Fiduciary or Not? Healthcare Systems and Oncology

Websters’ ( www.Merriam-Webster.com ) defines “fiduciary” as any situation in which one person justifiably places confidence and trust in another. While often thought of in financial terms, the trust, and the responsibilities to maintain and satisfy that trust, are not necessarily limited to monetary activities and transactions, but represent a broad concept of interdependency and support. Typically, there is a disparity in power or expertise for any fiduciary relationship, with the subordinate party “trusting” that the dominant party will act to their benefit, and with the dominant party obligated to do so. Such a relationship exists in nearly all areas of healthcare delivery, and is perhaps most essential for vulnerable populations such as patients with cancer. In this chapter, we will explore the relationship of various components of the healthcare system to cancer patients and delve into how this does, or does not, represent a fiduciary association. We will examine the level of trust in different components of the healthcare system and address some special circumstances including dealing with disadvantaged and indigenous populations. Finally, we will explore how the relationship between patients and their healthcare delivery system is affected by the “value paradigm”, and discuss who does, or should, monitor implementation of such a paradigm in order to maintain patient trust.