Letters to the editor
Medwave 2016 Sep;16(8):e6554 doi: 10.5867/medwave.2016.08.6554

Searching for trust

Miguel Hugo Kottow Lang

Dear editor:

Distrust in public health is globally on the rise at a dramatic pace, regardless of whether medical systems are public or private [1]. C. Cuadrado’s article in Medwave (September 2016) [2], holds that reconstructing lost trust might contribute to legitimate the public realm. Nevertheless, when following Habermas the relationship is reversed: democratic participation is the key to legitimation that will enhance trust. The inversion may be produced by the text having adopted a definition of legitimation based on “the power of government to take binding decisions that are justified and appropriate”; but legitimation is not justified, it justifies. In the article’s section on “The role of healthcare professionals and the medical profession”, a sociological argument states that mistrust towards doctors results from their pursuance of conflicting interests, and failure to honor public health commitments.

These are real issues that require an approach from medical anthropology to account for a clinical encounter based on friendship (Laín Entralgo), fiduciarity (Ramsey, Pellegrino), strengthening a participative rather than contractual physician-patient relationship.

Medicine has evolved into biomedicine, which “symbolizes the alliance between medicine, biology, and also industry” [3]. Trust in doctors is shaken by managed care practices aimed at increasing costs rather than containing them, striking at the pockets and the trust of patients, now seen as clients or customers.

These issues are here brought up in order to recall that it is indispensable to improve democracy, legitimate public policies and develop effective as well as efficient public health programs, but trust in medicine and public health needs to be reconstructed bottom-up, beginning with trust in the doctor and also in the patient, in public health officials that convince rather than impose [4], in administrators that know the difference between running a hotel and managing a clinic. Recent concerns have acknowledged the need to rebuild trust in the encounter of healthcare agents and the public [5].

Otherwise, medicine will lose its residues of trust and prestige, as well as its effectiveness in solving clinical problems that are based on narrative, communication, mutual trust, in order to reinstate the “drug doctor” that is on its way to becoming toxic.


From the editor
The author originally submitted this article in Spanish and English. The Journal has not copyedited this English version.

Declaration of conflicts of interest
Authors declare no conflicts of interest.

The authors declare not having received any funding whatsoever for writing this letter.

  1. O’Neill. A Question of Trust. Canbridge, Cambridge University Press; 2002.
  2. Cuadrado C. Public health policies in Chile: seeking to regain trust. Medwave 2016 Sep;16(8):e6532. | CrossRef | PubMed |
  3. Sebag, V. Droit et bioèthique. Bruselas, Larcier; 2007.
  4. Wynia MK. Risk and Trust in Public Health: A Cautionary Tale Am J Bioethics 2006; 6(2):3-6. | CrossRef | PubMed |
  5. Eyal, N. Using informed consent to save trust. J Med Ethics. 2014 Jul;40(7):437-44. | PubMed |


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