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On the Interrelationship of Vulnerability and Trust

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Abstract

In this paper, I look at vulnerability from the point of view of the vulnerable. I will explain how to conceive of the vulnerable person as active, as someone who structures her situation of moral vulnerability in a significant way. I will explain why people may actively seek to become morally vulnerable, why vulnerability is not always an unfavourable condition, and why focusing on the negative sides of vulnerability has hidden from view some important aspects that are necessary for understanding the concept and the moral duties it entails. Vulnerability may be welcomed because it simplifies human interactions and creates morally meaningful relationships. However, in these cases we speak rather of trust. Trust and vulnerability are interrelated, since trust, as Carolyn McLeod puts it, implies being “vulnerable to betrayal”, and the vulnerability of the truster is, indeed, an essential aspect of the trusting relationship. Conceptualizing vulnerability in terms of trust may also broaden our view as to the appropriate responses and give rise to a different type of moral obligations.
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published in: Christine Straehle (Ed.): Vulnerability, Autonomy, and Applied Ethics.
Routledge: New York, pp. 157-170
On the Interrelationship of Vulnerability and Trust
Claudia Wiesemann (ttingen, Germany)
As scholars we all travel a lot and visit many a big city in countries all over the world.
Although this provides us with exciting opportunities to explore exotic places and unfamiliar
cultures, it may also confront us with an unsettling experience every now and then. Most of us
know how it feels to get lost in a foreign city, straying into quarters where suddenly danger
seems to lurk around every corner and realizing with a shock how useful it would have been
to learn some basics of the language so as to be able to decipher the unfamiliar street names.
In such a situation, most people would, like me, probably start looking for a local with a
sufficiently reassuring face to ask the quickest way to a more familiar spot.
As strangers lost in a foreign city, we are vulnerable in a paradigmatic way. We are
vulnerable in that we depend on someone else to give us reliable information. We are at risk
of being wronged because this person may just send us round the corner where her
accomplices are already waiting to mug us. In order to achieve something which is necessary
and good for us – not to wander through dangerous streets for hours and hours, to find the
way out, to arrive at a conference in time we fundamentally depend on some other person’s
help. Although we may be smart and autonomous academics with impressive educational
backgrounds and decent salaries, we have become vulnerable to a stranger’s sensitivity to and
empathy with our predicament. Admittedly, lost tourists are not among the classic groups
usually summoned to mind when vulnerability is discussed: the poor, uneducated,
incompetent, stigmatized, illegal, etc. Still, their vulnerability is not that different.
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I will take this example of an ordinary, commonplace experience as a starting point for
elucidating aspects of vulnerability that seem incoherent or at least difficult to grasp (Macklin
2012, Rogers 2014, pp. 70f). Some cases impose a duty to protect, yet, in others, protection
risks patronizing those who are deemed vulnerable. Jonathan Herring is afraid that “the
vulnerability narrative tends to promote disablist approaches to the issue." (Herring 2013, p.
256).1 Yet, how can we identify those critical situations when labelling someone as vulnerable
(and thus protecting her in a paternalistic way) would additionally wrong her either by
stigmatizing her or the group she belongs to or by calling forth unwelcome protection? In
healthcare, such a distinction is urgently needed. For example, when pregnant women are
considered vulnerable they are treated as being less autonomous than other adults. As a result
of protectively excluding them from research, there is less empirical evidence available of
drug effects in women who are pregnant. Eventually, women are deprived of the benefits of
medical progress in cases of pregnancy related diseases (Baylis 2010, Wild 2012, Rogers
2014, p.68f). Although vulnerability is obviously an indispensable concept in modern (bio-)
ethics, it is a dangerous one because it may stereotype the vulnerable as passive and in need of
protection, and so, risks encouraging unwarranted paternalism and even discrimination.
One way to avoid the implication of passivity is to look at vulnerability from the point
of view of the vulnerable. In what follows, I will explain how to conceive of the vulnerable
person as active, as someone who structures her situation of moral vulnerability in a
significant way. I will explain why people may actively seek to become morally vulnerable,
why vulnerability is not always an unfavourable condition, and why focusing on the negative
sides of vulnerability has hidden from view some important aspects that are necessary for
understanding the concept and the moral duties it entails. Vulnerability may be welcomed
because it simplifies human interactions and creates morally meaningful relationships.
However, in these cases we speak rather of trust. Trust and vulnerability are interrelated, since
trust, as Carolyn McLeod puts it, implies being “vulnerable to betrayal”, and the vulnerability
of the truster is, indeed, an essential aspect of the trusting relationship. Conceptualizing
vulnerability in terms of trust may also broaden our view as to the appropriate responses and
give rise to a different type of moral obligations.
1 See also the paper by Carla Bagnoli in this book.
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Is vulnerability always bad?
The example of vulnerability I described above clearly displays many of the
characteristics theorists of moral vulnerability have identified, so far. It illustrates the truism
that everybody may become morally vulnerable at one time or another, be they rich or poor,
educated or ignorant, competent or incompetent (Fineman 2008). It shows that moral
vulnerability is not a fixed characteristic of certain groups but occurs situationally and in
relation to other people (Goodin 1985, Luna 2009, Mackenzie 2014). It demonstrates that
vulnerability arises when a person wants to achieve something important to her (Anderson
2014, p. 135). And it shows that vulnerability entails the risk of being wronged (Hurst 2008).
Yet, the observation that the vulnerable person is, in particular, at a higher risk of
being wronged has nurtured the feeling that vulnerability is something bad that, if possible,
should be avoided or eliminated. In her paper “Elucidating the Concept of Vulnerability:
Layers not Labels”, Florencia Luna stresses that vulnerability is something women suffer
from and which therefore imposes on us the obligation to alleviate it: After we identify
different layers of vulnerability that these women suffer, we can think of various ways of
avoiding or minimizing those layers” (Luna 2009, p.131). In fact, most authors share the idea
that vulnerability is an unfavourable condition and put their efforts into developing measures
to alleviate or eliminate it.2 We can reasonably assume that we have a duty to eradicate
poverty, analphabetism, and the like. But should we also strive to eradicate vulnerability?
My claim is that we should not. Focusing on the interrelationship of vulnerability and
trust, it can be shown why vulnerability is not unfavourable or disadvantageous per se. To the
contrary, it can be a very helpful condition simplifying social as well as moral interaction.3
Take the example above. When asking a stranger in a strange city for directions I make
myself vulnerable to her possible wrongdoing. If her answer does not raise suspicions, I will
certainly follow her advice wherever it leads me, to safety or into danger. The main reason is
that doing so is most likely a simple and effective way to get myself back on track. Trusting a
2 Cf. Robert Goodin who defends the basic prescription of “preventing exploitable vulnerabilities” (Goodin
1985, pp. 189-203, p. 206).
3 With regard to theories of equality, Martha Fineman similarly argues that vulnerability “freed from its limited
and negative associations is a powerful conceptual tool with the potential to define an obligation for the state to
ensure a richer and more robust guarantee of equality than is currently afforded under the equal protection
model” (Fineman 2008, p. 8f). See also Gilson (2014), pp. 31-40, who criticizes a "reductively negative view of
vulnerability).
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reliable local can quickly help me out of my predicament whereas any other solution will be
much more complicated. Moreover, we will both feel rewarded by the encounter. I will be
thankful that a complete stranger has shown the kindness to help me. The helper will be
satisfied by having done me a favour. Making oneself momentarily vulnerable offers a quick
solution to a problem that is gratifying for all of the persons involved. Thus, though not
without some risk, it will usually be the preferred alternative. It is certainly what most people
do. On the other hand, reducing or avoiding vulnerability in such a case would be a very
complicated and often not very effective alternative. The local could try to reduce my
vulnerability by handing me a map of town that she carries with her for just such cases. Even
when she is considerate enough to show me on the map where I am, this method will in many
cases not be helpful, particularly when one has difficulties deciphering foreign street names.
Other options for avoiding or eliminating my vulnerability are memorizing the map before
leaving the hotel, learning the foreign language, etc. Obviously, these options, which aim at
reducing, minimizing or eliminating vulnerability in the first place, require a lot of effort, are
mostly impractical, and are not always successful. There are good reasons to accept
vulnerability instead.
Thus, embracing vulnerability in a situation like this is reasonable because it simplifies
an otherwise complicated problem. It opens up a shortcut for solving a problem which can
otherwise only be circumvented on long, winding roads. To achieve this effect, we often
make ourselves vulnerable when we lack full information about a social situation, for
example, when someone offers us food that we do not know or gives us a helping hand when
our car has broken down. In cases like these, people accept their vulnerability in exchange for
a smooth and rewarding encounter. In fact, it is precisely this widespread willingness that
tricksters are so apt at exploiting. Yet, as long as the participants in this type of interaction are
rewarded, it will continue to be a common behaviour in social life. Accepting vulnerability
from time to time makes life easier for all of us.
Vulnerability and trust as a helpful social resources
Vulnerability and trust can be understood as helpful social resources that alleviate
some of the stress of social interaction and rewards those participating in the practice by
simplifying their interactions and producing positive feelings. The literature on vulnerability
has focused too narrowly on situations which we evaluate as negative overall (like poverty) or
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entail high risks and are far from everyday experience (like human research). This has
directed our attention to the negative aspects of vulnerability. Yet, in everyday life, we
voluntarily and repeatedly enter into situations that render us vulnerable. We share a secret
with a friend and become vulnerable to betrayal; we fall in love and become vulnerable to the
beloved’s lack of respect and caring; we trust a doctor’s advice to undergo a burdensome and
costly treatment and become vulnerable to her failure to comply with the rules of professional
integrity. Although we know about the risks, we actively engage in such behaviours.
Obviously, most people do not, in general, share the view that vulnerability is inherently
detrimental or that it should be avoided in the first place. As Christine Straehle points out,
“for most, the vulnerability that comes with relationships is something we accept; we risk
getting into relationships, because the promise of our emotional gains outweighs the risk of
having our interests harmed” (Straehle 2014, p. 199). Yet, despite our readiness to accept
some risks, these situations should not be disregarded as morally irrelevant. They are of moral
concern, all the same, and they are necessary for elucidating those instances of the concept
which are more directly associated with risk and harm and have gained far more attention in
the debate.
Thus, if we take a fresh look at the definitions of ‘vulnerability’ provided so far, they
can be identified as one-sided if referring only to the negative causes and consequences of
vulnerability. For example, the well known definition by the Council of International
Organizations of Medical Science (CIOMS) holds that ‘vulnerability’ refers to a substantial
incapacity to protect one's own interests owing to such impediments as lack of capability to
give informed consent, lack of alternative means of obtaining medical care or other expensive
necessities, or being a junior or subordinate member of a hierarchical group(CIOMS,
General Ethical Principles). Though this definition is not entirely wrong, it captures only
certain aspects of the phenomenon and ignores other important ones.4 The same is true for
Samia Hurst’s definition of ‘vulnerability’ as “an identifiably increased likelihood of
incurring additional or greater wrong” (Hurst 2008, p. 191).5 Both definitions grasp only part
4 See also the definition rendered by Beauchamp and Childress: "In biomedical ethics, the notion of vulnerability
often focuses on a person's susceptibility, whether as a result of internal or external factors, to inducement or
coercion, on the one hand, or to harm, loss, or indignity, on the other" (Beauchamp, Childress 2009, p. 254).
5 In a recent publication, Hurst and co-authors are somewhat inconsistent in their view. At times, they hold that a
manifest moral wrong is a prerequisite for vulnerability (Martin et al. 2014, p. 59). But they also maintain that
vulnerability comes only with an increased likelihood of incurring a moral wrong. Moreover, they distinguish
between vulnerability as such and the manifestation of vulnerability and claim that only the latter can and should
be reduced (p. 67).
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of what is at stake when vulnerability occurs. Thus, they capture only part of the nature of
vulnerability and, in consequence, cannot tell us the full story of what cases require morally.
Personal goods
Instead, it might be more helpful to conceive of vulnerability more neutrally as what a
person necessarily experiences when she wants to achieve something and can do so only, or in
a significantly less burdensome way, with the help of others. This is not meant to include
cooperation aiming at a purely functional result, like sawing up an especially heavy log,
which can only be achieved by two persons working together. Morally relevant vulnerability
occurs when the good a person wants to achieve is of personal importance to her, for example,
like maintaining well-being or health, receiving education, etc. She is vulnerable because she
depends on the willingness of others to acknowledge this fact and react to it accordingly.
The immediate benefit of this approach towards vulnerability is that it explains how
we can all become more or less vulnerable, regardless of whether we are children or adults,
dependent or independent beings, or even if we happen to be the richest person in the world.
Certainly, the adult, independent, and rich have numerous opportunities to circumvent
becoming vulnerable in the first place, but even for them some personal goods cannot be
bought. They depend on the readiness of others to acknowledge their good, friendship for
example, which depends on others accepting one as a friend and behaving accordingly.
This approach also helps us to understand why mere physical or emotional
susceptibilities to harm do not necessarily take on moral significance. Only at first glance
might one get the impression that, for example, a disease makes one vulnerable; a closer look
reveals that this is not sufficient. Rather, it is the sick person’s willingness to entrust her
health and well-being to the integrity and goodwill of the healthcare professional or institution
that makes her vulnerable. A sick person could, in principle, choose to react otherwise, like
relying on the self-healing forces of nature. But if she seeks professional help, she renders
herself vulnerable in a morally significant way. Susceptibilities to harm become moral issues
once we depend on others to overcome our physical or emotional limitations. Thus, patients
are morally vulnerable not just because their bodies malfunction, but because they depend on
healthcare personnel to take seriously the personal goods that are at stake.
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Trust
We are vulnerable in relation to an important personal good and the support of some
other person (or group of persons) to whom we render ourselves vulnerable because that is a
less burdensome, easier, shorter or otherwise simpler – though not always less risky way of
achieving this good. We have another name for this special way of relating to other human
beings: trust’. A trusting person deliberately makes herself vulnerable by entrusting someone
else with a personal good. In contrast, to rely on someone means depending on someone (or
something) without any further personal or emotional investment. When I trust my doctor I
entrust her with discretionary power in my own interest. As Carolyn McLeod reminds us,
there are some things we can say for certain about trust and trustworthiness that are relevant
to deciding when trust is warranted. The trustor must be able to accept that by trusting, s/he is
vulnerable, in particular to betrayal” (McLeod 2011). For Annette Baier, another philosopher
of trust, to trust is “to give discretionary power to the trusted, to let the trusted decide how, on
a given matter, one's welfare is best advanced, to delay the accounting for a while, to be
willing to wait to see how the trusted has advanced one's welfare” (Baier 1995, p. 136). The
wrong the vulnerable person risks is not simply the harm induced by a certain sort of
treatment but, more specifically, being betrayed when a personal good is at stake (Wiesemann
2016).
What do we gain by conceptualizing vulnerability in terms of trust? First, since we all
value trusting relationships, we can better understand why being vulnerable is not bad per se.
Annette Baier points to the fact that by participating in trust practices we pursue a social good
that is important to us and that satisfies both truster and trusted: “The belief that [the trusteds]
will is good is itself a good, not merely instrumentally but in itself, and the pleasure we take
in that belief is no mere pleasure, but part of an important good” (Baier 1995, p. 132).
Moreover, sociologists tell us that in order to flourish, modern technological societies, in
general, rely on their citizens’ readiness to invest trust. In the healthcare system, much
depends on the basic trust of both patients and healthcare workers in the reliability of
medicine as science and as practice. A complicated treatment for, say, breast cancer which is
based on the most recent scientific studies and involves complicated technical apparatuses,
like radiation devices, would not be possible without some basic trust on the part of the
persons involved, and particularly from the patients treated, in the validity and reliability of
medical science. In his influential study from 1968, the most prominent sociologist of trust,
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Niklas Luhmann, describes trust as an effective social resource of advanced technological
societies for the reduction of complexity (Luhmann 1968). Luhmann’s point is that modern
societies could not have developed into the complex entities they are if people were not
thoroughly motivated to invest trust in persons and institutions.
Second, we can better address a widely discussed, critical aspect of the concept of
vulnerability, viz., that by labelling persons as vulnerable they may be patronized and reduced
to passive objects of care (Kipnis 2001, Levine 2004, Mackenzie et al. 2014). If a person is
thought to be vulnerable, she is at risk of being wronged in two different ways: either by the
event to which she is thought to be vulnerable (which is the type of wrong people usually
think of) or by the very protection her vulnerability allegedly calls for but by which she can
be denied the full range of available options. The second sort of wrong becomes all the more
pertinent when we attribute vulnerability to whole groups of persons without looking closely
at each case. For example, excluding every pregnant woman from the full range of medical
research has the potential to wrong them since it reduces them to passive objects of
benevolent paternalism and prevents the pharmaceutical industry from developing safe and
effective medical treatments for pregnancy-related diseases (Wild 2012). By denying them
access to research they are no longer considered active moral agents who have a say in the
process of decision-making and might prefer trusting researchers to develop safe procedures
for them. This is not to say that pregnant women in medical research can dispense with all
forms of protection. However, as Verina Wild shows, protective measures should be gauged
to the personal needs of the women involved instead of imposed on them in a paternalistic
way. A trust-based approach enables us to focus on the vulnerable as the relevant moral
agents and encourages us to devise appropriate means for developing and maintaining
relationships of trust.
The vulnerable as moral agents
Conceptualizing vulnerability in terms of trust helps to orientate the decision-making
process towards the (potentially) vulnerable as moral agents. By moral agent, I mean a
person who actively takes part in a moral relationship. Many ethicists have a much more
demanding concept of a moral agent which is traditionally linked with autonomy and
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accountability.6 Yet, recently, bioethical theory has rediscovered those agents, like children or
adults with mild dementia, who are not competent and accountable in the classical sense but
who nevertheless can be morally hurt and are able to have moral feelings, like dismay, shame
or guilt, which require consideration. Authors critical of the classical approach, like Nomy
Arpaly, argue against autonomy as a necessary condition of agency (Arpaly 2003).7 A moral
agent in a broader sense is one who is capable of moral feelings and who acts in accord with
those feelings in ways that other moral agents can understand and share. This includes the
cognitively disabled and children, both considered to be classic examples of vulnerable
groups.
Members of these groups are considered prototypically vulnerable because they
existentially rely on other persons’ care and protection (Herring 2013, Mullin 2014). They
depend on other persons’ goodwill and integrity to safeguard their personal interests and
prevent harm (Macleod 2015). Obviously, children are in need of good parents to promote
their health and happiness and engaged teachers to foster their educations. Yet, children
should not be considered as just the passive objects of some adults’ efforts at upbringing. Like
the members of other vulnerable groups, children are at risk of being stereotyped and
objectified by such a patronizing treatment. Thus, although children are vulnerable and need
protection, such protection should not simply be imposed on the allegedly passive child as an
object of care but should acknowledge and encompass the agency of the child taking part in
the process (Macleod 2010). Obviously, a young child does not choose who cares for her. But
even the young child will react individually to situations of care by bestowing or refusing
trust. She can, for example, choose not to trust her caregiver, and, in consequence, the
caregiver’s relationship with a mistrustful and uncooperative child will change significantly.
Instead of being characterized by care and protection, it can mutate into one of force and
oppression. By bestowing and refusing trust, the child actively engages in relationships with
those who are to protect her in her vulnerability. In this regard, the child, though existentially
vulnerable, should be considered an active moral agent in her relationships because she can
choose to trust (Wiesemann 2016).
6 For example, Robert Noggle states that a moral agent “sees herself and her interests and projects as
persisting through time, and … can reflect on her present preferences in light of her own future interests”
(Noggle 2002, p. 101).
7 Others, like Mahowald (1989), Carnevale (2004), and Macleod (2010) criticize standard conceptions of moral
agency as adult centric and denying children adequate moral consideration. This follows a more recent trend in
childhood studies focusing, in general, on the agency of the child. For an overview, see Allison (2009) and
Mayall (2013).
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A focus on trust changes the way we react to the vulnerability of the child. Good
caregivers usually strive to earn the child’s trust. Whoever has tried to convince a child to do
or tolerate something that is good for her knows that child trust is not a simple, automatic
reaction to adult persuasion. Instead, it demands a truly personal engagement, respectful
communication and a real knowledge of the child’s personality. Stable trusting relationships
depend on reliable, respectful and sincere personal interactions. Doctors who have wanted to
win over their young patients to particularly lengthy and burdensome treatments, like
chemotherapy, can tell stories of how challenging it can be to earn a child’s trust.8 Yet, in the
long run, only stable relationships of trust that acknowledge the vulnerable as a morally
relevant partner in the decision-making process will facilitate those complicated and
burdensome forms of treatment that medicine is ready to offer.
A new definition of vulnerability
Child trust is an example well suited to illuminate the interrelationship of vulnerability
and trust. The relations between child and parent, friends, and healthcare professional and
patient, to cite some of the more prominent examples, are alike in that they rely on mitigating
vulnerability by maintaining trust. Although one might think, given how much insecurity and
vulnerability is involved, that this renders them unpopular, they are, on the contrary,
considered very rewarding types of human relationship. They are considered so because of the
vulnerability involved, not despite it. Since we cherish the idea that someone is committed to
promote our personal good, we welcome relationships that are characterized by vulnerability
and trust. Thus, it is not just easier to trust, it is also more gratifying. This explains why
vulnerability is not bad per se.
By understanding vulnerability in terms of trust, we can learn how to conceive of the
vulnerable as more than the passive objects of care and avoid patronizing those who are
deemed vulnerable. To this end, one has to acknowledge the positive, socially significant
aspects of vulnerability as well as the agency of the persons concerned: Vulnerability occurs
because, and to the extent that, a person has to put trust in others in order to achieve a
8 However, today, many paediatricians are convinced that simply forcing children to comply is no longer a
justifiable alternative, as we have recently shown in a representative survey in Germany (Wiesemann, Peters
2013).
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personal good. Referring to trust explains why vulnerability is a ubiquitous phenomenon.
Other well-known characteristics are incorporated as well, viz., that vulnerability is relational,
involves risks, may occur to a greater or lesser extent to anyone, implies a certain dependency
on others, and involves the aim of realizing a certain good.
Most importantly, by referring to the phenomenon of trust, we can better derive the
moral obligations which arise from the fact that someone is vulnerable.9 These are the
obligations that we owe to persons who trust. Vulnerability does not always or exclusively
call forth attempts to minimize or eliminate it; one must also encourage and safeguard trusting
relationships.10 Typically, the truster lacks the means to control the situation but, instead of
resigning herself or struggling to regain control, she chooses to accept her vulnerability in a
“leap of faith”, to quote a famous line by the sociologist Georg Simmel (1908/1992). This
readiness to invest trust in others by relying on them to promote one’s personal good creates
similar types of moral relationships. Even when two strangers meet as in the example
provided at the beginning – and no personal relationship, no institutional or professional
codes warrant expectations of trustworthiness, the fact that one person puts her trust in the
other gives rise to some basic obligations of trustworthiness. If one is not able, or not willing,
to help the other, the moral minimum required is that she rejects the other’s trusting attitude.
Thus, one owes other persons at least a hint like, “Don’t trust me – I can’t/won’t help you”.
Carelessly, or deliberately, sending someone the wrong way would certainly be morally
wrong. Even thoroughly naïve and unwise trust requires, as a moral minimum, such a
clarifying comment.
The interesting thing about trust as a moral concept is that it does not define any one
particular obligation. There are many ways to meet the duty to be trustworthy, depending on
the person who trusts and the means available. This somehow makes it seem a hazy concept.
Yet, it is important to note that trust is not functional in the sense that an instance of trust
requires a concrete and specific reaction. Instead, the truster leaves it up to the trusted to
choose what is best (or what she can do best) from a range of reactions, as long as her choice
is in line with the personal good that is at stake.
9 See also the paper by Michael J. Deem in this book.
10 McLeod argues that moral integrity is a relevant motive for all trust relations (McLeod 2002, pp.2127). In
striving for moral integrity, one has to ask how one can render situations in which people make themselves
vulnerable safe for them.
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Conclusion
The literature has focused on methods to minimize vulnerability, and this often can be
a feasible and helpful reaction. In healthcare, informed consent requirements, which are by
now acknowledged as the ethical standard in most parts of the Western world, have
significantly reduced the amount of trust patients have to put in their doctors and, thus,
decreased their vulnerability.11 A dementia patient participating in clinical research can be
given special information or assisted in decision-making by specially trained persons.
Anonymous medical services can be provided for the illegal. Still, trying to eliminate every
sort of vulnerability is not just a futile endeavour, it also does not make sense because people
often prefer a momentary state of vulnerability to all other options since trying to avoid
vulnerability results in a much more costly, burdensome, and less effective way of coping
with a problem. Particularly in the healthcare context, there is an ever-increasing number of
situations in which many people lack the means or the time or both to figure out and control
all of the relevant factors and make up their minds accordingly. Making oneself vulnerable to
the integrity and goodwill of a healthcare professional is a reasonable way to cope with the
complexities of medical treatment – so long as the professional, and the organization in the
background, is aware of this fact and acts accordingly.12 Many complicated medical
technologies like, for example, those involved in the treatment of breast cancer, would not be
possible without a culture of trust based on an interplay of scientific accuracy, professional
codes, personal responsibility, cultural narratives, and reassuring individual experience.13
Vulnerability arises from the need to trust other people in pursuing certain personal
goods when it is very difficult to realize these goods without their help and there are
reasonable grounds for expecting them to do so. It occurs because, and to the extent that, a
11 Yet, moral vulnerability in the context of healthcare is often disguised since the professionalism of healthcare
workers incorporates a number of rules that help patients feel that contacting a doctor in the case of illness is the
only sensible thing to do. Historically, this was by far not always the case. The medical system with its
institutions and professional roles developed over a long period of time to cope with the moral vulnerability
arising from the doctor-patient encounter. Today, physicians acquire a scientific education that enables them to
offer a broad range of evidence-based treatments. Hospitals are well organized so as to reduce to a minimum the
risks for patients and staff. In consequence, most people today find the propriety of relying on professional
hospital treatment in case of illness, instead of trying to cure themselves, self-evident. So, vulnerability manifests
itself only now and then as when special populations are in need of medical help or institutional and professional
routines cannot adequately cope with the personal goods that are at stake. Yet, this should not blind us to the fact
that patients, in general, are vulnerable to the professional integrity of the persons caring for them.
12 Christine Straehle has written about the deficits of state-run healthcare institutions in complying with this
ethos (Straehle 2013, 2014).
13 Even the system of scientific medical research is based on a culture of trust enhanced by the existence of legal
regulations, professional codes, and institutional review boards.
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person has to put trust in others in order to achieve a personal good. This is the case when, for
example, children trust their parents, patients trust their doctors, and citizens trust state
institutions. Parents, doctors, and state institutions derive much of their moral and legal status
from epitomizing trustworthiness and, thus, mitigating vulnerability. Modern societies are
characterized by the fact that many personal goods can only, or much more easily and
effectively, be achieved with the help of others, often specially trained or equipped persons or
institutions which, in turn, incorporate a trust-inspiring professional ethos to compensate for
this special type of dependency.14 The greater the actual dependency and the more important
the personal good involved, the stronger the duty not to betray. The illegal migrant worker
who is seriously ill and has to trust a doctor not to betray her to the authorities creates a
significant obligation on the part of the doctor just by virtue of making herself vulnerable to
her actions.
Vulnerability might therefore trigger two different types of reactions. One is to prevent
the respective person to enter situations that render her vulnerable, altogether. This is, for
example, the case when vulnerable groups are protectively excluded from participating in
medical research. The other is to improve the conditions for trusting relationships and, thus,
acknowledge the vulnerable person’s moral agency. Vulnerability is then understood as the
incentive to create a trustworthy environment. In effect, every case of vulnerability should
encourage reflection about whether the best reaction is to minimize the need to trust or, to the
contrary, to invest in those factors assuring and maintaining trustworthiness. In cancer
treatment, one can go on refining informed consent procedures and intensifying information
procurement so as to impart every piece of knowledge related to therapy and prognosis or one
can develop trust-enhancing, peer-reviewed professional treatment standards to spare patients
the need to pass a medical exam before being able to consent to a treatment plan. Most cases
combine both, and one approach cannot easily replace the other. The first strategy,
minimizing vulnerability, is not realizable in every situation given the complexities of
medical progress and the natural limitations of (patient) autonomy; the second strategy tends
to put too much power into the hands of a few and risks turning trustworthiness and integrity
into arrogance and abuse. In the end, both strategies are indispensable for controlling
vulnerability.
14 Groups of specialists whose job it is to pursue other persons’ personal goods are called ‘professionals’
physicians (health), lawyers (justice), engineers (safety), teachers (education), etc.
14
C. Wiesemann: Interrelationship of Vulnerability and Trust
14
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Claudia Wiesemann
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C. Wiesemann: Interrelationship of Vulnerability and Trust
16
Dept. of Medical Ethics and History of Medicine
Goettingen University Medical Centre
Humboldtallee 36
37073 Goettingen, Germany
www.egmed.uni-goettingen.de
cwiesem@gwdg.de
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... Obwohl die Berücksichtigung kindlicher Interessen insgesamt an Bedeutung zugenommen hat, wie der Wandel des häuslichen Umfelds vieler Kinder von einem "Befehlshaushalt" zu einem "Verhandlungshaushalt" zeigt(Bois-Reymond 1994;Olk 2003; Posch und Bieneck 2016), so belegt die Aktualität der genannten Fälle, dass die besondere Situation des erkrankten Kindes weiterhin einen intensiven Paternalismus-Gebrauch erlaubt. Dies gilt, obwohl in der Pädiatrie insgesamt, analog zum angeführten häuslichen Umfeld, zunehmend auf Kooperation und weniger auf Zwang gesetzt wird(Wiesemann 2017; Wiesemann und Peters 2013).Eine Aufklärung und Kontextualisierung des Begriffs des Paternalismus, den man sehr allgemein als fremdbestimmende Fürsorgehandlungen verstehen kann, der allerdings mit einem intentionalen Missachten eines als defekt erachteten, aktuellen Willens einer anderen Person verbunden ist(Beauchamp 2009), soll hier in drei Schritten und zur weiteren Klärung des Bezugs zur sexualisierten Gewalt erfolgen: Nach einem Hinweis zu a) Alltagsproblemen des Paternalismus folgt unter K b) eine definitorische Präzisierung von Paternalismus und Schein-Paternalismus in Auseinandersetzung mit Joel Feinberg und Gerald Dworkin; bereits mit Bezügen zum Anwendungsfall der sexualisierten Gewalt. Unter c) folgt eine Einordnung in die medizinethische Debatte des Paternalismus, wobei auch hier der Bezug zum Spezialproblem der sexualisierten Gewalt hergestellt wird. ...
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Definition of the problem It is a standard argument in medical ethics to indicate the potential for abuse of such instruments that can be legitimate when used lege artis. One established instrument in medical practice is paternalistic practice that should ensure responsible treatment in cases of reduced individual decision-making ability, such as in minors. In the previous debate, paternalism in medical ethics has primarily been discussed as to its unjustified or excessive use. In contrast, the problem of what we call abusive as-if-paternalism has not been sufficiently discussed. As such, the issue of sexual violence against minors in a medical setting and specific enabling structures, including paternalistic relationship structures, is currently underexplored. The contemporary case of Larry Nassar, doctor of the US acrobatics team, who sexually abused young patients in hundreds of instances, sheds light on the opportunities to carry out specific sexual abuse as medical personnel. Arguments If the paternalism debate discusses the question of the contexts in which paternalism is or is not problematic, then this study contributes the problematic aspect of deceivability in connection with sexual violence. This study focusses on as-if-paternalism, which allows for specific forms of sexual violence in a medical context. As-if-paternalism will be described as practice that use seemingly paternalist action in order to follow one’s own interests instead of aiming at the benefit of the dependent person. Moreover, this contributes to the issue of sexual violence in a clinical context (which must be addressed in medical training, practice, and quality assurance) and to the debate of paternalism in medical ethics and outlines the dangers of deceptive as-if-paternalism. Since children can become accustomed to the transient subordination of their own will and body in an asymmetrical clinical context, this can be used to establish as-if-paternalism. Conclusions The discourse of an only seeming paternalism should however not hide the fact that actually a border regiment between paternalism and non-paternalism in practice is just as complex as the one between sexual bodily violence and non-sexual bodily violence. A precise and transparent lege artis model of paternalism will be discussed as preventive means against sexual violence within clinical contexts. Structurally, this work is based on an evaluation of the interdisciplinary literature on sexual violence in medical contexts (A) and on paternalism (B). The assemblage of these findings will lead to a more complex thesis AB about the relationship between sexual violence and as-if-paternalism.
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