The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge, Cambridge, UK.
The Division of Health Sciences, Warwick Medical School, Coventry, UK.
J Med Ethics. 2019 Jan;45(1):31-35. doi: 10.1136/medethics-2018-104866. Epub 2018 Oct 26.
As many studies around the theme of 'too much medicine' attest, investigations are being ordered with increasing frequency; similarly the threshold for providing treatment has lowered. Our contention is that trust (or lack of it) is a significant factor in influencing this, and that understanding the relationship between trust and investigations and treatments will help clinicians and policymakers ensure ethical decisions are more consistently made. Drawing on the philosophical literature, we investigate the nature of trust in the patient-doctor relationship, arguing that at its core it involves a transfer of discretion. We show that there is substantial empirical support for the idea that more trust will reduce the problem of too much medicine. We then investigate ways in which trust can be built, concentrating on issues of questioning, of acknowledging uncertainty and of shouldering responsibility for it. We argue that offering investigations or treatments as a way of generating trust may itself be an untrustworthy way of proceeding, and that healthcare systems should provide the institutional support for facilitating continuity, questioning and the entrusting of uncertainty.
正如许多围绕“过度医疗”主题的研究证明的那样，现在越来越频繁地进行调查；同样，提供治疗的门槛也降低了。我们认为，信任（或缺乏信任）是影响这一点的一个重要因素，理解信任与调查和治疗之间的关系将有助于临床医生和政策制定者确保更一致地做出符合伦理的决策。我们借鉴哲学文献，研究了医患关系中信任的本质，认为信任的核心是一种权力转移。我们表明，有大量的实证支持这样一种观点，即更多的信任将减少过度医疗的问题。然后，我们研究了建立信任的方法，集中讨论了质疑、承认不确定性和承担责任的问题。我们认为，将调查或治疗作为建立信任的一种方式本身可能是一种不可信的做法，医疗保健系统应该提供机构支持，以促进连续性、质疑和不确定性的委托。
