Editorial: Ethics and Trust

Michael McCabe
Issue 7, August 2002

"Trust is most problematic when we are in states of special dependence – in illness, old age, or infancy or when we are in need of healing, justice, spiritual help, or learning. This is the situation in our relationships with the professions that circumstances force us to trust. We are forced to trust professionals if we wish access to their knowledge and skill. We need the help of doctors, lawyers, ministers, rabbis, priests, chaplains, or teachers to surmount or cope with our most pressing needs. We must depend on their fidelity to trust and their desire to protect rather than exploit our vulnerability."

—Edmund Pellegrino and David Thomasma [1]

The concept of community is a central motif in bioethics. It is based upon the belief that the human person is fundamentally a social and cultural being who lives in relationship, and finds meaning in and through those relationships. The term "the common good", for example, illustrates the belief that the welfare of the individual is inextricably connected with the welfare of others.

A profession can be viewed as a "community" which exists for the purpose of meeting a human need, and which is based upon a body of knowledge and a particular set of skills. Professions have unique educational and socialisation processes, together with codes of ethical practice, which help to guarantee and shape the integrity of relationships both within the profession and between the professionals and those they serve. Professional codes of ethics help to establish accountability and to preserve the ethical boundaries within which the nurturing and continuation of trust can happen. When professional obligations are neglected or exploited by some members of a professional community, the sense of belonging can be undermined for others in the community. Members of a profession can feel isolated and let down by the unethical actions of fellow professionals.

Recent experiences in the medical and teaching professions and in the Church could lead to a deep-seated ambivalence about involvement with professionals in various fields, and relationships in general. Because people require the services of the caring professions when they are at their most vulnerable, a betrayal of trust exacerbates this sense of vulnerability, eroding a sense of security for the injured individual, the community and the particular profession itself. This feeling of heightened vulnerability, the consequence of very real hurts and grave injustices, may lead us to become even more cautious and diffident in our relationships with others, and possibly deter us from seeking professional help when it is needed. In these circumstances such diffidence in relationships becomes a form of self-protection.

When trust is removed or lacking in human relationships the ability to live fully in society and the ability to attain the essentials of a satisfying life are diminished. Possibilities of growth and fulfillment are restricted. Loss of trust inevitably impacts on the transcendent dimension of life for individuals and for communities, namely, in the ability to be creative and in the ability to anticipate the future in a hope-filled manner. Ultimately, the withdrawal of trust removes the very possibility of healthy community life.

Trust entails risk. As Pellegrino and Thomasma note, to trust and entrust is to become vulnerable and dependent upon the goodwill and motivations of those we trust. In times of conflict and hurt, such as in the betrayal of professional trust, whether individually and/or institutionally, the ability and willingness to risk trusting requires even greater courage. While the withdrawal of trust can be justified as a form of self-protection, personal growth is only fully achieved within community and will always involve taking risks.

The restoration of trust cannot be achieved without the building and maintenance of clear boundaries. Neither can it be restored without fulfilling the requirements of justice. In the Catholic tradition justice is prior to charity, which means relationships cannot be fully restored while any injustice remains.

It is possible that talking about the betrayal of trust may only further erode an already battered professional confidence, and threaten the fragile relationships between professionals and those they serve. That is a risk for those involved, and it is a real risk. But the damage that will ultimately be done by silence or concealment is a much greater risk. Renewed wisdom and potential healing can only emerge with honesty and with courage. Silence prevents both reconciliation and growth and provides conditions for multiplying the harm. That has been the lesson at the heart of recent events in the Catholic Church.

In recent months the actions of medical personnel at Green Lane Hospital provide an illustration of how trust can be rebuilt. Following revelations of organs being retained without consent by hospitals in Great Britain and in Australia, Green Lane Hospital initiated its own self-review of procedures. Subsequently, they accepted responsibility for the fact that certain actions of hospital staff, the result of both individual decisions and systemic processes, were both unacceptable and unethical. Most importantly, in the face of uncertainty over the current laws in New Zealand relating to post mortems, they have not sought to hide behind legal ambiguities but have acknowledged the need to do things differently. Significantly, the ability to move ahead and the potential that now exists for trust to be re-established between the caregivers and patients at Green Lane Hospital is a result of the honesty and courage to name and discuss the issues. Painful as this process has been, the openness with which the discussions have taken place has allowed both the deep hurts and pain to be expressed and a more ethical practice to emerge. In my view this is a wonderful example of rebuilding trust so that patient care and respect, high quality research, and professional practice are all enhanced.

Rebuilding trust has profound implications for those who have broken a trust, be they individuals in the professions, or within the institution itself. Even after this has been achieved, and it will inevitably be a very painful process, the rebuilding of trust will also have implications that are personal, communal and institutional. Nevertheless, to rebuild trust is to reinvest in a hope-filled future.

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[1] Pellegrino, E., Thomasma, D. (1993) The Virtues in Medical Practice. New York: Oxford University Press. p. 65.

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Rev Michael McCabe, PhD
Director
The Nathaniel Centre