Medical ethics is typically discussed in terms of autonomy, beneficence, and justice. The authors of this chapter believe that Erik Erikson’s approach will provide a more practical framework.

Erikson presented his theory of the Golden Rule at the George W. Gay Lecture Upon Medical Ethics, at Harvard Medical School on May 4, 1962. Erikson’s reformulation of the Golden Rule emphasizes mutuality between the physician and patient. For Erikson, medical ethics involves not only rational decision making but also ideals related to a higher good.⁹ Ethical acts are grounded in a sense of justice, a universal sense of responsibility toward all human beings, and the need for mutual respect and recognition.¹⁰ Erikson emphasized partnership and mutuality in the physician-patient relationship, which provide the opportunity for growth in both the physician and patient and bidirectional trust between physician and patient. For Erikson,^10(p233) the Golden Rule encourages that “it is best to do to another what will strengthen you even as it will strengthen him—that is, what will develop his best potentials even as it develops your own.”

Two primary elements of Erikson’s Golden Rule are trust and mutuality.¹¹ Investigating an ethical approach to a medical decision to stop the use of opioids begins with an understanding of these components of ethical practice.

According to Erikson, over an individual’s life span, an “individual develops the propensity for ethics as he passes through eight (developmental) stages.”^12(p171) Developmental experiences in infancy involving trust with caregivers form the bedrock on which the later seven psychosocial stages will be experienced.¹³ To develop a sense of trust, infants must be able to count on their caregivers to feed them, soothe them, arouse or quiet them when needed, and mirror smiles and babbles.¹⁴ In an optimal environment, the infant learns that the world is generally a safe and consistent place and that people are mostly “good.” The infant gains the strength of “hope,” which is the perception that, even if there is waiting, one’s needs will be met and other people can be relied on to be responsive to the one’s needs. Over the life span, trust is transformed and provides a guiding principle for daily life and relationships with others.¹⁵

However, people with less optimal early lives may learn that their needs will not be met and that people are unreliable; these individuals may develop mistrust in their relationships as adults. Chronic pain patients may have a greater likelihood of histories of early challenges in developing trust¹⁶ and, therefore, go through life burdened with vulnerability to mistrust.¹⁷

Trust is one of the central features of the physician-patient relationship.¹⁸ Sass, a philosopher and ethicist, states that “trust becomes the overriding principle and virtue that establishes and safeguards all expert-lay interactions, particularly in the clinic.”^19(p354)

Patient trust in a physician manifests as the expectation that the physician will behave in a way that makes it safe for the patient to take the risk of sharing personal information. Dimensions of physician behavior on which patients are believed to base their trust in their physician are “competence, compassion, reliability and dependability, and communication.”^18(p509) Pearson and Raeke¹⁸ identify the importance of interpersonal trust, the trust built through repeated interactions with a physician within which the patient learns over time that his or her needs will be met in a predictable and consistent way despite changes in the medical environment that may threaten trust.

O’Neill²⁰ also describes trust building as a dynamic activity and views physician trust as a partnership. Physician trust in a patient is not only determined by the trustworthiness of the patient but can also be influenced by external factors, including media events, current research, racial bias,^21,22 practices of
colleagues, and the physicians’ own experiences.²³ With each patient, the physician’s trust is based on the assumption that the patient’s motive is pain reduction and improvement in function and that the patient is truthful in his or her self-report of symptoms and prior treatment. Trust is confirmed via observation of patient adherence to a treatment plan, patient efforts at participation in treatment, and prompt patient communication with the physician if problems arise.⁴

According to Erikson,^10(p231) the relationship between the parent and the infant involves mutuality, which is a bidirectional process by which the “partners depend on each other for the development of their respective strengths.” Relevant to the focus of this chapter, Erikson^10(p231) asserts, “The fact is that the mutuality of adult and baby is the original source of hope, the basic ingredient of all effective as well as ethical human action.” The parent tries to understand the variety of needs in the child in regard to soothing, eating, sleeping, and elimination. Parent and infant work to read each other’s signals and to learn to regulate the amount of time that passes between the expression of the need and satisfaction of the need. The work of creating mutuality of interaction and communication is characterized as a process of coordination, mismatch, and repair.²⁴ Mutuality emerges from patterns of physical (e.g., eye gaze, proximity, offering food), verbal (patterns of speaking/vocalizing and responding), and affective (e.g., smiling) expressions. Erikson¹⁰ emphasized that through mutuality, the parent reinforces his or her own sense of trust or revisits issues of mistrust. Thus, mutuality is the focus on the relationship with others that becomes a source of information about one’s identity and interactions with others.

Over the life span, mutuality is not exclusive to parent-child relationships but manifests in different types of adult relationships, where mutuality means “personal recognition, joint work, effective communication, and understanding and respect for each other’s roles.”^25(p741)