First, Do No Harm: Institutional Betrayal in Healthcare
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Seeking healthcare is an act of trust: patients reveal private information, pain, and vulnerability to physicians who have specialized knowledge and skills. Patients may endure risk and uncertain treatment outcomes based on the assurance of a trusted physician. Physicians’ professional oaths compel them to protect patients’ welfare first, and the power imbalance in these relationships is tolerable precisely because of the bond of trust. When this trust is protected, it is a powerful tool: patients are more engaged, benefit more from medical interventions, and are healthier overall. Yet these healthcare relationships are contained within larger institutions – hospitals, insurance companies, government programs – that may circumscribe physicians’ abilities to protect patients’ trust to the fullest and even contribute to negative medical experiences. Because trust and vulnerability characterize patients’ interactions with healthcare institutions, institutional actions and inactions that contribute to negative medical experiences constitute institutional betrayal. In this dissertation I address this largely unexamined issue in healthcare research by drawing on research and theory in trauma psychology. I report the results of a study based on the survey responses of 707 American adults. Institutional betrayal in healthcare was reported by two-thirds of the participants and predicted lower trust in participants’ own physicians, doctors in general, and healthcare organizations. These negative effects were more pronounced for patients who reported higher levels of trust in healthcare institutions prior to the betrayal and did not seem to be influenced by a general tendency to trust others. However, the effects of institutional betrayal on trust in healthcare organizations were buffered by trust in one’s own physician. Institutional betrayal also predicted worse physical health and increased symptoms of depression, dissociation, and post-traumatic distress – both directly and through disengagement from healthcare. Consistent with betrayal trauma theory, participants who experienced institutional betrayal were five times more likely to report some difficultly remembering that betrayal and negative medical experiences. This unawareness may allow patients to continue to seek necessary medical care, even in the presence of institutional betrayal. In order to understand what contributes to patient trust and engagement in healthcare and why some patients experience worse mental and physical health outcomes, institutional betrayal must be taken into account.