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Gender and Trust in Medicine:
Vulnerabilities, Abuses, and Remedies
Abstract

Trust is taken to be one of the foundational values in the doctor–patient relationship, facilitating access to the benefits of health care and providing a guarantee against possible harms. Despite this foundational role, some doctors betray the trust of their patients. Trusting involves granting discretionary powers and makes the truster vulnerable to the trustee. Patients trust medical practitioners to act with goodwill and to act competently. Some patients carry pre-existing vulnerabilities, for reasons such as gender, poverty, age, ethnicity, or disability, and these vulnerabilities can be exacerbated when such patients extend their trust to a doctor. Gender stereotypes reduce women's ability to challenge and thereby assess their doctor's competency. In addition, women are more likely to be distrusted by their doctors and have their experiences of medical symptoms discounted. In this paper, we analyze two extreme examples of breaches of medical trust that exploited the vulnerability of women in the health care system: the "unfortunate experiment" at the National Women's Hospital in New Zealand and the Harold Shipman murders of elderly patients in the United Kingdom, examining the potential role of gender in the outcomes with regard to trust. Major [End Page 48] breaches of medical trust such as these typically lead to government inquiries, revisions of ethical guidelines, and substantive policy change in an effort to re-establish public and patient trust. We argue that the medical profession has an ethical obligation to put mechanisms in place to protect vulnerable patients from abuses of trust, to monitor colleagues' competence, and to be prepared to blow the whistle to protect patients who are not in a position to recognize misplaced trust. Such mechanisms will act disproportionately to reduce harm to women as patients.

Introduction

Trusting and being trusted is a fundamental part of human relationships. The presence of trust eases communication and cooperative action, letting us relax our vigilance and share responsibility. Baier has defined interpersonal trust as "accepted vulnerability to another's possible but not expected ill will (or lack of goodwill) toward one" (Baier 1986). When we trust another person, we give that person power over something that is valuable to us in the belief that the person will care for our goods, because they are both competent and bear us sufficient goodwill to carry out the task (Jones 1996). Both goodwill and competence in relation to the matter in question are important in deciding how and whom to trust: we may trust a loved one with our overall emotional or material security, while not trusting them to load new software onto the computer. Trusting involves granting discretionary powers. This makes us vulnerable when we trust, risking harm, which is proportionate to both the value of the good entrusted and the extent of the discretionary powers that we grant.

The role of trust in health care

Trust is taken to be one of the foundational values in the doctor–patient relationship, facilitating access to the benefits of health care and providing a guarantee against possible harm. Patients trust medical practitioners to act with goodwill and to act competently both in their diagnosis and treatment decisions. If doctors are trustworthy, we are able to access health care, confident in the skills and knowledge of the practitioners and comfortable in the intimacy of the consultation. Our fear and uncertainty about symptoms may be resolved, and appropriate treatments adopted. The practical benefits are real and significant. If we asked a patient about trusting her doctor, she might say things like "I trust him to work out what is wrong, and to know what to advise. I trust that [End Page 49] he is up to date with medical information, and that if he doesn't know what is wrong, that he will refer me to someone else who does. I trust that he will behave professionally and not betray confidential material or take advantage of my situation. I trust that when he recommends a treatment, it is because he believes this is the best treatment for me, and not because he is doing a drug trial" (Rogers and Braunack-Mayer 2004, 20–21).

Without trust, we may be reluctant to seek medical care, leading to exclusion from the benefits of diagnosis and treatment. Although these are significant disadvantages, they must, at times, be weighed against the possible harm that may befall us if the doctor is in fact, untrustworthy.

Trusting a doctor can exacerbate existing vulnerabilities. Vulnerability can be broadly defined as the inability to protect one's interests and can derive from both intrinsic and extrinsic features of individuals or populations. Extrinsic vulnerability is due to external circumstances, such as lack of socio-economic power, poverty, discrimination, or lack of education. Intrinsic vulnerability is due to features of the individual, such as mental illness, intellectual disability, severe illness, or the extremes of age (young children and some elderly) (Ballantyne and Rogers 2007). These sources of vulnerability can intersect and compound in individual cases. Patients with existing vulnerabilities are less likely to have the power and resources to monitor and assess doctors' trustworthiness.

Gender, trust, and medicine

We focus on three reasons why trust is an especially important value in medicine for female patients: women are more frequently exposed to health care interactions than men; they carry existing vulnerabilities due to gender stereotypes; and doctors are more likely to dismiss female patients' reports of pain and other symptoms as uncreditable. Vulnerability is not limited to female patients (witness Tuskegee), therefore parts of our analysis may apply equally to men; however a substantive comparison between the nature and degrees of vulnerability experienced by men and women is beyond our present scope.

Women more regularly engage in the health care system than men. Feminists have noted the ever expanding scope of medical involvement in women's lives and biology (Purdy 2001). Medical surveillance related to the female reproductive tract includes cervical smears, breast examinations, and check-ups related to pregnancy and childbirth. In addition, the processes of menarche, menstruation, and menopause attract medical attention such as pharmacological interventions. This construction of normal female physiology as pathological has various consequences. [End Page 50] First, the idea that expertise about women's bodies lies with the medical profession rather than with the woman herself can lead to a distrust of her own experiences in favor of the (trusted) clinician's expertise. Second, women are regularly and repeatedly placed in positions of physical exposure in the clinical setting, exacerbating power inequalities in the relationship, and increasing feelings of vulnerability. Men are not subject to the same frequency and intensity of medical surveillance of their reproductive organs or processes.

Research consistently demonstrates gender differences in levels of self-reported medical symptoms, medical care utilization, morbidity, and mortality. Reasons why women visit health care professionals more frequently than men include being more sensitive to symptoms, having a greater interest in health, and being subject to a greater number of morbidities than men (Green and Pope 1999; Redondo-Sendino 2006). Regardless of the cause, women are exposed to higher rates of interactions with health care providers over their lifetime and are therefore more often called upon to trust doctors. Men may be more vulnerable to morbidity and mortality in the long run, perhaps in part due to their comparative aversion to seeking medical care; however, this particular vulnerability does not occur within the doctor–patient relationship and is therefore outside the scope of this paper.

Gender stereotypes of female passivity and male assertiveness generate an extrinsic vulnerability for female patients. Medicine continues to have an uneasy relationship with gender (Doyal 2000); for women this has manifested in both biological essentialism and gender blindness (Inhorn and Whittle 2001). Biological essentialism has led to a focus on women as reproducers, so that women's health is primarily considered in terms of reproductive capacity and function. Historically, this has led to a tendency for a wide variety of women's illnesses to be attributed to their gender—the attribution of mental illness (hysteria) to a wandering uterus for example. Biological essentialism marginalizes women's health issues that are not related to biological aspects of reproduction.

The focus on women as reproducers has led to gender blindness with regard to other health problems that have important sex and gender dimensions, including coronary heart disease, depression, HIV/AIDS, and other infectious diseases (Kaiser 2005; Wizemann and Pardue 2001; Lawlor et al. 2001). This has led to both the under treatment of women and the historical exclusion of women from clinical research (GAO 1990; Dresser 1992; Davis 2001; Sherr 2000). Exclusion from research can have a cascade effect with regard to reducing access to medical resources and a lack of appropriate knowledge about women's health (Rogers 2004). Some jurisdictions have implemented policy and guidelines [End Page 51] encouraging appropriate inclusion of women in research (National Health and Medical Research Council 2007; Canadian Institutes of Health Research 1998). The United States has a legislative requirement for federally-funded research to include women (U.S. Congress Public Law 103-43 1993) and a monitoring system that tracks the inclusion of men and women in research (National Institutes of Health 2007). Despite these initiatives, most contemporary guidelines for prevention, diagnostic testing, and medical and surgical treatments for cardiovascular disease, for example, are still based on studies conducted predominately on middle-aged men (Wenger 2006). Outside of the United States there is no firm data about the inclusion of women in research and the perception that women are excluded persists (Franconi 2007).

The implications of these trends are that women do not enter the medical encounter on an equal footing; they do not have the same status as medical subjects or as recipients of medical care as that enjoyed by men. These gender stereotypes reduce women's ability to challenge or evaluate their doctor's competency.

Finally, women are vulnerable to disbelief about their symptoms, to not being trusted as reliable historians. Female patients typically are subjected to greater skepticism from their medical practitioners than male patients. According to Rebecca Dresser, "physicians frequently are patronizing, detached, disrespectful . . . and unwilling to trust the reports of their women patients. Subjective experiences of illness and treatment are frequently ignored" (Dresser 1996, 147). The subjective nature of pain requires doctors to trust patients' description of the nature and severity of their pain. There is a significant body of literature demonstrating that women's self-reports of pain are discounted and as a result, female patients are systematically undertreated for pain (Bouchardy et al. 2007; Vallerand 1995; Hoffmann et al. 2001). Withholding of trust by doctors in this situation creates an extra burden for those patients who are not believed (Rogers 2002). This kind of vulnerability can occur with both male and female doctors, as both men and women are susceptible to gender stereotyping.

As described, women are more likely than men to be stereotyped, and less likely to be trusted, creating increased opportunities for failures of trust in the doctor–patient relationship. Failures of trustworthiness on the part of doctors have greater potential to affect women than men just because women seek medical care more frequently than men. Taken together, these factors create greater vulnerability for women as patients, with the potential for greater harm. Susan Wolf argues that "[in] examining health care and science, a feminist bioethics should begin with attention to those historically least served and most harmed" [End Page 52] (Wolf 1996, 23). In the next section, we provide an analysis of two serious breaches of trust and consideration of those most harmed.

Betrayals of women's trust

There is no accurate way of knowing how often doctors are untrustworthy; information is scarce. Perhaps this is because betrayals are rare, or perhaps because such betrayals rarely come to public attention. There is anecdotal evidence of routine betrayals of medical trust such as the continuing practice of unauthorized genital examinations of anesthetized patients for medical training purposes, unnecessary disclosure of patient records to those outside the treating team, and closing of professional ranks to protect incompetent colleagues. However, in this paper, we discuss two extreme episodes in which medical care proved particularly untrustworthy for women. Extreme breaches of medical trust are important for two reasons. First, extreme cases are more likely to become public knowledge and so directly influence public perception of the doctor–patient relationship and patients' assumptions about whether and how they should trust medical processionals. Second, extreme cases act as triggers for regulatory reform; therefore, they have a direct impact on the regulation of doctors and the protection of patients.

An 'unfortunate experiment' at the National Women's Hospital

Our first example of betrayed trust is Dr. Green's cervical cancer research at the National Women's Hospital in Auckland, New Zealand, known as the unfortunate experiment (Coney 1988; Crosthwaite 2000). Dr. Green was a consultant gynecologist and in the mid-1950s, he developed a theory that the condition known as carcinoma in situ (CIS) was not the precursor to cervical cancer, (as doctors accept, both then and now), but rather a separate and non-malignant condition. He investigated this theory over the next thirty years, both informally and from 1966, as part of a funded research project. His research was approved by the National Women's Hospital ethical committee. His subjects were women who presented to the hospital for what they believed was routine medical care.

The research involved observing the natural history of CIS in the women over a period of many years, during which time the women were required to return to the hospital for frequent examinations and diagnostic cervical biopsies. Cancer of the cervix developed in numerous women, twenty-six of whom are known to have died of their disease by the late 1980s. At no stage were the women told that they were subjects in a research study or that they were being [End Page 53] excluded from the usual options for treatment that may well have prevented the development of widespread or fatal cancer.

Dr. Green's professional colleagues were aware of his research, but despite misgivings, did not act to stop him. The findings of his research, complete with errors and inconsistencies, were published in peer-reviewed medical journals. The program was finally halted after exposure by two journalists who published the story in a popular magazine (Coney and Bunkle 1987). This exposure led to cessation of the research, treatment for the remaining women, and eventually to a national inquiry (the Cartwright Inquiry) in 1988.

Harold Shipman: General practioner and mass murderer

Dr. Shipman was a general practitioner (GP) who worked in small towns in the northwest of England for twenty-four years. In January 2000, he was convicted of the murder of fifteen of his patients. Subsequent investigations have suggested that the true number is probably between 215 and 260. At the time of his arrest, he was running a solo practice, having previously been part of a group practice in the same town. He had approximately 3,000 patients on his list, providing general medical services, per the usual general practice contract with the National Health Service. In March 1998, one of the GPs in a neighboring practice, together with her partners and the local undertaker, had become concerned about the large number of deaths occurring among Dr. Shipman's patients. She contacted the coroner, who asked the Greater Manchester Police to investigate. This investigation concluded that there was no evidence to substantiate the concerns. Later the same year, the daughter of a deceased patient contacted the police about her mother's will. The will, which favored Shipman, was thought to be a forgery. Shipman was arrested, brought to trial for murder and forgery, and convicted on fifteen counts of murder in January 2000. He committed suicide in prison in January 2004 (BBC 2004).

An audit commissioned by the Department of Health examined several features of Shipman's practice and the circumstances of the patients' deaths that he had certified (Department of Health 2000). The audit found features that characterized what were termed "suspicious deaths": the victims were likely to be older women, with the deaths occurring at home and in the afternoon, and the association between clinical history and certified cause of death was weak. One analysis in the audit compared the number of deaths certified by Shipman with other general practitioners with similar patients in the same area, and found an excess of 297 deaths among Shipman's patients. The excess was greatest [End Page 54] for women aged seventy-five years and above, followed by women aged sixty-five to seventy-four, and then men aged seventy-five and older. Using this analysis, the excess death rate for women aged seventy-five and older was evident from an early stage in Shipman's career. It is possible that he had been murdering elderly women for over twenty years. At no time during the trial or afterward did Shipman offer any explanation of his actions.

The role of patient and family trust in the Shipman murders

The death of Mrs Jose Richards on 22nd July 1993 is similar to the others. Mrs Richards was 74. She suffered from chronic obstructive airways disease. However, she had no history of heart trouble. . . . Her state of health immediately before the death is not clear, as a crucial date in the medical records has been overwritten and is virtually illegible. Shipman visited of his own volition on 22nd July. Mrs Richards spoke to a friend at about 12.15 pm and seemed perfectly well. When the friend called at her house at about 1.45 pm, she found Shipman there. He announced that Mrs Richards had "just gone," meaning that she was dead. He told the friend that he had given Mrs Richards an injection for her pain and that the injection had killed her; he had not realised how frail she had become. He was very matter of fact. He had made himself a cup of tea. Mrs Richards was sitting in her chair. Her dentures had been removed. In the medical records Shipman claimed that he had found Mrs Richards suffering from a heart attack. He had given her an intravenous injection of 10mg diamorphine. Mrs Richards had died half an hour later.

Text from the Shipman Inquiry (Smith 2002, 163).

The boxed text is taken from the Shipman Inquiry and tells of the murder of Mrs. Jose Richards. The features of the story demonstrate the trust extended to Shipman by his patients and the community: he called on patients at home and uninvited, he made himself at home in their houses (helping himself to tea), and neighbors and family were apparently unsurprised to find him alone in the house of the deceased. [End Page 55]

Analysis

These two cases illustrate the potentially terrible consequences for patients if their doctors are untrustworthy. In both cases, we are left wondering whether things would have turned out differently if these two doctors had chosen different victims. First, was it because the victims were mostly elderly women or poor, working-class women that no one noticed or cared enough to speak out until much time had passed? And second, did the gender of the victims lead them to be more trusting than they should have been? In considering these questions, it is important to look at what the patients trusted the doctors to do in each case.

Goodwill

The primary duty of doctors to care for their patients is enshrined in various medical oaths and codes of conduct (General Medical Council 2001). Goodwill is not equivalent to kindly feelings toward a patient; rather, trust in the doctor's goodwill should be interpreted as "confidence that the doctor will do what is right in the circumstances" (McLeod 2004). This requires a common understanding of what the right action would entail. As a patient is typically not familiar with her doctor's personal moral values, trust in her doctor's goodwill requires trust that the doctor possesses "moral competence" and is motivated to adopt the ethical standards of the medical profession (McLeod 2004). Once trust is present, it acts as a lens, so that actions are interpreted in the light of beliefs about the trustworthiness of the other. If we trust that a person bears us goodwill, we tend to interpret his or her actions as further proof of trustworthiness.

This assumptive trust is likely to have been a significant barrier to patients identifying Dr. Green's deception. His manner was described by some patients as kind and caring, attributes that were likely to inspire trust (Cartwright 1988). The women were subject to intensive follow-up and this prolonged surveillance could be taken as a sign of caring diligence or goodwill. For example, one woman who died of her cervical cancer attended the hospital sixty-five times over a twenty year period and had at least fifty vaginal examinations and twenty-four major procedures (Cartwright 1988). Dr. Green's attentiveness in this regard gave the women no reason to suspect that he lacked goodwill towards them.

Dr. Shipman's actions appear to be entirely a breach of goodwill. Like Dr. Green, he has been described by patients as caring and kind (Smith 2002, 181). The vast majority of Shipman's victims were elderly women, and many lived alone at the time of their death. Of the 215 murders Shipman is believed to have committed, 171 were women and 44 were men (BBC 2004). In this largely working-class area [End Page 56] of northwest England, women traditionally would have had a great deal of respect and trust for their family doctor. The first report of the Shipman Inquiry states Shipman was "idolised by many of his patients" (Smith 2002, 194). For reasons of age, gender, and class, it would have been almost impossible for these women to conceive of Dr. Shipman's malevolence, despite the growing number of deaths. More importantly, it is unlikely that his patients would have been able to detect his lack of goodwill as this appears to have manifested only at the time of the murder of each patient. His victim's families found Dr. Shipman compelling and persuasive; he often convinced them that a post-mortem examination was unnecessary (Smith 2002, 116). Dr. Shipman was clearly deceptive and manipulative; this kind of covert ill will is notoriously difficult to detect.

Competence

Many factors mitigated against the women challenging Green's competence. There were significant power imbalances between Dr. Green and his patients. Many of his patients were poorly educated and from working class or Maori backgrounds (Coney 1988). Gender, class, and cultural differences would have made it difficult for patients to request further explanations, let alone challenge him in a more robust way or seek second opinions. Much of the investigation and treatment involved vaginal examinations. Having a gynecological problem may be experienced as embarrassing or shameful, particularly when the disease causes bleeding or other discharge, further increasing feelings of powerlessness or incompetence. In addition, the women may have experienced guilt and worthlessness at the "failure" to get better, despite the ongoing medical attention. All of these features exacerbated the vulnerability that occurs within doctor–patient relationships, decreased the potential for the women to challenge Dr. Green's competence, and increased the scope of his discretionary powers.

Dr. Green's specialist qualifications were a public and certified form of licensing that should have guaranteed his competence. In addition, he worked at the National Women's Hospital, which is both a major obstetric and gynecological training hospital and the research base for a university department of obstetrics and gynecology. His location and qualifications would be taken as a prima facie guarantee to patients that doctors working there would have a high level of competence. It is particularly difficult for patients to assess the competence of medical specialists as they lack technical knowledge of the discipline. This situation is exacerbated when patients cannot see the physical manifestation of their condition and have few or no apparent symptoms to monitor, as was the case with Dr. Green's [End Page 57] patients, who could not see their cervical cancer nor likely make sense of the results of cytological tests, reported in technical terms that would have been alien to many of the women. These issues may all have contributed to creating an aura of trustworthiness around Dr. Green's competence and acted as significant barriers to any questioning of him by the women involved.

Issues of competence do not arise in relation to Dr. Shipman as there is no suggestion that he was incompetent.

The role played specifically by gender in these two examples is impossible to determine with any accuracy, but it is reasonable to think that female gender contributed in a number of ways to both assumptive and ongoing trust in these two untrustworthy doctors. As outlined previously, the women involved had apparent reasons to trust both doctors. Both were appropriately qualified, both had long-term involvement in their health care, and both had manners to inspire trust. The women were not well equipped to consider that their doctor might not be trustworthy and did not have the skills or knowledge to challenge the standard of care. What about wider issues of gender? It is possible to speculate that if Shipman had murdered 171 men, there may have been earlier scrutiny of his actions, not least perhaps because there would likely have been bereaved wives to deal with. His actions were made easier by the fact that many of the women were living alone at the time of death and perhaps lacked someone who was intimate with their general well-being to speak out on their behalf after death. The apparently peaceful deaths of single elderly women might be considered by some to be a blessing in disguise, saving them from increasing frailty and saving others from the need for increased care as they grew more dependent.

Given the difficulties for women to challenge the trustworthiness of individual doctors and given the increased vulnerability experienced by women in their multiple encounters with the medical profession, what kind of systemic responses could contribute to a climate of warranted trust, thereby reducing potential harm to women? In the next section, we outline the responses triggered by Drs. Green and Shipman.

Breaches of trust leading to policy reform

Serious breaches of medical trust often lead to legal and policy reform and the development of new professional and ethical guidelines. For example, the Tuskegee study led to the development of the Belmont report in the United States (Thomas and Quinn 1991). Tuskegee was sponsored by the United States Public Health Service and tracked the natural progression of untreated syphilis in 600 [End Page 58] poor African-American men in Alabama between 1932 and 1972. The level of public outrage surrounding the Tuskegee study was enormous (James 1992; Jones 1993) and prompted the development of the National Research Act in 1974. This act required the establishment of institutional review boards at centers receiving federal grants for research (Harold 1992). The act also created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which, via the Belmont report, laid the foundation for the ethical requirements that continue to govern the conduct of research on human subjects in the United States (National Commission 1979). The Belmont report established ethical principles for clinical research that were designed to protect vulnerable populations from exploitation at the hands of medical researchers.

Both the unfortunate experiment and the Shipman murders resulted in similar step changes in the regulation of doctors and medical research in their respective jurisdictions. Like Tuskegee and Belmont, these can be understood as efforts to rebuild justified trust in doctors and the systems within which they provide health care, thereby increasing protections for patients.

Cartwright Inquiry

Dr. Green's experiments were publicly exposed by Sandra Coney and Phillida Bunkle who wrote an article about the research in 1987, naming the case "the unfortunate experiment" (Coney and Bunkle 1987). This article led to a public inquiry directed by Judge Silvia Cartwright. After months of investigation, the Cervical Cancer Inquiry Report (known as the Cartwright Inquiry) was published in 1988 with broad ranging recommendations for major reforms of ethics committees, hospitals, and patient advocacy in New Zealand. In particular, the report recommended that the "ethical committee" at the National Women's Hospital be disbanded, and the Auckland Area Health Board establish external ethics committees, which were to have half lay membership. Ethics committees now operate throughout New Zealand and are accredited by the Health Research Council Ethics Committee (Coney 1998). Judge Cartwright also recommended the establishment of a nationally planned population-based cervical screening program and in 1990 the National Cervical Screening Programme (NCSP) was initiated, which was the first organized cancer-screening program in New Zealand.

The Cartwright Inquiry was a foundational bioethics document in New Zealand, leading directly to the enactment of the Health and Disability Commissioner Act in 1994 and the establishment of the office of the Health and Disability Commissioner. The Commissioner promotes and protects the rights of consumers [End Page 59] who use health and disability services and helps resolve problems between consumers and providers of these services. In response to Judge Cartwright's call for a national code of patients' rights, the Commission released the Code of Health and Disability Services Consumers' Rights in 1996 (New Zealand HDC 2007).

Shipman Inquiry

In February 2001 an independent public inquiry was initiated, chaired by Dame Janet Smith DBE, a High Court judge. The Shipman Inquiry sought to establish the extent of Shipman's killing and to recommend changes to current systems to safeguard patients in the future. The Inquiry published its findings in six reports between July 2002 and January 2005. In the first report Smith states:

Deeply shocking though it is, the bare statement that Shipman has killed over 200 patients does not fully reflect the enormity of his crimes. As a general practitioner, Shipman was trusted implicitly by his patients and their families. He betrayed their trust in a way and to an extent that I believe is unparalleled in history.

In the fifth report, Smith recommends numerous changes to the delivery and regulation of health care in the United Kingdom, including clinical governance and practice accreditation systems, the monitoring of doctors, and mechanisms for raising complaints against doctors (Smith 2004). The Shipman Inquiry recommendations sparked, among other government reports, the 2007 White Paper Trust, Assurance and Safety—The Regulation of Health Professionals in the 21st Century (SSH 2007). This White Paper sets out a policy of substantive reform of medical regulation, licensing, and accreditation. It recommends, for example, changing the composition of the U.K. General Medical Council to ensure a balanced membership of those who receive and provide health care across the United Kingdom. The White Paper seeks to adopt a supportive rather than punitive regulatory approach, noting that:

It is all too easy to focus on the incompetent or malicious practice of individuals and seek to build a system from that starting point, instead of recognising that excellent health professionals far outnumber the few who let patients down substantially.

Action will be initiated over the next few years to implement these recommendations. [End Page 60]

Recommendations

In this final section we discuss our recommendations for how doctors, professional bodies, and governments can act to protect women and other vulnerable groups from breaches of medical trust. We do not mean to imply that these policy changes could necessarily prevent cases such as Shipman occurring in the future. As indicated previously, extreme breaches of trust serve as prompts to tighten the regulatory structure and to improve professional standards and mechanisms for patient protection across the board. The ongoing development of medical regulation in the United Kingdom hopefully would ensure that Shipman's crimes would now be detected much earlier.

Medical regulation

The lack of goodwill on the part of some doctors and their active deception and manipulation of patients and families can create a trustworthy façade beyond which it is very difficult for vulnerable patients to see. Therefore, we require external mechanisms to monitor doctors' activities. The U.K. White Paper suggests that doctors have their licenses renewed every five years and undergo specialist recertification to demonstrate their continued fitness to practice. It further recommends the establishment of local registers of Recorded Concerns that will facilitate local responses to problems and allow patterns of misconduct or behavior to be tracked over time (SSH 2007).

It is easier to monitor doctors' technical competence than it is to monitor and assess their goodwill towards patients. Health professionals are now taught medical ethics during their training, and their competence in at least identifying appropriate ethical behaviors can be assessed during these years. However, once they are practicing, there are no standard mechanisms for testing doctors' ongoing goodwill. Informal systems, such as peer review and whistle blowing, remain essential components of a safe health care system. Judge Cartwright commented on the failure of Dr. Green's colleagues to adequately review his research:

When it came to evaluating or reviewing the 1966 trial, Dr Green's peers failed him. Twenty-one years after the first oral and written challenge to the proposal, an article in a non-medical magazine achieved in a few days what his colleagues could not. . . . I believe that unless the profession can establish adequate peer review and adequate systems to cope with the inevitable mistakes or problems caused by incompetence, then there will be a continuing succession of inquiries of this nature.

Recent research in the United Kingdom demonstrated that despite the considerable government and public focus on patient safety and trust (including and following the Shipman Inquiry), nurses remained reluctant to blow the whistle on unsafe practices and colleagues (Attree 2007). Attree found that fear of repercussions, retribution, and blame acted as disincentives to raising concerns. Nurses lacked confidence in the reporting systems and predicted that no action would be taken to rectify the problem even if concerns were voiced. Reporting was therefore perceived as a high-risk, low-benefit action (Attree 2007). There is no reason to think that doctors would be different; as the Bristol pediatric heart surgery case demonstrated, medical whistle-blowing is a very difficult process (Dyer 1999). The establishment of the N.Z. Health and Disability Commissioner and the recommendations in the U.K. White Paper attempt to strengthen the systems for complaint resolution in the health care system.

A focus on patient safety and whistle blowing inevitably will be limited by the willingness of health care providers to use these mechanisms. Traditional codes of medical ethics emphasize doctors' duties to their own patients, tending to ignore both the socio-economic context and the plight of others who are not their patients. However, this conception of duties is too narrow. Doctors and other professionals are far better placed, in comparison to patients, to know whether their colleagues are trustworthy. In particular, they are often well aware of a colleague's incompetence and may also have insights into their general good or ill will towards patients. For these reasons, doctors and other professionals ought to have an ethical duty of care, not only to their own patients, but to other patients seeking care and treatment from their profession. In so far as patients come to harm through professional silence, the colleagues of incompetent doctors may be held responsible, in part, if they have failed to speak out despite having the knowledge and power to do so.

Doctors

There is a need for greater recognition of the importance of trust in medical relationships, together with a detailed account of what it is for a doctor to be trustworthy, especially in his or her dealings with women and other vulnerable groups. A necessary first step is for doctors to realize that, as a profession, they have not proved trustworthy in the past. This puts the onus upon them to demonstrate their trustworthiness, rather than assume that patient trust is warranted with no further action on their part. Expanded teaching of medical history may help in this regard. Simple measures to promote trust include sharing more information with patients [End Page 62] and being open to questions. Sharing information helps to mitigate the power imbalance, decreasing the vulnerability generated by medical ignorance (Sherwin 1992). This would give patients greater insights into their doctor's medical reasoning, which is a first step in having the means to assess their competence (Davison 2006; Tuil et al. 2007). Questions from patients should be welcomed as an opportunity to earn patient trust, rather than being met with indignation or defensiveness. Thus, trustworthy doctors have a role in increasing the confidence and health literacy of their patients to equip them better to protect themselves from untrustworthy doctors in the future.

As a community we must aim for a fine balance between trust and distrust. Too much distrust can be destructive, distorting innocent actions into malevolent ones, undermining public trust in doctors, and thereby threatening the benefits of trust in medical care that we value. On the other hand, too much trust, or insufficient vigilance, can have tragic consequences for the victims of untrustworthy doctors. Mechanisms to increase scrutiny of the competence of doctors and to facilitate the making and recording of complaints will be of benefit to all vulnerable patients, with disproportionate benefits flowing to women as the most frequent recipients of health care.

Conclusion

This paper has focused on two examples of untrustworthy behavior on the part of doctors. We have argued that, in relation to their general increased vulnerability, women's risks are proportionately greater when they trust doctors; and that gender may play a role in the way that society responds to a breach of medical trust in the care of women. This creates an onus upon doctors to consciously demonstrate their trustworthiness, and for communities to be vigilant for untrustworthy doctors, through improved regulatory mechanisms and through an increased willingness to blow the whistle on incompetent and/or dangerous doctors.

Wendy Rogers

Wendy Rogers runs the program of ethics, law, and professionalism in the medical course at Flinders University. She is a Chief Investigator on several Australian Research Council funded projects and has served on the National Health and Medical Research Council (NHMRC)'s Australian Health Ethics Committee. Her main research interests are research ethics, public health ethics, and feminist ethics.

Angela Ballantyne

Angela Ballantyne has a BSc in Genetics and a PhD in Bioethics. She has worked for the World Health Organization (Geneva), Imperial College London (UK), Monash University, and Flinders University (Australia). Her interests include research ethics, global health, exploitation, genethics, and public health ethics.

References

Attree, M. 2007. Factors influencing nurses' decisions to raise concerns about care quality. Journal of Nursing Management 15 (4): 392-402.
Baier, A. 1986. Trust and Antitrust. Ethics 96:231-60.
Ballantyne, A. and W. A. Rogers. 2007. Vulnerability and protection in human research. Harvard Health Policy Review 8 (1): 47-56.
BBC. Harold Shipman found dead in cell. BBC News, January 13, 2004. http://news.bbc. co.uk/2/hi/uk_news/3391871.stm (accessed August 9, 2007). [End Page 63]
Bouchardy, C., E. Rapiti, S. Blagojevic, A. T. Vlastos, and G. Vlastos. 2007. Older female cancer patients: importance, causes, and consequences of undertreatment. Journal of Clininical Oncology. 25 (14):1858-69.
Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada. 1998. Tri-Council policy statement: Ethical conduct for research involving humans. Government of Canada.
Cartwright, S. 1988. The report of the inquiry into allegations concerning the treatment of cervical cancer at National Women's Hospital and other related matters. Wellington: Department of Health.
Coney, S. 1988. The unfortunate experiment: The full story behind the inquiry into cervical cancer treatment. Auckland: Penguin Books.
Coney, S. 1998. The Cartwright report ten years on: A critical evaluation. Women's health watch: 47.
Coney, S. and P. Bunkle. 1987. An "unfortunate experiment" at National Women's. Metro: 47-65.
Crosthwaite, J. 2000. New Zealand's "Tuskegee"? Some comparisons between the Tuskegee syphilis study and a study at the National Women's Hospital. Unpublished paper.
Davis, L., J. Evans, J. Strickland, L. Shaw, and G. Wagner. 2001. Delays in thrombolytic therapy for acute myocardial infarction: Association with mode of transportation to the hospital, age, sex, and race. American Journal of Critical Care 10: 35-42.
Davison, S. N. 2006. Facilitating advance care planning for patients with end-stage renal disease: The patient perspective. Clinical Journal of the American Society of Nephrology (5):1023-28.
Department of Health. 2000. Harold Shipman's clinical practice 1974-1988. An audit commissioned by the chief medical officer. Department of Health, London. http:// www.doh.gov.uk/hshipmanpractice/.
Doyal, L. 2000. Gender equity in health: Debates and dilemmas. Social Science and Medicine 51: 931-39.
Dresser, R. 1992. Wanted: single, white male for medical research. Hastings Center Report 22: 24-29.
———. 1996. What bioethics can learn from the Women's Health Movement. Feminism and Bioethics. Ed. S. Wolf. New York: Oxford University Press.
Dyer, C. 1999. Whistleblower in Bristol case says funding was put before patients. British Medical Journal 319 (7222): 1387.
Franconi, F., S. Brunelleschi, L. Steardo, and V. 2007. Gender differences in drug responses. Pharmacological Research 55(2): 81-95.
General Medical Council. 2001. Good medical practice: The duties of a doctor registered with the General Medical Council. Medical Education 35 (Suppl. 1): 70-78.
Green, C. A. and C. R. Pope. 1999. Gender, psychosocial factors, and the use of medical services: A longitudinal analysis. Social Science and Medicine 48(10): 1363-72.
Harold, E. 1992. Outside the community. Hastings Center report 22 (6): 32-35. [End Page 64]
Hoffmann, D. E. and A. J. Tarzian. 2001. The girl who cried pain: A bias against women in the treatment of pain. Journal of Law, Medicine & Ethics 29 (1):13-27. http:// www.gmc-uk.org/standards/standards_frameset.htm.
Inhorn, M. and K. Whittle. 2001. Feminism meets the "new" epidemiologies: Towards an appraisal of antifeminist biases in epidemiological research on women's health. Social Science and Medicine 53: 553-67.
James, J. H. 1992. The Tuskegee legacy: AIDS and the black community. Hastings Center Report 22 (6): 38-40.
Jones, J. 1993. Bad blood: The Tuskegee syphilis experiment. New York: Free Press.
Jones, K. 1996. Trust as an affective attitude. Ethics 107: 4-25.
Kaiser, J. 2005. Gender in the pharmacy: Does it matter? Science 308 (5728): 1572.
Lawlor, D., S. Ebrahim, and G. Davey Smith. 2001. Sex matters: Secular and geographical trends in sex differences in coronary heart disease mortality. British Medical Journal 323: 541-45.
McLeod, C. 2004. Understanding Trust. In Baylis, F., J. Downie, B. Hoffmaster, S. Sherwin, eds. Health care ethics in Canada. 2nd ed. Canada: Thomson Nelson.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 1979. The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. Bethesda, MD: National Institutes of Health.
National Health and Medical Research Council. 2007. National statement on ethical conduct of research involving humans. Canberra: Australian Government. http:// www.nhmrc.gov.au/publications/synopses/_files/e72.pdf (accessed August 1, 2007).
National Institutes of Health (Department of Health and Human Services). 2007. Monitoring adherence to the NIH policy on the inclusion of women and minorities as subjects in clinical research. Bethesda, MD: National Institutes of Health.
National Institutes of Health: Problems in implementing policy on women in study populations. (GAO). Testimony. Washington, DC: General Accounting Office, 1990. GAO/T-HRD-90-38.).
New Zealand Health and Disability Commissioner Web site. (HDC). 2007. http://www. hdc.org.nz/ (accessed August 7, 2007).
Purdy, L. 2001. Medicalization, medical necessity, and feminist medicine. Bioethics 15: 248-61.
Redondo-Sendino, A., P. Guallar-Castillón, J. R. Banegas, and F. Rodríguez-Artalejo. 2006. Gender differences in the utilization of health-care services among the older adult population of Spain. BioMed Central Public Health 6: 155.
Rogers, W. A. 2002. Is there a moral duty for doctors to trust patients? Journal of Medical Ethics 28: 77-80.
———. 2004. Evidence-based medicine and women: Do the principles and practice of EBM further women's health? Bioethics 18 (1): 50-71.
Rogers, W. A. and A. J. Braunack-Mayer. 2004. Practical ethics for general practice. Oxford: Oxford University Press. [End Page 65]
Secretary of State for Health. (SSH). 2007. Trust, assurance, and safety—The regulation of health professionals in the 21st century. London: the Stationery Office.
Sherr, L. 2000. Women and clinical trials. In L. Sherr and J. St. Lawrence, eds. Women, health and the mind. Chichester: John Wiley and Sons Ltd., 47-58.
Sherwin, S. 1992. No longer patient. Philadelphia: Temple University Press.
Smith, S. 2002. The Shipman inquiry: Vol. 1—Death disguised. Norwich: Crown Copyright.
———. 2004. The Shipman inquiry: Vol. 5—Safeguarding patients: Lessons from the past—Proposals for the future. Norwich: Crown Copyright.
Thomas, S. B. and S.C. Quinn. 1991. The Tuskegee syphilis study, 1932 to 1972: Implications for HIV education and AIDS risk education programs in the black community. American Journal of Public Health 81 (11): 1489-1505.
Tuil, W. S., C. M. Verhaak, D. D. Braat, P. F. de Vries Robbé, and J. A. Kremer. 2007. Empowering patients undergoing in vitro fertilization by providing Internet access to medical data. Fertility and Sterility 88 (2): 361-68.
U.S. Congress Public Law 103-43. National Institutes of Health Revitalization Act of 1993. Washington, DC: June 10, 1993.
Vallerand, A. H. 1995. Gender differences in pain. Image - The Journal of Nursing Scholarship 27 (3): 235-37.
Wenger, N. 2006. Coronary heart disease in women: Highlights of the past two years—Stepping stones, milestones, and obstructing boulders. National Clinical Practice Cardiovascular Medicine 3 (4): 194-202.
Wizemann, T. M. and M-L Pardue, eds. 2001. Institute of Medicine Committee on Understanding the Biology of Sex and Gender Differences. Exploring the biological contributions to human health: Does sex matter? Washington, DC: National Academy Press.
Wolf, S. M. 1996. Introduction: Gender and feminism in bioethics. In Feminism and bioethics. Ed. S. Wolf. New York: Oxford University Press. [End Page 66]