Introduction

No discussion of equity in healthcare access and treatment outcomes among patients of different backgrounds is complete without touching upon the issue of medical mistrust. Trust between a patient and physician is often considered a foundational aspect of the therapeutic relationship, and the absence of this trust can have a deleterious impact on patient health and wellbeing. Due to the historical development of medicine in the midst of widespread racial inequality and oppression in America, for example, medical mistrust is higher among nonwhite patients.

Historically, there is good reason for patients from racial minorities to mistrust not just their own physician but healthcare institutions themselves. Consider the collection and misuse of Henrietta Lacks’ cells during research on her cervical cancer which were collected without her knowledge or consent. Unknown to her family, Lacks’ cell line was retained and ultimately commercialized long after her death due to their unique properties. Neither Lacks nor her family or estate benefitted financially from the continued use of HELA cells (as they came to be known). Or consider the history of gynecology, in which Dr. James Sims performed experiments on enslaved black women without anesthesia – work that led to him serving as President of the American Medical Association in 1875. As medical ethics and bioethics advance with a focus on equity for underserved groups, strategies for addressing medical mistrust must come from an appreciation for the reasons for such mistrust, as well as concrete proposals and procedures for avoiding the abuses which lead to this mistrust in the first place.

Assigned Readings

Laura Specker Sullivan, “Trust, Risk, and Race in American Medicine,” Hastings Center Report 50, no. 1 (2020): 18-26. DOI:10.1002/hast.1080

Thesis: Specker Sullivan provides an outline of the ways medical mistrust is delineated empirically in bioethics, contending that present theories of trust are unable to capture the trust dynamics among racially diverse medical contexts. To help establish a relationship of trust, Specker Sullivan argues that “in an atmosphere of mistrust, comprehension of the existence and source of suspicion is essential to effective signaling of trustworthiness,” (19). She provides a three-part proposal for addressing medical mistrust which focuses on competence, care, and comprehension such that physicians can attempt to address cases of mistrust through signaling their medical competence, their care for the patient, and their understanding of patient concerns and past experiences.

Discussion Questions

  1. For Specker Sullivan, what feature(s) of medical mistrust on the part of racial minorities mark it out as a unique context or example in discussions about theories of trust?
  2. How does trust go beyond reliance? (20-21)
  3. What is Specker Sullivan’s three component proposal (competence, care, comprehension) for trustworthiness (signaling trustworthiness) in the clinician/patient relationship? (20-24)
  4. How can we account for the fact that sometimes medical mistrust is a rational response on the part of some patients? (21- 22)
  5. Is Specker Sullivan’s proposal empirical, normative, or both? In what ways?
  6. Specker Sullivan suggests in her conclusion that her proposal about medical mistrust must now be tested – how might we go about designing a test or empirical measure for her proposal?

Additional Reading

Best, Alicia L., Faith E. Fletcher, Mika Kadono, and Rueben C. Warren. 2021. “Institutional Distrust among African Americans and Building Trustworthiness in the COVID-19 Response: Implications for Ethical Public Health Practice.” Journal of Health Care for the Poor and Underserved 32 (1): 90–98. https://doi.org/10.1353/hpu.2021.0010.

Jaiswal, Jessica, and Perry N. Halkitis. 2019. “Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science.” Behavioral Medicine (Washington, D.C.) 45 (2): 79–85. https://doi.org/10.1080/08964289.2019.1619511.

Lacks, Henrietta. n.d. “The International Journal of Science / 3 September 2020.”

Suarez, Joanne C. 2022. “Latinx Bioethics: Toward a Braver, Broader, and More Just Bioethics.” Hastings Center Report 52 (S1): S60–62. https://doi.org/10.1002/hast.1373.

Thomas, Shameka Poetry. 2022. “Trust Also Means Centering Black Women’s Reproductive Health Narratives.” Hastings Center Report 52 (S1): S18–21. https://doi.org/10.1002/hast.1362.

Warren, Rueben C., Lachlan Forrow, David Augustin Hodge, and Robert D. Truog. 2020. “Trustworthiness before Trust — Covid-19 Vaccine Trials and the Black Community.” New England Journal of Medicine 383 (22): e121. https://doi.org/10.1056/NEJMp2030033.

Wilson, Yolonda. 2022. “Is Trust Enough? Anti‐Black Racism and the Perception of Black Vaccine ‘Hesitancy.’” The Hastings Center Report 52 (S1): S12–17. https://doi.org/10.1002/hast.1361.