The illusion of trust: A phenomenological and theological investigation of the medical profession's fiduciary commitment

The professional work of physicians always has entailed the application of specialized knowledge in the interest of patients. The control of medical knowledge provides the medical profession with great authority in society. This control also shapes the phenomenological horizon of meaning for the profession's members. However, as the physician's technical knowledge and expertise has increased in recent years, the trust marking the fiduciary side of the relationship with patients has eroded. In an effort to assert social control over physicians, society has resorted to mistrusting the profession. An atmosphere or climate of mistrust is pervading the relationship between physician and patient. This climate affects the fiduciary component of physicians' professional identity. Consequently, there is a predisposition for physicians to use their fiduciary reputation to shape their relations with patients. The profession's traditional commitment to trustworthiness becomes a form of social control assumed by physicians in a potentially adversarial relationship with clients. With physicians' employment of trust as a form of social control, trust becomes a commodity to be brokered between self-interested parties. The sense of trust reflected by the profession's accent of meaning becomes a 'confidence' based on competent performance, no longer a 'trust' grounded in the risk and dependency that accompanies interaction with others. As a result, the profession's declaration of fiducial commitment to the patient's interest becomes illusory, and an economy of domination occurs in which the physician secures his or her own autonomy at the expense of the patient. The theological discussion begins with the declaration that separation from God creates the basic human condition of dependency from which an awareness of incompleteness flows. The movement in medicine towards trust-as-control represents the attempt to eliminate dependency and ensure professional autonomy. Trust-as- faith, as a response to others and a reliance on others, requires relationships of mutual dependency. If God is envisioned as a presence whose divine life is enriched by relationship with humans, interdependence becomes the basis for relationship. Thus, a theological analysis of an 'illusion of trust' argues for an understanding and appreciation of interdependence in the medical relationship.