Honesty

There are many reasons why it is important that the honesty of a healthcare professional can be consistently relied upon.

The most obvious requirement is that members of the public must be able to believe and place their trust in what they are told by a healthcare professional, especially in the context of the consent process. Patients who are contemplating a dental procedure have a right to be told the truth

But that very concept also makes things a little more complicated. Firstly because telling someone something which is factually incorrect, is not the same thing as omitting to supply an important piece of material information  even though the effect might be precisely the same as far as the patient is concerned. Secondly, the question arises of whether you knew (or should have known) that what you were saying was untrue (in the first example) or 'economical with the truth' in the second example. If you did know, and your actions were therefore deliberate, a third question arises in terms of your motivation. These variables suggest a spectrum of honest and dishonest behaviour, while the use of language mirrors the ambiguity in phrases such as, 'a little white lie'.

An exceptional privilege

Even the law recognises a situation known as 'therapeutic privilege'  a concept which involves the clinician electing not to tell a patient something which, if disclosed, might be prejudicial to the patient's health, wellbeing and general welfare.

This qualification is interesting because the clinician is certainly being dishonest in giving a selective and incomplete account of the truth, but is only doing so in what he or she believes to be the best interests of the patient.

This concept could encourage the erroneous belief that any form of dishonesty can be condoned if the patient (rather than the clinician) is the beneficiary. This is certainly not the case, however, and therapeutic privilege should be regarded very much as the exception within a general expectation of honesty.

This expectation, it should be stressed, extends well beyond the confines of one's professional life because dishonest behaviour in one's personal/social life, or in financial/business dealings, is seen as a reflection of the character and integrity of the individual, rather than specifically of that person in the capacity of being a dentist.

Regulatory bodies (such as Dental Boards and Dental Councils), Courts of Law, and Tribunals will attach great importance to their perception of a dentist's honesty, because it impacts directly upon the extent to which the dentist's statements and evidence can be believed.

Let us now look at some of the different ways in which a dentist's honesty could be called into question.

Consent

This is the subject of a separate module in this series (Number 8), but the importance of a clinician's honesty in the consent process is conveniently summarised by the UK case of Appleton and others  vs  Garrett (1996). The Trial Judge concluded that the dentist has sought to obtain the patient's consent (to quite extensive restorative treatment in most of the cases) in bad faith, ie. by telling the patients that they needed treatment that the dentist would or should have known to be unnecessary. Reflecting this serious breach of trust and the deliberate act of dishonesty for personal gain, punitive damages were awarded in the patient's favour.

It follows that dentists must be truthful when recommending treatment, when describing different treatment options and when explaining what they involve and how they compare.

Patients should not be misled into accepting treatment that they do not need, nor allowed to agree to a certain item of treatment being provided because they have deliberately been left unaware of other treatment alternatives, or other material facts that might have influenced the decision.

Included here would be any act or omission which is calculated to obtain the patient's agreement to proceed with treatment from the dentist in question, when that dentist believed that, if given some further or different information, the patient would have sought treatment elsewhere.

It would be unethical to manipulate a patient's decision in this or any other way.

Misleading statements

Another element of dishonesty arises when statements are made which a dentist knows (or should know) to be untrue, inaccurate, or likely to be misleading. An instance of this is providing incomplete information, or biased information, especially if this involves a conscious, deliberate decision to withhold information or to present it in a way which will alter the way in which the information is received, understood and interpreted.

For example, it is not uncommon to find a patient enquiring about the whereabouts of a dentist who has been treating them for some years, but who has recently left the practice where this treatment was provided. Practice owners have been known to give instructions to reception staff that such information should not be released, and/or the patient should be told that the dentist has left the area/left the country or is no longer practising etc  when in reality, the dentist is known to be practising elsewhere in the same area.

Dentists, or members of staff acting on a dentist's instructions, should not knowingly make dishonest, untrue or deceptive statements to protect or further their own interests or those of their employers. The fact that the departing dentist in this example may have acted in breach of a contract by continuing to work in the same area after leaving the practice, still does not justify or excuse a deliberate act of dishonesty which was designed to mislead a patient at the former practice.

Misleading statements may be made to a range of parties in addition to patients. Dentists have been challenged in the past for making such misleading statements in a range of ways. For example:

• Claiming to have a qualification that they do not possess, or describing a valid qualification in a way which makes it sound more grandiose.
• Improperly or incorrectly claiming to have a special level of expertise, skill or training, when this is not the case.
• Making a claim or statement that is not capable of being substantiated or justified.
• Making untrue statements in applications for mortgages, loans etc or job applications.
• Making untruthful statements when making passport/visa applications, or making false declarations on behalf of third parties when countersigning or witnessing documents.
• Claiming fees for treatment that has not been provided.
• Making fraudulent representations on claim forms in relation to insurance companies, health funds, or any other third party providers or funding organisations, or in relation to business transactions.
• Giving fabricated accounts of events and/or untrue statements calculated to lower the reputation of a third party in the eyes of another.

There have also been instances where research has been misrepresented, or research findings manipulated, and situations where dentists have been found to have plagiarised the research or publications of others, presenting it as their own work. Another example of dishonesty would be that of cheating in professional examinations. These are all examples of dishonest behaviour, and whether such acts are committed in one's professional, business or social life, they all have the capacity to undermine the credibility and integrity of the dentist concerned.

Records

'Contemporaneous' means 'recorded at the time', and it is easier than may be generally known to identify entries that were made after the event, or to recognise record cards which have been altered. Records should, wherever possible, be in chronological order, and therefore in diary sequence with other dated entries. No attempt should ever be made to 'cover one's tracks' by altering or 'improving' an original record card entry, or by substituting a modified or rewritten record card for the original.

Courts of Law and regulatory bodies (Dental Councils and Dental Boards) take an extremely serious view of non-contemporaneous records being presented and stated, dishonestly, to be the originals. Any such attempts can quickly transform a relatively minor matter into a major one. This applies equally to computerised records and digital images of all kinds and although sophisticated editing and image enhancing software makes it surprisingly easy to alter previous records, the same developments in information technology also make it surprisingly easy to recover the original data, in its unmodified form, from a computer's hard drive when the earlier record had apparently been 'deleted'.

In a serious case, dishonest actions to interfere with records or documents of any kind such as this, can contribute towards a criminal conviction for criminal deception, fraud and/or forgery.

Forgery

The offence of forgery has two elements. Firstly, the making of a false statement or the creation of a false document (or 'instrument'), with the intention that it should be accepted by another party as being genuine. Secondly, that this false instrument should be intended to induce the recipient to act to his/her own prejudice, or that of a third party. 'Prejudice' in this context usually amounts to a loss of property, or money, or the loss of an opportunity to gain in monetary or other terms.

Occasionally a dentist, or a member of staff employed by a dentist, becomes a party to a situation where a false statement is made, or allowed to be made, which the dentist believes (or knows) to be untrue. An example of this might be a false declaration as to the identity of the patient for whom certain treatment was provided, or when the treatment took place, or what treatment was in fact provided. As a result of this false statement, a third party may be able to obtain a benefit to which they would not properly be entitled. If this creates a prejudice to another party, this may be sufficient to lead to a criminal prosecution, even if the dentist and/or staff member did not benefit personally in any way from their actions  which might even have been a misguided attempt to assist a patient. Certainly, it is the act of dishonesty that would concern a Dental Council or Dental Board, much more than what the intention was, or who was the intended beneficiary. Obviously, their concern would be all the greater if the dishonesty was clearly motivated by the prospect of personal gain for the dentist.

Deception and fraud

Concealing, or disguising the true nature of things is sometimes referred to as 'dissembling'. In dentistry, there is often a wide gulf in knowledge and understanding between patients and dentists, and if abused, this creates the potential for patients to be deceived or misinformed about the treatment being provided for them. Past examples have included:

• Patients receiving more fillings and crowns than they had been led to expect. When the fees are being paid directly by the patient, this results in patients being charged too much, or at least, more than they had been expecting. Where fees are being paid by a health fund/insurer or third party fund of any kind, this results in a higher claim against such bodies being made by the dentist, and higher fees being received by the dentist.
• Patients (or third party funds) being charged for more procedures than have actually been carried out.
• Providing treatment which is materially different from that which is said to have been provided  such cases often relate to the materials used in the construction of crowns or other fixed restorations, (an example of this follows in due course).

In cases of this kind, a dentist is taking improper advantage of the fact that the patient is not in a position to know precisely what treatment is being provided for them; they take this on trust, accepting the word of a dentist as a professional person. Any deliberate deception of a patient is self-evidently a breach of this trust, and is therefore unethical as well as (in many instances) a breach of contract and/or a criminal offence.

Indirect threats

It is not always appreciated that one can become tainted by the dishonest action of others around you. When acts of dishonesty are uncovered and investigated, a natural progression of any such investigation would be to establish who else was involved, and to what extent. Dentists who are aware of, or who suspect acts of dishonesty of others around them unwittingly place themselves in a potentially vulnerable position, even if they are not involved in, or personally benefiting from the dishonest actions of the others.

It is particularly important for young dentists to be aware of this fact, because it is easy for a young or inexperienced dentist to become sucked into what seems to be a well-established practice policy, and to find that they have  perhaps by default  become involved in fraudulent activities.

It is obviously difficult for them to question or challenge what everyone else in the practice seems to be taking for granted, particularly if senior members of the practice are involved. But however young or inexperienced they are, such dentists are still, after all, professional people in their own right and one's professional reputation and integrity is much too precious to entrust it to the hands of others whose motives might be based on self-interest. If in doubt, it is wise to seek the advice of one's professional indemnity organisation.

There have been instances where dental laboratories have supplied crowns and bridges with little or no precious metal content, contrary to the required specification. Dentists have accepted and fitted these restorations, presuming them to have the precious metal content that they had requested or assumed to be present, and they have claimed fees on this same understanding.

When a systematic fraud such as this is uncovered, the question will be asked whether the dentist was complicit in the deception, or alternatively, an innocent victim of circumstance. Clinical records, laboratory tickets and invoices will all be important in demonstrating what material the dentist had actually specified at the time, and what he/she should have assumed had been provided.

Perceptions of dishonesty

Even when the dentist's actions had been entirely honest, there are several ways in which an unhelpful doubt can be created:

• When a crucial entry in a clinical record (which is helpful to the dentist and upon which the fate of a case may be determined), is made out of its proper and logical chronological place in the records, or is undated, or appears to have been added as an afterthought. In all these instances, this can appear suspicious when viewed by others after problems have arisen.
• When entries are deleted or obscured  particularly when done with the obvious intention of preventing the original entry from ever being discovered. To avoid this perception, it is wise to strike through any incorrect entry with a single line (leaving the original entry visible), and then to insert the correct entry alongside it. Initial and date any such alteration.
• When critical records or x-rays are 'mislaid', destroyed or lost, or said not to exist.

Once a perception of dishonesty, or attempts at deception have been created or uncovered, it has a tendency to undermine the credibility of the dentist to an extent which casts serious doubt upon anything and everything he or she has said.

Dentists should bear in the mind the importance of records  of all kinds  in helping them to demonstrate their good faith and integrity, and the fact that they have given an honest account of events, to the best of their ability.

• Appointment books
• Computer schedules
• Laboratory documentation
• Telephone records
• Copies of correspondence can all assist in this process

But ultimately, much will depend upon the extent to which a dentist is felt to be a reliable and trustworthy witness, and anything that undermines this belief will be detrimental.

Summary

Honesty is a central pillar of the professional person's integrity. One's professional reputation can often 'survive' an honest mistake or lapse in judgement, if the response and subsequent actions are open, honest and transparent.

It is far more difficult for personal integrity to survive a minor transgression if this is then compounded by serial acts of dishonesty committed in a desperate, but misguided attempt to recover the situation.

At times of great stress, it is not always easy to think clearly and sensibly. Many acts of dishonesty are committed as a panic reaction.

It is also true that one act of dishonesty frequently necessitates further acts of dishonesty with the aim of preventing the discovery of the original lack of truthfulness.

Honesty, truthfulness and a straightforward, open approach to patients and others, is one of the most precious attributes of the professional person.