The Dangers of Naïve Trusting Behavior

If there is no risk, there is no role for trust. Trust is never certainty. Some vulnerability is always present, and some probability of incompleteness or failure must be taken into account (Luhmann, 1988). A physician might eventually disappoint, deceive, or betray a trusting patient. High patient’s trust might be related to a passive role (Arora, Ayanian, & Guadagnoli, 2005; Hack, Degner, & Dyck, 1994; Tarn et al., 2005). Patients who are highly confident that their physicians have their best interests at heart and that the physicians know the best way to address their health problems may plausibly have feelings of inertia and may fail to recognize why their own contributions to health care are appropriate. Nevertheless, because physicians do have limitations their knowledge, attitudes, and abilities, naive patient’s trust has possible faults, as discussed next.

2.5.1. Trust may lower incentives to participate in decision-making

For many decades, the dominant approach to making decisions about treatment has been one of paternalism. Emphasis is increasingly placed on the patient's involvement in making decisions about health care. This major shift has several benefits for patients.

First, disease patterns have changed toward a high prevalence of chronic disease, increasing the number of conditions for which no overall best treatment is available.

Moreover, almost any medical procedure or therapeutic agent involves potential benefits and potential harms. Holman and Lorig argued (2000) that patients themselves are in the best positions to evaluate the trade-offs between the benefits and risks of various treatments. In shared decision-making, a consensus is reached about the most feasible and practical

treatment plan for a particular patient. Second, even physicians with expertise to maximize a patient’s medical well-being are not expected to be knowledgeable about the patient’s total well-being. We have no reason to assume that the physician is skilled in making the

value-based trade-offs between the medical sphere and the psychological, economic, familial, and social spheres (Veatch, 2000). To balance these competing areas, physicians rely on the patient, who is the most reliable source of information about his or her personal interests.

Although patients' passivity in decision-making is now discouraged, patients who prefer passive roles generally have high, sometimes naive, levels of trust (Kraetschmer et al., 2004).

Patients who totally depend on their physician to make medical decisions trust their

physicians significantly more than other patients do (Arora et al., 2005). The belief “doctor knows best” may be due to the intense sense of vulnerability and anxiety that illness creates.

Nevertheless, such unrealistic beliefs lower patients’ incentives to participate in shared decision-making.

2.5.2. Trust may lower incentives to search for information

Because trust is a strong predictor of continuity with a health care provider (Safran et al., 2001; Thom et al., 1999), a patient with a high level of trust tends to overly depend on the clinician and to not seek a second opinion or other information (Hall et al., 2002). However, largely because of advances in science and technology, the medical-care system is far more complex now than ever before in terms of the number of institutions and the types of health care practitioners involved. Medicine today encompasses more than 220 categories of health care professionals and more than a hundred specialties (Lawrence, 2005). Numerous medical studies are reported every day to update our knowledge of care. Therefore, some physicians are likely to be unaware of recommended best practices for the diagnosis and treatment of particular diseases, whereas others may be aware of the best recommended guidelines but not implementing them. Furthermore, however carefully physicians are selected and trained, some are more competent than others. Patients’ godlike expectations of their physicians may pose a risk of over-embeddedness, which may not only limit their ability to exploit internal information (e.g. the patient’s own coping strategies and problem-solving abilities), but also lower their incentives to explore external information (e.g. secondary opinions, Internet resources). In some circumstances, this decreased opportunity to obtain additional, nonredundant information or to switch to another, more competent physician may compromise patient’s health care.

2.5.3. Trust may lower incentives to question inadequate care

Patients must recognize that their physicians are not infallible. The Institute of Medicine report increased awareness of physician errors in making treatment decisions (Kohn, Corrigan,

& Donaldson, 1999). Prescribing errors and negligence are relatively common in busy transactions (Dean, Barber, & Schachter, 2000). These errors may increase as medical care becomes increasingly complex because of additional miscommunication and systemic

problems.

Gibson and Singh (2003) argued that the health care system has an inherent bias to cover up errors that allows and even encourages physicians to hide their mistakes. They suggested that a trust-but-verify approach is crucial to prevent these adverse events. However, patients with high levels of trust may have a low incentive to question inadequate medical service (Thom et al., 2002). Such excessive trust is criticized as irrational and unjustified (Veatch, 2000). Meanwhile, trust may also permit exploitation and enhance opportunities for

malfeasance (Gilson, 2003; Granovetter, 1985). Granovetter (1985) stated that one person’s trust in another results places him or her in a position far more vulnerable than that of a stranger. Because of the potential power imbalance in the medical encounter, patients may be forced to act in their physicians' interests and against their own. Although a corrosive

skepticism that trusts no one exacts certain costs, placing trust in untrustworthy behavior can also be directly damaging.

In sum, the rich evidence documenting naïve trust in physicians has its drawbacks. An overreliance on trust may cause patients to neglect appropriate ways of dealing with their diseases and risks. Although trust is an essential ingredient of the patient-physician

relationship and though it affects patient’s behavior and outcomes, it has been neglected in favor of autonomy (O’Neill, 2002). The recent attention on medical ethics and patient safety urges physicians to include patients as active participants in their own care. As a result, patient’s preferences for autonomy should be included as a critical variable in advancing our understanding of trust on health outcomes.