despite the mother's clear wish to avoid surgery, led to a breakdown of trust, resulting in the exclusion of medical staff from caring for her during delivery. Their ability to help when an emergency arose was thus constrained, and the baby died (pp. 89–92).15 In another well-known New Zealand case, a child with cancer was taken into hiding by his parents, in response to a court order mandating medical treatment,16 and was then taken overseas by his parents to pursue alternative treatment, where he died (pp. 95–98).17 In both of these cases, a breakdown in trust between health professionals and patients appear to have influenced patient choices and ultimately the outcomes. In the childbirth case, a loss of trust in the medical staff to provide supportive care in line with the parents' wishes led them to exclude medical staff from caring for them. In the cancer case, the application for a court order to mandate treatment had the result of preventing further communication with the family and medical assessment.18 Breakdown in trust has also occurred within medical research. In Chapter 6 Henaghan reviews a number of research projects involving indigenous populations, which caused enormous damage to the ability of those populations to trust health professionals.19 Medical researchers have ethical and, in most places, legal duties to make full disclosure about their research methods, and obtain full and informed consent to the use of material obtained from human subjects.20 Nevertheless, Henaghan posits that ‘unless the researchers work in a way that equalises power with those they work with, and build relationships of trust with them, ethics approval comes to nothing’ (p. 120). Finally, in Chapter 7 Henaghan considers how trust can be built into a healthcare system.21 He reviews a number of empirical studies in the USA, the UK, the Netherlands, Canada, Australia, and New Zealand about health quality and healthcare inequality (pp. 124–128). Overall, research shows a relationship between equality and performance in healthcare, and reducing healthcare inequality may be the key to rebuilding trust in healthcare. However, the answer needs to come from within healthcare professionals themselves, who should take every opportunity to equalise power with patients in order to foster trust. The onus to enhance trust also lies on others involved in the healthcare system, including patients, educators, policy makers, governing bodies, and governments. On the theme of building trust into healthcare, Henaghan posits that ‘without trust, all the rights in the world do not matter. This is because rights and responsibilities go hand in hand. One person's right is dependent on another's responsibility’ (p. 128). Responsibility, in turn, depends upon trust. The approach taken to rights in this book is worthy of further exploration. Rights-language is pervasive in 21st century healthcare, although it is arguable that a true ‘rights-culture’ has yet to develop, in some jurisdictions at least. The relationship between rights, responsibilities, and trust in improving healthcare is worthy of further analysis. Overall, this book contains a fascinating collection of international literature from philosophy, bioethics, law, and public health. It is persuasively written with numerous real examples to illustrate both the problems when trust breaks down, and solutions to building trust. It is clear that improvements in health knowledge do not always translate into positive patient experiences, and that patient dissatisfaction undermines the health system a whole. Henaghan's theory is that the key to improving healthcare is building trust. It is hard to understand why any health professional would not want to improve trust in their relationships with patients. Given the importance of improving healthcare and patients' experiences of healthcare and the wide relevance of building trust in healthcare, Heath Professionals and Trust should be essential reading for health professionals, health policy-makers, lawyers, and ethicists alike. 1 ‘Healthy Healthcare Law Depends on Trust’. 2 S Cartwright, The Report of the Cervical Cancer Inquiry 1988 (Government Printing Office: Auckland, 1988). 3 J Jones, Bad Blood: The Tuskegee Experiment (Free Press: New York, 1981). 4 J Smith, The Shipman Inquiry Volume 1: Death Disguised (HMSO: London, July 2002). 5 He cites in support ‘2008 New Zealand's Most Trusted Professionals’ Readers Digest Magazine (2008) accessed 9 February 2015; ‘Australia's Most Trusted Professions 2008’ Readers Digest Magazine (2008) accessed 9 February 2015; Royal College of Physicians, Trust in Doctors 2009: Annual Survey of Public Trust in Professions (Ipsos MORI: London, 2009). 6 M Ahern and M Hendryx, ‘Social Capital and Trust in Providers’ (2003) 57 Soc Sci Med 1195. 7 ‘What is Trust?’ 8 A Beier, Moral Prejudices: Essays in Ethics (Harvard University Press: Cambridge MA, 1994); O O'Neil, A Question of Trust (Cambridge University Press: Cambridge, 2002). 9 ‘The Emergency Situation - A Premium on Trust’. 10 W Cunningham, R Crump and A Tomlin, ‘The Characteristics of Doctors Receiving Medical Complaints: A Cross-Sectional Survey of Doctors in New Zealand’ (2003) 116 N Z Med J U625; Health and Disability Commissioner, Annual Report of the Health and Disability Commissioner for the Year Ended 30 June 2009 (Auckland, 2009); Z Kmietowicz, ‘Complaints against UK Doctors Rise 50 Percent’ (2001) 322 Br Med J 448; The Health and Social Care Information Centre, ‘Data on Written Complaints in the NHS 2008-2009’ (2009) accessed 8 February 2015. 11 W Cunningham and H Wilson, ‘Shame, Guilt and the Medical Practitioner’ (2003) 116 N Z Med J U629; W Cunningham and S Dovey, ‘The Effect on Medical Practice of Disciplinary Complaints: Potentially Negative for Patient Care’ (2000) 113 N Z Med J 464. 12 ‘Complaints Processes - A Chance to Build Trust’. 13 World Health Organization, ‘Surgical Safety Checklist’ accessed 8 February 2015. 14 ‘What Happens When Trust Breaks Down?’ 15 The midwives were later unsuccessfully prosecuted for manslaughter, a course of action criticized by the Health and Disability Commissioner: Midwife Ms B, Midwife Ms C: A Report of the Health and Disability Commissioner (Case 04HDC05503)) 28 November 2006. 16 Healthcare Otago v Williams-Holloway [1999] NZFLR 804. 17 For a similar case in England and Wales see Portsmouth City Council v King [2014] EWHC 2964 (Fam). 18 For this reason and because the orders were unable to be implemented, they were later revoked: Healthcare Otago v Williams-Holloway [1999] NZFLR 812. 19 ‘Trust, Emerging Technologies and Indigenous Peoples’. 20 For example, World Medical Association, ‘Declaration of Helsinki’ (June 1964) as amended; International Covenant on Civil and Political Rights (adopted December 1966, entry into force March 1976), Article 7; Constitution of the Republic of South Africa 1996, Ch 2: Bill of Rights, s 12; New Zealand Bill of Rights Act 1990, s 10. 21 ‘Building Trust into the Healthcare System’. © The Author 2015. Published by Oxford University Press; all rights reserved. For Permissions, please email: journals.permissions@oup.com TI - Health Professionals and Trust: The Cure for Healthcare Law and Policy JF - Medical Law Review DO - 10.1093/medlaw/fwv005 DA - 2015-07-01 UR - https://www.deepdyve.com/lp/oxford-university-press/health-professionals-and-trust-the-cure-for-healthcare-law-and-policy-1hIkJarq0C SP - 494 EP - 498 VL - 23 IS - 3 DP - DeepDyve ER -