Trust in Health-care Systems and Vaccine Hesitancy

Healthcare systems can positively influence personal decision-making and health-related behaviour only if we trust them. In this article, Elisabetta Lalumera proposes a conceptual analysis of the trust relation between the public and a healthcare system, drawing from healthcare studies and philosophical proposals. She applies her analysis of public trust in healthcare systems to vaccine hesitancy, a tendency to question vaccine policies and to seek alternative vaccine schedules or to refuse vaccination. In her estimation, the phenomenon is not just a side effect of scientific illiteracy, irrationality, or misinformation on the public's part, factors that may nevertheless have an impact; it is, more centrally, a case of decline of trust in health care.

In Lalumera's account, the trust relation is based on an epistemic component - epistemic authority - and on a value component, the benevolence of the healthcare system. She argues that it is also modified by the vulnerability of the public on healthcare matters, and by the system's credibility. To make the case, following an introduction, in Section 2, she provides a bird's-eye view of cooperation relations holding in health care systems, and of the main causes of the current crisis in public trust, mainly drawing from the sociological and healthcare literature. In Section 3, she spells out the details of a conceptual model of the relation of public trust in health care, which she applies to vaccine hesitancy in Section 4. Concluding remarks are in Section 5.

Work in the fields of healthcare studies and sociology has shown that various relations that facilitate coordination and cooperation have to be in place among all stakeholders in the healthcare system for the overall institution of health care to accomplish its goals. The patient-practitioner relation is the most widely studied, but Lalumera focuses on the relation between the public as a whole and the healthcare system as an institution. The ways in which the relation has seen an erosion of trust include: (i) Public trust in health care has been shaken by the intense media coverage of scandals involving medical errors, hidden agendas of pharma and industry partners, and corruption of managers and practitioners; (ii) people increasingly find themselves in situations where their access to care is limited, so they come to believe that financial gain or at least money saving is what the system actually cares about; and (iii) in high-income countries, there is a decline in deference to authority and trust in experts in all fields.

Lalumera argues that trust in health care from the public is a 3-place relation, involving an institution (a community's healthcare system), a collective entity (the public), and a field of application (e.g., immunisation campaigns). She submits that trust in health care from the public is an expectation that the system will act at every level with a view on promoting, maintaining, and restoring people's health. We trust an institution because we are unable to manage some area of our life by ourselves, as individuals, and in that area we are vulnerable in that we are not self-protected. An additional degree of vulnerability that we (the public) bring to our relation to a healthcare system comes from the fact that the trusted good (our health and the health of our dear ones and fellow citizens) is itself conceptually linked with vulnerability.

Other elements of Lalumera's account include: "Epistemic authority of health care practitioners, and of health systems collectively taken, over the public means that they know more than we do about our health - they are experts. to which we are prepared to defer, without even realizing how many steps of deference we need to make....In attributing epistemic authority to health practitioners, we - the public - give them epistemic trust, namely, we are disposed to rely on their knowledge, competence and skills." Yet, that is not enough; the public must perceive healthcare systems as pursuing goals and embodying values - not merely displaying knowledge and expertise. "We trust our health care system and practitioners when we feel confident that they will act on the knowledge, competence and skills they possess in order to promote, maintain or restore our health [that is, benevolence], and not with other goals in view." A final conceptual matter relates to credibility: The public is willing to grant trust if the health care system is credible enough. "A point that has been raised by feminist epistemologists is that science appears less credible when the public feels to be socially underrepresented within scientific research communities..."

Next, Lalumera argues that the features of vaccine hesitancy qualify it as a case of public distrust - or of decline in trust - towards healthcare systems that can be explained by employing the conceptual points of the model she has proposed. She looks at:

• Epistemic trust - Lalumera shows why the alleged association between vaccination and autism remains a reason for vaccine hesitancy despite the publication and public dissemination of studies that disconfirm the hypothesis or show the small incidence of adverse effects after vaccination. "Repeated attempts at providing more scientific information on vaccination are...bound to fail to defuse vaccine hesitancy because they are perceived by the public as mere opinions, with the same epistemic authority as other views, and even as one's own."
• Attribution of values - Lalumera explains that the public expects that a healthcare system pursues its goals with honesty and transparency, and not with a view to profit of its managers and authorities. However, these values were lacking in cases such as the H1N1 pandemic.
• Value sharing - Per Lalumera, vulnerability is deeply involved in our relation with health care, and parents' fears of adverse side effects for children increase both vulnerability and demand for trust. While the healthcare system embodies solidarity and benevolence towards weaker ones, hesitant parts of the public endorse an individualistic stance grounded in autonomy in pedaetric decisions; "this is a case of value disagreement between the institution and the public, and as such it undermines the grounds of the trust relation."
• Credibility - Several studies in health communication show that the public looks for and receives information about vaccines from different sources and perspectives, such as public health officials and practitioners, but also friends and acquaintances, celebrities, blogs, and traditional media; non-health professional sources are perceived as credible by a small, but not insignificant, percentage of people.

In conclusion: "The contours of the concept of trust, philosophically described and applied to the public-health care relationship, can draw lines of direction for initiatives aimed at restoring the damaged good, together with sociological, psychological and organization studies. It is plausible that such initiatives, especially in the case of vaccine hesitancy, should insist on value transparency, carefully planned communication, and ethical education of citizens."