Dependency,trust and choice? Examining agency and ‘forced options’ within secondary-healthcare contexts

Abstract

Spanish

French

This article seeks to extend understandings of the ways in which trust is integral to analysing ‘choice’ within healthcare contexts, while also reappraising choice and its salience for grasping the nature of trust. Interrogating processes of ‘choosing to trust’, the authors describe various mechanisms through which ‘decisions’ are constrained while emphasising enduring agency to (dis)trust, even amid contexts where choice would appear annihilated by patients’ vulnerability. Drawing initially on Greener, Luhmann and Giddens, the article develops an analysis of how features of vulnerability, time and consciousness function in bounding choices and trust. Multiple structurations of choosing and trusting, alongside continuing agency, help further illuminate various power dimensions within clinical encounters. This theoretical analysis is illustrated using qualitative interview data from two studies across contrasting service settings in Australia and England, enabling recognition of further system and contextual influences upon patients’ vulnerability, dependency and trust, as these characterise processes of ‘choice’.

Keywords

Choice dependence structuration trust vulnerability

Introduction

A growing consensus regarding the appropriateness and effectiveness of patient choice within public healthcare systems is apparent among policy-makers across many post-industrial welfare states (Le Grand, 2007: 94), not least within Australia and England (Department of Health, 2012; Luxford et al., 2010). This trend continues despite important concerns regarding the popularity, equity and viability of choice within imperfect healthcare markets characterised by limited and asymmetric information (Brown and Calnan, 2012; Calnan and Rowe, 2008a; Greener, 2003; Taylor-Gooby, 2008). The promotion of patient choice emerges from, while also stimulating, a politicised awareness that services and professionals are of varying quality and safety; thereby shifting patients from a position of relative confidence (where professionals’ quality was more taken-for-granted) to one where contingency, risk and possibilities for regret make trust more salient (Giddens, 1991; Luhmann, 1988): ‘trust is only required if a bad outcome would make you regret your action’ (Luhmann, 1988: 98).

Greener (2003) argues that given the impossibility of calculative decisions between healthcare options – due to imperfect information, market structure and the complexity of medical practice – trust in professionals becomes a proxy for choice. In this sense trust is vital to understanding patients’ ‘choices’ but Greener also asserts the importance of choice for analysing trust. As noted already, emphasising healthcare choices renders trust more explicit and less taken-for-granted (Luhmann, 1988). Earlier models characterised by a less-questioning confidence or ‘hegemonic trust’ (Greener, 2003), wherein ‘the citizen is expected to give up all but the most humble rights, to put himself into the hands of the expert and trust his judgement and good intentions’ (Friedson, 1970: 355), are described as being increasingly replaced by more conditional, reflexive approaches (Calnan and Rowe, 2008b). Yet Greener (2003) is concerned that in many healthcare settings a lack of plausible alternatives shapes a ‘coercive’ form of trust, where patients are obliged to cooperate due to the impossibility of ‘exit’. In this manner different types of trust can be characterised in terms of choice or its absence (Greener, 2003: 84).

Meyer and Ward (2013) go further to suggest that where vulnerability or related power dynamics act to preclude choice then trust is no longer relevant and we should instead refer to dependence. As a logical continuation of Luhmannian (1988) arguments this would seem appropriate and compelling but further complications remain. Möllering (2005) and Barbalet (2009) consider, respectively, vulnerability and dependence as central to the purpose and nature of trust. And thus tensions emerge (Brown and Calnan, 2012) between, on the one hand, a recognition of the way vulnerability and related configurations of power may inhibit choices to trust (Goold, 2002; Greener, 2003; Meyer and Ward, 2013) and, on the other hand, arguments that emphasise that it is vulnerability (alongside uncertainty) which makes trust necessary in the first place (Möllering, 2005). After all, if one is not vulnerable to a future outcome then there is little need to trust.

Drawing on data from two qualitative interview-based studies – one in Australia, one in England – investigating trust in contrasting healthcare contexts, we interrogate these tensions. In doing so we aim to enhance understandings of the extent to which choice and trust are complexly interwoven and structured within power relations. Following brief sketches of these studies, we first move to problematise neat distinctions between choice and no choice, trust and no trust, as have thus far been defining of the literature (e.g., Davis and Rundall, 2000; Greener, 2003; Luhmann, 1988; Meyer and Ward, 2013). Pursuing this line of enquiry further, we consider structures of health system formats, and patients’ socio-economic background and related location within such contexts, as shaping divergent understandings and horizons of possibilities within patient lifeworlds (Scambler and Britten, 2001; Schutz, 1967: 59). We then explore chronologies of events and experiences (time), alongside habitus, emotions and related boundedness (consciousness), as further mechanisms by which agency to choose and to trust is configured.

The studies

By way of exposition and to ground our theoretical framework in the empirical, we consider data from two recent studies we have undertaken into trust in healthcare. The finer methodological details of these studies are available elsewhere (Brown, 2009; Meyer and Ward, 2013), however we offer brief synopses here in order to clarify the provenance of the data.

Both studies employed qualitative methodologies to explore the nature, extent and bases of trust via semi-structured interviews with patients in two distinct secondary-care settings. The England-based study, conducted in 2007, investigated trust among 20 cervical cancer patients across various diagnostic and treatment paths. Interviews with 20 healthcare professionals from a range of specialisms were also undertaken. The Australia-based study was conducted between 2008 and 2009, investigating the trust of 37 patients at various stages of treatment for heart disease (22 men and 15 women). Healthcare systems differ across these two countries, facilitating recognition of agency amid vulnerability and dependence in contrasting system contexts. In brief, the National Health Service (NHS) provides healthcare to all citizens in England, funded entirely from taxation. Australia, similarly, has a universal healthcare arrangement, Medicare. However the Australian government offers tax incentives to encourage those who can afford private health insurance to opt for this, in an effort to minimise strain on the public system (Harley et al., 2011). This creates a much higher take-up of private health insurance than in England (50% contrasting with 11% in 2012) – as approximately reflected in our samples (5/20 in the English study were private patients, 17/37 in the Australian study). Different system formats have implications for patients’ choice in accessing healthcare, as will be noted in later sections.

Both studies were theoretically driven and designed to critically examine social theories of trust. Data analysis for both studies was carried out via the coding and connecting of reoccurring themes, in light of theories of trust. The use of abductive and retroductive inference facilitated a more comprehensive analysis of the data while concurrently questioning and refining theory in light of data (Meyer and Lunnay, 2013). Although theoretically driven, the analysis was informed by considerations of the data within the wider context of each participant, including their illness and healthcare system experiences (Coffey and Atkinson, 1996).

The impossibility of choice?

A defining characteristic of sociological analysis is an understanding of the way actors’ thoughts and actions are constrained by, enabled through and a reaction against (Giddens, 1984) a complex tapestry of cultural norms and material structures (Archer, 1996), taken-for-granted assumptions (Schutz, 1967), tastes and dispositions (Bourdieu and Wacquant, 1992) and acquired embodied understandings and emotions (Barbalet, 2001; Merleau-Ponty, 1968). The shaping of preferences within social environments is by no means a purely sociological perspective (e.g. Simon, 1982), however sociological theorists have devoted particular attention to interrogating the manner by which decision-making tendencies are bounded and supported by ‘the social’ and, in particular, how the ‘power of the individual is confined by a range of specifiable circumstances’ (Giddens, 1984: 14–15).

Tensions between constraint and freedom lie at the heart of Giddens’s (1984) ‘duality of structure’, providing a useful departure point for considering choice, trust and their mutual relationship. The choice to trust can be said to never exist, in a wholly unfettered sense, but moreover as never fully ceasing to exist – in that a certain agency always endures: ‘it is of the first importance to recognise that circumstances of social constraint in which individuals “have no choice” are not to be equated with the dissolution of action as such’ (Giddens, 1984: 15).

Although stressing a rather stark ‘choice’/‘no choice’ distinction in parts of his 1988 chapter on trust, a recognition of these finer subtleties around choice is very much evident elsewhere within Luhmann’s writings on complexity and contingency (Luhmann, 1985: 25). Due to the problems of stress, disappointment and fear (1985: 32) which complexity and contingency otherwise give rise to, not to mention the ‘impossibility’ of making fully conscious selections ‘at every point in time for everyone’s every expectation’ (1985: 31), assumptions are inevitably resorted to. Assumptions which become commonly shared and adopted over time can develop into social structures, as patterns of understandings and expectations become routinised. These structures necessarily ‘limit the scope of options by the act of choosing, which is almost not consciously conceived of as such’ (1985: 31). ‘Choices’ in healthcare settings, including those involving trust, should be understood in this light.

Things become further complicated however when acknowledging that trust, as a format of expectation which reduces complexity (Luhmann, 1988), also fits a number of Luhmann’s (1985: 32) criteria of ‘structure’. Thus a ‘choice’ over whether to trust is shaped by prevailing assumptions and structures but in turn becomes a ‘structuring’ force itself, so reducing the complexity and contingency of later ‘choices’. This setting in motion of pathways of structured decisions which play out over time will be returned to (see section on time). For now it is sufficient to acknowledge that complexity and contingency are sufficiently problematic to render the development of solutions, such as trust, a ‘life necessity’ (1985: 40) in limiting choice.

This inherent need to overcome complexity and contingency should not be misinterpreted as necessitating trust however (cf. Greener, 2003). Luhmann (1979) underlines that distrust is also a viable solution to complexity. Yet this latter approach precludes cooperation with a potential trustee that would enable particular positive outcomes to be realised: ‘either A trusts B to achieve C, or A cannot have C’ (Barbalet, 2009: 372). This leads Barbalet (2009) to describe trust in William James’s terms as a ‘forced option’, yet further potentialities for agency and choice endure. Such other options include pursuing C but with significant doubts and anxiety, in the relative absence of trust.

This latter path, as well as various forced options to trust, were apparent across our two studies. In the example below it seemed that knowledge asymmetry created a certain form of dependence upon the expert through which trust was compelled (Meyer and Ward, 2013):

Aus-5 (public healthcare; male; age 77):

They’re [doctors] the ones that have the knowledge and they’re the ones that are in control of medicines and things like that. Where else are you going to go? I mean, you just have to do that. You’ve gotta have trust in – there are some people you know you’ve gotta have trust in.

Moreover the fundamental vulnerability of the patient amid the illness experience and the need to fend against anxiety similarly ‘forced’ the patient quoted below towards focusing on positive expectations:

Eng-5 (public; female; age 48):

No, because when it happens to you, you’ve got to deal with it and what’s happening to you. And the whole of what’s gone [wrong recently] in the NHS is irrelevant really. Cos you’d just drive yourself crazy wouldn’t you.

Yet a small number of respondents in the English study referred to distinctly distrusting. This suggested that a choice remained around trust, even when choice over treatment was not envisaged. For these patients, although they were indeed obliged to go down the route of treatment for their cancer due to no perceived alternative, agency was still apparent in forming negative expectations and attitudinal-evaluative positions towards particular professionals. The patient below, having said more generally, ‘Doctors: [I] don’t trust them’, went on to explain her distrust of the main doctor overseeing her care, due to poor communication:

Eng-14 (public; female; age 48):

I know sometimes you get people who are highly intelligent and they can’t communicate. But then he shouldn’t be in that position, he should learn how to deal with people.

Similarly, another patient expressed how she did not trust the doctor who had recently performed her colposcopy examination. She went on to refer to her negative concerns regarding the possibility of another appointment with the same clinician a few months later:

Interviewer:

Is [the next appointment] with the same chap again?

Eng-10 (public; female; age 28):

I bloody hope not … I’m sure he’s very skilled … You just need to put someone at ease the first time you see them.

And when he said – ‘have you ever smoked?’ And I said, ‘yes’, and I told him that I’d smoked for a couple of years, like six years ago. And I’d stopped, but I sometimes smoke … you know … socially. And he said – ‘why do you do that?’ And I thought, ‘well, fuck you, it’s none of your fucking business’.

Here we see clear expressions of distrust, despite apparently limited choice over undergoing further treatment with that particular clinician. As will be explored below, an array of choices and moments of agency thus emerge within the process of (dis)trust – which is best seen as an evolving sequence of embedded agency rather than a single momentary decision (Greener, 2003; Rapley, 2008; Schutz, 1967).

Social structures, horizons of possibilities and the limiting of choice

Stratified patterns of exit, voice or loyalty: Socio-economic, cultural and healthcare system influences

A number of curtailed choices were apparent within the accounts of participants in both studies. It is possible to conceive that patient Eng-10’s negative experiences (directly above) and corresponding expectations might have led her to demand a different doctor for her next appointment, or might even have led her to avoid returning for any further examinations. It would seem though that neither of these alternatives were considered viable, or perhaps even considered at all. At least two features of structuring assumptions (cf. Greener, 2003) were implicit within this case and across many participants’ narrative accounts: (a) patients’ experienced need to deal with an apparent physical abnormality, perceived as such through first-hand concerns that something was problematic (unusual patterns of bleeding or vaginal discharge, or chest pains) or indirectly through medical testing (the findings of a cervical smear, or through electro-cardiogram in the case of the cardiology patients); (b) patients’ understandings of their healthcare system and interpretations of choice within that system. Regardless of recent policy developments in the English NHS, Eng-10’s account implies understandings that she had no choice over the professional that she was to be examined by, or to voice concerns when not feeling comfortable with particular professionals.

Assumption ‘a’ pertains to a medicalised society which inculcates dispositions towards being responsible for one’s health and pursuing appropriate treatment when ‘necessary’ (Ballard and Elston, 2005), where this responsibilising discourse and the problematising of ‘out of place’ emissions are especially powerful around women’s bodies (Grosz, 1994; Howson, 1998), and where the spectre of cancer is unusually haunting and compelling (Brown et al., 2011). Similarly in the cardiac case, the cultural resonance of heart risk, combined with the pain and suffering of heart attacks, may render these as powerful ‘fateful moments’ (Giddens, 1991) which, in the example below, were described as exerting a powerful responsibilising effect:

Aus-14 (public; female; age 71):

Since I’ve had this heart attack, I have read up on the medication I’m on. I know what it’s for.

Interviewer:

Why do you think?

Aus-14:

I don’t know. I think this time, I feel that – it’s not somebody else’s responsibility – it’s my responsibility to know and to be responsible for what I’m taking and – you know? I think I’ve gone through life ‘ah well they know’ – you know, ‘I’ll do whatever they [doctors] write out for me’ and so forth. I think … I’ve just got to this stage now where I think that it’s my responsibility. It’s up to me to learn it.

This is one example of internalised norms of pursuing health through biomedicine. Ballard and Elston (2005: 233), however, draw attention to various ways in which scepticism and other formats of resistance may be leading to a divergent array of conforming and resisting responses within ostensibly ‘medicalised’ societies, as defined by social class and gender among other intersecting factors.

Assumption ‘b’, meanwhile, pertains to healthcare system formats and the related (non-) existence of options – either in granting alternatives beyond the mainstream provider, or by shaping horizons of possible choices within a particular system. These (non-) possibilities, interacting with socially structured experiences of these possibilities – such as those stratified by public or private health insurance, as influenced by socio-economic position (Hankivsky and Christoffersen, 2008) – shape the manner by which healthcare is accessed. So while choices may be made possible, as has been the goal of recent NHS policies in England and private health insurers in Australia, a range of socio-economic and related psycho-social factors may furthermore intersect in shaping the extent to which choices are actually enacted.

If we typify patient responses to negative experiences or expectations as one of either exit, voice or (obliged) loyalty (Hirschman, 1970), we can see that certain socio-economic positions granted some patients possibilities to choose to exit public systems, and/or exercise choice within private systems (Greener, 2003):

Aus 29 (private insurance; female; age 32):

Even though it keeps getting more expensive … I wouldn’t be without it [private healthcare insurance].

… ’cause I see people get put on waiting lists for things that are urgent and … we’ve got a very good health system – we really do but, you know, I kind of want to choose who’s going to cut me open.

Other patients without private insurance, perhaps with less economic capital, but with certain forms of cultural capital, may be better equipped and confident in voicing concerns regarding care and pushing for demands to be met, despite being in a system context where choice is limited or non-existent. Knowledge and education, as one further form of capital, has already been seen to impact upon trust choices, where patient Aus-5 above referred to insufficient knowledge leaving him little option but to trust. In our secondary-care contexts the complexity of information was often a barrier to understanding and choice:

Eng-1 (public; female; age 71):

I sometimes think though, that they give you too much information, that they blind you a little bit with information, and by the time you come away, you’re thinking – ‘now what did he really say about that?’

Others with more knowledge and understanding would be more inclined to voice questions. Conversely, patients with least economic, cultural and knowledge capital may be much more prone to experiencing the anxious, somewhat resigned, loyalty we saw in patient Eng-10 in the preceding section.

The will to trust and its constraining influence

Forced options to trust were apparent within the data already presented. One respondent (Eng-5) above acknowledged alternatives to trusting, such as focusing on uncertainty and/or negative media depictions of the NHS. Yet these alternatives were deemed unviable due to experiences of stress and anxiety – to the extent that ‘you’d drive yourself crazy’. Such vulnerability, amid a perceived lack of alternative treatment options, rendered necessary the bracketing-out of some possibilities which enabled patients to look past uncertainty and vulnerability towards positive outcomes in the future (Brown, 2009; Möllering, 2001). Below, Aus-5 described an awareness of healthcare failings but drew on hopeful emotions (Maturo, 2004) to set these concerns to one side:

Aus-5 (public; male; age 77):

You might be a bit concerned about things sometimes when something goes wrong like … things that happen in a hospital or a doctor or something like that, through lack, or error or somebody not doing their job properly. You got those things, but you hope it won’t happen in your area.

Such bracketing narratives implied the presence of a ‘will to trust’ (Luhmann, 1979; Möllering, 2005). Brown (2009: 401) points to the positive association between vulnerability and such a willingness to trust – where ‘the employment of “a trustful and not necessarily practical attitude” (Vaitkus, 1990: 287) may be a highly rational action within the “game” of interpretation … where the intended goal is the minimisation of anxiety in the face of heightened vulnerability and lack of alternatives’. Thus in contexts where vulnerability is more pronounced, so does the ‘option’ to trust become more attractive (or ‘coerced’ – Greener, 2003), in that the utility of trust, in coping with vulnerability, is also greater – accordingly ‘the level of vulnerability experienced within such a context will shape the nature and extent of an actor’s “choice” to trust’ (Brown and Calnan, 2012: 80).

Time – the chronology of decision-making pathways

The preceding section denoted interwoven features of the patient experience – including system perceptions, societal discourses on health, individual stocks of capital and experiences of vulnerability – which led to the structuring of patients’ horizons of possibilities or lifeworlds (Scambler and Britten, 2001). This shaping of lifeworlds took place both more deliberatively – by actively bracketing-off uncertainty and negative futures – and/or passively – through taken-for-granted assumptions and related understandings (Schutz, 1967). The focus thus far has been upon how choices and trust were shaped via structures, experiences and interpretations in the present, but less about processes already set in motion in the recent past. This section aims to draw out the fundamental role played by time as a further basis for considering the dialectical interaction between structure and ‘choice’. Trust, as a format of linking the present to the future, by drawing on knowledge derived from the past, is inherently formatted by the lived chronology of the truster and time can be seen to structure choices through a number of mechanisms.

Acuteness, chronicity and the extent of reflexive decision-making

Alongside the ‘will to trust’ noted above, mechanisms connecting illness chronologies to healthcare interactions and decision-making are further important considerations regarding the embeddedness of trust choices within vulnerability (Meyer and Ward, 2013). At one end of a spectrum we have the type of vulnerability which manifests itself within acute care situations, as described by this England-based Accident and Emergency (A&E) doctor:

A&E registrar:

In emergency care [patients] are very vulnerable, in some ways it’s nice [easier] for me, but they’re very, very vulnerable, hence they trust you.

Interviewer:

Because they have to?

A&E registrar:

Because they have to. And I’ve done that before when I’ve injured myself. You just put yourself in … you know.

The urgency of a patient’s need for care, as manifest within this particular format of vulnerability, alongside the potential state of shock which may influence the patient’s affective experience and understanding (Pilgrim et al., 2011), may curtail possibilities not to trust in this situation as well as making a more ‘blind’ (Calnan and Rowe, 2008b), ‘swift’ (Dibben and Lean, 2003), less reflexive trust more likely (Meyer and Ward, 2013).

In contrast, within contexts of chronic illness, the lack of urgency and the extensive experiential knowledge of the ‘expert’ patient may allow for a much more long-term, negotiated and reflexive formation of trust (Dibben and Lean, 2003). The following patient ‘decided’ to trust specific doctors to assist in the management of chronic heart disease:

Aus-35 (private; male; age 61):

I’ve decided to trust them [the doctors] to deal with the problems, so I trust that they have the information that I need.

The contrast between the acute and the chronic thus changes the way dependency is manifest within the professional–patient relationship and the relative presence or absence of conscious choices to trust (Meyer and Ward, 2013).

Current choices constrained by earlier events and decisions

Deeper exploration of forms and chronologies of dependence are useful in specifying various further constraints upon choices to trust. Barbalet (2009) emphasises that choosing to trust involves choosing to depend upon the trustee. But in various senses someone who experiences illness may implicitly plan to rely upon an imagined ‘type’ (Schutz, 1967) of professional even before there is a specific choice to trust within a healthcare encounter – due to the monopolisation of ‘help’ for this particular form of vulnerability whereby the assistance of one particular profession is the only conceived/conceivable ‘option’ (Brown and Calnan, 2012: 72).

Here it becomes possible to distinguish between two stages of dependence: the form of dependence which emerges as trust is invoked within a specific encounter (Barbalet, 2009), and the ‘pre-trust’ dependence manifest through the need for help/treatment (Brown and Calnan, 2012). The constraining influence of dependence which exists before trust has been enacted may be especially potent in the case of a man in the midst of experiencing severe chest pains, and somewhat less potent for a privately insured woman with abnormal vaginal discharge. These power structures of dependence may involve a more generalised ‘system trust’ and other taken-for-granted assumptions regarding biomedicine and knowledge-systems, while being further delineated by the national health system context and individual insurance coverage.

Thus long before the patient and professional even meet, an access pathway has already been implicitly mapped out and embarked upon, through the organisational structuring of possibilities as well as patients’ taken-for-granted assumptions and expectations (lifeworld) concerning these (Scambler and Britten, 2001; Schutz, 1967: 67). With many of the patients in our two studies, choice over pursuing treatment could thus be said to have been fully closed off by the experiences of, and related structures of thinking about, their illness and its treatment. Patient Aus-17 described how his previous partial ‘exiting’ of chronic cardiac care – through non-compliance – had led to an acute cardiac event and life-threatening complications. These experiences were narrated as culminating in an obliged, but welcomed, loyalty, whereby:

Aus-17 (private; male; age 68):

If they said ‘jump’ I’d say ‘how high?’

The pursuit of treatment with a particular professional could then be further bounded by prior decisions to trust this professional, for example in having already been examined by them and having trusted their diagnosis. These past decisions could lead onto further situations where greater levels of trust were required, assumed or expected. Deferential politeness, among other normative structures, could then oblige loyalty (Ward et al., 2015), rather than exit or voice strategies, despite newly emerging misgivings.

At this point it is useful to return to our assessment, drawing upon Luhmann (1985, 1988), that trust requires a degree of choice but also resembles structure – in that it reduces complexity in the future. Applying this understanding to different phases of dependency, a chain of moments becomes apparent whereby the agency within any one momentary action – either to behave in a certain way or to hold certain expectations – is profoundly embedded within a whole host of events, decisions and structures which have earlier taken place. Agency is still further constrained by the imagined future which the actor longs for (see earlier discussion regarding vulnerability and forced options). In their multiplicity and interconnectedness across time, decisions pertaining to trust relations and healthcare choices are in this light most accurately characterised as embedded in an ongoing ‘process’ (Khodyakov, 2007) rather than involving any one-off decisiveness (Rapley, 2008; Schutz, 1967).

Reconsidering the consciousness of trust – the influence of socio-biographies upon trust

Influences of power in constraining ‘choices’ to trust, via wider socio-structural and chronological processes, are regularly overlooked within the social-scientific literature, due to a focus on the distinctive features of trustees and systems and how these are appraised by the truster. Trust furthermore tends to be depicted as a largely conscious and highly reflexive ‘decision’, yet we have already stressed that many ‘choices’ to trust are less-than-consciously conceived (Brown, 2009; Giddens, 1984; Luhmann, 1985) and that prior trust (in systems and individuals) encourages a ‘docility’ (Simon, 1982) which bounds or brackets reflection. Starting from these limits to the ‘consciousness’ of trust and choice, this final main section explores how mechanisms of habitus, emotions and bounded rationality, as are inherent to trust (Misztal, 1996), constitute further dimensions by which healthcare decisions are embedded within socio-historical contexts and the power relations pervading therein.

Habitus

Trust within many contexts, not least those involving healthcare professionals, involves a process by which the ‘latent intentionality’ (Merleau-Ponty, 1968) and capability of another person is inferred through an array of communicative utterances and embodied interactions (Brown et al., 2011; Lee-Treweek, 2002). Which indicators or ‘signs’ of care and competence are focused upon or overlooked, and the manner by which these are interpreted, relate to certain hermeneutic competencies, a ‘theory of mind’, and other such forms of social learning which are the product of manifold prior interactions. This history of previous social experiences can therefore be seen as endowing the potential truster with a stock of knowledge, interpretative inclinations and basic starting assumptions (Schutz, 1967).

In both studies, participants identified specific, if intangible, characteristics of their doctors which were interpreted as signs of trustworthy care:

Eng-11 (public; female; age 38):

He’s just got a very good manner, he’s quite authoritarian, so you feel like you can trust, like you’re being looked after.

Conversely, within these hermeneutical accomplishments, a negative history of being let down by important others in the past appeared to inculcate dispositions towards an interpretation of signs as indicating deficiencies in the competence and care of the potential trustee. Saliently, of the England gynae-oncology patients, the two women (Eng-10 and Eng-14 – both quoted earlier) whose narratives were particularly characterised by distrust recounted decidedly negative experiences of gynaecological examinations and treatment in their teens (many years earlier) which emerged in their narratives as relevant for more recent experiences of distrust.

Such forming of inclinations towards or away from trust are described by Brown and Calnan (2012), where some of the narrative accounts of service users with severe mental health problems described rather extreme tendencies towards either trust or distrust. All social actors may be considered somewhere on a spectrum between these two poles, with past experiences inculcating (dis)trust dispositions via a less-than-conscious habitus (Misztal, 1996; Scambler and Britten, 2001). More deeply still, socially orchestrated tendencies towards a trust in self and the generalised consistency of others (ontological security) may also have a marked impact upon trust-related behaviour (Giddens, 1991; Pilgrim et al., 2011).

Emotions

This salience of ‘the self’ for trust is often overlooked, yet Barbalet (2009) underlines the extent to which trust decisions incorporate a ‘self-trust’ in one’s decision-making capabilities, alongside the more commonly acknowledged appraisal of others. A decision to trust can, therefore, be seen to involve multiple implicit appraisals and constructions of knowledge: of systems and contexts, of potential trustees embedded in these systems and contexts, of one’s own situation and needs, and of trust in one’s own decision-making capabilities (Pilgrim et al., 2011). This multifariousness of objects, judgements and forms of evaluating make apparent the existence of an ‘integration problematic’ (Brown and Calnan, 2012: 62) which must be overcome for trust-decisions to be made. It is in this light that the limits of narrow, formal/procedural and calculative conceptions of rationality as a basis of healthcare decision-making become glaring and the salience of emotions and heuristics become strongly apparent (Barbalet, 2009; Brown and Calnan, 2012; Zinn, 2008).

Emotions of confidence in self, as integrated with the emotions generated within the interactions with the potential trustee, have been emphasised as effective ways of knowing and trusting (Barbalet, 2009: 376). These emotional reactions, as with (and as part of) habitus, are learned via a complex history of prior social interactions across social contexts/fields (Barbalet, 2009; Brown and Calnan, 2012; Pilgrim et al., 2011). Aus-15 (public; male; age 50) described a socio-biographically inculcated proclivity to trust the profession of medicine:

I sort of trust in the field – it was the way I’ve been brought up, with dad being a medico and that. You’ve got to learn to trust the medical professionals and all that – I tend to trust them all.

A heterogeneous amalgam of ‘memories, emotions, cognitions and bodily sensations’, rooted in the past (Pilgrim et al., 2011; Young et al., 2003: 61), accordingly linked socio-biographical contexts to the choice tendencies of individual patients.

Bounded rationality through cultural norms – alongside continuing agency

Habitus and affect can both be understood as ‘short-cuts’ towards decision-making, cutting through, bracketing or bypassing complexity and therefore representing two of many formats by which rationality is ‘bounded’ in everyday life (Simon, 1982; Zinn, 2008). In this way culture has a profound bearing upon healthcare ‘decisions’ through the manner by which ‘collective mentalities, patterns for thinking and doing widespread in society, provid[e] ready-made templates for individual actions’ (Sztompka, 1999: 6) – such as trusting doctors:

Aus-21 (public; female; 77):

I think with our generation, because we were brought up respecting doctors, teachers and policeman – so anybody coming by who’s in a white coat could say anything to you and you’d trust them. I don’t think … [we] query about it much.

Such recognition of the embeddedness of trust decisions within mass cultural frames of reference (the white coat – as a symbol or aesthetic of trust), alongside personal biographical journeys (see the example of Aus-15 above), enables us to recognise a multidimensional, multilayered interaction between a range of fields and habitus which in turn shapes certain structures of ‘docility’ (Scambler and Britten, 2001; Simon, 1982). Power dynamics of inequality and of representation, working across socio-cultural fields, thus come to shape past experiences and inculcated assumptions and accordingly bear upon trust and choice.

Conclusion

Within the preceding sections we have sought to illuminate an array of mechanisms by which choices – to receive treatment and/or to trust – are embedded. Considering our data, trust was seemingly a sufficient but not necessary proxy for choosing healthcare options, forming one important mechanism among others which acted to bound reflection upon pursuing particular healthcare paths (cf. Greener, 2003; Rapley, 2008). Various features of system understandings, socio-economic structures, illness vulnerabilities and chronology interacted to constrain but not annihilate choices to trust (cf. Greener, 2003), with trust usefully understood as an emergent enactment of structure from the (near or distant) past which in turn structures, but does not determine, ‘choice’ in the present.

Continuing agency is apparent amid each of the various structuring mechanisms addressed in our analysis. Emotions, for example, while rooting decisions in past experiences, are not an overwhelming force which removes agency. A swathe of literature following Hochschild (1979) among others notes various ways in which emotions are ‘worked on’ within social contexts and therefore the influence of affect is open to shaping by the individual. Similarly, the manner by which a ‘will to trust’ impacts upon individuals in vulnerable circumstances still requires a positive construction of expectations and a wilful ‘bracketing away’ of negative possibilities, emphasising the ‘highly active role’ played by the truster within these situations (Brown, 2009: 394). Of course both these forms of ‘agency’ are constrained, respectively, by feeling rules (Hochschild, 1979) and by limited alternatives and vulnerability when in need. The perpetual tension around the ‘duality of structure’ thus endures (Giddens, 1984).

Narratives of distrust were more apparent among the small English gynaecological-oncology patient sample than from the Australian cardiac-care case study. Rational-actor understandings of healthcare choice would predict that such distrust would lead to patients exiting care, or at least voicing their concerns and demanding alternatives. It was striking however that distrust seldom led to exit or even to voice, but importantly influenced the meaning and experience of healthcare for patients – often in terms of heightened vulnerability and anxiety. Possibilities for exit or voice were importantly shaped by varying stocks of capital (especially socio-economic and cultural-educational), with these impacting via private insurance possibilities, understandings of choice and more or less deferential interactions with professionals. It is here that the power dynamics of choice and trust become most palpable, with the economically and/or culturally privileged, alongside the less unwell, more able – via exit or voice capacities – to afford not to trust. That the loyalty of the less privileged and/or more seriously ill may be eased by trust may therefore oblige such a bracketing of uncertainty (Brown, 2009). Examples of distrust in these contexts suggest, nevertheless, that trust is obliged amid continuing agency rather than coerced (cf. Greener, 2003). Meanwhile those who are ‘loyal’ and distrusting may be most vulnerable of all.

Footnotes

Funding

The interview data involving patients in England is drawn from a doctoral study funded by the UK Economic and Social Research Council.

Author biographies

Patrick R Brown is an Assistant Professor within the Department of Sociology at the University of Amsterdam, where he is also a member of the Centre for Social Science and Global Health. Patrick’s research focuses on how various social actors – patients, professionals and other ‘decision-makers’ – construct sense amid and act within late modern healthcare settings which are often characterized by experiences of vulnerability and uncertainty. Accordingly this research has led to various explorations of processes of trust, risk and/or hope, with a wide range of publications resulting from these studies. These include two recent books: Trusting on the Edge: Managing Vulnerability and Uncertainty in the Midst of Severe Mental Health Problems (Policy Press, 2012; with Michael Calnan) and Making Health Policy: A Critical Introduction (Polity, 2011; with Andy Alaszewski).

Samantha B Meyer is an Assistant Professor in Public Health and Health Systems at the University of Waterloo, Canada. She also holds an adjunct position in the Discipline of Public Health at Flinders University, Australia. Her current research focus is the critical issue of trust in healthcare and the related implications for preventative service utilization. Specifically, she is interested in the role of trust in the use of immunisation and cancer screening programmes. Meyer’s research interests also include access to and social determinants of bariatric surgery; patient–provider interactions; equity in access to healthcare services; food regulation and policy; and trust in food.

References

Archer

(1996) Culture and Agency: The Place of Culture in Social Theory. Cambridge: Cambridge University Press.

Ballard

Elston

(2005) Medicalisation: A multi-dimensional concept. Social Theory and Health 3(3): 228–241.

Barbalet

(2009) A characterization of trust, and its consequences. Theory and Society 38(4): 367–382.

Bourdieu

Wacquant

(1992) An Invitation to Reflexive Sociology. Evanston, IL: University of Chicago Press.

Brown

(2009) The phenomenology of trust: A Schutzian analysis of the social construction of knowledge by gynae-oncology patients. Health, Risk and Society 11(5): 391–407.

Brown

Calnan

(2012) Trusting on the Edge: Managing Uncertainty and Vulnerability in the Midst of Serious Mental Health Problems. Bristol: Policy Press.

Brown

Alaszewski

Swift

Nordin

(2011) Actions speak louder than words: The embodiment of trust by healthcare professionals in gynae-oncology. Sociology of Health and Illness 33(2): 280–295.

Calnan

Rowe

(2008a) Trust, accountability and choice. Health, Risk and Society 10(3): 201–206.

Calnan

Rowe

(2008b) Trust Matters in Health Care. Buckingham: Open University Press.

10.

Coffey

Atkinson

(1996) Making Sense of Qualitative Data: Complementary Research Strategies. London: Sage.

11.

Davis

Rundall

(2000) Managing patient trust in managed care. Milbank Quarterly 78(4): 609–624.

12.

Department of Health (2012) Liberating the NHS: No Decision About Me Without Me. London: Department of Health.

13.

Dibben

Lean

(2003) Achieving compliance in chronic illness management: Illustrations of trust relationships between physicians and nutrition clinic patients. Health, Risk and Society 5(3): 241–248.

14.

Friedson

(1970) Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Harper Row.

15.

Giddens

(1984) The Constitution of Society: Outline of the Theory of Structuration. Berkeley: University of California Press.

16.

Giddens

(1991) Modernity and Self-identity: Self and Society in the Late Modern Age. Stanford: Stanford University Press.

17.

Goold

(2002) Trust, distrust and trustworthiness. Journal of General Internal Medicine 17(1): 79–81.

18.

Greener

(2003) Patient choice in the NHS: The view from economic sociology. Social Theory and Health 1(1): 72–89.

19.

Grosz

(1994) Volatile Bodies: Towards a Corporeal Feminism. Bloomington: Indiana University Press.

20.

Hankivsky

Christoffersen

(2008) Intersectionality and the determinants of health: A Canadian perspective. Critical Public Health 18(3): 271–283.

21.

Harley

Willis

Gabe

. (2011) Constructing health consumers: Private health insurance discourses in Australia and the United Kingdom. Health Sociology Review 20(3): 306–320.

22.

Hirschman

(1970) Exit, Voice, and Loyalty: Reponses to Decline in Firms, Organizations, and States. Cambridge, MA: Harvard University Press.

23.

Hochschild

(1979) Emotion work, feeling rules and social structure. American Journal of Sociology 85(3): 551–575.

24.

Howson

(1998) Embodied obligation: The female body and health surveillance. In: Nettleton

Watson

(eds) The Body in Everyday Life. London: Routledge, pp. 218–239.

25.

Khodyakov

(2007) Trust as a process: A three-dimensional approach. Sociology 4(1): 115–132.

26.

Lee-Treweek

(2002) Trust in complementary medicine: The case of cranial osteopathy. Sociological Review 50(1): 48–68.

27.

Le Grand

(2007) The Other Invisible Hand: Delivering Public Services through Choice and Competition. Princeton, NJ: Princeton University Press.

28.

Luhmann

(1979) Trust and Power: Two Works by Niklas Luhmann. Chichester: John Wiley and Sons.

29.

Luhmann

(1985) A Sociological Theory of Law. London: Routledge and Kegan Paul.

30.

Luhmann

(1988) Trust: Making and breaking cooperative relations. In: Gambetta

(ed.) Familiarity, Confidence, Trust: Problems and Alternatives. New York: Basil Blackwell, pp. 94–107.

31.

Luxford

Piper

Dunbar

Poole

(2010) Patient-centred Care: Improving Quality and Safety by Focusing Care on Patients and Consumers. Canberra: Australian Commission on Safety and Quality in Health Care.

32.

Maturo

(2004) Network governance as a response to risk society dilemmas: A proposal from the sociology of health. Topoi 23: 195–202.

33.

Merleau-Ponty

(1968) The Visible and the Invisible. Evanston, IL: Northwestern University Press.

34.

Meyer

Lunnay

(2013) The application of abductive and retroductive inference for the design and analysis of theory-driven sociological research. Sociological Research Online 18(1).

35.

Meyer

Ward

(2013) Differentiating between trust and dependence of patients with coronary heart disease: Furthering the sociology of trust. Health, Risk and Society 15(3): 279–293.

36.

Misztal

(1996) Trust in Modern Societies. Cambridge: Polity Press.

37.

Möllering

(2001) The nature of trust: From Georg Simmel to a theory of expectation, interpretation and suspension. Sociology 35(2): 403–420.

38.

Möllering

(2005) The trust/control duality: An integrative perspective on positive expectations of others. International Sociology 20(3): 283–305.

39.

Pilgrim

Tomasini

Vassilev

(2011) Trust in Healthcare: An Interdisciplinary Approach. Basingstoke: Palgrave.

40.

Rapley

(2008) Distributed decisions making: The autonomy of decision-in-action. Sociology of Health and Illness 30(3): 429–444.

41.

Scambler

Britten

(2001) System, lifeworld and doctor-patient interaction: Issues of trust in a changing world. In: Scambler

(ed.) Habermas, Critical Theory and Health. London: Routledge, pp. 45–67.

42.

Schutz

(1967) The Phenomenology of the Social World. Evanston, IL: Northwestern University Press.

43.

Simon

(1982) Models of Bounded Rationality: Behavioral Economics and Business Organization. Cambridge, MA: The MIT Press.

44.

Sztompka

(1999) Trust: A Sociological Theory. Cambridge: Cambridge University Press.

45.

Taylor-Gooby

(2008) Reframing Social Citizenship. Oxford: Oxford University Press.

46.

Vaitkus

(1990) The crisis as a bankruptcy of trust: The fiduciary attitude, human nature and ethical science. International Sociology 5(3): 287–298.

47.

Ward

Coffee

Wilson

. (2015) Trust, dependence and obligation: A qualitative study of enablers to colorectal cancer screening in South Australia. Sociology of Health and Illness. Epub ahead of print. DOI: 10.1111/1467-9566.12280.

48.

Young

Klosko

Weisshar

(2003) Schema Therapy: A Practitioner’s Guide. New York: Guilford.

49.

Zinn

(2008) Heading into the unknown: Everyday strategies for managing risk and uncertainty. Health, Risk and Society 10(5): 439–450.