Intended for healthcare professionals

Editor's Choice

Transparency: a modern essential

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:0-f
  1. Richard Smith (rsmith{at}, editor

    “What isn't transparent is assumed to be biased, incompetent, or corrupt until proved otherwise.” This sentence “came to me” in some way. I might have dreamt it (I have strange dreams), composed it during a discussion, or even heard it said by somebody else. Usually when I use the sentence—which is very often—I precede it with “Whether you like it or not…” The sentence is much less a judgment of how things should be and much more an observation of how they are.

    Did the British prime minister have his baby son given the measles, mumps, and rubella (MMR) vaccine? The fact that he won't tell, which I entirely support, creates huge suspicion. In the last week we've had mutterings about bias at the Royal Society because its opaque system for electing fellows has failed to elect Baroness Greenfield, the “miniskirted” neuroscientist who is loved by the media. And why did George Bush have to appear in private before the committee investigating his administration's strategy on terrorism? “What's he got to hide?” asks the man on the Topeka omnibus.

    Yet much, probably most, of health care has been far from transparent. Which are the best hospitals and doctors? Why do some people get admitted to intensive care and not others? Why is so much of the evidence that is used to license drugs secret? How is it decided which patients are “not for resuscitation”? Why do doctors keep quiet about incompetent colleagues? Why did we not know until recently about the many errors that occur in health care?

    I will argue at the European Forum on Health Care Improvement in Copenhagen next week that increasing the degree of transparency in health care is inevitable, but I will also agree with the philosopher Onora O'Neill that transparency can never completely replace trust. Repeated examples of abuse of trust have led to calls for greater accountability, and transparency seems to be essential for accountability. “The efforts to prevent abuse of trust,” writes O'Neill in her book A Question of Trust, “are gigantic, relentless, and expensive; their results are always less than perfect.” She argues that as transparency has advanced, trust has receded—perhaps because transparency leads people into “evasions, half truths, and hypocrisies.”

    The great enemy of trust, she argues, is not secrecy but “deception and lies.” As we all know, deception can destroy trust dramatically, immediately, and irrevocably. Trust, argues O'Neill, grows out of “active inquiry not blind acceptance.” So what is needed to increase trust is not a flood of information but accurate, understandable, interpretable, unspun, checkable information. This proposition explains why England's star system rapidly became discredited. But what is also needed to increase trust is a capacity on the part of those trusting to understand, interpret, and check information. Trust is an active, not a passive, process. Transparency should, I think, be helpful in increasing trust, but it needs to be done well and accompanied by dialogue.

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