Accountability, trust and informed consent in medical practice and research.

During the last 25 years public policy in the UK has aimed to replace 'club' cultures and their supposedly suspect reliance on trust between professionals and public with a new public culture based on accountability and 'transparency'. These transformations have changed both clinical practice and public health policy in deep ways. Are the new conceptions of accountability adequate? Are obligations to be 'transparent' any more than requirements to disclose information which overlook the need for genuine communication? Can demands for ever fuller informed consent improve accountability to individual patients and research subjects? Could we devise more intelligent conceptions of accountability that support more intelligent placing and refusal of trust? What might intelligent conceptions of accountability suggest about proper clinical practice, public health medicine and professional responsibilities?