Bioethics Forum Essay
Exhortations to Trust Biomedical Experts: What’s Missing?
Recently, trust is on everybody’s lips. The public is insistently encouraged to trust scientific experts and the medical community. In times of Covid-19, lack of trust in the scientific community is a catastrophe, and so scientists, scholars, and relevant authorities wring their collective hands trying to persuade the public to trust biomedical experts. But current disagreements among biomedical experts regarding whether the scientific evidence supports delaying the second shot of Covid-19 vaccines or pausing the AstraZeneca and Johnson & Johnson vaccines because of very rare side effects bring to the fore missing aspects in exhortations to trust biomedical experts.
Concern with epistemic trust seems, of course, reasonable. Laypeople are dependent on the knowledge that scientific communities produce. We must rely on scientific knowledge not only for many of our individual choices –should I smoke, take this medication—but also to participate in democratic discussions that implicate scientific knowledge, such as whether to mandate Covid vaccines, what activities are likely to increase infections, whether schools should stay open, and so on. Lack of trust in scientific testimony can be an obstacle to achieving an important goal of science: benefiting society.
But missing from these encouragements to trust are some important points. When we simply urge people to trust biomedical experts, we seem to assume either that experts agree or that when they do not, we would know to trust the appropriate ones –whomever those might be. But as we are now seeing, scientists disagree about whether delaying the second dose of some Covid vaccines to a period longer than the one studied in clinical trials is safe and effective. And they disagree about whether the scientific evidence support pausing the use of AstraZeneca and Johnson & Johnson vaccines because of reports of severe, rare blood clots. These disagreements can be perfectly reasonable, e.g., the evidence is insufficient or it can plausibly be interpreted in various ways. In a context like the one we are enduring, where scientific evidence is limited and changing rapidly, disagreements among experts can be the rule rather than the exception. When people are asked simply to trust biomedical experts, there seems to be a discounting of the real possibility and the appropriateness of scientific disagreements. The exhortations might leave people confused, skeptical, and unsure about whom to trust.
Another aspect that is neglected when asking people to trust scientists is that trust can be warranted or misplaced, justified or not. Sometimes we trust those on whom we are epistemically dependent when they are untrustworthy and thus undeserving of our trust. When we do so, we can be harmed; we should not have believed them. Sometimes we fail to trust those who are in fact trustworthy. In doing so, we not only risk harming ourselves—because we should have believed trustworthy experts—but we also commit an injustice—because we undermine their ability to contribute to knowledge production.
But when we ask people to trust, the emphasis is on the one who is trusting rather than the one who is trusted, on trusting rather than on trustworthiness. This emphasis is particularly problematic when it involves racial and ethnic minorities. Members of minority communities are said to show more hesitancy towards Covid-19 vaccines, for instance, and they are underrepresented in clinical trials. This is often attributed to the history of abuses that racial and ethnic minorities have endured at the hands of the biomedical community. But when people’s trust has been betrayed, as it has been the case with racial and ethnic minorities, urging them to trust misses the point. The scientific community should show why they are trustworthy, rather than say, trust us.
Furthermore, putting the emphasis on the trustor calls attention to something that the trustor should be doing but is not doing. Even when everyone can understand that there are good reasons for racial and ethnic communities’ mistrust, still the burden is on them. They are the ones not trusting. This emphasis, however, downplays the many things that the biomedical community fails to do to ensure that racial and ethnic minorities have access to vaccines or to clinical trial participation: increasing the diversity of the biomedical community, ensuring better access to health care institutions, reducing bias in health care professionals, providing appropriate information, and conducting research on issues that are of particular importance to minority communities. A focus on the trustee, rather than on the trustor, would call attention to the barriers that need to be removed for trust to exist.
There is still another factor that is usually missed when exhorting people to trust the biomedical community. In general, when we trust people, we rarely trust them completely. Usually warranted trust involves trusting people to do something in particular. I trust scientists in general to provide me with reliable and pertinent knowledge. Because scientific knowledge is complex and requires specialization, I trust scientists in a specific area of expertise, say immunology but not physics, to produce reliable knowledge regarding antibodies responses. This is very important in the context of asking the public to trust scientific and medical experts. Their expertise is related to science, not public policy.
Placing trust in scientific experts to provide us with reliable information regarding the nature of SARS-CoV-2, its genomic variability, its health effects, or the safety and efficacy of particular medical interventions to treat Covid-19 can be warranted. But scientific experts have no more authority than anyone else when making recommendations about what public policies to follow, which ones are worth the risks, or how to solve conflicts between different policy options. Not only are scientists unrepresentative of the diversity of stakeholders who are affected by science, there can be some reasonable disagreements about social, political, and ethical values. These values, and not just the scientific evidence, are also of relevance to public policy decisions. Reasonable people might disagree about whether strict lockdowns have been the best way to address various pandemic-related concerns (e.g., health, economics, freedom, children’s needs, and so on), whether immunity passports should be implemented, when school closings are justified, or whether vaccines should be mandatory. Scientific evidence is relevant to all of these public policy decisions, but scientific evidence alone—even reliable evidence about which there is consensus– does not dictate policy.
Exhortations to trust the scientific community often neglect this important aspect of trust. When people reject certain public policies–when they refuse to get vaccinated or protest lockdowns– let’s not always attribute such opposition simply to lack of trust in scientists or scientific evidence. Doubtless, sometimes people unjustifiably reject the scientific evidence. But disagreements, sometimes reasonable ones, about what is valuable can also underlie the rejection of certain public policies. Disagreement calls not for insisting that the public trust scientific experts or what the science says, but for recognizing that value differences are at stake and for promoting respectful discussions about such values. Of course, policymakers will have to make decisions that quite likely will be opposed by some constituencies. And such rejection might well be the result not only of value differences but also of a justified lack of trust in policymakers rather than in the scientific community.
Inmaculada de Melo-Martín, PhD, MS, is a professor of medical ethics in medicine at Weill-Cornell Medical College and a Hastings Center fellow.